CLM-2026-034105
Lakeside Physical Therapy, Physical Therapy. Service 2025-11-29 at office (POS 11). Received 2026-01-29.
Member
Resolved through the identity graph
- Member
- Arthur Munoz
- Member ID
- UHC-55142-03
- Date of birth
- 1956-01-04
- Identity
- Verified4 records, confidence 0.94
- Claim record
- CLMCLM-419818
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6278
- Coverage period
- 2025-11-01 to present
- Deductible
- $1,570.14 of $2,500.0063%
- Out-of-pocket maximum
- $1,377.10 of $7,500.0018%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 4129074496
- Network
- In network
- Rendering NPI
- 9906820367
- Location
- Mesa, AZ · TIN 85-1332515
- 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 | $225.00 | $139.50 | — | — | DeniedCO18 |
| 2 | 97140 | Manual therapy, 15 minutes | — | 1 | 2 | $60.00 | $37.20 | — | — | DeniedCO18 |
| 3 | 97161 | PT evaluation, low complexity | — | 1 | 1 | $178.00 | $110.36 | — | — | DeniedCO18 |
| Totals | $463.00 | $287.06 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-125096
- 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-000323 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2025-11-29: SELECT-EPO (EPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 61 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-034104: 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 (4129074496). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 16 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 Therapy2025-11-29 13:29
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-01-29 03:28
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-29 08:40
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 engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-034104: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004649 | 2025-12-10 | Valley Imaging Center | $3,624.00 | Denied |
| CLM-2026-034104 | 2025-11-29 | Lakeside Physical Therapy | $463.00 | 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.