Professional claim · CMS-1500 · EDI 837P
CLM-2026-003932
Lakeside Physical Therapy, Physical Therapy. Service 2025-12-17 at office (POS 11). Received 2026-01-23.
Billed
$408.00
3 lines
Allowed
$252.96
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Anthony Ryan
- Member ID
- none on golden record
- Date of birth
- 1964-10-12
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-417136
- Relationship
- Spouse
Coverage and accumulators
Found by name and date of birth
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9028
- Coverage period
- 2021-04-01 to present
- Deductible
- $2,044.58 of $2,500.0082%
- Out-of-pocket maximum
- $4,700.33 of $10,000.0047%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9861124797
- Network
- In network
- Rendering NPI
- 8742990392
- 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 | — | 2 | 1 | $134.00 | $83.08 | — | — | PendedIDQ |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $84.00 | $52.08 | — | — | PendedIDQ |
| 3 | 97161 | PT evaluation, low complexity | 25 | 1 | 1 | $190.00 | $117.80 | — | — | PendedIDQ |
| Totals | $408.00 | $252.96 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
Claim header
- Patient account
- PA-835820
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001854; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2025-12-17: CHOICE-PLUS-PPO (PPO), effective 2021-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 37 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 19 of 20. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Physical Therapy2025-12-17 10:22
Patient seen for aftercare following joint replacement surgery.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-001854; payment withheld until the identity is confirmed. Eligibility: Active on 2025-12-17: CHOICE-PLUS-PPO (PPO), effective 2021-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. Benefit limits: Physical therapy visits used 19 of 20.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
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.