CLM-2026-015078
Mesa Physical Therapy, Physical Therapy. Service 2026-06-05 at office (POS 11). Received 2026-06-09.
Member
Resolved through the identity graph
- Member
- Janet Adams
- Member ID
- UHC-23374-71
- Date of birth
- 1969-08-27
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-414385
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7471
- Coverage period
- 2022-05-01 to present
- Deductible
- $858.98 of $1,000.0086%
- Out-of-pocket maximum
- $130.87 of $2,000.007%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7870543981
- Network
- In network
- Rendering NPI
- 9777948388
- Location
- Houston, TX · TIN 58-9513034
- Authorisation / referral
- none / REF317650
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 | $168.00 | $104.16 | — | — | DeniedLIM |
| 2 | 97161 | PT evaluation, low complexity | 59 | 1 | 1 | $165.00 | $102.30 | — | — | DeniedLIM |
| Totals | $333.00 | $206.46 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-799129
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026402 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-05: NAVIGATE-HMO (HMO), effective 2022-05-01. | |
| Timely filing | Pass | Received 4 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 (7870543981). | |
| 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 | Fail | LIM | Physical therapy visits used 22 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: Mesa Physical Therapy2026-06-05 09:43
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-09 05:59
Member has used the annual physical-therapy visit benefit for the plan year.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit limits: Physical therapy visits used 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
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.