CLM-2026-030921
Mesa Physical Therapy, Physical Therapy. Service 2026-03-08 at office (POS 11). Received 2026-04-04.
Member
Resolved through the identity graph
- Member
- Julie Cunningham
- Member ID
- UHC-66087-50
- Date of birth
- 1995-02-07
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-423903
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-8766
- Coverage period
- 2023-03-01 to present
- Deductible
- $1,287.00 of $2,500.0051%
- Out-of-pocket maximum
- $1,495.82 of $5,000.0030%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7870543981
- Network
- In network
- Rendering NPI
- 9775475772
- Location
- Houston, TX · TIN 58-9513034
- 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 | 59 | 4 | 1 | $256.00 | $158.72 | — | — | Review |
| 2 | 97014 | Electrical stimulation, unattended | 59 | 1 | 1 | $30.00 | $18.60 | — | — | Review |
| 3 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $80.00 | $49.60 | — | — | Review |
| Totals | $366.00 | $226.92 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-736102
- 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-024031 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-08: UNKNOWN (PPO), effective 2023-03-01. | |
| Timely filing | Pass | Received 27 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 Mesa Physical Therapy (7870543981). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| Benefit limits | Pass | Physical therapy visits used 2 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 Therapy2026-03-08 10:43
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-04-04 02:37
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-736102.pdf7 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
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
Bundled code pair; modifier 59 not supported by the operative note.