CLM-2026-012934
Heritage Physical Therapy, Physical Therapy. Service 2025-12-26 at office (POS 11). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- Larry Black
- Member ID
- UHC-35995-09
- Date of birth
- 2002-04-26
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-417987
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2721
- Coverage period
- 2024-02-01 to present
- Deductible
- $1,108.68 of $1,500.0074%
- Out-of-pocket maximum
- $2,185.97 of $4,500.0049%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7650650246
- Network
- In network
- Rendering NPI
- 9431233177
- Location
- Miami, FL · TIN 30-1447638
- 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 | $150.00 | $93.00 | — | — | Review |
| 2 | 97140 | Manual therapy, 15 minutes | 59 | 1 | 1 | $94.00 | $58.28 | — | — | Review |
| Totals | $244.00 | $151.28 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-569081
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002211 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-26: OPTIONS-PPO (PPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 12 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) | 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 14 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: Heritage Physical Therapy2025-12-26 10:21
Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-01-07 02:03
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-07 11:09
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Medical recordrecords_PA-569081.pdf4 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 engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationDenied2026-10-21 14:15The claim uses modifier 59 on a code pair that is normally bundled, but the clinical note [N1] indicates that both procedures were performed at the same site during the same session as part of one service. This contradicts the use of modifier 59, which is only acceptable when the record documents a distinct anatomical site or separate session. Therefore, the claim is denied with reason code CO97.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 72f3d1a9
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013768 | 2026-06-05 | Heritage Family Practice | $232.00 | Approved |
| CLM-2026-018890 | 2026-04-24 | Lakeside Bone and Joint Center | $178.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO97 Benefit included in another service already adjudicated
The claim uses modifier 59 on a code pair that is normally bundled, but the clinical note [N1] indicates that both procedures were performed at the same site during the same session as part of one service. This contradicts the use of modifier 59, which is only acceptable when the record documents a distinct anatomical site or separate session. Therefore, the claim is denied with reason code CO97.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO97 Benefit included in another service already adjudicated
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.