CLM-2026-006010
Lakeside Physical Therapy, Physical Therapy. Service 2026-04-19 at office (POS 11). Received 2026-09-28.
Member
Resolved through the identity graph
- Member
- Zachary Ray
- Member ID
- UHC-38123-88
- Date of birth
- 2007-06-03
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-409112
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0602
- Coverage period
- 2024-08-01 to present
- Deductible
- $248.63 of $3,500.007%
- Out-of-pocket maximum
- $3,500.26 of $14,000.0025%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 2744323421
- Network
- In network
- Rendering NPI
- 2083068173
- Location
- Minneapolis, MN · TIN 46-4889069
- Authorisation / referral
- none / REF941664
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 | — | 3 | 1 | $195.00 | $120.90 | — | — | DeniedCO29 |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 2 | $187.00 | $115.94 | — | — | DeniedCO29 |
| Totals | $382.00 | $236.84 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-519927
- 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-027537 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-19: CORE-HMO (HMO), effective 2024-08-01. | |
| Timely filing | Fail | CO29 | Received 162 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (2744323421). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 4 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 Therapy2026-04-19 13:58
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-28 04:49
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 162 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016465 | 2026-07-19 | Unity Primary Care Associates | $478.00 | Denied |
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
Received after the timely-filing limit.