CLM-2026-014187
Lakeside Physical Therapy, Physical Therapy. Service 2026-09-08 at outpatient hospital (POS 22). Received 2026-09-15.
Member
Resolved through the identity graph
- Member
- Austin Williams
- Member ID
- UHC-25905-92
- Date of birth
- 2001-10-15
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-405297
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9324
- Coverage period
- 2023-06-01 to present
- Deductible
- $2,040.30 of $2,500.0082%
- Out-of-pocket maximum
- $1,700.62 of $5,000.0034%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 4129074496
- Network
- In network
- Rendering NPI
- 5931512755
- Location
- Mesa, AZ · TIN 85-1332515
- Authorisation / referral
- PA2025200380 / none
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 | $8,541.00 | $4,697.55 | — | — | Review |
| Totals | $8,541.00 | $4,697.55 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-459234
- 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-030854 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-09-08: SELECT-EPO (EPO), effective 2023-06-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025200380 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Physical Therapy (4129074496). | |
| 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 Therapy2026-09-08 13:55
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-15 06:55
Member has used the annual physical-therapy visit benefit for the plan year.
Attachments
Documents received with the claim
- Prior auth letterPA2025200380_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-09-08 to 2026-12-07.
- Itemized billitemized_PA-459234.pdf2 pages
Itemised statement totalling $8541.00 across 1 line.
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
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
Annual visit limit exhausted.