CLM-2026-003859
Heritage Physical Therapy, Physical Therapy. Service 2026-05-12 at office (POS 11). Received 2026-06-11.
Member
Resolved through the identity graph
- Member
- Diana Obrien
- Member ID
- UHC-82105-09
- Date of birth
- 1971-09-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-410425
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9836
- Coverage period
- 2022-08-01 to present
- Deductible
- $16.64 of $500.003%
- Out-of-pocket maximum
- $473.91 of $2,000.0024%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7650650246
- Network
- In network
- Rendering NPI
- 7129738424
- Location
- Miami, FL · TIN 30-1447638
- 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 | — | 2 | 1 | $170.00 | $105.40 | — | — | DeniedLIM |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $41.00 | $25.42 | — | — | DeniedLIM |
| Totals | $211.00 | $130.82 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-607548
- 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-020820 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-12: SELECT-EPO (EPO), effective 2022-08-01. | |
| Timely filing | Pass | Received 30 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 Heritage Physical Therapy (7650650246). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 20 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: Heritage Physical Therapy2026-05-12 10:01
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-06-11 06:39
Member has used the annual physical-therapy visit benefit for the plan year.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Benefit limits: Physical therapy visits used 20 of 20 for the plan year.
Other claims for this member
Same resolved identity
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.