CLM-2026-028582
Heritage Physical Therapy, Physical Therapy. Service 2026-03-23 at office (POS 11). Received 2026-05-09.
Member
Resolved through the identity graph
- Member
- Sharon Gomez
- Member ID
- UHC-34933-75
- Date of birth
- 1967-02-08
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-412771
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4425
- Coverage period
- 2021-09-01 to present
- Deductible
- $642.64 of $3,500.0018%
- Out-of-pocket maximum
- $158.46 of $10,500.002%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7650650246
- Network
- In network
- Rendering NPI
- 2492181153
- Location
- Miami, FL · TIN 30-1447638
- 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 | $280.00 | $173.60 | — | — | Review |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $66.00 | $40.92 | — | — | Review |
| Totals | $346.00 | $214.52 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-902768
- 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-001121 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-23: MEDICARE-ADV-B (MA), effective 2021-09-01. | |
| Timely filing | Pass | Received 47 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-028581, billed by a different provider. Possible duplicate |
| 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 11 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 Therapy2026-03-23 14:44
Follow-up for unspecified rotator cuff tear, unspecified shoulder. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-05-09 03:50
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Duplicate check: Same member, date of service and procedures as CLM-2026-028581, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028581 | 2026-03-23 | Lakeside Physical Therapy | $346.00 | Approved |
| CLM-2026-016575 | 2025-12-16 | Canyon Counseling Center | $140.00 | Needs review |
| CLM-2026-016574 | 2025-12-16 | Canyon Counseling Center | $140.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.