CLM-2026-030905
Sunrise Physical Therapy, Physical Therapy. Service 2026-04-26 at office (POS 11). Received 2026-05-17.
Member
Resolved through the identity graph
- Member
- Steven Griffin
- Member ID
- UHC-31694-08
- Date of birth
- 1964-06-03
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-402307
- Relationship
- Child, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5962
- Coverage period
- 2022-12-01 to 2026-01-25
- Deductible
- $1,994.18 of $3,500.0057%
- Out-of-pocket maximum
- $1,224.76 of $10,500.0012%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7462471310
- Network
- In network
- Rendering NPI
- 1618063592
- Location
- Tampa, FL · TIN 63-7352988
- 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 | $246.00 | $152.52 | — | — | DeniedCO27 |
| Totals | $246.00 | $152.52 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-200469
- 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-031107 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-26 is after coverage terminated on 2026-01-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 21 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 | Pass | Physical therapy visits used 17 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: Sunrise Physical Therapy2026-04-26 11:17
Follow-up for aftercare following joint replacement surgery. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-17 02:45
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-05-17 14:43
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-26 is after coverage terminated on 2026-01-25.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005301 | 2026-08-29 | Heritage Rehabilitation Center | $234.00 | Denied |
| CLM-2026-024883 | 2026-05-08 | Pinecrest Regional Medical Center | $2,022.00 | Denied |
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
Service after coverage termination.