CLM-2026-028317
Harbor Rehabilitation Center, Physical Therapy. Service 2025-12-29 at office (POS 11). Received 2026-01-27.
Member
Resolved through the identity graph
- Member
- Grace Davis
- Member ID
- UHC-22284-67
- Date of birth
- 2000-05-18
- Identity
- Verified4 records, confidence 0.93
- Claim record
- CLMCLM-427152
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-7197
- Coverage period
- 2024-04-01 to present
- Deductible
- $184.51 of $500.0037%
- Out-of-pocket maximum
- $731.60 of $1,500.0049%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 1139592160
- Network
- In network
- Rendering NPI
- 3968745737
- 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 | — | 4 | 1 | $320.00 | $198.40 | — | — | DeniedCO18 |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $56.00 | $34.72 | — | — | DeniedCO18 |
| Totals | $376.00 | $233.12 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-473656
- 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-004818 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2025-12-29: NULL (PPO), effective 2024-04-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-028316: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 2 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 Center2025-12-29 15:31
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-27 00:04
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-27 15:06
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 engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-028316: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002857 | 2026-06-02 | Cornerstone Digestive Health Center | $2,502.00 | Needs review |
| CLM-2026-028316 | 2025-12-29 | Harbor Rehabilitation Center | $376.00 | 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
Exact duplicate of an earlier submission.