CLM-2026-009377
Pinecrest Physical Therapy, Physical Therapy. Service 2026-09-14 at office (POS 11). Received 2026-10-06.
Member
Resolved through the identity graph
- Member
- Megan Castillo
- Member ID
- UHC-34234-24
- Date of birth
- 1955-03-05
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-422245
- Relationship
- Child, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9822
- Coverage period
- 2022-05-01 to present
- Deductible
- $768.58 of $3,500.0022%
- Out-of-pocket maximum
- $234.58 of $10,500.002%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8748441127
- Network
- In network
- Rendering NPI
- 5319064965
- Location
- Miami, FL · TIN 41-8840384
- 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 | $228.00 | $141.36 | — | — | DeniedLIM |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 2 | $165.00 | $102.30 | — | — | DeniedLIM |
| Totals | $393.00 | $243.66 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-414786
- 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-011315 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-14: NULL (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 22 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 Pinecrest Physical Therapy (8748441127). | |
| 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: Pinecrest Physical Therapy2026-09-14 14:56
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-06 02:52
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 engineDenied2026-10-21 13:43Benefit limits: Physical therapy visits used 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022651 | 2026-01-03 | Riverside Bone and Joint Center | $8,578.00 | Approved |
| CLM-2026-023420 | 2026-01-21 | Riverside Bone and Joint Center | $8,312.00 | 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.