CLM-2026-026510
Meadow Physical Therapy, Physical Therapy. Service 2026-05-15 at office (POS 11). Received 2026-05-30.
Member
Resolved through the identity graph
- Member
- Rebecca Little
- Member ID
- UHC-55146-08
- Date of birth
- 1941-01-15
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-400329
- Relationship
- Spouse, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1112
- Coverage period
- 2022-01-01 to present
- Deductible
- $394.06 of $500.0079%
- Out-of-pocket maximum
- $50.17 of $1,000.005%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9574290588
- Network
- Out of network
- Rendering NPI
- 7990854276
- 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 | — | 2 | 1 | $156.00 | $70.20 | — | — | DeniedLIM |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $56.00 | $25.20 | — | — | DeniedLIM |
| Totals | $212.00 | $95.40 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-595936
- 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-007557 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-15: CHOICE-PLUS-PPO (PPO), effective 2022-01-01. | |
| Timely filing | Pass | Received 15 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 | Fail | LIM | Physical therapy visits used 22 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 Therapy2026-05-15 12:05
Patient seen for unspecified rotator cuff tear, unspecified shoulder.
- SystemSystem: Claims system2026-05-30 00:33
Member has used the annual physical-therapy visit benefit for the plan year.
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: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Benefit limits: Physical therapy visits used 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020796 | 2026-01-27 | Lakeside Heart Institute | $10,569.00 | Approved |
| CLM-2026-010421 | 2025-12-27 | Unity Counseling Center | $144.00 | Needs review |
| CLM-2026-010420 | 2025-12-27 | Lakeside Behavioral Health | $144.00 | 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.