CLM-2026-023205
Lakeside Physical Therapy, Physical Therapy. Service 2025-11-26 at office (POS 11). Received 2026-01-16.
Member
Resolved through the identity graph
- Member
- Santiago Alvarado
- Member ID
- UHC-29527-53
- Date of birth
- 1998-06-16
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-426405
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0632
- Coverage period
- 2024-02-01 to present
- Deductible
- $1,285.58 of $1,500.0086%
- Out-of-pocket maximum
- $1,412.21 of $4,500.0031%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9861124797
- Network
- In network
- Rendering NPI
- 6359194407
- Location
- Houston, TX · TIN 40-0662041
- 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 | — | 1 | 1 | $75.00 | $46.50 | — | — | Review |
| Totals | $75.00 | $46.50 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. Z47.1 Aftercare following joint replacement surgery
- Patient account
- PA-818940
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000178 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-26: SELECT-EPO (EPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 51 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-023204; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| 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 3 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 Therapy2025-11-26 15:48
Patient seen for low back pain, unspecified. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-01-16 02:31
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-16 15:12
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-023204.pdf1 page
Provider cover letter requesting replacement of CLM-2026-023204.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Replacement claim: Frequency code 7 replaces CLM-2026-023204; the original must be voided when this adjudicates.
- AI recommendationApproved2026-10-23 19:14The claim is a replacement for an earlier claim (CLM-2026-023204) with corrected units [N1]. The provider is in-network [R-network], and the service is medically necessary [R-clinical_edit]. The original claim must be voided [R-replacement]. The member is eligible [R-eligibility], and the claim is within the benefit limits [R-benefit_limit]. The claim is complete [R-completeness] and within the high-dollar review limit [R-high_dollar].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:14 · 1ce0528d
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027654 | 2026-04-08 | Desert Internal Medicine Associates | $617.00 | Approved |
| CLM-2026-023204 | 2025-11-26 | Lakeside Physical Therapy | $150.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim is a replacement for an earlier claim (CLM-2026-023204) with corrected units [N1]. The provider is in-network [R-network], and the service is medically necessary [R-clinical_edit]. The original claim must be voided [R-replacement]. The member is eligible [R-eligibility], and the claim is within the benefit limits [R-benefit_limit]. The claim is complete [R-completeness] and within the high-dollar review limit [R-high_dollar].
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
Replacement claim supersedes the original.