CLM-2026-005513
Lakeside Physical Therapy, Physical Therapy. Service 2025-12-30 at office (POS 11). Received 2026-01-15.
Member
Resolved through the identity graph
- Member
- Harold Matthews
- Member ID
- UHC-47451-76
- Date of birth
- 1967-11-23
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-426994
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1782
- Coverage period
- 2024-02-01 to present
- Deductible
- $1,464.94 of $2,500.0059%
- Out-of-pocket maximum
- $496.19 of $7,500.007%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 4129074496
- Network
- In network
- Rendering NPI
- 4161524366
- Location
- Mesa, AZ · TIN 85-1332515
- Authorisation / referral
- none / REF251362
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 | $260.00 | $161.20 | — | — | DeniedLIM |
| Totals | $260.00 | $161.20 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-746254
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004436 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-30: CORE-HMO (HMO), effective 2024-02-01. | |
| Timely filing | Pass | Received 16 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 22 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 Therapy2025-12-30 11:02
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-01-15 04:37
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-01-15 13:04
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Benefit limits: Physical therapy visits used 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000699 | 2026-05-25 | Pinecrest Cardiovascular Associates | $301.00 | Needs review |
| CLM-2026-000698 | 2026-05-25 | Pinecrest Cardiovascular Associates | $301.00 | Approved |
| CLM-2026-001036 | 2026-04-14 | Heritage Medical Group | $425.00 | 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.