CLM-2026-000311
Lakeside Physical Therapy, Physical Therapy. Service 2026-05-26 at office (POS 11). Received 2026-07-06.
Member
Resolved through the identity graph
- Member
- Sophia Larson
- Member ID
- UHC-69834-51
- Date of birth
- 1987-04-20
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-417235
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-0695
- Coverage period
- 2023-07-01 to present
- Deductible
- $307.62 of $1,000.0031%
- Out-of-pocket maximum
- $772.44 of $3,000.0026%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8769647701
- Network
- In network
- Rendering NPI
- 8855569736
- Location
- Austin, TX · TIN 82-6971924
- 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 | 59 | 2 | 1 | $188.00 | $116.56 | — | — | Review |
| 2 | 97140 | Manual therapy, 15 minutes | 59 | 1 | 1 | $61.00 | $37.82 | — | — | Review |
| Totals | $249.00 | $154.38 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- Patient account
- PA-873204
- 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-017324 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-26: N/A (PPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 41 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 Lakeside Physical Therapy (8769647701). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| Benefit limits | Pass | Physical therapy visits used 15 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: Lakeside Physical Therapy2026-05-26 09:19
Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-07-06 01:32
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-06 11:37
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Medical recordrecords_PA-873204.pdf6 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.