CLM-2026-000030
Meadow Physical Therapy, Physical Therapy. Service 2025-12-02 at office (POS 11). Received 2026-05-22.
Member
Resolved through the identity graph
- Member
- Angela Chapman
- Member ID
- UHC-53091-93
- Date of birth
- 1938-05-15
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-404645
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2060
- Coverage period
- 2025-03-01 to present
- Deductible
- $825.11 of $2,500.0033%
- Out-of-pocket maximum
- $1,725.22 of $5,000.0035%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9574290588
- Network
- Out of network
- Rendering NPI
- 2995070663
- Location
- Denver, CO · TIN 57-2119772
- Authorisation / referral
- none / REF441048
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 | — | 4 | 1 | $380.00 | $171.00 | — | — | DeniedCO29 |
| 2 | 97014 | Electrical stimulation, unattended | 25 | 1 | 1 | $58.00 | $26.10 | — | — | DeniedCO29 |
| Totals | $438.00 | $197.10 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-487727
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022893 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-02: NAVIGATE-HMO (HMO), effective 2025-03-01. | |
| Timely filing | Fail | CO29 | Received 171 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 | Fail | CO204 | Billing provider 9574290588 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| 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: Meadow Physical Therapy2025-12-02 12:18
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-05-22 00:08
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 engineDenied2026-10-21 13:43Timely filing: Received 171 days after the last date of service (limit 90). Provider network: Billing provider 9574290588 is out of network and the HMO plan has no out-of-network benefit. 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-2026-012844 | 2026-03-27 | Canyon Primary Care Associates | $407.00 | 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.