CLM-2026-017707
Mesa Physical Therapy, Physical Therapy. Service 2025-11-19 at office (POS 11). Received 2026-04-08.
Member
Resolved through the identity graph
- Member
- Jeffrey Allen
- Member ID
- UHC-29346-52
- Date of birth
- 1990-01-02
- Identity
- Verified5 records, confidence 0.87
- Claim record
- CLMCLM-403799
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8541
- Coverage period
- 2021-01-01 to present
- Deductible
- $815.73 of $2,500.0033%
- Out-of-pocket maximum
- $1,672.12 of $10,000.0017%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7870543981
- Network
- In network
- Rendering NPI
- 4169819354
- Location
- Houston, TX · TIN 58-9513034
- Authorisation / referral
- none / REF340942
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 | $166.00 | $102.92 | — | — | DeniedCO29 |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1 | $206.00 | $127.72 | — | — | DeniedCO29 |
| Totals | $372.00 | $230.64 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-137443
- 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-007471 (verified, link confidence 0.87). | |
| Eligibility | Pass | Active on 2025-11-19: NAVIGATE-HMO (HMO), effective 2021-01-01. | |
| Timely filing | Fail | CO29 | Received 140 days after the last date of service (limit 90). Time limit for filing has expired |
| 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) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 0 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: Mesa Physical Therapy2025-11-19 16:17
Patient seen for unspecified rotator cuff tear, unspecified shoulder.
- SystemSystem: Claims system2026-04-08 05:59
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-08 08:57
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 12:44Timely filing: Received 140 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018034 | 2026-07-21 | Unity Primary Care Associates | $350.00 | Approved |
| CLM-2026-021087 | 2026-02-03 | Pinecrest Clinical Laboratories | $152.00 | Approved |
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
Received after the timely-filing limit.