CLM-2026-032502
Harbor Rehabilitation Center, Physical Therapy. Service 2026-03-23 at office (POS 11). Received 2026-04-09.
Member
Resolved through the identity graph
- Member
- Douglas Salazar
- Member ID
- UHC-82593-56
- Date of birth
- 1999-09-04
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-402505
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5262
- Coverage period
- 2025-07-01 to present
- Deductible
- $865.82 of $1,500.0058%
- Out-of-pocket maximum
- $2,187.16 of $6,000.0036%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 1139592160
- Network
- In network
- Rendering NPI
- 8336444194
- Location
- Mesa, AZ · TIN 48-8489623
- 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 | $248.00 | $153.76 | — | — | DeniedLIM |
| Totals | $248.00 | $153.76 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-250881
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-024860 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-23: SELECT-EPO (EPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 17 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 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 Center2026-03-23 14:26
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-09 05:59
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-09 10:00
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 engineDenied2026-10-22 12:44Benefit limits: Physical therapy visits used 22 of 20 for the plan year.
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
Annual visit limit exhausted.