CLM-2026-016949
Lakeside Physical Therapy, Physical Therapy. Service 2026-01-29 at office (POS 11). Received 2026-03-20.
Member
Resolved through the identity graph
- Member
- Logan Hamilton
- Member ID
- UHC-20469-91
- Date of birth
- 1972-01-12
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-409233
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8065
- Coverage period
- 2024-06-01 to present
- Deductible
- $282.61 of $1,000.0028%
- Out-of-pocket maximum
- $885.51 of $2,000.0044%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 4129074496
- Network
- In network
- Rendering NPI
- 7281357971
- Location
- Mesa, AZ · TIN 85-1332515
- Authorisation / referral
- none / REF210979
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 | $225.00 | $139.50 | — | — | DeniedCO18 |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $56.00 | $34.72 | — | — | DeniedCO18 |
| Totals | $281.00 | $174.22 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- Patient account
- PA-345766
- 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-006408 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-01-29: CORE-HMO (HMO), effective 2024-06-01. | |
| Timely filing | Pass | Received 50 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-016948: 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 (4129074496). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 0 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 Therapy2026-01-29 16:54
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-03-20 05:14
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-20 11:15
Member services inquiry logged on this claim; member asked about the status of payment.
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-2026-016948: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027919 | 2026-05-14 | Riverside Medical Group | $22.00 | Approved |
| CLM-2026-016948 | 2026-01-29 | Lakeside Physical Therapy | $281.00 | Approved |
| CLM-2026-009353 | 2026-01-03 | Pinecrest GI Associates | $1,725.00 | 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.