CLM-2026-006043
Meadow Physical Therapy, Physical Therapy. Service 2025-12-18 at office (POS 11). Received 2026-01-16.
Member
Resolved through the identity graph
- Member
- Cheryl Harper
- Member ID
- UHC-35989-19
- Date of birth
- 1996-10-02
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-419826
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group NULL
- Coverage period
- 2024-12-01 to present
- Deductible
- $799.21 of $2,500.0032%
- Out-of-pocket maximum
- $1,524.30 of $7,500.0020%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9574290588
- Network
- Out of network
- Rendering NPI
- 6655843509
- Location
- Denver, CO · TIN 57-2119772
- Authorisation / referral
- none / REF916592
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 | $324.00 | $145.80 | — | — | DeniedCO204 |
| 2 | 97014 | Electrical stimulation, unattended | 25 | 1 | 1 | $42.00 | $18.90 | — | — | DeniedCO204 |
| Totals | $366.00 | $164.70 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-186709
- 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-005006 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-18: CORE-HMO (HMO), effective 2024-12-01. | |
| Timely filing | Pass | Received 29 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 9 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 Therapy2025-12-18 11:39
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-01-16 04:26
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)2026-01-16 10:41
Reviewed with the member's history on file. Holding for the items listed above.
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-2026-026117 | 2026-07-09 | Evergreen Medical Group | $219.00 | Denied |
| CLM-2026-026116 | 2026-07-09 | Evergreen Medical Group | $219.00 | Approved |
| CLM-2026-009891 | 2026-06-07 | Riverside Primary Care Associates | $317.00 | 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
No out-of-network benefit on this plan.