CLM-2026-016804
Lakeside Physical Therapy, Physical Therapy. Service 2026-05-11 at office (POS 11). Received 2026-05-29.
Member
Resolved through the identity graph
- Member
- Nathan Martinez
- Member ID
- UHC-89061-19
- Date of birth
- 1944-04-01
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-421546
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-8010
- Coverage period
- 2022-11-01 to present
- Deductible
- $496.42 of $1,500.0033%
- Out-of-pocket maximum
- $452.57 of $4,500.0010%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8769647701
- Network
- In network
- Rendering NPI
- 3533980629
- Location
- Austin, TX · TIN 82-6971924
- 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 | $332.00 | $205.84 | $25.00 | $180.84 | Paid |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $88.00 | $54.56 | $0.00 | $54.56 | Paid |
| Totals | $420.00 | $260.40 | $25.00 | $235.40 | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-423219
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009420 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-11: NULL (PPO), effective 2022-11-01. | |
| Timely filing | Pass | Received 18 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 (8769647701). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 5 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 Therapy2026-05-11 16:29
Follow-up for aftercare following joint replacement surgery. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-05-29 03:58
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-423219.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006031 | 2026-05-02 | Sunrise Dermatology Clinic | $775.00 | Approved |
| CLM-2026-015739 | 2026-01-11 | Canyon Cardiovascular Associates | $424.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.