CLM-2026-005431
Meadow Physical Therapy, Physical Therapy. Service 2026-04-08 at office (POS 11). Received 2026-04-12.
Member
Resolved through the identity graph
- Member
- Eric Rojas
- Member ID
- UHC-17335-35
- Date of birth
- 2005-01-24
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-422783
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5950
- Coverage period
- 2023-07-01 to present
- Deductible
- $1,068.19 of $1,500.0071%
- Out-of-pocket maximum
- $788.38 of $4,500.0018%
- Copays
- office $40.00, specialist $40.00, 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
- 6582971746
- Location
- Denver, CO · TIN 57-2119772
- 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 | — | 4 | 1 | $248.00 | $111.60 | — | — | DeniedLIM |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 1,2 | $56.00 | $25.20 | — | — | DeniedLIM |
| Totals | $304.00 | $136.80 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-210054
- 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-025415 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-08: OPTIONS-PPO (PPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 4 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Therapy2026-04-08 17:59
Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-12 03:56
Member has used the annual physical-therapy visit benefit for the plan year.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Benefit limits: Physical therapy visits used 20 of 20 for the plan year.
Other claims for this member
Same resolved identity
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.