CLM-2026-034577
Lakeside Physical Therapy, Physical Therapy. Service 2026-07-27 at office (POS 11). Received 2026-07-31.
Member
Resolved through the identity graph
- Member
- Harold Guerrero
- Member ID
- UHC-12102-20
- Date of birth
- 1963-05-17
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-417036
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7289
- Coverage period
- 2023-10-01 to present
- Deductible
- $1,454.17 of $3,500.0042%
- Out-of-pocket maximum
- $3,625.38 of $14,000.0026%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Physical TherapyPhysical Therapy · taxonomy 225100000X
- NPI
- 2744323421
- Network
- In network
- Rendering NPI
- 8038189998
- Location
- Minneapolis, MN · TIN 46-4889069
- Authorisation / referral
- none / REF344380
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 | $316.00 | $195.92 | $25.00 | $170.92 | Paid |
| 2 | 97014 | Electrical stimulation, unattended | 25 | 1 | 2 | $55.00 | $34.10 | $0.00 | $34.10 | Paid |
| Totals | $371.00 | $230.02 | $25.00 | $205.02 | ||||||
- 1. Z47.1 Aftercare following joint replacement surgeryprincipal
- Patient account
- PA-824666
- 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-038505 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-27: NAVIGATE-HMO (HMO), effective 2023-10-01. | |
| Timely filing | Pass | Received 4 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 (2744323421). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | Physical therapy visits used 6 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 Therapy2026-07-27 14:30
Follow-up for aftercare following joint replacement surgery. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-07-31 02:05
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-31 15:30
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-824666.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Explanation of benefits
What the member will see
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
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Authorisation must be confirmed with UM before payment.