CLM-2026-016698
Heritage Physical Therapy, Physical Therapy. Service 2025-12-29 at office (POS 11). Received 2026-02-06.
Member
Resolved through the identity graph
- Member
- Joe Stewart
- Member ID
- none on golden record
- Date of birth
- 1953-02-11
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-421514
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- CORE-HMO HMO group GRP-4592
- Coverage period
- 2023-01-01 to present
- Deductible
- $691.51 of $2,500.0028%
- Out-of-pocket maximum
- $916.99 of $5,000.0018%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7650650246
- Network
- In network
- Rendering NPI
- 2404767859
- Location
- Miami, FL · TIN 30-1447638
- Authorisation / referral
- none / REF348084
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 | $156.00 | $96.72 | — | — | PendedIDQ |
| Totals | $156.00 | $96.72 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- Patient account
- PA-705839
- 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 | Fail | IDQ | Member record is in open steward case CASE-001297; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2025-12-29: CORE-HMO (HMO), effective 2023-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 39 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) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 15 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 Therapy2025-12-29 09:51
Patient seen for unspecified rotator cuff tear, unspecified shoulder.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001297; payment withheld until the identity is confirmed. Eligibility: Active on 2025-12-29: CORE-HMO (HMO), effective 2023-01-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.