CLM-2026-023126
Heritage Physical Therapy, Physical Therapy. Service 2026-02-27 at outpatient hospital (POS 22). Received 2026-03-04.
Member
Resolved through the identity graph
- Member
- Roy Sullivan
- Member ID
- UHC-76918-42
- Date of birth
- 2003-08-27
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-405368
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5668
- Coverage period
- 2025-07-01 to present
- Deductible
- $94.75 of $500.0019%
- Out-of-pocket maximum
- $125.13 of $1,500.008%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7650650246
- Network
- In network
- Rendering NPI
- 8315430222
- Location
- Miami, FL · TIN 30-1447638
- Authorisation / referral
- PA2025901871 / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 70553 rev 0610 | MRI brain with and without contrast | — | 4 | 1 | $9,108.00 | $5,009.40 | — | — | Review |
| Totals | $9,108.00 | $5,009.40 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-230647
- 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-017414 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-27: MEDICARE-ADV-B (MA), effective 2025-07-01. | |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025901871 on file for 70553. | |
| Provider network | Pass | In-network provider Heritage Physical Therapy (7650650246). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Heritage Physical Therapy2026-02-27 10:34
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-04 05:59
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-04 14:33
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2025901871_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-02-27 to 2026-05-28.
- Itemized billitemized_PA-230647.pdf9 pages
Itemised statement totalling $9108.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
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
Annual visit limit exhausted.