CLM-2026-023543
Harbor Rehabilitation Center, Physical Therapy. Service 2026-06-08 at office (POS 11). Received 2026-07-16.
Member
Resolved through the identity graph
- Member
- Alexander Thompson
- Member ID
- UHC-81966-47
- Date of birth
- 1999-03-02
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-400628
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5349
- Coverage period
- 2023-09-01 to present
- Deductible
- $512.68 of $1,000.0051%
- Out-of-pocket maximum
- $476.92 of $2,000.0024%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 1139592160
- Network
- In network
- Rendering NPI
- 2824081188
- Location
- Mesa, AZ · TIN 48-8489623
- 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 | $234.00 | $145.08 | $20.00 | $125.08 | Paid |
| Totals | $234.00 | $145.08 | $20.00 | $125.08 | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-924635
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019013 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-06-08: SELECT-EPO (EPO), effective 2023-09-01. | |
| Timely filing | Pass | Received 38 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 (1139592160). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 11 of 20. | |
| 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 Center2026-06-08 16:45
Follow-up for aftercare following joint replacement surgery. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-07-16 02:02
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-16 08:12
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-924635.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019329 | 2026-06-08 | Heritage Clinical Laboratories | $95.00 | Needs review |
| CLM-2026-019328 | 2026-06-08 | Heritage Clinical Laboratories | $95.00 | Approved |
| CLM-2026-002058 | 2026-05-03 | Harbor Medical Group | $355.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.