Professional claim · CMS-1500 · EDI 837P
CLM-2026-030842
Lakeside Physical Therapy, Physical Therapy. Service 2026-02-12 at office (POS 11). Received 2026-02-14.
Approved
Billed
$456.00
3 lines
Allowed
$282.72
contract rate applied
Plan pays
$242.72
approved
Member owes
$40.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Jose Hawkins
- Member ID
- UHC-88472-34
- Date of birth
- 1949-01-28
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-410020
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5418
- Coverage period
- 2021-08-01 to present
- Deductible
- $723.76 of $3,500.0021%
- Out-of-pocket maximum
- $122.49 of $7,000.002%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9861124797
- Network
- In network
- Rendering NPI
- 5899235456
- Location
- Houston, TX · TIN 40-0662041
- Authorisation / referral
- none / REF832246
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 | — | 2 | 1 | $130.00 | $80.60 | $40.00 | $40.60 | Paid |
| 2 | 97140 | Manual therapy, 15 minutes | 25 | 1 | 2 | $90.00 | $55.80 | $0.00 | $55.80 | Paid |
| 3 | 97161 | PT evaluation, low complexity | — | 1 | 1,2 | $236.00 | $146.32 | $0.00 | $146.32 | Paid |
| Totals | $456.00 | $282.72 | $40.00 | $242.72 | ||||||
Diagnoses (ICD-10-CM)
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M75.100 Unspecified rotator cuff tear, unspecified shoulder
Claim header
- Patient account
- PA-838876
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013001 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-12: NAVIGATE-HMO (HMO), effective 2021-08-01. | |
| Timely filing | Pass | Received 2 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 (9861124797). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 4 of 20. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Physical Therapy2026-02-12 17:34
Patient seen for aftercare following joint replacement surgery.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$456.00
Plan discount
$173.28
contracted rate
Plan paid
$242.72
You may owe
$40.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015388 | 2026-04-17 | Sunrise Diabetes Center | $491.00 | Approved |
| CLM-2026-030843 | 2026-02-12 | Harbor Rehabilitation Center | $456.00 | Needs review |
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.