CLM-2026-017273
Lakeside Physical Therapy, Physical Therapy. Service 2026-06-28 at office (POS 11). Received 2026-06-30.
Member
Resolved through the identity graph
- Member
- Abigail Rios
- Member ID
- UHC-06532-92
- Date of birth
- 1979-05-26
- Identity
- Verified6 records, confidence 0.93
- Claim record
- CLMCLM-427980
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7946
- Coverage period
- 2025-03-01 to present
- Deductible
- $1,817.93 of $3,500.0052%
- Out-of-pocket maximum
- $559.47 of $10,500.005%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 2744323421
- Network
- In network
- Rendering NPI
- 5441231789
- Location
- Minneapolis, MN · TIN 46-4889069
- 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 | $228.00 | $141.36 | — | — | DeniedLIM |
| Totals | $228.00 | $141.36 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- Patient account
- PA-713733
- 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-015346 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-06-28: SELECT-EPO (EPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 2 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 (2744323421). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 22 of 20 for the plan year. Benefit limit reached |
| 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 Therapy2026-06-28 14:54
Patient seen for aftercare following joint replacement surgery.
- SystemSystem: Claims system2026-06-30 04:52
Member has used the annual physical-therapy visit benefit for the plan year.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Benefit limits: Physical therapy visits used 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023552 | 2026-07-15 | Evergreen Rehabilitation Center | $288.00 | Denied |
| CLM-2026-023207 | 2026-04-07 | Harbor Primary Care Associates | $194.00 | Approved |
| CLM-2026-001688 | 2026-02-27 | Riverside Family Practice | $322.00 | Approved |
| CLM-2026-008498 | 2026-02-16 | Northgate Clinical Laboratories | $55.00 | 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
Annual visit limit exhausted.