Professional claim · CMS-1500 · EDI 837P
CLM-2026-026303
Mesa Physical Therapy, Physical Therapy. Service 2026-03-22 at office (POS 11). Received 2026-03-25.
Denied
Billed
$381.00
3 lines
Allowed
$236.22
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Alan Mills
- Member ID
- UHC-85719-06
- Date of birth
- 1998-02-18
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-415888
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6762
- Coverage period
- 2025-04-01 to 2026-03-18
- Deductible
- $754.25 of $1,500.0050%
- Out-of-pocket maximum
- $2,856.51 of $6,000.0048%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7870543981
- Network
- In network
- Rendering NPI
- 3498298702
- Location
- Houston, TX · TIN 58-9513034
- 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 | — | 4 | 1 | $292.00 | $181.04 | — | — | DeniedCO27 |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1,2 | $34.00 | $21.08 | — | — | DeniedCO27 |
| 3 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $55.00 | $34.10 | — | — | DeniedCO27 |
| Totals | $381.00 | $236.22 | — | — | ||||||
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-556422
- 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-021875 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-22 is after coverage terminated on 2026-03-18. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 3 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 (7870543981). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 12 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 Therapy2026-03-22 17:48
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-25 03:05
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 2026-03-22 is after coverage terminated on 2026-03-18.
Other claims for this member
Same resolved identity
No other claims.
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.