Claims workbench/CLM-2026-011700

Institutional claim · UB-04 · EDI 837I

CLM-2026-011700

Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-07-25 at emergency room (POS 23). Received 2026-08-06.

Needs reviewOut of network

Billed

$746.00

1 line

Allowed

$335.70

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Zachary Greene
Member ID: UHC-69793-13
Date of birth: 1992-12-26
Identity: Verified5 records, confidence 0.93
Claim record: CLMCLM-422876
Relationship: Self, Los Angeles, CA

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-0529
Coverage period: 2022-02-01 to present
Deductible: $21.04 of $1,000.002%
Out-of-pocket maximum: $1,127.44 of $4,000.0028%
Copays: office $25.00, specialist $60.00, emergency $150.00
Physical therapy visits: 0 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 / 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	99283 rev 0450	Emergency department visit, moderate severity	—	1	1	$746.00	$335.70	—	—	Review
Totals						$746.00	$335.70	—	—

Diagnoses (ICD-10-CM)

1. J18.9 Pneumonia, unspecified organismprincipal

Claim header

Patient account: PA-228334
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-023741 (verified, link confidence 0.93).
Eligibility	Pass		Active on 2026-07-25: OPTIONS-PPO (PPO), effective 2022-02-01.
Timely filing	Pass		Received 12 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	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Review	CO16	Documentation incomplete: “Patient seen for pneumonia, unspecified organism. Note dictated; signature pending.”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 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 Center2026-07-25 12:27
Patient seen for pneumonia, unspecified organism. Note dictated; signature pending.
SystemSystem: Claims system2026-08-06 02:50
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-06 14:19
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Itemized billitemized_PA-228334.pdf5 pages
Itemised statement totalling $746.00 across 1 line.
Er reported_report_PA-228334.pdf2 pages
Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Patient seen for pneumonia, unspecified organism. Note dictated; signature pending.”.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-018088	2026-09-25	Sunrise Dermatology Clinic	$453.00	Approved
CLM-2026-032461	2026-08-13	Summit Imaging Center	$148.00	Needs review

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

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity