CLM-2026-020271
Heritage Physical Therapy, Physical Therapy. Service 2026-05-13 at office (POS 11). Received 2026-05-28.
Member
Resolved through the identity graph
- Member
- Madison Adams
- Member ID
- UHC-70742-05
- Date of birth
- 1984-01-18
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-421075
- Relationship
- Spouse, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-2155
- Coverage period
- 2023-11-01 to 2026-07-17
- Deductible
- $1,373.62 of $3,500.0039%
- Out-of-pocket maximum
- $4,997.61 of $10,500.0048%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7650650246
- Network
- In network
- Rendering NPI
- 3145125431
- Location
- Miami, FL · TIN 30-1447638
- 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 | — | — | Review |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 2 | $53.00 | $32.86 | — | — | Review |
| Totals | $389.00 | $241.18 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-711628
- 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-029880 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-13: N/A (PPO), effective 2023-11-01, terms 2026-07-17. | |
| Timely filing | Pass | Received 15 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 Heritage Physical Therapy (7650650246). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 4 of 20. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for pain in right knee. Plan discussed, medications reconciled. Note dictated; s”. 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: Heritage Physical Therapy2026-05-13 09:44
Follow-up for pain in right knee. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-05-28 00:51
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-28 08:04
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 engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Follow-up for pain in right knee. Plan discussed, medications reconciled. Note dictated; s”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010227 | 2026-04-18 | Cornerstone Internal Medicine Associates | $462.00 | Approved |
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.