CLM-2026-007068
Mesa Physical Therapy, Physical Therapy. Service 2026-05-15 at office (POS 11). Received 2026-06-05.
Member
Resolved through the identity graph
- Member
- Nicholas Jenkins
- Member ID
- UHC-11466-95
- Date of birth
- 1953-07-18
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-423192
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8268
- Coverage period
- 2021-04-01 to 2026-08-22
- Deductible
- $603.62 of $3,500.0017%
- Out-of-pocket maximum
- $308.00 of $7,000.004%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7870543981
- Network
- In network
- Rendering NPI
- 6750842570
- Location
- Houston, TX · TIN 58-9513034
- 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 | — | 3 | 1 | $258.00 | $159.96 | $20.00 | $139.96 | Paid |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $84.00 | $52.08 | $0.00 | $52.08 | Paid |
| 3 | 97161 | PT evaluation, low complexity | — | 1 | 2 | $258.00 | $159.96 | $0.00 | $159.96 | Paid |
| Totals | $600.00 | $372.00 | $20.00 | $352.00 | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-268771
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022352 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-15: MEDICARE-ADV-B (MA), effective 2021-04-01, terms 2026-08-22. | |
| Timely filing | Pass | Received 21 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 Mesa Physical Therapy (7870543981). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 12 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 Therapy2026-05-15 17:50
Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-06-05 01:37
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-05 13:06
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-268771.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021100 | 2026-05-12 | Heritage GI Associates | $1,664.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.