Claims workbench/CLM-2026-016767

Institutional claim · UB-04 · EDI 837I

CLM-2026-016767

Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-05-08 at emergency room (POS 23). Received 2026-06-03.

DeniedOut of network

Billed

$1,483.00

3 lines

Allowed

$815.65

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Mary Lee
Member ID: UHC-16620-48
Date of birth: 1950-04-12
Identity: Verified2 records, confidence 1.00
Claim record: CLMCLM-409117
Relationship: Self, Glendale, AZ

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group N/A
Coverage period: 2024-05-01 to 2026-03-02
Deductible: $159.61 of $500.0032%
Out-of-pocket maximum: $433.32 of $1,000.0043%
Copays: office $20.00, specialist $75.00, emergency $150.00
Physical therapy visits: 7 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 / REF963881

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	96374 rev 0260	IV push, single drug	—	1	1	$244.00	$134.20	—	—	DeniedCO27
2	99283 rev 0450	Emergency department visit, moderate severity	—	1	1	$1,020.00	$561.00	—	—	DeniedCO27
3	71046 rev 0320	Chest X-ray, two views	25	1	1	$219.00	$120.45	—	—	DeniedCO27
Totals						$1,483.00	$815.65	—	—

Diagnoses (ICD-10-CM)

1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal

Claim header

Patient account: PA-302223
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-033457 (verified, link confidence 1.00).
Eligibility	Fail	CO27	Date of service 2026-05-08 is after coverage terminated on 2026-03-02. Expenses incurred after coverage terminated
Timely filing	Pass		Received 26 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. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Regional Medical Center2026-05-08 09:20
Follow-up for sprain of unspecified ligament of right ankle, initial encounter. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-06-03 04:13

Attachments

Documents received with the claim

Itemized billitemized_PA-302223.pdf6 pages
Itemised statement totalling $1483.00 across 3 lines.
Er reported_report_PA-302223.pdf4 pages
Emergency department record: triage acuity 3, 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 2026-05-08 is after coverage terminated on 2026-03-02. 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

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