CLM-2026-010063
Mesa Physical Therapy, Physical Therapy. Service 2026-06-21 at office (POS 11). Received 2026-07-05.
Member
Resolved through the identity graph
- Member
- Jan Santos
- Member ID
- UHC-52788-39
- Date of birth
- 1966-06-17
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-426396
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6069
- Coverage period
- 2024-03-01 to present
- Deductible
- $327.06 of $1,500.0022%
- Out-of-pocket maximum
- $1,041.34 of $3,000.0035%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7870543981
- Network
- In network
- Rendering NPI
- 5674910596
- 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 | — | 4 | 1 | $364.00 | $225.68 | — | — | PendedIDQ |
| 2 | 97161 | PT evaluation, low complexity | 25 | 1 | 2 | $168.00 | $104.16 | — | — | PendedIDQ |
| Totals | $532.00 | $329.84 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- Patient account
- PA-890232
- 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 | Fail | IDQ | Member record is in open steward case CASE-002402; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-06-21: SELECT-EPO (EPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 14 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 17 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 Therapy2026-06-21 17:06
Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-002402; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010064 | 2026-06-21 | Mesa Physical Therapy | $532.00 | Pended |
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
Clean claim, priced at contract rate.