CLM-2026-026034
Pinecrest Physical Therapy, Physical Therapy. Service 2026-08-26 at office (POS 11). Received 2026-08-31.
Member
Resolved through the identity graph
- Member
- Doris McDonald
- Member ID
- UHC-03403-62
- Date of birth
- 1956-04-19
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-426545
- Relationship
- Child, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0413
- Coverage period
- 2024-01-01 to present
- Deductible
- $1,209.71 of $2,500.0048%
- Out-of-pocket maximum
- $1,966.91 of $7,500.0026%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8748441127
- Network
- In network
- Rendering NPI
- 2613416637
- Location
- Miami, FL · TIN 41-8840384
- Authorisation / referral
- none / REF602118
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 | $168.00 | $104.16 | $30.00 | $74.16 | Paid |
| Totals | $168.00 | $104.16 | $30.00 | $74.16 | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-959503
- 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-031522 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-26: CORE-HMO (HMO), effective 2024-01-01. | |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Physical Therapy (8748441127). | |
| 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: Pinecrest Physical Therapy2026-08-26 10:55
Follow-up for unspecified rotator cuff tear, unspecified shoulder. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Benefit limits: Physical therapy visits used 18 of 20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009496 | 2026-05-03 | Valley Bone and Joint Center | $168.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.