Claims workbench/CLM-2026-013684

Institutional claim · UB-04 · EDI 837I

CLM-2026-013684

Sunrise Community Hospital, Emergency Medicine. Service 2025-12-15 at emergency room (POS 23). Received 2026-03-23.

DeniedOut of network

Billed

$1,073.00

1 line

Allowed

$590.15

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Julie Rios
Member ID: UHC-27625-41
Date of birth: 1994-08-06
Identity: Verified4 records, confidence 0.96
Claim record: CLMCLM-415914
Relationship: Self, Los Angeles, CA

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-5825
Coverage period: 2024-06-01 to present
Deductible: $160.43 of $1,500.0011%
Out-of-pocket maximum: $54.63 of $3,000.002%
Copays: office $40.00, specialist $60.00, emergency $150.00
Physical therapy visits: 5 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Community Hospital
Emergency Medicine · taxonomy 207P00000X
NPI: 2411187117
Network: Out of network
Rendering NPI: 2411187117
Location: Tempe, AZ · TIN 19-3902018
Authorisation / referral: none / REF916259

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	$1,073.00	$590.15	—	—	DeniedCO29
Totals						$1,073.00	$590.15	—	—

Diagnoses (ICD-10-CM)

1. R10.9 Unspecified abdominal painprincipal
2. J18.9 Pneumonia, unspecified organism
3. S93.401A Sprain of unspecified ligament of right ankle, initial encounter

Claim header

Patient account: PA-248615
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-006583 (verified, link confidence 0.96).
Eligibility	Pass		Active on 2025-12-15: NAVIGATE-HMO (HMO), effective 2024-06-01.
Timely filing	Fail	CO29	Received 98 days after the last date of service (limit 90). Time limit for filing has expired
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Sunrise Community Hospital2025-12-15 12:52
Patient seen for unspecified abdominal pain.
SystemSystem: Claims system2026-03-23 02:55
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.

Attachments

Documents received with the claim

Itemized billitemized_PA-248615.pdf9 pages
Itemised statement totalling $1073.00 across 1 line.
Er reported_report_PA-248615.pdf6 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 98 days after the last date of service (limit 90). 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-2026-026200	2026-05-28	Harbor Primary Care Associates	$457.00	Denied
CLM-2026-032086	2025-12-13	Riverside Bone and Joint Center	$436.00	Denied

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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity