CLM-2026-018085
Mesa Physical Therapy, Physical Therapy. Service 2026-05-14 at office (POS 11). Received 2026-06-14.
Member
Resolved through the identity graph
- Member
- Elijah Gray
- Member ID
- UHC-73436-77
- Date of birth
- 2003-07-26
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-409358
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8140
- Coverage period
- 2025-09-01 to present
- Deductible
- $997.62 of $2,500.0040%
- Out-of-pocket maximum
- $1,812.53 of $10,000.0018%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 2562004855
- Network
- In network
- Rendering NPI
- 9808161761
- Location
- Tampa, FL · TIN 24-8766582
- Authorisation / referral
- none / REF808928
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 | $216.00 | $133.92 | — | — | DeniedLIM |
| Totals | $216.00 | $133.92 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-653791
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005635 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-14: CORE-HMO (HMO), effective 2025-09-01. | |
| Timely filing | Pass | Received 31 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 Mesa Physical Therapy (2562004855). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 20 of 20 for the plan year. Benefit limit reached |
| 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 Therapy2026-05-14 16:21
Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-14 06:10
Member has used the annual physical-therapy visit benefit for the plan year.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Benefit limits: Physical therapy visits used 20 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013701 | 2026-08-26 | Evergreen Medical Group | $246.00 | Needs review |
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
Annual visit limit exhausted.