CLM-2026-018602
Unity Physical Therapy, Physical Therapy. Service 2026-04-15 at office (POS 11). Received 2026-05-20.
Member
Resolved through the identity graph
- Member
- Roger Arnold
- Member ID
- UHC-95539-20
- Date of birth
- 2005-06-25
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-417954
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1864
- Coverage period
- 2021-12-01 to present
- Deductible
- $3,054.58 of $3,500.0087%
- Out-of-pocket maximum
- $6,348.09 of $14,000.0045%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8723835475
- Network
- In network
- Rendering NPI
- 7423207407
- Location
- Houston, TX · TIN 17-6644986
- 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 | $204.00 | $126.48 | — | — | DeniedLIM |
| Totals | $204.00 | $126.48 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-709238
- 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-029240 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-15: CHOICE-PLUS-PPO (PPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 35 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 Unity Physical Therapy (8723835475). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 22 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: Unity Physical Therapy2026-04-15 12:57
Established patient presents with unspecified rotator cuff tear, unspecified shoulder; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-20 06:47
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 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029345 | 2026-08-09 | Pinecrest Primary Care Associates | $473.00 | Approved |
| CLM-2026-027727 | 2026-05-04 | Pinecrest Diagnostic Imaging | $2,032.00 | 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
Annual visit limit exhausted.