CLM-2026-018155
Lakeside Physical Therapy, Physical Therapy. Service 2026-01-23 at office (POS 11). Received 2026-02-09.
Member
Resolved through the identity graph
- Member
- Edward Peterson
- Member ID
- UHC-42460-12
- Date of birth
- 1969-01-12
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-410366
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3872
- Coverage period
- 2024-11-01 to present
- Deductible
- $766.74 of $1,000.0077%
- Out-of-pocket maximum
- $1,446.27 of $4,000.0036%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 2744323421
- Network
- In network
- Rendering NPI
- 2894760554
- 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 | — | 4 | 1 | $324.00 | $200.88 | — | — | Review |
| Totals | $324.00 | $200.88 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-162235
- 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-004725 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-23: SELECT-EPO (EPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 17 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 | Pass | Physical therapy visits used 16 of 20. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for aftercare following joint replacement surgery. Note dictated; signature p”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Physical Therapy2026-01-23 12:55
Patient seen for aftercare following joint replacement surgery. Note dictated; signature pending.
- SystemSystem: Claims system2026-02-09 02:58
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-02-09 15:04
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for aftercare following joint replacement surgery. Note dictated; signature p”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013875 | 2025-12-16 | Mesa Diabetes Center | $266.00 | Approved |
| CLM-2026-025697 | 2025-12-07 | Heritage Primary Care Associates | $260.00 | Denied |
| CLM-2026-025696 | 2025-12-07 | Heritage Primary Care Associates | $260.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.