Claims workbench/CLM-2026-004077

Institutional claim · UB-04 · EDI 837I

CLM-2026-004077

Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-07-28 at emergency room (POS 23). Received 2026-09-02.

Denied

Billed

$4,248.00

3 lines

Allowed

$2,336.40

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Sophia Black
Member ID: UHC-45678-94
Date of birth: 1995-12-03
Identity: Verified2 records, confidence 0.99
Claim record: CLMCLM-430684
Relationship: Self, Houston, TX

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-2296
Coverage period: 2025-09-01 to 2026-05-05
Deductible: $147.89 of $1,000.0015%
Out-of-pocket maximum: $579.54 of $2,000.0029%
Copays: office $25.00, specialist $75.00, emergency $150.00
Physical therapy visits: 10 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI: 2061946325
Network: In network
Rendering NPI: 2061946325
Location: Denver, CO · TIN 60-4146079
Authorisation / referral: none / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	71046 rev 0320	Chest X-ray, two views	—	1	1	$232.00	$127.60	—	—	DeniedCO27
2	99285 rev 0450	Emergency department visit, high severity with threat to life	—	1	1,2	$2,502.00	$1,376.10	—	—	DeniedCO27
3	99284 rev 0450	Emergency department visit, high severity	25	1	1	$1,514.00	$832.70	—	—	DeniedCO27
Totals						$4,248.00	$2,336.40	—	—

Diagnoses (ICD-10-CM)

1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
2. J18.9 Pneumonia, unspecified organism

Claim header

Patient account: PA-768195
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-018916 (verified, link confidence 0.99).
Eligibility	Fail	CO27	Date of service 2026-07-28 is after coverage terminated on 2026-05-05. Expenses incurred after coverage terminated
Timely filing	Pass		Received 36 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 Pinecrest Regional Medical Center (2061946325).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Regional Medical Center2026-07-28 15:38
Patient seen for sprain of unspecified ligament of right ankle, initial encounter.
SystemSystem: Claims system2026-09-02 03:09
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-02 12:42
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Itemized billitemized_PA-768195.pdf5 pages
Itemised statement totalling $4248.00 across 3 lines.
Er reported_report_PA-768195.pdf5 pages
Emergency department record: triage acuity 4, chief complaint sprain of unspecified ligament of right ankle, initial encounter.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Eligibility: Date of service 2026-07-28 is after coverage terminated on 2026-05-05.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity