CLM-2026-022830
Meadow Physical Therapy, Physical Therapy. Service 2026-04-02 at office (POS 11). Received 2026-04-06.
Member
Resolved through the identity graph
- Member
- Joyce Robertson
- Member ID
- UHC-29622-20
- Date of birth
- 1954-12-23
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-406643
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2240
- Coverage period
- 2023-11-01 to 2026-03-27
- Deductible
- $1,573.00 of $2,500.0063%
- Out-of-pocket maximum
- $815.56 of $5,000.0016%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9574290588
- Network
- Out of network
- Rendering NPI
- 3531044717
- Location
- Denver, CO · TIN 57-2119772
- 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 | — | 4 | 1 | $320.00 | $144.00 | — | — | DeniedCO27 |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 2 | $54.00 | $24.30 | — | — | DeniedCO27 |
| Totals | $374.00 | $168.30 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- Patient account
- PA-594378
- 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 | Pass | Attached to MBR-016627 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-02 is after coverage terminated on 2026-03-27. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 4 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 | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 7 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 Therapy2026-04-02 13:13
Follow-up for unspecified rotator cuff tear, unspecified shoulder. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-06 05:42
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-02 is after coverage terminated on 2026-03-27. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032710 | 2026-03-01 | Canyon Primary Care Associates | $186.00 | 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
Service after coverage termination.