CLM-2026-026306
Heritage Rehabilitation Center, Physical Therapy. Service 2026-06-06 at office (POS 11). Received 2026-07-02.
Member
Resolved through the identity graph
- Member
- David Ryan
- Member ID
- UHC-48337-47
- Date of birth
- 1956-10-15
- Identity
- Verified6 records, confidence 0.98
- Claim record
- CLMCLM-414890
- Relationship
- Spouse, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8668
- Coverage period
- 2025-11-01 to present
- Deductible
- $370.55 of $500.0074%
- Out-of-pocket maximum
- $577.55 of $1,500.0039%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6638399413
- Network
- In network
- Rendering NPI
- 5253948603
- Location
- Nashville, TN · TIN 93-4440762
- 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 | $198.00 | $122.76 | — | — | DeniedLIM |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $73.00 | $45.26 | — | — | DeniedLIM |
| Totals | $271.00 | $168.02 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-272146
- 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-020233 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-06-06: UNKNOWN (PPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 26 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 Heritage Rehabilitation Center (6638399413). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 20 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: Heritage Rehabilitation Center2026-06-06 18:52
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-07-02 00:13
Member has used the annual physical-therapy visit benefit for the plan year.
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 20 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019055 | 2026-07-28 | Cornerstone Internal Medicine Associates | $409.00 | Approved |
| CLM-2026-011450 | 2026-07-05 | Heritage Primary Care Associates | $537.00 | Approved |
| CLM-2026-021692 | 2026-03-26 | Riverside Regional Medical Center | $2,270.00 | Approved |
| CLM-2026-028202 | 2026-02-12 | Harbor Clinical Laboratories | $171.00 | Approved |
| CLM-2026-000456 | 2026-03-14 | Unity Counseling Center | $289.00 | Approved |
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.