CLM-2026-032372
Lakeside Physical Therapy, Physical Therapy. Service 2026-08-10 at office (POS 11). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- Brittany Kim
- Member ID
- UHC-44063-25
- Date of birth
- 1958-12-16
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-403046
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2039
- Coverage period
- 2021-11-01 to 2026-03-26
- Deductible
- $2,584.86 of $3,500.0074%
- Out-of-pocket maximum
- $4,737.85 of $10,500.0045%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 9861124797
- Network
- In network
- Rendering NPI
- 1170750297
- 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 | — | 3 | 1 | $183.00 | $113.46 | — | — | DeniedCO27 |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $75.00 | $46.50 | — | — | DeniedCO27 |
| Totals | $258.00 | $159.96 | — | — | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- Patient account
- PA-922381
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-023566 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-10 is after coverage terminated on 2026-03-26. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 38 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 | Fail | LIM | Physical therapy visits used 22 of 20 for the plan year. Benefit limit reached |
| 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 Therapy2026-08-10 15:02
Follow-up for aftercare following joint replacement surgery. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-17 02:43
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-17 12:18
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 2026-08-10 is after coverage terminated on 2026-03-26. Benefit limits: Physical therapy visits used 22 of 20 for the plan year.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020911 | 2026-07-22 | Evergreen Dermatology Clinic | $667.00 | Denied |
| CLM-2026-025050 | 2026-07-09 | Pinecrest GI Associates | $333.00 | Denied |
| CLM-2026-017050 | 2026-02-17 | Valley Primary Care Associates | $41.00 | 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.