CLM-2026-032227
Unity Physical Therapy, Physical Therapy. Service 2026-03-02 at office (POS 11). Received 2026-06-08.
Member
Resolved through the identity graph
- Member
- Victoria Campbell
- Member ID
- UHC-88823-22
- Date of birth
- 1950-12-06
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-420422
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-4111
- Coverage period
- 2022-01-01 to present
- Deductible
- $337.34 of $1,500.0022%
- Out-of-pocket maximum
- $964.75 of $4,500.0021%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8723835475
- Network
- In network
- Rendering NPI
- 8366162963
- Location
- Houston, TX · TIN 17-6644986
- 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 | $174.00 | $107.88 | — | — | DeniedCO29 |
| Totals | $174.00 | $107.88 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- Patient account
- PA-768795
- 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-005123 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-03-02: NULL (PPO), effective 2022-01-01. | |
| Timely filing | Fail | CO29 | Received 98 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Unity Physical Therapy (8723835475). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 13 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: Unity Physical Therapy2026-03-02 13:47
Follow-up for aftercare following joint replacement surgery. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-08 00:35
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 98 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034388 | 2025-12-27 | Riverside Orthopedic Specialists | $279.00 | 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
Received after the timely-filing limit.