CLM-2026-026924
Harbor Rehabilitation Center, Physical Therapy. Service 2026-03-04 at office (POS 11). Received 2026-03-30.
Member
Resolved through the identity graph
- Member
- Nancy Espinoza
- Member ID
- UHC-50303-16
- Date of birth
- 1995-02-11
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-411252
- Relationship
- Child, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group NULL
- Coverage period
- 2024-06-01 to 2026-02-15
- Deductible
- $504.71 of $1,500.0034%
- Out-of-pocket maximum
- $99.07 of $6,000.002%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 5301440876
- Network
- In network
- Rendering NPI
- 4824304727
- 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 | — | 4 | 1 | $368.00 | $228.16 | — | — | DeniedCO27 |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 2 | $205.00 | $127.10 | — | — | DeniedCO27 |
| 3 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $46.00 | $28.52 | — | — | DeniedCO27 |
| Totals | $619.00 | $383.78 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- Patient account
- PA-964717
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004579 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-04 is after coverage terminated on 2026-02-15. Expenses incurred after coverage terminated |
| 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 Harbor Rehabilitation Center (5301440876). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 1 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 Center2026-03-04 18:11
Patient seen for aftercare following joint replacement surgery.
- SystemSystem: Claims system2026-03-30 04:58
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-03-30 13:08
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-04 is after coverage terminated on 2026-02-15.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017616 | 2026-05-04 | Mesa Clinical Laboratories | $59.00 | Denied |
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
Service after coverage termination.