CLM-2026-000106
Heritage Physical Therapy, Physical Therapy. Service 2026-05-22 at office (POS 11). Received 2026-05-27.
Member
Resolved through the identity graph
- Member
- Wayne Castillo
- Member ID
- UHC-95042-59
- Date of birth
- 1957-03-05
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-427480
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0218
- Coverage period
- 2023-12-01 to present
- Deductible
- $1,225.55 of $3,500.0035%
- Out-of-pocket maximum
- $1,190.80 of $7,000.0017%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7650650246
- Network
- In network
- Rendering NPI
- 7654570945
- Location
- Miami, FL · TIN 30-1447638
- 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 | — | 3 | 1 | $207.00 | $128.34 | — | — | DeniedLIM |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $84.00 | $52.08 | — | — | DeniedLIM |
| Totals | $291.00 | $180.42 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-659684
- 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-032533 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-22: MEDICARE-ADV-A (MA), effective 2023-12-01. | |
| Timely filing | Pass | Received 5 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 Heritage Physical Therapy (7650650246). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 21 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: Heritage Physical Therapy2026-05-22 14:32
Patient seen for aftercare following joint replacement surgery.
- SystemSystem: Claims system2026-05-27 06:24
Member has used the annual physical-therapy visit benefit for the plan year.
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 21 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013830 | 2026-09-27 | Riverside Medical Group | $312.00 | Approved |
| CLM-2026-019499 | 2026-07-07 | Desert Cardiovascular Associates | $1,540.00 | Approved |
| CLM-2026-033731 | 2026-05-04 | Evergreen Digestive Health Center | $231.00 | 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.