CLM-2026-009530
Sunrise Physical Therapy, Physical Therapy. Service 2026-08-08 at office (POS 11). Received 2026-09-08.
Member
Resolved through the identity graph
- Member
- Jacob Hall
- Member ID
- UHC-90583-09
- Date of birth
- 2001-06-06
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-416571
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1696
- Coverage period
- 2025-03-01 to present
- Deductible
- $975.65 of $1,500.0065%
- Out-of-pocket maximum
- $2,398.48 of $6,000.0040%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7462471310
- Network
- In network
- Rendering NPI
- 8679748292
- Location
- Tampa, FL · TIN 63-7352988
- Authorisation / referral
- none / REF458445
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 | $280.00 | $173.60 | — | — | Review |
| Totals | $280.00 | $173.60 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-229350
- 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-006692 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-08: NAVIGATE-HMO (HMO), effective 2025-03-01. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-009529, billed by a different provider. Possible duplicate |
| 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 | Pass | Physical therapy visits used 6 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: Sunrise Physical Therapy2026-08-08 14:10
Patient seen for aftercare following joint replacement surgery. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-09-08 01:20
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-08 15:17
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Duplicate check: Same member, date of service and procedures as CLM-2026-009529, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009529 | 2026-08-08 | Lakeside Physical Therapy | $280.00 | Approved |
| CLM-2026-004715 | 2026-06-08 | Sunrise Digestive Health Center | $2,118.00 | Denied |
| CLM-2026-031384 | 2025-12-13 | Lakeside Physical Therapy | $156.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.