CLM-2026-017415
Sunrise Physical Therapy, Physical Therapy. Service 2025-12-23 at office (POS 11). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Cheryl Johnson
- Member ID
- UHC-75959-53
- Date of birth
- 1973-02-07
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-432289
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2300
- Coverage period
- 2021-04-01 to present
- Deductible
- $2,916.23 of $3,500.0083%
- Out-of-pocket maximum
- $4,703.66 of $14,000.0034%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7462471310
- Network
- In network
- Rendering NPI
- 9773719452
- Location
- Tampa, FL · TIN 63-7352988
- 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 | — | 1 | 1 | $93.00 | $57.66 | — | — | Review |
| Totals | $93.00 | $57.66 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-514464
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000283 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-23: MEDICARE-ADV-B (MA), effective 2021-04-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-017414; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Sunrise Physical Therapy (7462471310). | |
| 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: Sunrise Physical Therapy2025-12-23 11:39
Patient seen for low back pain, unspecified. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-01-08 02:16
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-08 08:42
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-017414.pdf1 page
Provider cover letter requesting replacement of CLM-2026-017414.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Replacement claim: Frequency code 7 replaces CLM-2026-017414; the original must be voided when this adjudicates.
- AI recommendationApproved2026-10-21 14:15This is a replacement claim (frequency code 7) for a previously approved claim (CLM-2026-017414) that had an error in the units billed. The provider has submitted a corrected claim with the correct units, and the original claim must be voided when this one adjudicates. The member is eligible, the provider is in-network, and the service is medically necessary and within benefit limits. The claim is complete and within the auto-adjudication ceiling.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 5adb7271
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018441 | 2026-03-21 | Riverside Digestive Health Center | $352.00 | Approved |
| CLM-2026-017414 | 2025-12-23 | Sunrise Physical Therapy | $279.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
This is a replacement claim (frequency code 7) for a previously approved claim (CLM-2026-017414) that had an error in the units billed. The provider has submitted a corrected claim with the correct units, and the original claim must be voided when this one adjudicates. The member is eligible, the provider is in-network, and the service is medically necessary and within benefit limits. The claim is complete and within the auto-adjudication ceiling.
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
Replacement claim supersedes the original.