CLM-2026-031009
Lakeside Physical Therapy, Physical Therapy. Service 2026-06-07 at office (POS 11). Received 2026-07-19.
Member
Resolved through the identity graph
- Member
- Priya Ortega
- Member ID
- UHC-14105-31
- Date of birth
- 1998-10-25
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-421169
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2451
- Coverage period
- 2024-07-01 to 2026-01-24
- Deductible
- $478.44 of $1,000.0048%
- Out-of-pocket maximum
- $894.26 of $3,000.0030%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9861124797
- Network
- In network
- Rendering NPI
- 9516681225
- Location
- Houston, TX · TIN 40-0662041
- 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 | $376.00 | $233.12 | — | — | DeniedCO27 |
| Totals | $376.00 | $233.12 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-734208
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-023139 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-07 is after coverage terminated on 2026-01-24. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 42 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 8 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 Therapy2026-06-07 12:20
Patient seen for aftercare following joint replacement surgery.
- SystemSystem: Claims system2026-07-19 04:13
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-19 09:52
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-07 is after coverage terminated on 2026-01-24.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033152 | 2026-08-14 | Northgate Clinical Laboratories | $214.00 | Denied |
| CLM-2026-026343 | 2026-03-05 | Harbor Medical Group | $90.00 | 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.