CLM-2026-011993
Sunrise Physical Therapy, Physical Therapy. Service 2026-01-16 at office (POS 11). Received 2026-03-01.
Member
Resolved through the identity graph
- Member
- Carol Olson
- Member ID
- UHC-73394-99
- Date of birth
- 1943-01-24
- Identity
- Verified2 records, confidence 0.98
- Claim record
- CLMCLM-430232
- Relationship
- Child, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-3835
- Coverage period
- 2023-03-01 to present
- Deductible
- $295.98 of $1,000.0030%
- Out-of-pocket maximum
- $659.11 of $3,000.0022%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7462471310
- Network
- In network
- Rendering NPI
- 6247961363
- Location
- Tampa, FL · TIN 63-7352988
- 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 | 59 | 2 | 1 | $136.00 | $84.32 | — | — | Review |
| 2 | 97140 | Manual therapy, 15 minutes | 59 | 1 | 1,2 | $80.00 | $49.60 | — | — | Review |
| 3 | 97014 | Electrical stimulation, unattended | — | 1 | 1,2 | $50.00 | $31.00 | — | — | Review |
| Totals | $266.00 | $164.92 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-558755
- 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-016766 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-01-16: NULL (PPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 44 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 Sunrise Physical Therapy (7462471310). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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: Sunrise Physical Therapy2026-01-16 10:48
Patient seen for pain in right knee. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-03-01 02:51
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-558755.pdf5 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
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
Bundled code pair; modifier 59 not supported by the operative note.