Professional claim · CMS-1500 · EDI 837P
CLM-2026-025032
Mesa Physical Therapy, Physical Therapy. Service 2026-06-26 at office (POS 11). Received 2026-07-05.
Denied
Billed
$302.00
2 lines
Allowed
$187.24
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Bruce Henry
- Member ID
- UHC-59684-25
- Date of birth
- 2001-02-18
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-400351
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9329
- Coverage period
- 2023-11-01 to 2026-06-05
- Deductible
- $883.18 of $1,000.0088%
- Out-of-pocket maximum
- $395.90 of $3,000.0013%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 2562004855
- Network
- In network
- Rendering NPI
- 9720363719
- Location
- Tampa, FL · TIN 24-8766582
- 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 | $261.00 | $161.82 | — | — | DeniedCO27 |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $41.00 | $25.42 | — | — | DeniedCO27 |
| Totals | $302.00 | $187.24 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
Claim header
- Patient account
- PA-313248
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006749 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-26 is after coverage terminated on 2026-06-05. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 9 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 (2562004855). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Note | Physical therapy visits used 19 of 20. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Mesa Physical Therapy2026-06-26 11:05
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-07-05 06:45
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-26 is after coverage terminated on 2026-06-05. Benefit limits: Physical therapy visits used 19 of 20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004237 | 2026-05-23 | Cornerstone Internal Medicine Associates | $230.00 | Denied |
| CLM-2026-004236 | 2026-05-23 | Cornerstone Internal Medicine Associates | $230.00 | Approved |
| CLM-2026-020955 | 2026-01-12 | Desert Primary Care Associates | $203.00 | Denied |
| CLM-2026-020954 | 2026-01-12 | Desert Primary Care Associates | $203.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.