CLM-2026-001475
Meadow Physical Therapy, Physical Therapy. Service 2026-04-08 at office (POS 11). Received 2026-04-19.
Member
Resolved through the identity graph
- Member
- Nicole Kelley
- Member ID
- UHC-85597-57
- Date of birth
- 1961-04-04
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-403775
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8039
- Coverage period
- 2025-11-01 to present
- Deductible
- $1,299.31 of $2,500.0052%
- Out-of-pocket maximum
- $925.01 of $7,500.0012%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9574290588
- Network
- Out of network
- Rendering NPI
- 4921216139
- Location
- Denver, CO · TIN 57-2119772
- Authorisation / referral
- none / REF701568
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 | $248.00 | $111.60 | — | — | DeniedCO204 |
| Totals | $248.00 | $111.60 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-895710
- 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-014299 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-08: NAVIGATE-HMO (HMO), effective 2025-11-01. | |
| Timely filing | Pass | Received 11 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 | 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 | Pass | Physical therapy visits used 3 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: Meadow Physical Therapy2026-04-08 14:31
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-19 01:04
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-19 09:38
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Provider network: Billing provider 9574290588 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028326 | 2026-07-08 | Summit Regional Medical Center | $2,332.00 | Needs review |
| CLM-2026-026937 | 2026-01-17 | Canyon Heart Institute | $268.00 | Denied |
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
No out-of-network benefit on this plan.