CLM-2026-013032
Meadow Physical Therapy, Physical Therapy. Service 2026-06-24 at office (POS 11). Received 2026-08-04.
Member
Resolved through the identity graph
- Member
- Frank Carter
- Member ID
- none on golden record
- Date of birth
- 1990-09-19
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-407220
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group GRP-7723
- Coverage period
- 2022-06-01 to present
- Deductible
- $66.30 of $1,000.007%
- Out-of-pocket maximum
- $1,462.63 of $4,000.0037%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- 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
- 1551830940
- Location
- Houston, TX · TIN 60-4048186
- Authorisation / referral
- none / REF849930
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 | $264.00 | $163.68 | — | — | PendedIDQ |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1,2 | $51.00 | $31.62 | — | — | PendedIDQ |
| Totals | $315.00 | $195.30 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-683133
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001869; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-06-24: NAVIGATE-HMO (HMO), effective 2022-06-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 41 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 Therapy2026-06-24 11:04
Follow-up for aftercare following joint replacement surgery. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001869; payment withheld until the identity is confirmed. Eligibility: Active on 2026-06-24: NAVIGATE-HMO (HMO), effective 2022-06-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.