CLM-2026-001987
Lakeside Physical Therapy, Physical Therapy. Service 2026-08-12 at office (POS 11). Received 2026-08-27.
Member
Resolved through the identity graph
- Member
- Camila Turner
- Member ID
- UHC-89373-58
- Date of birth
- 1990-05-10
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-411231
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5273
- Coverage period
- 2024-04-01 to present
- Deductible
- $368.62 of $500.0074%
- Out-of-pocket maximum
- $888.63 of $2,000.0044%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 4129074496
- Network
- In network
- Rendering NPI
- 8592700396
- Location
- Mesa, AZ · TIN 85-1332515
- Authorisation / referral
- none / REF131384
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 | $136.00 | $84.32 | — | — | DeniedLIM |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $74.00 | $45.88 | — | — | DeniedLIM |
| Totals | $210.00 | $130.20 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-293591
- 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-033209 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-12: NAVIGATE-HMO (HMO), effective 2024-04-01. | |
| Timely filing | Pass | Received 15 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 (4129074496). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 20 of 20 for the plan year. Benefit limit reached |
| 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 Therapy2026-08-12 17:12
Patient seen for aftercare following joint replacement surgery.
- SystemSystem: Claims system2026-08-27 06:03
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-27 14:00
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Benefit limits: Physical therapy visits used 20 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014205 | 2026-05-13 | Riverside Orthopedic Specialists | $1,669.00 | 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
Annual visit limit exhausted.