CLM-2026-003170
Pinecrest Physical Therapy, Physical Therapy. Service 2025-12-09 at office (POS 11). Received 2026-01-20.
Member
Resolved through the identity graph
- Member
- Kevin Rojas
- Member ID
- UHC-91709-03
- Date of birth
- 1993-01-19
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-428660
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2118
- Coverage period
- 2025-03-01 to present
- Deductible
- $451.17 of $3,500.0013%
- Out-of-pocket maximum
- $26.40 of $7,000.000%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8020189691
- Network
- In network
- Rendering NPI
- 7974183353
- Location
- Austin, TX · TIN 13-9684371
- 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 | $264.00 | $163.68 | — | — | DeniedCO18 |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $86.00 | $53.32 | — | — | DeniedCO18 |
| Totals | $350.00 | $217.00 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- Patient account
- PA-891040
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003496 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-09: OPTIONS-PPO (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-003169: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Physical Therapy (8020189691). | |
| 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Physical Therapy2025-12-09 13:26
Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-20 01:24
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-20 11:31
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-003169: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004074 | 2026-03-26 | Northgate Internal Medicine Associates | $723.00 | Approved |
| CLM-2026-003169 | 2025-12-09 | Pinecrest Physical Therapy | $350.00 | 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
Exact duplicate of an earlier submission.