CLM-2026-025711
Lakeside Physical Therapy, Physical Therapy. Service 2026-05-29 at office (POS 11). Received 2026-07-02.
Member
Resolved through the identity graph
- Member
- Mary Clark
- Member ID
- UHC-63821-24
- Date of birth
- 2004-05-11
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-414834
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6779
- Coverage period
- 2022-11-01 to 2026-01-13
- Deductible
- $1,915.66 of $3,500.0055%
- Out-of-pocket maximum
- $4,717.55 of $14,000.0034%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 4129074496
- Network
- In network
- Rendering NPI
- 1103659391
- 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 | $248.00 | $153.76 | — | — | DeniedCO27 |
| 2 | 97014 | Electrical stimulation, unattended | — | 1 | 1 | $49.00 | $30.38 | — | — | DeniedCO27 |
| Totals | $297.00 | $184.14 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- Patient account
- PA-971993
- 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-008476 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-29 is after coverage terminated on 2026-01-13. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 34 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 11 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 Therapy2026-05-29 09:56
Patient seen for aftercare following joint replacement surgery.
- SystemSystem: Claims system2026-07-02 00:15
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-02 15:39
Member services inquiry logged on this claim; member asked about the status of payment.
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 2026-05-29 is after coverage terminated on 2026-01-13.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009509 | 2026-08-23 | Unity Medical Group | $83.00 | Denied |
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.