CLM-2026-034565
Evergreen Rehabilitation Center, Physical Therapy. Service 2026-05-07 at office (POS 11). Received 2026-06-20.
Member
Resolved through the identity graph
- Member
- Helen Hicks
- Member ID
- UHC-81077-42
- Date of birth
- 1962-07-12
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-404146
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8939
- Coverage period
- 2023-01-01 to present
- Deductible
- $2,989.87 of $3,500.0085%
- Out-of-pocket maximum
- $6,095.20 of $14,000.0044%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 8258289502
- Network
- In network
- Rendering NPI
- 1366071953
- Location
- Phoenix, AZ · TIN 14-6171767
- 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 | $142.00 | $88.04 | — | — | Review |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $59.00 | $36.58 | — | — | Review |
| Totals | $201.00 | $124.62 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-347004
- 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-035656 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-07: OPTIONS-PPO (PPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 44 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 Evergreen Rehabilitation Center (8258289502). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 13 of 20. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for low back pain, unspecified. 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: Evergreen Rehabilitation Center2026-05-07 09:36
Patient seen for low back pain, unspecified. Note dictated; signature pending.
- SystemSystem: Claims system2026-06-20 05:15
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-20 14:40
Called the provider office; awaiting documentation.
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 low back pain, unspecified. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024142 | 2026-09-16 | Evergreen Medical Group | $171.00 | Approved |
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.