CLM-2026-012199
Meadow Physical Therapy, Physical Therapy. Service 2025-09-05 at office (POS 11). Received 2026-01-29.
Member
Resolved through the identity graph
- Member
- Mariana Berry
- Member ID
- UHC-67182-96
- Date of birth
- 1988-03-20
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-400672
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-1121
- Coverage period
- 2021-03-01 to present
- Deductible
- $1,829.44 of $2,500.0073%
- Out-of-pocket maximum
- $2,222.48 of $7,500.0030%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7881128434
- Network
- In network
- Rendering NPI
- 7609174363
- 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 | — | 2 | 1 | $176.00 | $109.12 | — | — | DeniedCO29 |
| 2 | 97140 | Manual therapy, 15 minutes | 25 | 1 | 1,2 | $82.00 | $50.84 | — | — | DeniedCO29 |
| Totals | $258.00 | $159.96 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-237967
- 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-004018 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-09-05: UNKNOWN (PPO), effective 2021-03-01. | |
| Timely filing | Fail | CO29 | Received 146 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 | 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 15 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 Therapy2025-09-05 17:48
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-29 03:52
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 engineDenied2026-10-22 12:44Timely filing: Received 146 days after the last date of service (limit 90).
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
Received after the timely-filing limit.