CLM-2026-025841
Lakeside Physical Therapy, Physical Therapy. Service 2026-06-09 at office (POS 11). Received 2026-07-01.
Member
Resolved through the identity graph
- Member
- Linda James
- Member ID
- UHC-74269-33
- Date of birth
- 1949-08-16
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-404990
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1944
- Coverage period
- 2021-04-01 to present
- Deductible
- $229.10 of $1,000.0023%
- Out-of-pocket maximum
- $1,302.05 of $3,000.0043%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 2744323421
- Network
- In network
- Rendering NPI
- 5227126310
- Location
- Minneapolis, MN · TIN 46-4889069
- 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 | — | 3 | 1 | $219.00 | $135.78 | — | — | DeniedCO18 |
| Totals | $219.00 | $135.78 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-270386
- 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-035038 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-09: MEDICARE-ADV-A (MA), effective 2021-04-01. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-025840: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Lakeside Physical Therapy (2744323421). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 0 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 Therapy2026-06-09 17:25
Follow-up for unspecified rotator cuff tear, unspecified shoulder. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-01 02:20
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-01 09:42
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 12:44Duplicate check: Exact duplicate of CLM-2026-025840: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025840 | 2026-06-09 | Lakeside Physical Therapy | $219.00 | 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
Exact duplicate of an earlier submission.