CLM-2026-007830
Mesa Physical Therapy, Physical Therapy. Service 2025-07-16 at office (POS 11). Received 2026-01-02.
Member
Resolved through the identity graph
- Member
- Lauren Davis
- Member ID
- UHC-98479-36
- Date of birth
- 1997-11-20
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-400301
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0491
- Coverage period
- 2022-03-01 to present
- Deductible
- $362.16 of $500.0072%
- Out-of-pocket maximum
- $7.02 of $1,000.001%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 2562004855
- Network
- In network
- Rendering NPI
- 6038028620
- Location
- Tampa, FL · TIN 24-8766582
- 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 | $228.00 | $141.36 | — | — | DeniedCO29 |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1 | $163.00 | $101.06 | — | — | DeniedCO29 |
| Totals | $391.00 | $242.42 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- Patient account
- PA-878746
- 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-000611 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-07-16: - (PPO), effective 2022-03-01. | |
| Timely filing | Fail | CO29 | Received 170 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (2562004855). | |
| 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 Therapy2025-07-16 18:36
Patient seen for unspecified rotator cuff tear, unspecified shoulder.
- SystemSystem: Claims system2026-01-02 01:13
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 170 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006856 | 2025-12-10 | Summit Endocrine Associates | $594.00 | 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
Received after the timely-filing limit.