CLM-2026-030900
Harbor Rehabilitation Center, Physical Therapy. Service 2026-02-15 at office (POS 11). Received 2026-08-26.
Member
Resolved through the identity graph
- Member
- Frances West
- Member ID
- UHC-96840-78
- Date of birth
- 1971-03-02
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-407627
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9407
- Coverage period
- 2021-05-01 to present
- Deductible
- $170.68 of $500.0034%
- Out-of-pocket maximum
- $425.76 of $2,000.0021%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 1139592160
- Network
- In network
- Rendering NPI
- 1717381226
- Location
- Mesa, AZ · TIN 48-8489623
- Authorisation / referral
- none / REF940018
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 | — | 2 | 1 | $122.00 | $75.64 | — | — | DeniedCO29 |
| 2 | 97014 | Electrical stimulation, unattended | 25 | 1 | 1,2 | $52.00 | $32.24 | — | — | DeniedCO29 |
| 3 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $67.00 | $41.54 | — | — | DeniedCO29 |
| Totals | $241.00 | $149.42 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-995122
- 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-029073 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-15: CORE-HMO (HMO), effective 2021-05-01. | |
| Timely filing | Fail | CO29 | Received 192 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (1139592160). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 3 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 Center2026-02-15 11:35
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-26 02:14
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-26 10:21
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 13:43Timely filing: Received 192 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.