CLM-2026-030422
Mesa Physical Therapy, Physical Therapy. Service 2026-03-07 at office (POS 11). Received 2026-04-13.
Member
Resolved through the identity graph
- Member
- Dennis Perez
- Member ID
- UHC-14032-93
- Date of birth
- 1960-12-25
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-412214
- Relationship
- Child, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2472
- Coverage period
- 2021-02-01 to present
- Deductible
- $1,067.89 of $1,500.0071%
- Out-of-pocket maximum
- $388.16 of $3,000.0013%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 2562004855
- Network
- In network
- Rendering NPI
- 1432110538
- Location
- Tampa, FL · TIN 24-8766582
- 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 | — | 3 | 1 | $264.00 | $163.68 | — | — | DeniedCO18 |
| Totals | $264.00 | $163.68 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-364422
- 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-022525 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-07: MEDICARE-ADV-A (MA), effective 2021-02-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-030421: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa Physical Therapy (2562004855). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 6 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: Mesa Physical Therapy2026-03-07 16:25
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-13 05:48
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-13 13:13
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-030421: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023855 | 2026-09-24 | Meadow Heart Institute | $10,569.00 | Needs review |
| CLM-2026-013150 | 2026-07-26 | Mesa Orthopedic Specialists | $254.00 | Approved |
| CLM-2026-030421 | 2026-03-07 | Mesa Physical Therapy | $264.00 | 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
Exact duplicate of an earlier submission.