CLM-2026-014743
Mesa Physical Therapy, Physical Therapy. Service 2026-06-03 at office (POS 11). Received 2026-07-17.
Member
Resolved through the identity graph
- Member
- Joshua Moreno
- Member ID
- UHC-31320-52
- Date of birth
- 1994-08-02
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-412779
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2966
- Coverage period
- 2024-10-01 to present
- Deductible
- $129.68 of $3,500.004%
- Out-of-pocket maximum
- $1,424.52 of $14,000.0010%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7870543981
- Network
- In network
- Rendering NPI
- 8458222188
- Location
- Houston, TX · TIN 58-9513034
- Authorisation / referral
- none / REF492721
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 | $130.00 | $80.60 | — | — | DeniedCO18 |
| 2 | 97161 | PT evaluation, low complexity | 25 | 1 | 2 | $235.00 | $145.70 | — | — | DeniedCO18 |
| 3 | 97014 | Electrical stimulation, unattended | — | 1 | 1,2 | $58.00 | $35.96 | — | — | DeniedCO18 |
| Totals | $423.00 | $262.26 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-662005
- 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-002882 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-03: NAVIGATE-HMO (HMO), effective 2024-10-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-014742: 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 (7870543981). | |
| 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 Therapy2026-06-03 09:31
Established patient presents with unspecified rotator cuff tear, unspecified shoulder; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-17 02:44
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
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-2026-014742: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014742 | 2026-06-03 | Mesa Physical Therapy | $423.00 | 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.