Claims workbench/CLM-2026-029833
Professional claim · CMS-1500 · EDI 837P

CLM-2026-029833

Lakeside Physical Therapy, Physical Therapy. Service 2026-01-19 at office (POS 11). Received 2026-01-24.

Approved
Billed
$304.00
1 line
Allowed
$188.48
contract rate applied
Plan pays
$158.48
approved
Member owes
$30.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Paul Estrada
Member ID
UHC-79041-01
Date of birth
1981-06-25
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-426399
Relationship
Spouse, Mesa, AZ

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group GRP-8469
Coverage period
2021-08-01 to 2026-03-24
Deductible
$565.62 of $1,500.0038%
Out-of-pocket maximum
$341.03 of $6,000.006%
Copays
office $30.00, specialist $40.00, emergency $350.00
Physical therapy visits
16 of 20 used

Provider

Billing and rendering

Billing provider
Lakeside Physical Therapy
Physical Therapy · taxonomy 225100000X
NPI
8769647701
Network
In network
Rendering NPI
1652733506
Location
Austin, TX · TIN 82-6971924
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
197110Therapeutic exercise, 15 minutes—41$304.00$188.48$30.00$158.48Paid
Totals$304.00$188.48$30.00$158.48
Diagnoses (ICD-10-CM)
  • 1. Z47.1 Aftercare following joint replacement surgeryprincipal
Claim header
Patient account
PA-591495
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-007211 (verified, link confidence 0.99).
EligibilityPassActive on 2026-01-19: SELECT-EPO (EPO), effective 2021-08-01, terms 2026-03-24.
Timely filingPassReceived 5 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Lakeside Physical Therapy (8769647701).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassPhysical therapy visits used 16 of 20.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Lakeside Physical Therapy2026-01-19 12:29

    Established patient presents with aftercare following joint replacement surgery; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$304.00
Plan discount
$115.52
contracted rate
Plan paid
$158.48
You may owe
$30.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-21 13:43
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity