CLM-2026-026529
Valley Rehabilitation Center, Physical Therapy. Service 2026-04-28 at office (POS 11). Received 2026-06-11.
Member
Resolved through the identity graph
- Member
- Jordan Oliver
- Member ID
- UHC-96881-31
- Date of birth
- 1981-11-21
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-422971
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8541
- Coverage period
- 2022-05-01 to present
- Deductible
- $1,853.49 of $3,500.0053%
- Out-of-pocket maximum
- $3,129.39 of $14,000.0022%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6713462326
- Network
- In network
- Rendering NPI
- 3253565204
- Location
- Tempe, AZ · TIN 20-6528291
- 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 | — | 2 | 1 | $180.00 | $111.60 | — | — | DeniedLIM |
| Totals | $180.00 | $111.60 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- Patient account
- PA-670522
- 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-001088 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-28: CORE-HMO (HMO), effective 2022-05-01. | |
| Timely filing | Pass | Received 44 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 Valley Rehabilitation Center (6713462326). | |
| 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: Valley Rehabilitation Center2026-04-28 14:25
Established patient presents with unspecified rotator cuff tear, unspecified shoulder; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-11 02:29
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 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023475 | 2025-11-23 | Unity Counseling Center | $317.00 | 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.