CLM-2026-003209
Mesa Physical Therapy, Physical Therapy. Service 2026-05-06 at office (POS 11). Received 2026-06-08.
Member
Resolved through the identity graph
- Member
- Nick Washington
- Member ID
- UHC-18391-87
- Date of birth
- 1968-08-08
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-417908
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-1485
- Coverage period
- 2025-05-01 to present
- Deductible
- $309.67 of $1,000.0031%
- Out-of-pocket maximum
- $159.49 of $3,000.005%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 2562004855
- Network
- In network
- Rendering NPI
- 9168387469
- Location
- Tampa, FL · TIN 24-8766582
- 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 | 59 | 3 | 1 | $228.00 | $141.36 | — | — | Review |
| 2 | 97140 | Manual therapy, 15 minutes | 59 | 1 | 1 | $93.00 | $57.66 | — | — | Review |
| Totals | $321.00 | $199.02 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- Patient account
- PA-828691
- 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-032645 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-06: - (PPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 33 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 (2562004855). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| Benefit limits | Pass | Physical therapy visits used 10 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: Mesa Physical Therapy2026-05-06 12:58
Follow-up for aftercare following joint replacement surgery. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-06-08 02:05
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-828691.pdf14 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
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
Bundled code pair; modifier 59 not supported by the operative note.