CLM-2026-030463
Harbor Rehabilitation Center, Physical Therapy. Service 2025-12-14 at office (POS 11). Received 2026-01-17.
Member
Resolved through the identity graph
- Member
- Emily Palmer
- Member ID
- UHC-80821-83
- Date of birth
- 1961-07-18
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-427890
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9863
- Coverage period
- 2022-01-01 to present
- Deductible
- $1,605.45 of $3,500.0046%
- Out-of-pocket maximum
- $1,901.85 of $10,500.0018%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 5301440876
- Network
- In network
- Rendering NPI
- 9465747738
- 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 | $276.00 | $171.12 | — | — | DeniedLIM |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $57.00 | $35.34 | — | — | DeniedLIM |
| Totals | $333.00 | $206.46 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-497241
- 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-005149 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-14: MEDICARE-ADV-B (MA), effective 2022-01-01. | |
| Timely filing | Pass | Received 34 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 | 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: Harbor Rehabilitation Center2025-12-14 15:23
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-17 04:55
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-17 11:43
Escalated to nurse reviewer for clinical opinion.
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-2026-003431 | 2026-09-08 | Pinecrest Heart Institute | $5,465.00 | Approved |
| CLM-2026-001619 | 2026-02-19 | Evergreen Family Practice | $180.00 | 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.