Claims workbench/CLM-2026-009117

Professional claim · CMS-1500 · EDI 837P

CLM-2026-009117

Lakeside Physical Therapy, Physical Therapy. Service 2026-09-07 at office (POS 11). Received 2026-10-27.

Needs review

Billed

$491.00

2 lines

Allowed

$304.42

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

DUP

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Yuki Sullivan
Member ID: UHC-25113-73
Date of birth: 1941-10-26
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-413245
Relationship: Self, Las Vegas, NV

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-3656
Coverage period: 2024-08-01 to present
Deductible: $486.62 of $1,000.0049%
Out-of-pocket maximum: $445.56 of $4,000.0011%
Copays: office $40.00, specialist $60.00, emergency $150.00
Physical therapy visits: 13 of 20 used

Provider

Billing and rendering

Billing provider: Lakeside Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI: 9861124797
Network: In network
Rendering NPI: 1947696369
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	—	3	1	$285.00	$176.70	—	—	Review
2	97161	PT evaluation, low complexity	—	1	2	$206.00	$127.72	—	—	Review
Totals						$491.00	$304.42	—	—

Diagnoses (ICD-10-CM)

1. Z47.1 Aftercare following joint replacement surgeryprincipal
2. M75.100 Unspecified rotator cuff tear, unspecified shoulder

Claim header

Patient account: PA-703506
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-014409 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-09-07: OPTIONS-PPO (PPO), effective 2024-08-01.
Timely filing	Pass		Received 50 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-009116, billed by a different provider. Possible duplicate
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 13 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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Lakeside Physical Therapy2026-09-07 18:00
Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-10-27 00:09
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-10-27 11:46
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Duplicate check: Same member, date of service and procedures as CLM-2026-009116, billed by a different provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-009116	2026-09-07	Harbor Rehabilitation Center	$491.00	Approved
CLM-2026-032641	2026-02-26	Northgate Orthopedic Specialists	$10,200.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity