CLM-2026-017572
Lakeside Physical Therapy, Physical Therapy. Service 2026-04-22 at office (POS 11). Received 2026-09-26.
Member
Resolved through the identity graph
- Member
- Roy Wright
- Member ID
- none on golden record
- Date of birth
- 2005-01-27
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-413533
- Relationship
- Child, Nashville, TN
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-1669
- Coverage period
- 2025-12-01 to present
- Deductible
- $337.04 of $2,500.0013%
- Out-of-pocket maximum
- $2,395.53 of $10,000.0024%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 2744323421
- Network
- In network
- Rendering NPI
- 6991500490
- 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 | — | 2 | 1 | $160.00 | $99.20 | — | — | DeniedCO29 |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $37.00 | $22.94 | — | — | DeniedCO29 |
| Totals | $197.00 | $122.14 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- Patient account
- PA-605952
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-045140 (verified, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-04-22: MEDICARE-ADV-B (MA), effective 2025-12-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Fail | CO29 | Received 157 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 | Pass | Physical therapy visits used 8 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 Therapy2026-04-22 13:43
Follow-up for aftercare following joint replacement surgery. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-26 00:06
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Active on 2026-04-22: MEDICARE-ADV-B (MA), effective 2025-12-01. Coverage found by name and date of birth because the claim carried no usable member ID. Timely filing: Received 157 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028070 | 2026-09-09 | Canyon Reference Lab | $116.00 | Needs review |
| CLM-2026-028069 | 2026-09-09 | Canyon Reference Lab | $116.00 | 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
Received after the timely-filing limit.