CLM-2026-021387
Meadow Physical Therapy, Physical Therapy. Service 2026-05-08 at office (POS 11). Received 2026-06-02.
Member
Resolved through the identity graph
- Member
- Jose Kennedy
- Member ID
- UHC-68721-38
- Date of birth
- 1954-07-19
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-420487
- Relationship
- Child, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0383
- Coverage period
- 2024-05-01 to present
- Deductible
- $420.50 of $1,000.0042%
- Out-of-pocket maximum
- $1,288.00 of $4,000.0032%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7881128434
- Network
- In network
- Rendering NPI
- 1296564218
- 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 | $158.00 | $97.96 | — | — | DeniedLIM |
| Totals | $158.00 | $97.96 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-990203
- 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-003034 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-08: MEDICARE-ADV-B (MA), effective 2024-05-01. | |
| Timely filing | Pass | Received 25 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 | Fail | LIM | Physical therapy visits used 20 of 20 for the plan year. Benefit limit reached |
| 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 Therapy2026-05-08 14:58
Patient seen for aftercare following joint replacement surgery.
- SystemSystem: Claims system2026-06-02 06:05
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-02 10:57
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Benefit limits: Physical therapy visits used 20 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016585 | 2025-11-30 | Summit Regional Medical Center | $3,418.00 | Denied |
| CLM-2026-016584 | 2025-11-30 | Summit Regional Medical Center | $3,418.00 | Approved |
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
Annual visit limit exhausted.