CLM-2026-004764
Sunrise Physical Therapy, Physical Therapy. Service 2026-05-26 at office (POS 11). Received 2026-07-03.
Member
Resolved through the identity graph
- Member
- Eugene Obrien
- Member ID
- UHC-43357-48
- Date of birth
- 2005-10-05
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-432740
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-5705
- Coverage period
- 2021-12-01 to present
- Deductible
- $1,086.47 of $3,500.0031%
- Out-of-pocket maximum
- $5,657.17 of $14,000.0040%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7462471310
- Network
- In network
- Rendering NPI
- 5450982355
- 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 | — | 4 | 1 | $364.00 | $225.68 | — | — | DeniedCO18 |
| Totals | $364.00 | $225.68 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-162061
- 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-036796 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-26: - (PPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-004763: 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 Sunrise Physical Therapy (7462471310). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| 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: Sunrise Physical Therapy2026-05-26 12:44
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-07-03 04:17
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-07-03 15:16
Called the provider office; awaiting documentation.
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-2026-004763: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004763 | 2026-05-26 | Sunrise Physical Therapy | $364.00 | 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.