Professional claim · CMS-1500 · EDI 837P
CLM-2026-008167
Lakeside Physical Therapy, Physical Therapy. Service 2026-06-19 at office (POS 11). Received 2026-06-29.
Approved
Billed
$521.00
3 lines
Allowed
$323.02
contract rate applied
Plan pays
$293.02
approved
Member owes
$30.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Samantha Olson
- Member ID
- UHC-70649-18
- Date of birth
- 1980-08-18
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-418050
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6248
- Coverage period
- 2021-12-01 to present
- Deductible
- $451.87 of $1,500.0030%
- Out-of-pocket maximum
- $1,101.85 of $3,000.0037%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 4129074496
- Network
- In network
- Rendering NPI
- 8925642356
- Location
- Mesa, AZ · TIN 85-1332515
- 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 | — | 4 | 1 | $232.00 | $143.84 | $30.00 | $113.84 | Paid |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 2 | $202.00 | $125.24 | $0.00 | $125.24 | Paid |
| 3 | 97140 | Manual therapy, 15 minutes | 25 | 1 | 1,2 | $87.00 | $53.94 | $0.00 | $53.94 | Paid |
| Totals | $521.00 | $323.02 | $30.00 | $293.02 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
Claim header
- Patient account
- PA-836622
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009467 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-19: MEDICARE-ADV-B (MA), effective 2021-12-01. | |
| Timely filing | Pass | Received 10 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 | Pass | Physical therapy visits used 6 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. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Physical Therapy2026-06-19 18:21
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$521.00
Plan discount
$197.98
contracted rate
Plan paid
$293.02
You may owe
$30.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025230 | 2026-08-24 | Lakeside Skin Care Associates | $688.00 | Approved |
| CLM-2026-020264 | 2026-06-30 | Pinecrest Internal Medicine Associates | $529.00 | Denied |
| CLM-2026-020263 | 2026-06-30 | Pinecrest Internal Medicine Associates | $529.00 | Approved |
| CLM-2026-009080 | 2026-02-27 | Summit Counseling Center | $284.00 | Denied |
| CLM-2026-009079 | 2026-02-27 | Summit Counseling Center | $284.00 | Approved |
| CLM-2026-021153 | 2025-12-20 | Summit Medical Group | $166.00 | 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.