CLM-2026-032687
Valley Rehabilitation Center, Physical Therapy. Service 2026-03-29 at office (POS 11). Received 2026-04-07.
Member
Resolved through the identity graph
- Member
- Wayne Sanchez
- Member ID
- UHC-45559-54
- Date of birth
- 1962-10-15
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-412483
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8351
- Coverage period
- 2025-10-01 to present
- Deductible
- $1,578.79 of $2,500.0063%
- Out-of-pocket maximum
- $1,235.54 of $10,000.0012%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 6713462326
- Network
- In network
- Rendering NPI
- 1146636711
- Location
- Tempe, AZ · TIN 20-6528291
- Authorisation / referral
- none / REF287445
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 | $280.00 | $173.60 | — | — | DeniedLIM |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1,2 | $231.00 | $143.22 | — | — | DeniedLIM |
| Totals | $511.00 | $316.82 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-151452
- 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-024466 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-03-29: CORE-HMO (HMO), effective 2025-10-01. | |
| Timely filing | Pass | Received 9 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 | 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: Valley Rehabilitation Center2026-03-29 18:30
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-04-07 02:08
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-07 09:21
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 13:43Benefit 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-2026-021062 | 2026-04-17 | Unity Medical Group | $739.00 | 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.