CLM-2026-032523
Valley Rehabilitation Center, Physical Therapy. Service 2026-08-25 at office (POS 11). Received 2026-10-05.
Member
Resolved through the identity graph
- Member
- David Shaw
- Member ID
- UHC-39003-12
- Date of birth
- 1953-04-17
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-413607
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6681
- Coverage period
- 2024-12-01 to present
- Deductible
- $207.16 of $1,000.0021%
- Out-of-pocket maximum
- $748.48 of $3,000.0025%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6713462326
- Network
- In network
- Rendering NPI
- 8948418164
- Location
- Tempe, AZ · TIN 20-6528291
- Authorisation / referral
- none / REF663620
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 | — | 3 | 1 | $174.00 | $107.88 | — | — | Review |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 2 | $161.00 | $99.82 | — | — | Review |
| Totals | $335.00 | $207.70 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-927269
- 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-017788 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-25: CORE-HMO (HMO), effective 2024-12-01. | |
| Timely filing | Pass | Received 41 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 Valley Rehabilitation Center (6713462326). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 2 of 20. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for pain in right knee. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Valley Rehabilitation Center2026-08-25 15:37
Patient seen for pain in right knee. Note dictated; signature pending.
- SystemSystem: Claims system2026-10-05 01:15
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-10-05 08:14
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 engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for pain in right knee. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.