Professional claim · CMS-1500 · EDI 837P
CLM-2026-002655
Lakeside Physical Therapy, Physical Therapy. Service 2026-08-07 at office (POS 11). Received 2026-09-02.
Approved
Billed
$276.00
1 line
Allowed
$171.12
contract rate applied
Plan pays
$146.12
approved
Member owes
$25.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Angela Wheeler
- Member ID
- UHC-87508-67
- Date of birth
- 1952-02-15
- Identity
- Verified4 records, confidence 0.93
- Claim record
- CLMCLM-424446
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6763
- Coverage period
- 2022-12-01 to 2026-08-28
- Deductible
- $1,967.92 of $3,500.0056%
- Out-of-pocket maximum
- $2,905.90 of $14,000.0021%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9861124797
- Network
- In network
- Rendering NPI
- 4257221216
- Location
- Houston, TX · TIN 40-0662041
- Authorisation / referral
- none / REF130347
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 | $276.00 | $171.12 | $25.00 | $146.12 | Paid |
| Totals | $276.00 | $171.12 | $25.00 | $146.12 | ||||||
Diagnoses (ICD-10-CM)
- 1. M25.561 Pain in right kneeprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
Claim header
- Patient account
- PA-909404
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011169 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-08-07: NAVIGATE-HMO (HMO), effective 2022-12-01, terms 2026-08-28. | |
| Timely filing | Pass | Received 26 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 | Pass | Physical therapy visits used 8 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 Therapy2026-08-07 13:19
Patient seen for pain in right knee.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$276.00
Plan discount
$104.88
contracted rate
Plan paid
$146.12
You may owe
$25.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032765 | 2026-06-13 | Northgate Heart Institute | $575.00 | 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.