CLM-2026-030392
Lakeside Physical Therapy, Physical Therapy. Service 2026-06-14 at office (POS 11). Received 2026-08-02.
Member
Resolved through the identity graph
- Member
- Willie Millre
- Member ID
- UHC-30726-46
- Date of birth
- 1998-07-08
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-418582
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4500
- Coverage period
- 2021-07-01 to present
- Deductible
- $344.24 of $1,000.0034%
- Out-of-pocket maximum
- $45.94 of $3,000.002%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9861124797
- Network
- In network
- Rendering NPI
- 5105043421
- Location
- Houston, TX · TIN 40-0662041
- Authorisation / referral
- none / REF627627
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 | $312.00 | $193.44 | — | — | DeniedCO18 |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $63.00 | $39.06 | — | — | DeniedCO18 |
| 3 | 97161 | PT evaluation, low complexity | 25 | 1 | 1 | $210.00 | $130.20 | — | — | DeniedCO18 |
| Totals | $585.00 | $362.70 | — | — | ||||||
- 1. M75.100 Unspecified rotator cuff tear, unspecified shoulderprincipal
- Patient account
- PA-480060
- 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-038800 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-06-14: NAVIGATE-HMO (HMO), effective 2021-07-01. | |
| Timely filing | Pass | Received 49 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-030391: 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 (9861124797). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 10 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 Therapy2026-06-14 12:58
Follow-up for unspecified rotator cuff tear, unspecified shoulder. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-02 00:17
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
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-2026-030391: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030391 | 2026-06-14 | Lakeside Physical Therapy | $585.00 | 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.