CLM-2026-003297
Pinecrest Physical Therapy, Physical Therapy. Service 2026-05-20 at outpatient hospital (POS 22). Received 2026-06-17.
Member
Resolved through the identity graph
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6357
- Coverage period
- 2023-02-01 to 2026-06-19
- Deductible
- $776.87 of $1,000.0078%
- Out-of-pocket maximum
- $565.75 of $3,000.0019%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8020189691
- Network
- In network
- Rendering NPI
- 5119425580
- Location
- Austin, TX · TIN 13-9684371
- Authorisation / referral
- PA2025340139 / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 70553 rev 0610 | MRI brain with and without contrast | — | 4 | 1 | $10,944.00 | $6,019.20 | — | — | PendedCO16 |
| Totals | $10,944.00 | $6,019.20 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-131037
- 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 | CO16 | Claim record is not attached to a resolved identity. Claim lacks information needed for adjudication |
| Eligibility | Pass | Active on 2026-05-20: OPTIONS-PPO (PPO), effective 2023-02-01, terms 2026-06-19. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025340139 on file for 70553. | |
| Provider network | Pass | In-network provider Pinecrest Physical Therapy (8020189691). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| 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 Therapy2026-05-20 11:27
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-17 04:00
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-17 14:07
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025340139_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-05-20 to 2026-08-18.
- Itemized billitemized_PA-131037.pdf6 pages
Itemised statement totalling $10944.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Claim record is not attached to a resolved identity. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
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
Annual visit limit exhausted.