Professional claim · CMS-1500 · EDI 837P
CLM-2026-000683
Lakeside Physical Therapy, Physical Therapy. Service 2026-01-24 at office (POS 11). Received 2026-02-22.
Approved
Billed
$640.00
3 lines
Allowed
$396.80
contract rate applied
Plan pays
$366.80
approved
Member owes
$30.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Raymond Wood
- Member ID
- UHC-43430-18
- Date of birth
- 1977-12-17
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-404116
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5840
- Coverage period
- 2023-06-01 to present
- Deductible
- $508.78 of $1,000.0051%
- Out-of-pocket maximum
- $1,098.16 of $3,000.0037%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9861124797
- Network
- In network
- Rendering NPI
- 8374494804
- Location
- Houston, TX · TIN 40-0662041
- 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 | — | 4 | 1 | $356.00 | $220.72 | $30.00 | $190.72 | Paid |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $65.00 | $40.30 | $0.00 | $40.30 | Paid |
| 3 | 97161 | PT evaluation, low complexity | — | 1 | 1 | $219.00 | $135.78 | $0.00 | $135.78 | Paid |
| Totals | $640.00 | $396.80 | $30.00 | $366.80 | ||||||
Diagnoses (ICD-10-CM)
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
Claim header
- Patient account
- PA-222072
- 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-014993 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-24: MEDICARE-ADV-B (MA), effective 2023-06-01. | |
| 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 Lakeside Physical Therapy (9861124797). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Note | Physical therapy visits used 18 of 20. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Physical Therapy2026-01-24 15:16
Patient seen for unspecified rotator cuff tear, unspecified shoulder.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$640.00
Plan discount
$243.20
contracted rate
Plan paid
$366.80
You may owe
$30.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Benefit limits: Physical therapy visits used 18 of 20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022451 | 2026-06-12 | Meadow Family Practice | $202.00 | Approved |
| CLM-2026-001672 | 2026-04-17 | Unity Reference Lab | $60.00 | Approved |
| CLM-2026-021662 | 2026-03-30 | Harbor Primary Care Associates | $187.00 | Approved |
| CLM-2026-002438 | 2026-02-28 | Mesa Clinical Laboratories | $126.00 | Needs review |
| CLM-2026-002437 | 2026-02-28 | Mesa Clinical Laboratories | $126.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.