CLM-2026-025643
Lakeside Physical Therapy, Physical Therapy. Service 2026-08-15 at office (POS 11). Received 2026-09-06.
Member
Resolved through the identity graph
- Member
- Abigail Vasquez
- Member ID
- UHC-90186-63
- Date of birth
- 1992-01-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-408237
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3918
- Coverage period
- 2025-02-01 to 2026-03-13
- Deductible
- $3,104.46 of $3,500.0089%
- Out-of-pocket maximum
- $1,425.65 of $7,000.0020%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 4129074496
- Network
- In network
- Rendering NPI
- 5745764550
- Location
- Mesa, AZ · TIN 85-1332515
- Authorisation / referral
- none / REF218192
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 | — | 3 | 1 | $219.00 | $135.78 | — | — | DeniedCO27 |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $72.00 | $44.64 | — | — | DeniedCO27 |
| Totals | $291.00 | $180.42 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- Patient account
- PA-414425
- 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-007995 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-15 is after coverage terminated on 2026-03-13. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 22 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 | Pass | Physical therapy visits used 2 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 Therapy2026-08-15 09:25
Follow-up for unspecified rotator cuff tear, unspecified shoulder. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-06 00:46
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-06 09:57
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 12:44Eligibility: Date of service 2026-08-15 is after coverage terminated on 2026-03-13.
Other claims for this member
Same resolved identity
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
Service after coverage termination.