CLM-2026-031129
Harbor Rehabilitation Center, Physical Therapy. Service 2026-06-15 at office (POS 11). Received 2026-06-17.
Member
Resolved through the identity graph
- Member
- Andrea Guzman
- Member ID
- UHC-33667-52
- Date of birth
- 1992-05-15
- Identity
- Verified4 records, confidence 0.93
- Claim record
- CLMCLM-423827
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6054
- Coverage period
- 2021-02-01 to present
- Deductible
- $1,475.61 of $2,500.0059%
- Out-of-pocket maximum
- $2,243.95 of $7,500.0030%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 1139592160
- Network
- In network
- Rendering NPI
- 6816153681
- Location
- Mesa, AZ · TIN 48-8489623
- Authorisation / referral
- none / REF110699
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 | $150.00 | $93.00 | — | — | DeniedLIM |
| 2 | 97014 | Electrical stimulation, unattended | 25 | 1 | 1 | $44.00 | $27.28 | — | — | DeniedLIM |
| Totals | $194.00 | $120.28 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-113704
- 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-013241 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-06-15: CORE-HMO (HMO), effective 2021-02-01. | |
| Timely filing | Pass | Received 2 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 (1139592160). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 20 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 Center2026-06-15 13:33
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-17 05:31
Member has used the annual physical-therapy visit benefit for the plan year.
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 20 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017500 | 2026-01-09 | Cornerstone Diabetes Center | $473.00 | 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.