CLM-2026-025492
Lakeside Physical Therapy, Physical Therapy. Service 2026-07-04 at office (POS 11). Received 2026-07-21.
Member
Resolved through the identity graph
- Member
- Kayla Knight
- Member ID
- UHC-89655-06
- Date of birth
- 1977-10-25
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-428571
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group NULL
- Coverage period
- 2024-12-01 to present
- Deductible
- $722.24 of $1,500.0048%
- Out-of-pocket maximum
- $660.48 of $3,000.0022%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 8769647701
- Network
- In network
- Rendering NPI
- 2714712322
- Location
- Austin, TX · TIN 82-6971924
- 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 | $118.00 | $73.16 | — | — | DeniedLIM |
| 2 | 97161 | PT evaluation, low complexity | — | 1 | 2 | $257.00 | $159.34 | — | — | DeniedLIM |
| Totals | $375.00 | $232.50 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
- Patient account
- PA-199396
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-030527 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-04: CHOICE-PLUS-PPO (PPO), effective 2024-12-01. | |
| 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 (8769647701). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Fail | LIM | Physical therapy visits used 22 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 Therapy2026-07-04 17:16
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-21 02:08
Member has used the annual physical-therapy visit benefit for the plan year.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-21 08:21
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 engineDenied2026-10-22 12:44Benefit limits: Physical therapy visits used 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032716 | 2026-08-09 | Mesa Dermatology Clinic | $229.00 | Approved |
| CLM-2026-002616 | 2026-04-25 | Valley Medical Group | $308.00 | 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.