CLM-2026-012100
Pinecrest Physical Therapy, Physical Therapy. Service 2026-04-19 at office (POS 11). Received 2026-05-19.
Member
Resolved through the identity graph
- Member
- Russell Gibson
- Member ID
- UHC-03948-12
- Date of birth
- 1954-06-21
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-405269
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-0461
- Coverage period
- 2021-07-01 to present
- Deductible
- $2,659.24 of $3,500.0076%
- Out-of-pocket maximum
- $2,265.90 of $7,000.0032%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8748441127
- Network
- In network
- Rendering NPI
- 7249363483
- 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 | — | 3 | 1 | $225.00 | $139.50 | — | — | DeniedLIM |
| Totals | $225.00 | $139.50 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-931941
- 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-013143 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-19: UNKNOWN (PPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 30 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 | Fail | LIM | Physical therapy visits used 21 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: Pinecrest Physical Therapy2026-04-19 12:25
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-19 00:03
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-19 16:46
Reviewed with the member's history on file. Holding for the items listed above.
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 21 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005427 | 2026-04-26 | Mesa Medical Group | $253.00 | Approved |
| CLM-2026-007363 | 2026-02-05 | Summit Regional Medical Center | $2,371.00 | Needs review |
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.