CLM-2026-027865
Meadow Physical Therapy, Physical Therapy. Service 2026-09-03 at office (POS 11). Received 2026-10-02.
Member
Resolved through the identity graph
- Member
- Carolyn Schultz
- Member ID
- none on golden record
- Date of birth
- 1952-03-12
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-415411
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group GRP-6637
- Coverage period
- 2023-04-01 to present
- Deductible
- $1,728.80 of $3,500.0049%
- Out-of-pocket maximum
- $2,169.26 of $10,500.0021%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 7881128434
- Network
- In network
- Rendering NPI
- 4228207336
- 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 | $132.00 | $81.84 | — | — | DeniedLIM |
| Totals | $132.00 | $81.84 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-975183
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002622; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-09-03: NAVIGATE-HMO (HMO), effective 2023-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| 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 | 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 21 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 Therapy2026-09-03 15:56
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-10-02 04:04
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 engineDenied2026-10-22 12:44Member identity: Member record is in open steward case CASE-002622; payment withheld until the identity is confirmed. Eligibility: Active on 2026-09-03: NAVIGATE-HMO (HMO), effective 2023-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. Benefit limits: Physical therapy visits used 21 of 20 for the plan year.
Other claims for this member
Same resolved identity
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.