CLM-2026-026972
Sunrise Physical Therapy, Physical Therapy. Service 2026-08-05 at office (POS 11). Received 2026-09-03.
Member
Resolved through the identity graph
- Member
- Gary Stewart
- Member ID
- UHC-03014-10
- Date of birth
- 2004-07-21
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-420845
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2023
- Coverage period
- 2021-08-01 to present
- Deductible
- $2,097.18 of $3,500.0060%
- Out-of-pocket maximum
- $2,276.09 of $10,500.0022%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7462471310
- Network
- In network
- Rendering NPI
- 3633250832
- Location
- Tampa, FL · TIN 63-7352988
- Authorisation / referral
- none / REF832266
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 | — | 2 | 1 | $116.00 | $71.92 | — | — | DeniedLIM |
| Totals | $116.00 | $71.92 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-126281
- 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-000503 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-05: CORE-HMO (HMO), effective 2021-08-01. | |
| Timely filing | Pass | Received 29 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 Sunrise Physical Therapy (7462471310). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 22 of 20 for the plan year. Benefit limit reached |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Sunrise Physical Therapy2026-08-05 14:33
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-03 06:27
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-03 14:39
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Benefit limits: Physical therapy visits used 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Annual visit limit exhausted.