Claims workbench/CLM-2026-018709

Institutional claim · UB-04 · Paper

CLM-2026-018709

Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-06-09 at emergency room (POS 23). Received 2026-06-19.

PendedOut of networkIdentity on hold: CASE-001053

Billed

$1,766.00

1 line

Allowed

$971.30

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Debra Jensen
Member ID: none on golden record
Date of birth: 1953-08-27
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-400377
Relationship: Self, Las Vegas, NV

Coverage and accumulators

Found by name and date of birth

Plan: NAVIGATE-HMO HMO group GRP-5108
Coverage period: 2025-05-01 to present
Deductible: $1,051.26 of $1,500.0070%
Out-of-pocket maximum: $294.45 of $3,000.0010%
Copays: office $30.00, specialist $50.00, emergency $150.00
Physical therapy visits: 4 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 / REF609001

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	$1,766.00	$971.30	—	—	PendedIDQ
Totals						$1,766.00	$971.30	—	—

Diagnoses (ICD-10-CM)

1. J18.9 Pneumonia, unspecified organismprincipal

Claim header

Patient account: PA-562838
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-001053; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-06-09: NAVIGATE-HMO (HMO), effective 2025-05-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 10 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 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Regional Medical Center2026-06-09 17:23
Established patient presents with pneumonia, unspecified organism; 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 system2026-06-19 00:06
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

Itemized billitemized_PA-562838.pdf6 pages
Itemised statement totalling $1766.00 across 1 line.
Er reported_report_PA-562838.pdf6 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 enginePended2026-10-21 13:43
Member identity: Member record is in open steward case CASE-001053; payment withheld until the identity is confirmed. Eligibility: Active on 2026-06-09: NAVIGATE-HMO (HMO), effective 2025-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. 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

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

Approvedscenario: Oon emergency

Emergency: payable at in-network level.

Review queue Member identity