CLM-2026-029424
Pinecrest Physical Therapy, Physical Therapy. Service 2026-04-15 at office (POS 11). Received 2026-04-28.
Member
Resolved through the identity graph
- Member
- Megan Burton
- Member ID
- UHC-70543-77
- Date of birth
- 1962-12-19
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-415978
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1139
- Coverage period
- 2024-02-01 to present
- Deductible
- $612.71 of $2,500.0025%
- Out-of-pocket maximum
- $3,461.22 of $10,000.0035%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8748441127
- Network
- In network
- Rendering NPI
- 4762572269
- Location
- Miami, FL · TIN 41-8840384
- 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 | — | 2 | 1 | $144.00 | $89.28 | — | — | DeniedLIM |
| Totals | $144.00 | $89.28 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-951638
- 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-000319 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-15: OPTIONS-PPO (PPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 13 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 | 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: Pinecrest Physical Therapy2026-04-15 10:23
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-28 00:45
Member has used the annual physical-therapy visit benefit for the plan year.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023669 | 2026-07-15 | Heritage Internal Medicine Associates | $201.00 | Approved |
| CLM-2026-031499 | 2026-04-24 | Evergreen Medical Group | $298.00 | Approved |
| CLM-2026-013456 | 2025-12-30 | Sunrise Orthopedic Specialists | $33,974.00 | Needs review |
| CLM-2026-001713 | 2025-12-01 | Heritage Primary Care Associates | $218.00 | 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
Annual visit limit exhausted.