CLM-2026-019416
Pinecrest Physical Therapy, Physical Therapy. Service 2026-02-13 at office (POS 11). Received 2026-03-08.
Member
Resolved through the identity graph
- Member
- Juan Banks
- Member ID
- UHC-97584-08
- Date of birth
- 1967-11-12
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-422637
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6782
- Coverage period
- 2024-06-01 to present
- Deductible
- $257.63 of $500.0052%
- Out-of-pocket maximum
- $40.56 of $1,000.004%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- 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
- 5661006838
- Location
- Austin, TX · TIN 13-9684371
- 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 | — | 4 | 1 | $336.00 | $208.32 | — | — | DeniedLIM |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1,2 | $252.00 | $156.24 | — | — | DeniedLIM |
| Totals | $588.00 | $364.56 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-212028
- 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-018241 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-13: CHOICE-PLUS-PPO (PPO), effective 2024-06-01. | |
| Timely filing | Pass | Received 23 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 Therapy2026-02-13 11:58
Patient seen for aftercare following joint replacement surgery.
- SystemSystem: Claims system2026-03-08 02:41
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-03-08 16:37
Called the provider office; awaiting documentation.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006008 | 2026-06-06 | Mesa Family Practice | $39.00 | Approved |
| CLM-2026-000488 | 2026-03-29 | Sunrise Imaging Center | $993.00 | 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.