Claims workbench/CLM-2026-021533

Institutional claim · UB-04 · EDI 837I

CLM-2026-021533

Pinecrest Regional Medical Center, Emergency Medicine. Service 2026-01-14 at emergency room (POS 23). Received 2026-01-27.

Needs reviewReplacement of CLM-2026-021532Out of network

Billed

$170.00

1 line

Allowed

$76.50

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

REPL

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Frances Payne
Member ID: UHC-09678-38
Date of birth: 1999-10-16
Identity: Verified4 records, confidence 0.97
Claim record: CLMCLM-412503
Relationship: Self, San Diego, CA

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-8879
Coverage period: 2021-10-01 to present
Deductible: $17.64 of $3,500.001%
Out-of-pocket maximum: $5,375.85 of $14,000.0038%
Copays: office $40.00, specialist $40.00, emergency $250.00
Physical therapy visits: 16 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	71046 rev 0320	Chest X-ray, two views	—	1	1	$170.00	$76.50	—	—	Review
Totals						$170.00	$76.50	—	—

Diagnoses (ICD-10-CM)

1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
2. R55 Syncope and collapse
3. J18.9 Pneumonia, unspecified organism

Claim header

Patient account: PA-453369
Frequency code: 7 (replacement)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 12 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-007339 (verified, link confidence 0.97).
Eligibility	Pass		Active on 2026-01-14: OPTIONS-PPO (PPO), effective 2021-10-01.
Timely filing	Pass		Received 13 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-021532; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Regional Medical Center2026-01-14 15:25
Established patient presents with sprain of unspecified ligament of right ankle, initial encounter; symptoms reviewed and vitals within expected range. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-01-27 05:29
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.

Attachments

Documents received with the claim

Itemized billitemized_PA-453369.pdf4 pages
Itemised statement totalling $170.00 across 1 line.
Er reported_report_PA-453369.pdf6 pages
Emergency department record: triage acuity 2, chief complaint sprain of unspecified ligament of right ankle, initial encounter.
Corrected claimcorrected_CLM-2026-021532.pdf1 page
Provider cover letter requesting replacement of CLM-2026-021532.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Replacement claim: Frequency code 7 replaces CLM-2026-021532; the original must be voided when this adjudicates. 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-2026-024815	2026-02-03	Mesa Behavioral Health	$3,398.00	Needs review
CLM-2026-021532	2026-01-14	Pinecrest Regional Medical Center	$170.00	Approved

AI recommendation

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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

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: Replacement

Replacement claim supersedes the original.

Review queue Member identity