CLM-2026-006985
Sunrise Physical Therapy, Physical Therapy. Service 2026-05-31 at office (POS 11). Received 2026-07-08.
Member
Resolved through the identity graph
- Member
- Joseph Webb
- Member ID
- UHC-44238-24
- Date of birth
- 2008-01-15
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-418873
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0298
- Coverage period
- 2022-03-01 to present
- Deductible
- $884.82 of $1,000.0088%
- Out-of-pocket maximum
- $26.03 of $3,000.001%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7462471310
- Network
- In network
- Rendering NPI
- 3889728846
- Location
- Tampa, FL · TIN 63-7352988
- Authorisation / referral
- none / REF189326
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 | $114.00 | $70.68 | — | — | DeniedLIM |
| Totals | $114.00 | $70.68 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-736720
- 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-010315 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-31: NAVIGATE-HMO (HMO), effective 2022-03-01. | |
| Timely filing | Pass | Received 38 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 21 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 Therapy2026-05-31 15:32
Follow-up for unspecified rotator cuff tear, unspecified shoulder. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-08 05:47
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-08 17:11
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 engineDenied2026-10-21 13:43Benefit limits: Physical therapy visits used 21 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028985 | 2026-07-23 | Meadow Cardiovascular Associates | $411.00 | 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.