CLM-2026-004916
Mesa Physical Therapy, Physical Therapy. Service 2026-01-10 at office (POS 11). Received 2026-02-19.
Member
Resolved through the identity graph
- Member
- Anthony Brooks
- Member ID
- UHC-38979-10
- Date of birth
- 1992-02-12
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-402404
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5797
- Coverage period
- 2025-08-01 to present
- Deductible
- $800.21 of $3,500.0023%
- Out-of-pocket maximum
- $4,921.69 of $10,500.0047%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 2562004855
- Network
- In network
- Rendering NPI
- 2763947647
- Location
- Tampa, FL · TIN 24-8766582
- Authorisation / referral
- none / REF944184
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 | — | 1 | 1 | $86.00 | $53.32 | — | — | Review |
| Totals | $86.00 | $53.32 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-763760
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011676 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-10: CORE-HMO (HMO), effective 2025-08-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-004915; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| 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) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 13 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 Therapy2026-01-10 18:51
Patient seen for unspecified rotator cuff tear, unspecified shoulder. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-02-19 04:45
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-004915.pdf1 page
Provider cover letter requesting replacement of CLM-2026-004915.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Replacement claim: Frequency code 7 replaces CLM-2026-004915; the original must be voided when this adjudicates.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020108 | 2026-03-25 | Heritage Primary Care Associates | $256.00 | Approved |
| CLM-2026-004915 | 2026-01-10 | Mesa Physical Therapy | $344.00 | Approved |
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
Replacement claim supersedes the original.