CLM-2026-031394
Desert Rehabilitation Center, Physical Therapy. Service 2026-05-22 at office (POS 11). Received 2026-06-07.
Member
Resolved through the identity graph
- Member
- Michelle Hart
- Member ID
- UHC-85075-29
- Date of birth
- 1972-04-06
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-427306
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5827
- Coverage period
- 2022-05-01 to 2026-05-21
- Deductible
- $147.22 of $500.0029%
- Out-of-pocket maximum
- $701.30 of $2,000.0035%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 1142322233
- Network
- In network
- Rendering NPI
- 3628319295
- Location
- Mesa, AZ · TIN 33-5650925
- 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 | — | 2 | 1 | $188.00 | $116.56 | — | — | DeniedCO27 |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1 | $223.00 | $138.26 | — | — | DeniedCO27 |
| Totals | $411.00 | $254.82 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-502954
- 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 | Pass | Attached to MBR-002148 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-22 is after coverage terminated on 2026-05-21. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 16 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 Desert Rehabilitation Center (1142322233). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Note | Physical therapy visits used 18 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: Desert Rehabilitation Center2026-05-22 14:47
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-07 06:28
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-07 12:04
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-22 is after coverage terminated on 2026-05-21. Benefit limits: Physical therapy visits used 18 of 20.
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
Service after coverage termination.