CLM-2026-013662
Lakeside Physical Therapy, Physical Therapy. Service 2025-12-30 at office (POS 11). Received 2026-04-11.
Member
Resolved through the identity graph
- Member
- Barbara Bell
- Member ID
- UHC-39735-08
- Date of birth
- 1995-02-17
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-407465
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3905
- Coverage period
- 2025-02-01 to present
- Deductible
- $236.96 of $500.0047%
- Out-of-pocket maximum
- $137.99 of $2,000.007%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9861124797
- Network
- In network
- Rendering NPI
- 5157363966
- Location
- Houston, TX · TIN 40-0662041
- 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 | $352.00 | $218.24 | — | — | DeniedCO29 |
| Totals | $352.00 | $218.24 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-970952
- 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-025156 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-30: MEDICARE-ADV-B (MA), effective 2025-02-01. | |
| Timely filing | Fail | CO29 | Received 102 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (9861124797). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 20 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 Therapy2025-12-30 11:22
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-11 04:52
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 102 days after the last date of service (limit 90). Benefit limits: Physical therapy visits used 20 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010399 | 2026-07-05 | Evergreen Family Practice | $286.00 | Approved |
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
Received after the timely-filing limit.