CLM-2026-016705
Lakeside Physical Therapy, Physical Therapy. Service 2026-08-27 at office (POS 11). Received 2026-09-14.
Member
Resolved through the identity graph
- Member
- Charles Ortiz
- Member ID
- UHC-92395-20
- Date of birth
- 1938-04-02
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-425052
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8629
- Coverage period
- 2022-11-01 to present
- Deductible
- $584.10 of $1,000.0058%
- Out-of-pocket maximum
- $271.36 of $2,000.0014%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9861124797
- Network
- In network
- Rendering NPI
- 5741356757
- 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 | $292.00 | $181.04 | — | — | DeniedCO18 |
| Totals | $292.00 | $181.04 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-902120
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005373 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-27: SELECT-EPO (EPO), effective 2022-11-01. | |
| Timely filing | Pass | Received 18 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-016704: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 | Pass | Physical therapy visits used 13 of 20. | |
| 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 Therapy2026-08-27 16:48
Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-14 02:29
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-016704: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016704 | 2026-08-27 | Lakeside Physical Therapy | $292.00 | Approved |
| CLM-2026-002147 | 2026-01-28 | Canyon Reference Lab | $110.00 | Approved |
| CLM-2026-025268 | 2025-12-07 | Meadow Primary Care Associates | $51.00 | 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
Exact duplicate of an earlier submission.