Claims workbench/CLM-2026-025193

Institutional claim · UB-04 · EDI 837I

CLM-2026-025193

Pinecrest Regional Medical Center, Emergency Medicine. Service 2025-12-14 at emergency room (POS 23). Received 2026-06-11.

DeniedOut of network

Billed

$2,803.00

1 line

Allowed

$1,261.35

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: Kevin King
Member ID: UHC-00010-37
Date of birth: 1980-12-17
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-421553
Relationship: Self, Sacramento, CA

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-2139
Coverage period: 2022-10-01 to present
Deductible: $2,575.23 of $3,500.0074%
Out-of-pocket maximum: $3,355.94 of $7,000.0048%
Copays: office $20.00, specialist $40.00, emergency $250.00
Physical therapy visits: 21 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	$2,803.00	$1,261.35	—	—	DeniedCO29
Totals						$2,803.00	$1,261.35	—	—

Diagnoses (ICD-10-CM)

1. R55 Syncope and collapseprincipal
2. J18.9 Pneumonia, unspecified organism

Claim header

Patient account: PA-994745
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-028615 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2025-12-14: MEDICARE-ADV-A (MA), effective 2022-10-01.
Timely filing	Fail	CO29	Received 179 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	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. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Regional Medical Center2025-12-14 12:57
Follow-up for syncope and collapse. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-06-11 00:43
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-11 09:13
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Itemized billitemized_PA-994745.pdf3 pages
Itemised statement totalling $2803.00 across 1 line.
Er reported_report_PA-994745.pdf2 pages
Emergency department record: triage acuity 2, chief complaint syncope and collapse.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 179 days after the last date of service (limit 90). 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-2026-007226	2026-05-13	Sunrise Behavioral Health	$310.00	Approved
CLM-2026-001496	2026-03-23	Sunrise Clinical Laboratories	$56.00	Approved

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