CLM-2026-013181
Lakeside Physical Therapy, Physical Therapy. Service 2026-08-19 at outpatient hospital (POS 22). Received 2026-09-21.
Member
Resolved through the identity graph
- Member
- Elijah Hall
- Member ID
- UHC-02806-77
- Date of birth
- 1996-09-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-404373
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9289
- Coverage period
- 2022-01-01 to present
- Deductible
- $131.75 of $1,000.0013%
- Out-of-pocket maximum
- $37.91 of $2,000.002%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8769647701
- Network
- In network
- Rendering NPI
- 1241706328
- Location
- Austin, TX · TIN 82-6971924
- Authorisation / referral
- PA2026189026 / REF459182
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 70553 rev 0610 | MRI brain with and without contrast | — | 3 | 1 | $5,796.00 | $3,187.80 | — | — | Review |
| Totals | $5,796.00 | $3,187.80 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-489729
- 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-025123 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-19: CORE-HMO (HMO), effective 2022-01-01. | |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026189026 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Physical Therapy (8769647701). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| 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 Therapy2026-08-19 16:38
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
- SystemSystem: Claims system2026-09-21 06:41
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-21 11:56
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026189026_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-08-19 to 2026-11-17.
- Itemized billitemized_PA-489729.pdf3 pages
Itemised statement totalling $5796.00 across 1 line.
- Medical recordrecords_PA-489729.pdf13 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018077 | 2026-05-12 | Northgate Clinical Laboratories | $173.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Notes document medical necessity.