CLM-2026-001292
Lakeside Physical Therapy, Physical Therapy. Service 2025-12-16 at office (POS 11). Received 2026-01-26.
Member
Resolved through the identity graph
- Member
- Janice Stone
- Member ID
- UHC-82115-89
- Date of birth
- 1974-07-18
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-408287
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7510
- Coverage period
- 2024-12-01 to present
- Deductible
- $250.60 of $500.0050%
- Out-of-pocket maximum
- $413.47 of $1,500.0028%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8769647701
- Network
- In network
- Rendering NPI
- 3735331944
- 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 | — | 2 | 1 | $126.00 | $78.12 | — | — | DeniedCO18 |
| Totals | $126.00 | $78.12 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- Patient account
- PA-610665
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004522 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-16: OPTIONS-PPO (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-001291: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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) | Pass | No bundling conflicts. | |
| Benefit limits | Note | Physical therapy visits used 19 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 Therapy2025-12-16 11:54
Patient seen for aftercare following joint replacement surgery.
- SystemSystem: Claims system2026-01-26 00:10
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-01-26 14:56
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-001291: same member, date of service, procedures and billing provider. Benefit limits: Physical therapy visits used 19 of 20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001291 | 2025-12-16 | Lakeside Physical Therapy | $126.00 | 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
Exact duplicate of an earlier submission.