CLM-2026-023503
Harbor Rehabilitation Center, Physical Therapy. Service 2026-08-11 at office (POS 11). Received 2026-08-29.
Member
Resolved through the identity graph
- Member
- Doris Anderson
- Member ID
- UHC-85647-30
- Date of birth
- 1940-06-16
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-416026
- Relationship
- Child, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0758
- Coverage period
- 2024-12-01 to present
- Deductible
- $576.17 of $1,000.0058%
- Out-of-pocket maximum
- $529.04 of $4,000.0013%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 5301440876
- Network
- In network
- Rendering NPI
- 9356045481
- Location
- Denver, CO · TIN 55-4519384
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 97110 | Therapeutic exercise, 15 minutes | — | 3 | 1 | $249.00 | $154.38 | — | — | DeniedLIM |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $55.00 | $34.10 | — | — | DeniedLIM |
| Totals | $304.00 | $188.48 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-859793
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018748 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-11: OPTIONS-PPO (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 18 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Harbor Rehabilitation Center (5301440876). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 22 of 20 for the plan year. Benefit limit reached |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Rehabilitation Center2026-08-11 11:37
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-29 03:36
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-29 13:25
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Benefit limits: Physical therapy visits used 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Annual visit limit exhausted.