Professional claim · CMS-1500 · EDI 837P
CLM-2026-010846
Lakeside Physical Therapy, Physical Therapy. Service 2025-12-26 at office (POS 11). Received 2026-01-28.
Approved
Billed
$430.00
2 lines
Allowed
$266.60
contract rate applied
Plan pays
$241.60
approved
Member owes
$25.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Maria Hoffman
- Member ID
- UHC-58570-09
- Date of birth
- 2000-05-27
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-421148
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4312
- Coverage period
- 2022-02-01 to present
- Deductible
- $228.60 of $2,500.009%
- Out-of-pocket maximum
- $1,039.46 of $7,500.0014%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 2744323421
- Network
- In network
- Rendering NPI
- 9647625240
- Location
- Minneapolis, MN · TIN 46-4889069
- 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 | $372.00 | $230.64 | $25.00 | $205.64 | Paid |
| 2 | 97140 | Manual therapy, 15 minutes | 25 | 1 | 1,2 | $58.00 | $35.96 | $0.00 | $35.96 | Paid |
| Totals | $430.00 | $266.60 | $25.00 | $241.60 | ||||||
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-427385
- 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-008398 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-26: OPTIONS-PPO (PPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 33 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 (2744323421). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Note | Physical therapy visits used 18 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. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Physical Therapy2025-12-26 17:58
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$430.00
Plan discount
$163.40
contracted rate
Plan paid
$241.60
You may owe
$25.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Benefit limits: Physical therapy visits used 18 of 20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004109 | 2026-06-25 | Lakeside Bone and Joint Center | $6,123.00 | Denied |
| CLM-2026-027587 | 2026-04-11 | Summit Cardiovascular Associates | $563.00 | 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.