CLM-2026-017706
Pinecrest Physical Therapy, Physical Therapy. Service 2026-04-19 at office (POS 11). Received 2026-05-02.
Member
Resolved through the identity graph
- Member
- Jeffrey Shaw
- Member ID
- UHC-23558-85
- Date of birth
- 1971-09-20
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-412132
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7544
- Coverage period
- 2025-12-01 to present
- Deductible
- $80.23 of $1,500.005%
- Out-of-pocket maximum
- $1,163.72 of $3,000.0039%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8748441127
- Network
- In network
- Rendering NPI
- 2397355340
- Location
- Miami, FL · TIN 41-8840384
- 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 | — | 3 | 1 | $267.00 | $165.54 | $40.00 | $125.54 | Paid |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 2 | $32.00 | $19.84 | $0.00 | $19.84 | Paid |
| Totals | $299.00 | $185.38 | $40.00 | $145.38 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-374091
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011120 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-19: SELECT-EPO (EPO), effective 2025-12-01. | |
| Timely filing | Pass | Received 13 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 Pinecrest Physical Therapy (8748441127). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 3 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: Pinecrest Physical Therapy2026-04-19 11:47
Follow-up for pain in right knee. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-02 01:28
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-374091.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028206 | 2026-05-15 | Pinecrest Regional Medical Center | $185.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.