CLM-2026-012128
Mesa Physical Therapy, Physical Therapy. Service 2026-01-05 at office (POS 11). Received 2026-02-12.
Member
Resolved through the identity graph
- Member
- Ruth Mills
- Member ID
- UHC-50500-21
- Date of birth
- 2005-05-13
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-420996
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2449
- Coverage period
- 2025-06-01 to present
- Deductible
- $618.86 of $1,500.0041%
- Out-of-pocket maximum
- $1,957.36 of $6,000.0033%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 2562004855
- Network
- In network
- Rendering NPI
- 5121983725
- Location
- Tampa, FL · TIN 24-8766582
- Authorisation / referral
- none / REF639172
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 | — | 2 | 1 | $124.00 | $76.88 | $25.00 | $51.88 | Paid |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 2 | $248.00 | $153.76 | $0.00 | $153.76 | Paid |
| Totals | $372.00 | $230.64 | $25.00 | $205.64 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-680593
- 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-012518 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-05: NAVIGATE-HMO (HMO), effective 2025-06-01. | |
| Timely filing | Pass | Received 38 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 (2562004855). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 10 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 Therapy2026-01-05 09:20
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-02-12 06:26
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-680593.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-2026-006419 | 2026-08-02 | Canyon Counseling Center | $804.00 | Denied |
| CLM-2026-025435 | 2026-04-14 | Evergreen Rehabilitation Center | $210.00 | 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.