CLM-2026-033059
Sunrise Physical Therapy, Physical Therapy. Service 2026-08-30 at office (POS 11). Received 2026-09-04.
Member
Resolved through the identity graph
- Member
- Raymond Gardner
- Member ID
- UHC-31863-51
- Date of birth
- 1948-01-19
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-405604
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6767
- Coverage period
- 2022-03-01 to 2026-05-03
- Deductible
- $638.97 of $3,500.0018%
- Out-of-pocket maximum
- $2,131.69 of $7,000.0030%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7462471310
- Network
- In network
- Rendering NPI
- 5873169846
- 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 | — | 2 | 1 | $162.00 | $100.44 | — | — | DeniedCO27 |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1,2 | $234.00 | $145.08 | — | — | DeniedCO27 |
| Totals | $396.00 | $245.52 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-583305
- 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-005342 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-30 is after coverage terminated on 2026-05-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 5 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 1 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 Therapy2026-08-30 09:50
Follow-up for unspecified rotator cuff tear, unspecified shoulder. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-04 04:14
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-04 14:00
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 13:43Eligibility: Date of service 2026-08-30 is after coverage terminated on 2026-05-03.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019773 | 2026-05-23 | Mesa Physical Therapy | $331.00 | Denied |
| CLM-2026-017161 | 2025-12-07 | Sunrise Behavioral Health | $270.00 | 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
Service after coverage termination.