CLM-2026-015281
Meadow Physical Therapy, Physical Therapy. Service 2026-07-05 at office (POS 11). Received 2026-10-16.
Member
Resolved through the identity graph
- Member
- Jonathan Lawson
- Member ID
- UHC-79224-89
- Date of birth
- 1945-03-06
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-411171
- Relationship
- Child, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8454
- Coverage period
- 2024-04-01 to present
- Deductible
- $948.51 of $1,500.0063%
- Out-of-pocket maximum
- $1,324.22 of $6,000.0022%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- 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
- 1659884179
- Location
- Denver, CO · TIN 57-2119772
- Authorisation / referral
- none / REF544130
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 | $118.00 | $53.10 | — | — | DeniedCO29 |
| Totals | $118.00 | $53.10 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-176543
- 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-038389 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-05: CORE-HMO (HMO), effective 2024-04-01. | |
| Timely filing | Fail | CO29 | Received 103 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 | 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 Therapy2026-07-05 10:01
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-16 04:55
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-10-16 14:35
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 103 days after the last date of service (limit 90). Provider 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
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.