CLM-2026-008417
Meadow Physical Therapy, Physical Therapy. Service 2026-07-29 at office (POS 11). Received 2026-09-06.
Member
Resolved through the identity graph
- Member
- Samuel Holmes
- Member ID
- UHC-57779-10
- Date of birth
- 1960-02-12
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-410048
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-0417
- Coverage period
- 2023-09-01 to 2026-05-23
- Deductible
- $435.97 of $500.0087%
- Out-of-pocket maximum
- $990.51 of $2,000.0050%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7881128434
- Network
- In network
- Rendering NPI
- 4949931131
- Location
- Houston, TX · TIN 60-4048186
- 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 | $244.00 | $151.28 | — | — | DeniedCO27 |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $64.00 | $39.68 | — | — | DeniedCO27 |
| Totals | $308.00 | $190.96 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-659503
- 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-032943 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-29 is after coverage terminated on 2026-05-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 39 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 Meadow Physical Therapy (7881128434). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 10 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 Therapy2026-07-29 15:55
Follow-up for aftercare following joint replacement surgery. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-06 00:10
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-29 is after coverage terminated on 2026-05-23.
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
Service after coverage termination.