CLM-2026-033453
Meadow Physical Therapy, Physical Therapy. Service 2026-04-21 at office (POS 11). Received 2026-06-02.
Member
Resolved through the identity graph
- Member
- Mei Hart
- Member ID
- UHC-61106-25
- Date of birth
- 1961-06-13
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-415539
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9477
- Coverage period
- 2023-03-01 to present
- Deductible
- $972.58 of $1,500.0065%
- Out-of-pocket maximum
- $747.78 of $6,000.0012%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9574290588
- Network
- Out of network
- Rendering NPI
- 1168312340
- Location
- Denver, CO · TIN 57-2119772
- Authorisation / referral
- none / REF639587
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 | $178.00 | $80.10 | — | — | DeniedCO204 |
| Totals | $178.00 | $80.10 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-440705
- 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-004394 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-21: CORE-HMO (HMO), effective 2023-03-01. | |
| Timely filing | Pass | Received 42 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 HMO 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 0 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 Therapy2026-04-21 12:44
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-06-02 00:52
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
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 HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021352 | 2026-06-19 | Mesa Behavioral Health | $381.00 | Approved |
| CLM-2026-006392 | 2025-12-06 | Mesa Internal Medicine Associates | $141.00 | 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
No out-of-network benefit on this plan.