CLM-2026-021553
Mesa Physical Therapy, Physical Therapy. Service 2026-03-01 at office (POS 11). Received 2026-04-11.
Member
Resolved through the identity graph
- Member
- Jeffrey Baker
- Member ID
- UHC-91386-44
- Date of birth
- 1984-07-10
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-421368
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7670
- Coverage period
- 2022-05-01 to present
- Deductible
- $32.16 of $500.006%
- Out-of-pocket maximum
- $91.52 of $2,000.005%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7870543981
- Network
- In network
- Rendering NPI
- 7484970596
- Location
- Houston, TX · TIN 58-9513034
- Authorisation / referral
- none / REF571189
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 | $360.00 | $223.20 | — | — | DeniedLIM |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1 | $249.00 | $154.38 | — | — | DeniedLIM |
| Totals | $609.00 | $377.58 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-104511
- 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-016413 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-01: CORE-HMO (HMO), effective 2022-05-01. | |
| Timely filing | Pass | Received 41 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 (7870543981). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 22 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: Mesa Physical Therapy2026-03-01 09:04
Follow-up for unspecified rotator cuff tear, unspecified shoulder. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-11 01:56
Member has used the annual physical-therapy visit benefit for the plan year.
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 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026036 | 2026-03-09 | Mesa Orthopedic Specialists | $8,409.00 | Denied |
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.