CLM-2026-018192
Pinecrest Physical Therapy, Physical Therapy. Service 2026-03-15 at office (POS 11). Received 2026-03-18.
Member
Resolved through the identity graph
- Member
- Sihrley Gibson
- Member ID
- UHC-25275-60
- Date of birth
- 1981-01-24
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-412122
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4499
- Coverage period
- 2025-06-01 to present
- Deductible
- $255.04 of $1,500.0017%
- Out-of-pocket maximum
- $1,398.29 of $6,000.0023%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8020189691
- Network
- In network
- Rendering NPI
- 7421955155
- Location
- Austin, TX · TIN 13-9684371
- Authorisation / referral
- none / REF861183
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 | $140.00 | $86.80 | — | — | DeniedLIM |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $80.00 | $49.60 | — | — | DeniedLIM |
| Totals | $220.00 | $136.40 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-185360
- 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-014972 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-15: NAVIGATE-HMO (HMO), effective 2025-06-01. | |
| Timely filing | Pass | Received 3 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 (8020189691). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 21 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: Pinecrest Physical Therapy2026-03-15 14:53
Follow-up for unspecified rotator cuff tear, unspecified shoulder. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-18 01:58
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 21 of 20 for the plan year.
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
Annual visit limit exhausted.