CLM-2026-022425
Lakeside Physical Therapy, Physical Therapy. Service 2026-07-06 at office (POS 11). Received 2026-08-17.
Member
Resolved through the identity graph
- Member
- Billy Cook
- Member ID
- UHC-50005-94
- Date of birth
- 1978-11-21
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-419527
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2311
- Coverage period
- 2024-07-01 to present
- Deductible
- $1,630.37 of $3,500.0047%
- Out-of-pocket maximum
- $508.37 of $14,000.004%
- Copays
- office $20.00, 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
- 9861124797
- Network
- In network
- Rendering NPI
- 5285579509
- Location
- Houston, TX · TIN 40-0662041
- Authorisation / referral
- none / REF194139
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 | $320.00 | $198.40 | — | — | Review |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $36.00 | $22.32 | — | — | Review |
| Totals | $356.00 | $220.72 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-550367
- 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-009428 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-06: CORE-HMO (HMO), effective 2024-07-01. | |
| Timely filing | Pass | Received 42 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 (9861124797). | |
| 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 | 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 Therapy2026-07-06 18:42
Patient seen for aftercare following joint replacement surgery. Note dictated; signature pending.
- SystemSystem: Claims system2026-08-17 01:53
Rendering provider signature missing on the attached note. Development letter sent to provider.
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-2026-025356 | 2026-04-24 | Heritage Primary Care Associates | $23.00 | 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.