CLM-2026-010944
Lakeside Physical Therapy, Physical Therapy. Service 2026-03-22 at office (POS 11). Received 2026-04-01.
Member
Resolved through the identity graph
- Member
- Evelyn Kim
- Member ID
- UHC-97183-17
- Date of birth
- 1991-05-18
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-430212
- Relationship
- Child, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-8381
- Coverage period
- 2021-12-01 to 2026-01-11
- Deductible
- $878.42 of $1,000.0088%
- Out-of-pocket maximum
- $1,179.84 of $3,000.0039%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 4129074496
- Network
- In network
- Rendering NPI
- 9584183864
- 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 | — | 2 | 1 | $168.00 | $104.16 | — | — | DeniedCO27 |
| 2 | 97161 | PT evaluation, low complexity | 25 | 1 | 1,2 | $249.00 | $154.38 | — | — | DeniedCO27 |
| Totals | $417.00 | $258.54 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-643921
- 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-001005 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-22 is after coverage terminated on 2026-01-11. Expenses incurred after coverage terminated |
| 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 2 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 Therapy2026-03-22 14:33
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-04-01 03:31
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-01 13:03
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-22 is after coverage terminated on 2026-01-11.
Other claims for this member
Same resolved identity
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
Service after coverage termination.