CLM-2026-022046
Sunrise Physical Therapy, Physical Therapy. Service 2026-05-16 at office (POS 11). Received 2026-06-04.
Member
Resolved through the identity graph
- Member
- Nicholas Salazar
- Member ID
- UHC-48323-60
- Date of birth
- 2008-05-07
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-408027
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0844
- Coverage period
- 2021-11-01 to present
- Deductible
- $689.96 of $1,500.0046%
- Out-of-pocket maximum
- $2,915.88 of $6,000.0049%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7462471310
- Network
- In network
- Rendering NPI
- 3789671211
- Location
- Tampa, FL · TIN 63-7352988
- Authorisation / referral
- none / REF659019
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 | $261.00 | $161.82 | — | — | DeniedLIM |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1,2 | $54.00 | $33.48 | — | — | DeniedLIM |
| Totals | $315.00 | $195.30 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-213593
- 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-033527 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-16: CORE-HMO (HMO), effective 2021-11-01. | |
| Timely filing | Pass | Received 19 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 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: Sunrise Physical Therapy2026-05-16 12:36
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-04 01:08
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-04 10:20
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 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-2026-034342 | 2026-07-26 | Northgate Reference Lab | $135.00 | Needs review |
| CLM-2026-034341 | 2026-07-26 | Northgate Reference Lab | $135.00 | 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.