CLM-2026-019921
Pinecrest Physical Therapy, Physical Therapy. Service 2025-12-13 at office (POS 11). Received 2026-01-11.
Member
Resolved through the identity graph
- Member
- Terry Dominguez
- Member ID
- UHC-49400-42
- Date of birth
- 1950-07-25
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-414356
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group NULL
- Coverage period
- 2021-11-01 to present
- Deductible
- $1,819.79 of $3,500.0052%
- Out-of-pocket maximum
- $1,593.57 of $14,000.0011%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8020189691
- Network
- In network
- Rendering NPI
- 7455425570
- 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 | $268.00 | $166.16 | — | — | DeniedLIM |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 2 | $178.00 | $110.36 | — | — | DeniedLIM |
| 3 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $91.00 | $56.42 | — | — | DeniedLIM |
| Totals | $537.00 | $332.94 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-341017
- 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-003280 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-13: NULL (PPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 29 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 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: Pinecrest Physical Therapy2025-12-13 18:33
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-01-11 03:06
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-11 13:43
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Benefit 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-2026-030016 | 2026-06-24 | Canyon Medical Group | $258.00 | 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.