CLM-2026-011866
Heritage Physical Therapy, Physical Therapy. Service 2026-05-15 at office (POS 11). Received 2026-06-18.
Member
Resolved through the identity graph
- Member
- Sofia Woods
- Member ID
- UHC-13736-25
- Date of birth
- 1961-10-28
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-400249
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group NULL
- Coverage period
- 2022-08-01 to present
- Deductible
- $800.32 of $3,500.0023%
- Out-of-pocket maximum
- $1,285.58 of $14,000.009%
- Copays
- office $25.00, specialist $75.00, 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
- 2226735399
- Location
- Miami, FL · TIN 30-1447638
- Authorisation / referral
- none / REF510482
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 | $256.00 | $158.72 | — | — | DeniedLIM |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1,2 | $176.00 | $109.12 | — | — | DeniedLIM |
| Totals | $432.00 | $267.84 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-417336
- 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-009053 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-15: CORE-HMO (HMO), effective 2022-08-01. | |
| Timely filing | Pass | Received 34 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 Therapy2026-05-15 15:15
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-18 00:10
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.