CLM-2026-005235
Mesa Physical Therapy, Physical Therapy. Service 2026-01-27 at office (POS 11). Received 2026-03-24.
Member
Resolved through the identity graph
- Member
- Evelyn Black
- Member ID
- UHC-03263-23
- Date of birth
- 1953-10-02
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-428050
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6410
- Coverage period
- 2021-08-01 to present
- Deductible
- $217.98 of $1,000.0022%
- Out-of-pocket maximum
- $131.46 of $2,000.007%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 5720231351
- Network
- In network
- Rendering NPI
- 7605389254
- Location
- Scottsdale, AZ · TIN 18-6108832
- 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 | $146.00 | $90.52 | — | — | DeniedCO18 |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $44.00 | $27.28 | — | — | DeniedCO18 |
| Totals | $190.00 | $117.80 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-994524
- 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-009885 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-27: MEDICARE-ADV-A (MA), effective 2021-08-01. | |
| Timely filing | Pass | Received 56 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-005234: 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 Mesa Physical Therapy (5720231351). | |
| 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: Mesa Physical Therapy2026-01-27 13:33
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-24 06:00
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-24 16:18
Member services inquiry logged on this claim; member asked about the status of payment.
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-2026-005234: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005234 | 2026-01-27 | Mesa Physical Therapy | $190.00 | Approved |
| CLM-2026-012615 | 2026-01-03 | Harbor Medical Group | $267.00 | 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.