CLM-2026-024160
Mesa Physical Therapy, Physical Therapy. Service 2026-02-05 at office (POS 11). Received 2026-02-11.
Member
Resolved through the identity graph
- Member
- Brandon Kim
- Member ID
- UHC-37131-92
- Date of birth
- 1962-06-04
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-413045
- Relationship
- Child
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2379
- Coverage period
- 2023-11-01 to present
- Deductible
- $185.23 of $2,500.007%
- Out-of-pocket maximum
- $3,907.36 of $10,000.0039%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 5720231351
- Network
- In network
- Rendering NPI
- 6911388364
- Location
- Scottsdale, AZ · TIN 18-6108832
- 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 | — | 3 | 1 | $249.00 | $154.38 | — | — | PendedIDQ |
| 2 | 97140 | Manual therapy, 15 minutes | 25 | 1 | 1,2 | $86.00 | $53.32 | — | — | PendedIDQ |
| Totals | $335.00 | $207.70 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-122154
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002708; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-02-05: NULL (PPO), effective 2023-11-01. | |
| Timely filing | Pass | Received 6 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 (5720231351). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Note | Physical therapy visits used 18 of 20. | |
| 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 Therapy2026-02-05 17:56
Established patient presents with unspecified rotator cuff tear, unspecified shoulder; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-002708; payment withheld until the identity is confirmed. Benefit limits: Physical therapy visits used 18 of 20.
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
Clean claim, priced at contract rate.