CLM-2026-020435
Lakeside Physical Therapy, Physical Therapy. Service 2026-08-06 at office (POS 11). Received 2026-08-21.
Member
Resolved through the identity graph
- Member
- Abigail Lawrence
- Member ID
- UHC-25880-45
- Date of birth
- 1988-07-20
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-418238
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8143
- Coverage period
- 2023-12-01 to present
- Deductible
- $756.52 of $1,500.0050%
- Out-of-pocket maximum
- $1,066.14 of $3,000.0036%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 4129074496
- Network
- In network
- Rendering NPI
- 7730236149
- Location
- Mesa, AZ · TIN 85-1332515
- 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 | $276.00 | $171.12 | — | — | DeniedLIM |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 1 | $58.00 | $35.96 | — | — | DeniedLIM |
| 3 | 97161 | PT evaluation, low complexity | — | 1 | 1 | $235.00 | $145.70 | — | — | DeniedLIM |
| Totals | $569.00 | $352.78 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-614287
- 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-026744 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-06: CHOICE-PLUS-PPO (PPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 15 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 (4129074496). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 21 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 Therapy2026-08-06 13:01
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-21 02:37
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 21 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018458 | 2026-07-25 | Pinecrest Bone and Joint Center | $33,913.00 | Needs review |
| CLM-2026-021887 | 2026-05-26 | Sunrise Dermatology Clinic | $445.00 | 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.