Professional claim · CMS-1500 · EDI 837P
CLM-2026-015528
Lakeside Physical Therapy, Physical Therapy. Service 2026-06-09 at office (POS 11). Received 2026-06-15.
Approved
Billed
$325.00
2 lines
Allowed
$201.50
contract rate applied
Plan pays
$176.50
approved
Member owes
$25.00
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
- Carl Robertson
- Member ID
- UHC-87750-98
- Date of birth
- 1976-08-21
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-425847
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-2559
- Coverage period
- 2024-10-01 to present
- Deductible
- $426.94 of $500.0085%
- Out-of-pocket maximum
- $691.00 of $1,500.0046%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9861124797
- Network
- In network
- Rendering NPI
- 1420265765
- 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 | — | 3 | 1 | $264.00 | $163.68 | $25.00 | $138.68 | Paid |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $61.00 | $37.82 | $0.00 | $37.82 | Paid |
| Totals | $325.00 | $201.50 | $25.00 | $176.50 | ||||||
Diagnoses (ICD-10-CM)
- 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
- Patient account
- PA-564729
- 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-004951 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-06-09: - (PPO), effective 2024-10-01. | |
| 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 (9861124797). | |
| 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 Therapy2026-06-09 17:52
Patient seen for low back pain, unspecified.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$325.00
Plan discount
$123.50
contracted rate
Plan paid
$176.50
You may owe
$25.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Benefit limits: Physical therapy visits used 19 of 20.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029050 | 2026-05-29 | Pinecrest Medical Group | $84.00 | Approved |
| CLM-2026-024651 | 2026-04-17 | Meadow Imaging Center | $321.00 | Approved |
| CLM-2026-007245 | 2026-02-02 | Harbor Primary Care Associates | $324.00 | 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
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
Approvedscenario: Clean
Clean claim, priced at contract rate.