CLM-2026-008309
Heritage Physical Therapy, Physical Therapy. Service 2026-06-10 at office (POS 11). Received 2026-07-09.
Member
Resolved through the identity graph
- Member
- Steven Little
- Member ID
- UHC-14266-65
- Date of birth
- 1957-12-22
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-404174
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6357
- Coverage period
- 2023-02-01 to 2026-06-19
- Deductible
- $776.87 of $1,000.0078%
- Out-of-pocket maximum
- $565.75 of $3,000.0019%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7650650246
- Network
- In network
- Rendering NPI
- 6672012955
- Location
- Miami, FL · TIN 30-1447638
- 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 | $210.00 | $130.20 | — | — | DeniedLIM |
| 2 | 97140 | Manual therapy, 15 minutes | 25 | 1 | 1 | $92.00 | $57.04 | — | — | DeniedLIM |
| 3 | 97161 | PT evaluation, low complexity | — | 1 | 1 | $211.00 | $130.82 | — | — | DeniedLIM |
| Totals | $513.00 | $318.06 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-423597
- 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-036692 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-06-10: OPTIONS-PPO (PPO), effective 2023-02-01, terms 2026-06-19. | |
| Timely filing | Pass | Received 29 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 Heritage Physical Therapy (7650650246). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 22 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: Heritage Physical Therapy2026-06-10 18:27
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-07-09 03:31
Member has used the annual physical-therapy visit benefit for the plan year.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Benefit limits: Physical therapy visits used 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
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.