Claims workbench/CLM-2026-007843

Institutional claim · UB-04 · EDI 837I

CLM-2026-007843

Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-07-24 at emergency room (POS 23). Received 2026-08-18.

Needs reviewOut of network

Billed

$674.00

1 line

Allowed

$370.70

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

NET

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Dylan Gomez
Member ID: UHC-44561-38
Date of birth: 1963-08-12
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-429653
Relationship: Self, Los Angeles, CA

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group NULL
Coverage period: 2025-04-01 to present
Deductible: $674.90 of $1,000.0067%
Out-of-pocket maximum: $78.07 of $2,000.004%
Copays: office $30.00, specialist $50.00, emergency $250.00
Physical therapy visits: 22 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI: 1000861728
Network: Out of network
Rendering NPI: 1000861728
Location: Austin, TX · TIN 41-0807117
Authorisation / referral: none / REF577714

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	99283 rev 0450	Emergency department visit, moderate severity	—	1	1	$674.00	$370.70	—	—	Review
Totals						$674.00	$370.70	—	—

Diagnoses (ICD-10-CM)

1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
2. R10.9 Unspecified abdominal pain

Claim header

Patient account: PA-559439
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-020947 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-07-24: CORE-HMO (HMO), effective 2025-04-01.
Timely filing	Pass		Received 25 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	Review	NET	Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record. Out-of-network provider
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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Regional Medical Center2026-07-24 12:09
Follow-up for sprain of unspecified ligament of right ankle, initial encounter. Plan discussed, medications reconciled. Patient presented to the nearest emergency department with acute symptoms; care could not safely be delayed to reach an in-network facility.
SystemSystem: Claims system2026-08-18 00:45
Out-of-network emergency visit. Emergency services are payable at the in-network level when the prudent-layperson standard is met.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-18 12:15
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Itemized billitemized_PA-559439.pdf4 pages
Itemised statement totalling $674.00 across 1 line.
Er reported_report_PA-559439.pdf5 pages
Emergency department record: triage acuity 2, chief complaint sprain of unspecified ligament of right ankle, initial encounter.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-22 12:44
Provider network: Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-019562	2026-09-29	Sunrise Counseling Center	$391.00	Approved
CLM-2026-002312	2026-08-15	Sunrise Behavioral Health	$395.00	Approved

AI recommendation

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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

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

Approvedscenario: Oon emergency

Emergency: payable at in-network level.

Review queue Member identity