CLM-2026-016896
Heritage Physical Therapy, Physical Therapy. Service 2026-05-07 at office (POS 11). Received 2026-06-13.
Member
Resolved through the identity graph
- Member
- Frank Parker
- Member ID
- UHC-46530-32
- Date of birth
- 1984-07-23
- Identity
- Verified3 records, confidence 0.92
- Claim record
- CLMCLM-423803
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4262
- Coverage period
- 2025-12-01 to 2026-01-04
- Deductible
- $2,809.20 of $3,500.0080%
- Out-of-pocket maximum
- $2,307.48 of $14,000.0016%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7650650246
- Network
- In network
- Rendering NPI
- 3528891302
- Location
- Miami, FL · TIN 30-1447638
- Authorisation / referral
- none / REF576004
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 | $134.00 | $83.08 | — | — | DeniedCO27 |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 2 | $219.00 | $135.78 | — | — | DeniedCO27 |
| Totals | $353.00 | $218.86 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-532779
- 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-017919 (verified, link confidence 0.92). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-07 is after coverage terminated on 2026-01-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 37 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 13 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 Therapy2026-05-07 09:13
Patient seen for unspecified rotator cuff tear, unspecified shoulder.
- SystemSystem: Claims system2026-06-13 01:27
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-13 17:17
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-07 is after coverage terminated on 2026-01-04.
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
Service after coverage termination.