CLM-2026-019845
Mesa Physical Therapy, Physical Therapy. Service 2026-02-13 at office (POS 11). Received 2026-03-07.
Member
Resolved through the identity graph
- Member
- Janice Kelly
- Member ID
- UHC-98691-32
- Date of birth
- 1956-11-05
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-423914
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2264
- Coverage period
- 2023-10-01 to present
- Deductible
- $310.17 of $1,000.0031%
- Out-of-pocket maximum
- $193.45 of $2,000.0010%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 2562004855
- Network
- In network
- Rendering NPI
- 7747219302
- Location
- Tampa, FL · TIN 24-8766582
- 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 | $276.00 | $171.12 | — | — | Review |
| Totals | $276.00 | $171.12 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-829086
- 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-016341 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-02-13: SELECT-EPO (EPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 22 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 | Pass | Physical therapy visits used 0 of 20. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for unspecified rotator cuff tear, unspecified shoulder. Plan discussed, medicat”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Physical Therapy2026-02-13 09:42
Follow-up for unspecified rotator cuff tear, unspecified shoulder. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-07 01:26
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Follow-up for unspecified rotator cuff tear, unspecified shoulder. Plan discussed, medicat”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022589 | 2026-08-23 | Harbor Diabetes Center | $180.00 | Approved |
| CLM-2026-021642 | 2025-09-06 | Lakeside Internal Medicine Associates | $338.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.