CLM-2026-029991
Heritage Rehabilitation Center, Physical Therapy. Service 2026-09-20 at office (POS 11). Received 2026-10-15.
Member
Resolved through the identity graph
- Member
- Nancy Welch
- Member ID
- none on golden record
- Date of birth
- 1954-03-08
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-425644
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2228
- Coverage period
- 2022-05-01 to present
- Deductible
- $48.35 of $500.0010%
- Out-of-pocket maximum
- $376.35 of $2,000.0019%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6638399413
- Network
- In network
- Rendering NPI
- 6871881341
- 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 | — | 4 | 1 | $308.00 | $190.96 | — | — | PendedIDQ |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $47.00 | $29.14 | — | — | PendedIDQ |
| 3 | 97161 | PT evaluation, low complexity | 25 | 1 | 2 | $190.00 | $117.80 | — | — | PendedIDQ |
| Totals | $545.00 | $337.90 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-206311
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001108; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-09-20: NULL (PPO), effective 2022-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 25 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 | Pass | Physical therapy visits used 10 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: Heritage Rehabilitation Center2026-09-20 12:46
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-001108; payment withheld until the identity is confirmed. Eligibility: Active on 2026-09-20: NULL (PPO), effective 2022-05-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.