CLM-2026-004135
Sunrise Physical Therapy, Physical Therapy. Service 2026-01-10 at office (POS 11). Received 2026-01-12.
Member
Resolved through the identity graph
- Member
- Lori Robinson
- Member ID
- UHC-28139-43
- Date of birth
- 1955-05-14
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-422173
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6201
- Coverage period
- 2024-11-01 to present
- Deductible
- $477.11 of $1,000.0048%
- Out-of-pocket maximum
- $360.85 of $2,000.0018%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7462471310
- Network
- In network
- Rendering NPI
- 7448055864
- Location
- Tampa, FL · TIN 63-7352988
- 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 | $186.00 | $115.32 | — | — | DeniedLIM |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 2 | $231.00 | $143.22 | — | — | DeniedLIM |
| 3 | 97140 | Manual therapy, 15 minutes | — | 1 | 1,2 | $84.00 | $52.08 | — | — | DeniedLIM |
| Totals | $501.00 | $310.62 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-659232
- 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-003532 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-10: MEDICARE-ADV-B (MA), effective 2024-11-01. | |
| Timely filing | Pass | Received 2 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 Sunrise Physical Therapy (7462471310). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 22 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: Sunrise Physical Therapy2026-01-10 18:06
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-01-12 05:09
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-12 12:55
Escalated to nurse reviewer for clinical opinion.
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 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027368 | 2026-05-24 | Sunrise Behavioral Health | $525.00 | Approved |
| CLM-2026-017180 | 2026-04-25 | Pinecrest Bone and Joint Center | $1,919.00 | 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
Annual visit limit exhausted.