CLM-2026-001516
Mesa Physical Therapy, Physical Therapy. Service 2026-01-09 at office (POS 11). Received 2026-01-31.
Member
Resolved through the identity graph
- Member
- Raymond Wood
- Member ID
- UHC-06749-57
- Date of birth
- 1988-01-25
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-429986
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5296
- Coverage period
- 2023-03-01 to present
- Deductible
- $1,143.31 of $2,500.0046%
- Out-of-pocket maximum
- $293.09 of $5,000.006%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 5720231351
- Network
- In network
- Rendering NPI
- 1513756845
- Location
- Scottsdale, AZ · TIN 18-6108832
- Authorisation / referral
- none / REF371004
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 | $224.00 | $138.88 | — | — | DeniedLIM |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1 | $210.00 | $130.20 | — | — | DeniedLIM |
| 3 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $42.00 | $26.04 | — | — | DeniedLIM |
| Totals | $476.00 | $295.12 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- Patient account
- PA-345797
- 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-009283 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-09: CORE-HMO (HMO), effective 2023-03-01. | |
| Timely filing | Pass | Received 22 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 Mesa Physical Therapy (5720231351). | |
| 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: Mesa Physical Therapy2026-01-09 18:51
Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-31 04:43
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-31 17:43
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 21 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015912 | 2026-08-07 | Heritage Clinical Laboratories | $3,229.00 | Needs review |
| CLM-2026-031693 | 2026-04-24 | Harbor Regional Medical Center | $3,258.00 | 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.