CLM-2026-017653
Meadow Physical Therapy, Physical Therapy. Service 2025-11-26 at office (POS 11). Received 2026-01-03.
Member
Resolved through the identity graph
- Member
- Stephanie Ruiz
- Member ID
- UHC-28633-53
- Date of birth
- 1999-01-26
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-412180
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3242
- Coverage period
- 2022-10-01 to present
- Deductible
- $519.03 of $1,500.0035%
- Out-of-pocket maximum
- $2,065.52 of $4,500.0046%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9574290588
- Network
- Out of network
- Rendering NPI
- 4756650923
- Location
- Denver, CO · TIN 57-2119772
- Authorisation / referral
- none / REF531594
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 | $79.20 | — | — | DeniedCO204 |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1 | $205.00 | $92.25 | — | — | DeniedCO204 |
| Totals | $381.00 | $171.45 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-730267
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000519 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-26: CORE-HMO (HMO), effective 2022-10-01. | |
| Timely filing | Pass | Received 38 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 5 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 Therapy2025-11-26 12:41
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-01-03 02:08
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider 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-2026-013385 | 2026-08-03 | Pinecrest Medical Group | $2,820.00 | Needs review |
| CLM-2026-034547 | 2026-08-17 | Lakeside Medical Group | $288.00 | Denied |
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.