CLM-2026-013324
Lakeside Physical Therapy, Physical Therapy. Service 2026-01-04 at office (POS 11). Received 2026-01-31.
Member
Resolved through the identity graph
- Member
- Samuel Burns
- Member ID
- UHC-39209-26
- Date of birth
- 2001-12-03
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-401899
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1891
- Coverage period
- 2025-05-01 to present
- Deductible
- $83.88 of $500.0017%
- Out-of-pocket maximum
- $346.22 of $1,000.0035%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 4129074496
- Network
- In network
- Rendering NPI
- 2328595287
- 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 | 59 | 4 | 1 | $332.00 | $205.84 | — | — | DeniedLIM |
| 2 | 97161 | PT evaluation, low complexity | 59 | 1 | 1 | $234.00 | $145.08 | — | — | DeniedLIM |
| Totals | $566.00 | $350.92 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-687880
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009279 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-04: MEDICARE-ADV-A (MA), effective 2025-05-01. | |
| Timely filing | Pass | Received 27 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) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| Benefit limits | Fail | LIM | Physical therapy visits used 22 of 20 for the plan year. Benefit limit reached |
| 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 Therapy2026-01-04 18:33
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-01-31 06:33
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-31 12:38
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit limits: Physical therapy visits used 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011192 | 2026-03-14 | Cornerstone Internal Medicine Associates | $71.00 | Approved |
| CLM-2026-008518 | 2026-01-30 | Lakeside Physical Therapy | $373.00 | Denied |
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
Annual visit limit exhausted.