Claims workbench/CLM-2026-013122

Professional claim · CMS-1500 · EDI 837P

CLM-2026-013122

Lakeside Physical Therapy, Physical Therapy. Service 2026-09-11 at office (POS 11). Received 2026-09-17.

Approved

Billed

$180.00

1 line

Allowed

$111.60

contract rate applied

Plan pays

$91.60

approved

Member owes

$20.00

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: Ethan Miller
Member ID: UHC-54719-13
Date of birth: 1953-10-23
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-413121
Relationship: Self, Plano, TX

Coverage and accumulators

Found by member ID

Plan: NULL PPO group GRP-9254
Coverage period: 2021-04-01 to present
Deductible: $2,259.83 of $3,500.0065%
Out-of-pocket maximum: $62.55 of $7,000.001%
Copays: office $20.00, specialist $60.00, emergency $250.00
Physical therapy visits: 19 of 20 used

Provider

Billing and rendering

Billing provider: Lakeside Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI: 4129074496
Network: In network
Rendering NPI: 3138429113
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	$180.00	$111.60	$20.00	$91.60	Paid
Totals						$180.00	$111.60	$20.00	$91.60

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-629117
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	Detail
Member identity	Pass	Attached to MBR-025668 (verified, link confidence 0.99).
Eligibility	Pass	Active on 2026-09-11: NULL (PPO), effective 2021-04-01.
Timely filing	Pass	Received 6 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	Note	Physical therapy visits used 19 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 Therapy2026-09-11 13:21
Follow-up for aftercare following joint replacement surgery. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
SystemSystem: Claims system2026-09-17 04:35
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-17 16:42
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterface_sheet_PA-629117.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.

Explanation of benefits

What the member will see

Amount billed

$180.00

Plan discount

$68.40

contracted rate

Plan paid

$91.60

You may owe

$20.00

copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

Rules engineApproved2026-10-22 12:44
Benefit limits: Physical therapy visits used 19 of 20.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-026730	2026-09-21	Heritage Family Practice	$12.00	Approved
CLM-2026-030446	2026-04-03	Riverside Orthopedic Specialists	$206.00	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

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

PendedCO197scenario: Auth unverifiable

Authorisation must be confirmed with UM before payment.

Review queue Member identity