CLM-2026-006735
Pinecrest Physical Therapy, Physical Therapy. Service 2025-12-25 at office (POS 11). Received 2026-01-24.
Member
Resolved through the identity graph
- Member
- Amanda Watkins
- Member ID
- UHC-36888-31
- Date of birth
- 1955-12-16
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-416341
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8742
- Coverage period
- 2024-09-01 to present
- Deductible
- $273.87 of $500.0055%
- Out-of-pocket maximum
- $222.25 of $2,000.0011%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8020189691
- Network
- In network
- Rendering NPI
- 1390474892
- Location
- Austin, TX · TIN 13-9684371
- 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. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-760741
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000813 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-25: MEDICARE-ADV-A (MA), effective 2024-09-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-006734: 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 Pinecrest Physical Therapy (8020189691). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 7 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: Pinecrest Physical Therapy2025-12-25 12:24
Patient seen for aftercare following joint replacement surgery.
- SystemSystem: Claims system2026-01-24 00:03
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-006734: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018614 | 2026-07-28 | Pinecrest Regional Medical Center | $2,076.00 | Approved |
| CLM-2026-013779 | 2026-02-14 | Heritage Behavioral Health | $432.00 | Approved |
| CLM-2026-006704 | 2026-02-07 | Heritage Medical Group | $155.00 | Approved |
| CLM-2026-006734 | 2025-12-25 | Pinecrest 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.