CLM-2026-026012
Meadow Physical Therapy, Physical Therapy. Service 2026-08-08 at office (POS 11). Received 2026-09-06.
Member
Resolved through the identity graph
- Member
- Nancy Watkins
- Member ID
- UHC-11052-08
- Date of birth
- 2000-11-16
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-429657
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1382
- Coverage period
- 2025-11-01 to present
- Deductible
- $2.97 of $500.001%
- Out-of-pocket maximum
- $674.31 of $2,000.0034%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9574290588
- Network
- Out of network
- Rendering NPI
- 8838729217
- 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 | — | 3 | 1 | $267.00 | $120.15 | — | — | DeniedCO204 |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1 | $224.00 | $100.80 | — | — | DeniedCO204 |
| Totals | $491.00 | $220.95 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-224108
- 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-035796 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-08: SELECT-EPO (EPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 29 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 EPO 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 12 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 Therapy2026-08-08 13:17
Follow-up for pain in right knee. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-06 06:39
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-06 12:51
Member services inquiry logged on this claim; member asked about the status of payment.
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 EPO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032909 | 2026-05-23 | Heritage Primary Care Associates | $2,665.00 | Needs review |
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.