CLM-2026-026619
Meadow Physical Therapy, Physical Therapy. Service 2026-07-15 at office (POS 11). Received 2026-08-23.
Member
Resolved through the identity graph
- Member
- Marilyn Mills
- Member ID
- UHC-97613-50
- Date of birth
- 1958-04-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-425251
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7783
- Coverage period
- 2023-09-01 to present
- Deductible
- $1,797.46 of $3,500.0051%
- Out-of-pocket maximum
- $105.52 of $7,000.002%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7881128434
- Network
- In network
- Rendering NPI
- 1921423814
- Location
- Houston, TX · TIN 60-4048186
- Authorisation / referral
- none / REF363461
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 | $171.00 | $106.02 | — | — | DeniedCO18 |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 1,2 | $258.00 | $159.96 | — | — | DeniedCO18 |
| 3 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $50.00 | $31.00 | — | — | DeniedCO18 |
| Totals | $479.00 | $296.98 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-378008
- 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-016881 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-15: CORE-HMO (HMO), effective 2023-09-01. | |
| Timely filing | Pass | Received 39 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-026618: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 | Pass | Physical therapy visits used 2 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 Therapy2026-07-15 10:39
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-23 02:26
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-026618: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026618 | 2026-07-15 | Meadow Physical Therapy | $479.00 | 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
Exact duplicate of an earlier submission.