CLM-2026-032108
Meadow Physical Therapy, Physical Therapy. Service 2026-08-05 at office (POS 11). Received 2026-08-15.
Member
Resolved through the identity graph
- Member
- Charlotte Soto
- Member ID
- UHC-90420-43
- Date of birth
- 1999-07-06
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-404065
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6115
- Coverage period
- 2022-04-01 to present
- Deductible
- $2,855.02 of $3,500.0082%
- Out-of-pocket maximum
- $3,350.78 of $7,000.0048%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9574290588
- Network
- Out of network
- Rendering NPI
- 6630705807
- 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 | $195.00 | $87.75 | $25.00 | $62.75 | Paid |
| Totals | $195.00 | $87.75 | $25.00 | $62.75 | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-559014
- 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-023420 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-05: MEDICARE-ADV-A (MA), effective 2022-04-01. | |
| Timely filing | Pass | Received 10 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 1 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 Therapy2026-08-05 09:03
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-08-15 02:14
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-559014.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.