CLM-2026-002553
Unity Physical Therapy, Physical Therapy. Service 2026-01-26 at office (POS 11). Received 2026-03-01.
Member
Resolved through the identity graph
- Member
- Linda Green
- Member ID
- none on golden record
- Date of birth
- 1970-08-10
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-415616
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-7112
- Coverage period
- 2023-04-01 to present
- Deductible
- $586.91 of $1,500.0039%
- Out-of-pocket maximum
- $1,314.15 of $6,000.0022%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8723835475
- Network
- In network
- Rendering NPI
- 2445798970
- Location
- Houston, TX · TIN 17-6644986
- 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 | — | 4 | 1 | $372.00 | $230.64 | — | — | PendedIDQ |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $74.00 | $45.88 | — | — | PendedIDQ |
| Totals | $446.00 | $276.52 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-197973
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000154; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-01-26: MEDICARE-ADV-A (MA), effective 2023-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 34 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 Unity Physical Therapy (8723835475). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 9 of 20. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Unity Physical Therapy2026-01-26 11:02
Follow-up for pain in right knee. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-000154; payment withheld until the identity is confirmed. Eligibility: Active on 2026-01-26: MEDICARE-ADV-A (MA), effective 2023-04-01. Coverage found by name and date of birth because the claim carried no usable member ID.
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
Clean claim, priced at contract rate.