Claims workbench/CLM-2026-016789

Institutional claim · UB-04 · EDI 837I

CLM-2026-016789

Pinecrest Regional Medical Center, Emergency Medicine. Service 2025-12-02 at emergency room (POS 23). Received 2026-01-15.

ApprovedOut of network

Billed

$2,227.00

1 line

Allowed

$1,002.15

contract rate applied

Plan pays

$752.15

approved

Member owes

$250.00

copay / deductible / 30% coinsurance

Rules engine

Clean

no reason codes

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Margaret Cole
Member ID: UHC-65282-20
Date of birth: 1973-09-02
Identity: Verified6 records, confidence 0.99
Claim record: CLMCLM-416642
Relationship: Self, Sacramento, CA

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-4072
Coverage period: 2025-09-01 to present
Deductible: $427.02 of $1,500.0028%
Out-of-pocket maximum: $297.37 of $4,500.007%
Copays: office $40.00, specialist $60.00, emergency $250.00
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 / 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	99285 rev 0450	Emergency department visit, high severity with threat to life	—	1	1	$2,227.00	$1,002.15	$250.00	$752.15	Paid
Totals						$2,227.00	$1,002.15	$250.00	$752.15

Diagnoses (ICD-10-CM)

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

Claim header

Patient account: PA-243766
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Detail
Member identity	Pass	Attached to MBR-001759 (verified, link confidence 0.99).
Eligibility	Pass	Active on 2025-12-02: OPTIONS-PPO (PPO), effective 2025-09-01.
Timely filing	Pass	Received 44 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	Pass	Required documentation present.
High-dollar review	Pass	Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Regional Medical Center2025-12-02 14:28
Established patient presents with sprain of unspecified ligament of right ankle, initial encounter; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

Itemized billitemized_PA-243766.pdf2 pages
Itemised statement totalling $2227.00 across 1 line.
Er reported_report_PA-243766.pdf3 pages
Emergency department record: triage acuity 4, chief complaint sprain of unspecified ligament of right ankle, initial encounter.

Explanation of benefits

What the member will see

Amount billed

$2,227.00

Plan discount

$1,224.85

out-of-network allowance

Plan paid

$752.15

You may owe

$250.00

copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

Rules engineApproved2026-10-21 13:43
Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-014353	2026-01-04	Sunrise Orthopedic Specialists	$232.00	Needs review
CLM-2026-014352	2026-01-04	Pinecrest Bone and Joint Center	$232.00	Approved

AI recommendation

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

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved 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: Clean

Clean claim, priced at contract rate.

Review queue Member identity