CLM-2026-010233
Pinecrest Physical Therapy, Physical Therapy. Service 2026-06-14 at office (POS 11). Received 2026-07-15.
Member
Resolved through the identity graph
- Member
- Jesse Murray
- Member ID
- UHC-00502-63
- Date of birth
- 1963-12-17
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-415269
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7097
- Coverage period
- 2021-01-01 to present
- Deductible
- $1,361.37 of $2,500.0054%
- Out-of-pocket maximum
- $1,195.28 of $5,000.0024%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8748441127
- Network
- In network
- Rendering NPI
- 3314034737
- 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 | — | 4 | 1 | $264.00 | $163.68 | $20.00 | $143.68 | Paid |
| Totals | $264.00 | $163.68 | $20.00 | $143.68 | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-839468
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008900 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-14: OPTIONS-PPO (PPO), effective 2021-01-01. | |
| Timely filing | Pass | Received 31 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 | Pass | Physical therapy visits used 5 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: Pinecrest Physical Therapy2026-06-14 13:28
Patient seen for unspecified rotator cuff tear, unspecified shoulder. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-07-15 00:28
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-15 10:48
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-839468.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021019 | 2026-05-15 | Desert Reference Lab | $100.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.