CLM-2026-020923
Meadow Physical Therapy, Physical Therapy. Service 2026-09-07 at office (POS 11). Received 2026-09-21.
Member
Resolved through the identity graph
- Member
- Vincent Graham
- Member ID
- none on golden record
- Date of birth
- 1962-12-07
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-419273
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- CORE-HMO HMO group GRP-6730
- Coverage period
- 2021-09-01 to present
- Deductible
- $23.73 of $500.005%
- Out-of-pocket maximum
- $41.05 of $1,000.004%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9574290588
- Network
- Out of network
- Rendering NPI
- 2815641305
- Location
- Denver, CO · TIN 57-2119772
- Authorisation / referral
- none / REF330273
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 | — | 3 | 1 | $264.00 | $118.80 | — | — | DeniedCO204 |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 1,2 | $59.00 | $26.55 | — | — | DeniedCO204 |
| Totals | $323.00 | $145.35 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-113522
- 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-044674 (provisional, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-09-07: CORE-HMO (HMO), effective 2021-09-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 14 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 14 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 Therapy2026-09-07 17:40
Patient seen for aftercare following joint replacement surgery.
- SystemSystem: Claims system2026-09-21 04:22
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-21 12:13
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Active on 2026-09-07: CORE-HMO (HMO), effective 2021-09-01. Coverage found by name and date of birth because the claim carried no usable member ID. 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
No out-of-network benefit on this plan.