CLM-2026-019964
Sunrise Physical Therapy, Physical Therapy. Service 2026-08-27 at office (POS 11). Received 2026-09-12.
Member
Resolved through the identity graph
- Member
- Tyler Silva
- Member ID
- UHC-89750-63
- Date of birth
- 1993-01-21
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-424088
- Relationship
- Child, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1544
- Coverage period
- 2022-11-01 to present
- Deductible
- $1,834.09 of $2,500.0073%
- Out-of-pocket maximum
- $592.03 of $7,500.008%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7462471310
- Network
- In network
- Rendering NPI
- 2352177978
- Location
- Tampa, FL · TIN 63-7352988
- Authorisation / referral
- none / REF942263
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 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $39.00 | $24.18 | — | — | DeniedLIM |
| Totals | $307.00 | $190.34 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- Patient account
- PA-142744
- 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-019982 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-27: NAVIGATE-HMO (HMO), effective 2022-11-01. | |
| Timely filing | Pass | Received 16 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 Sunrise Physical Therapy (7462471310). | |
| 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: Sunrise Physical Therapy2026-08-27 09:49
Established patient presents with unspecified rotator cuff tear, unspecified shoulder; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-12 03:03
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-12 16:37
Escalated to nurse reviewer for clinical opinion.
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 20 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011706 | 2026-09-26 | Unity Bone and Joint Center | $3,523.00 | Needs review |
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.