CLM-2026-032513
Mesa Physical Therapy, Physical Therapy. Service 2026-01-02 at office (POS 11). Received 2026-02-09.
Member
Resolved through the identity graph
- Member
- Janice Montgomery
- Member ID
- UHC-33646-35
- Date of birth
- 2005-11-28
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-409284
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4004
- Coverage period
- 2021-01-01 to present
- Deductible
- $8.22 of $500.002%
- Out-of-pocket maximum
- $37.70 of $1,000.004%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 2562004855
- Network
- In network
- Rendering NPI
- 3318530821
- 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 | 59 | 2 | 1 | $174.00 | $107.88 | — | — | DeniedLIM |
| 2 | 97140 | Manual therapy, 15 minutes | 59 | 1 | 2 | $85.00 | $52.70 | — | — | DeniedLIM |
| Totals | $259.00 | $160.58 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-753552
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011637 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-02: OPTIONS-PPO (PPO), effective 2021-01-01. | |
| Timely filing | Pass | Received 38 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 (2562004855). | |
| 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 | Fail | LIM | Physical therapy visits used 20 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: Mesa Physical Therapy2026-01-02 11:41
Patient seen for aftercare following joint replacement surgery.
- SystemSystem: Claims system2026-02-09 02:58
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-09 17:02
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit limits: Physical therapy visits used 20 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001558 | 2026-08-22 | Cornerstone Internal Medicine Associates | $161.00 | 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.