CLM-2026-013177
Mesa Physical Therapy, Physical Therapy. Service 2025-12-03 at office (POS 11). Received 2026-01-21.
Member
Resolved through the identity graph
- Member
- Angla Burns
- Member ID
- UHC-40709-05
- Date of birth
- 1967-09-14
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-421509
- Relationship
- Child, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3704
- Coverage period
- 2025-12-01 to present
- Deductible
- $21.42 of $500.004%
- Out-of-pocket maximum
- $500.52 of $1,500.0033%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 5720231351
- Network
- In network
- Rendering NPI
- 6924570693
- Location
- Scottsdale, AZ · TIN 18-6108832
- 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 | — | 4 | 1 | $232.00 | $143.84 | — | — | DeniedCO18 |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1 | $241.00 | $149.42 | — | — | DeniedCO18 |
| Totals | $473.00 | $293.26 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-307568
- 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-005336 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-03: SELECT-EPO (EPO), effective 2025-12-01. | |
| Timely filing | Pass | Received 49 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-013176: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa Physical Therapy (5720231351). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| 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: Mesa Physical Therapy2025-12-03 17:24
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-21 03:21
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-21 12:47
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-013176: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014021 | 2025-12-07 | Summit Clinical Laboratories | $61.00 | Approved |
| CLM-2026-013176 | 2025-12-03 | Mesa Physical Therapy | $473.00 | Approved |
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
Exact duplicate of an earlier submission.