CLM-2026-028674
Valley Rehabilitation Center, Physical Therapy. Service 2026-10-11 at office (POS 11). Received 2026-10-28.
Member
Resolved through the identity graph
- Member
- Dylan Robertson
- Member ID
- UHC-45403-96
- Date of birth
- 1975-12-12
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-404380
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2727
- Coverage period
- 2024-01-01 to present
- Deductible
- $1,185.77 of $3,500.0034%
- Out-of-pocket maximum
- $4,655.33 of $14,000.0033%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6713462326
- Network
- In network
- Rendering NPI
- 2393479771
- 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 | — | 3 | 1 | $225.00 | $139.50 | — | — | DeniedCO18 |
| Totals | $225.00 | $139.50 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-957891
- 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-043601 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-10-11: MEDICARE-ADV-B (MA), effective 2024-01-01. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-028673: 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 Valley Rehabilitation Center (6713462326). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 8 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: Valley Rehabilitation Center2026-10-11 17:11
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-28 03:31
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-28 10:15
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 engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-028673: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028673 | 2026-10-11 | Valley Rehabilitation Center | $225.00 | 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.