Claims workbench/CLM-2026-012764

Institutional claim · UB-04 · EDI 837I

CLM-2026-012764

Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-01-07 at outpatient hospital (POS 22). Received 2026-01-20.

DeniedOut of network

Billed

$2,842.00

1 line

Allowed

$1,278.90

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO204

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Vincent George
Member ID: UHC-05005-65
Date of birth: 1996-04-01
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-412624
Relationship: Spouse, Miami, FL

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-0549
Coverage period: 2021-01-01 to present
Deductible: $1,556.05 of $3,500.0044%
Out-of-pocket maximum: $6,068.71 of $14,000.0043%
Copays: office $20.00, specialist $60.00, emergency $150.00
Physical therapy visits: 2 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: PA2025180012 / REF377782

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	70553 rev 0610	MRI brain with and without contrast	—	1	1	$2,842.00	$1,278.90	—	—	DeniedCO204
Totals						$2,842.00	$1,278.90	—	—

Diagnoses (ICD-10-CM)

1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
2. R55 Syncope and collapse

Claim header

Patient account: PA-389338
Frequency code: 1 (original)
Accident: Yes
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-001280 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-01-07: CORE-HMO (HMO), effective 2021-01-01.
Timely filing	Pass		Received 13 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025180012 on file for 70553.
Provider network	Fail	CO204	Billing provider 1000861728 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan
Medical necessity	Review	CO50	70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Regional Medical Center2026-01-07 16:19
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Patient presented to the nearest emergency department with acute symptoms; care could not safely be delayed to reach an in-network facility.
SystemSystem: Claims system2026-01-20 04:19
Out-of-network emergency visit. Emergency services are payable at the in-network level when the prudent-layperson standard is met.

Attachments

Documents received with the claim

Prior auth letterPA2025180012_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-07 to 2026-04-07.
Itemized billitemized_PA-389338.pdf4 pages
Itemised statement totalling $2842.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Provider network: Billing provider 1000861728 is out of network and the HMO plan has no out-of-network benefit. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-031236	2026-08-11	Lakeside Medical Group	$292.00	Approved
CLM-2026-011587	2026-06-08	Lakeside Bone and Joint Center	$193.00	Approved

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

Approvedscenario: Oon emergency

Emergency: payable at in-network level.

Review queue Member identity