CLM-2026-027212
Heritage Physical Therapy, Physical Therapy. Service 2026-03-18 at office (POS 11). Received 2026-07-01.
Member
Resolved through the identity graph
- Member
- Madison Cole
- Member ID
- UHC-18386-41
- Date of birth
- 1952-05-22
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-415130
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group -
- Coverage period
- 2021-05-01 to present
- Deductible
- $1,891.53 of $3,500.0054%
- Out-of-pocket maximum
- $1,694.73 of $7,000.0024%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7650650246
- Network
- In network
- Rendering NPI
- 5785220398
- Location
- Miami, FL · TIN 30-1447638
- Authorisation / referral
- none / REF835997
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 | $267.00 | $165.54 | — | — | DeniedCO29 |
| Totals | $267.00 | $165.54 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- Patient account
- PA-660988
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-036907 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-18: CORE-HMO (HMO), effective 2021-05-01. | |
| Timely filing | Fail | CO29 | Received 105 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Heritage Physical Therapy (7650650246). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 16 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: Heritage Physical Therapy2026-03-18 15:33
Follow-up for aftercare following joint replacement surgery. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-01 04:42
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-01 11:25
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 engineDenied2026-10-22 12:44Timely filing: Received 105 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012434 | 2026-05-23 | Valley Cardiovascular Associates | $241.00 | Denied |
| CLM-2026-012433 | 2026-05-23 | Valley Cardiovascular Associates | $241.00 | Approved |
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
Received after the timely-filing limit.