Claims workbench/CLM-2026-027467

Institutional claim · UB-04 · EDI 837I

CLM-2026-027467

Harbor Regional Medical Center, Emergency Medicine. Service 2026-02-28 at emergency room (POS 23). Received 2026-06-25.

Denied

Billed

$2,508.00

2 lines

Allowed

$1,379.40

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Michelle Luna
Member ID: UHC-80345-60
Date of birth: 2001-07-03
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-407709
Relationship: Self, Los Angeles, CA

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-5396
Coverage period: 2024-07-01 to present
Deductible: $353.22 of $1,500.0024%
Out-of-pocket maximum: $2,237.95 of $4,500.0050%
Copays: office $25.00, specialist $75.00, emergency $150.00
Physical therapy visits: 1 of 20 used

Provider

Billing and rendering

Billing provider: Harbor Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI: 9303939968
Network: In network
Rendering NPI: 9303939968
Location: Tempe, AZ · TIN 60-9523328
Authorisation / referral: none / REF660086

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	$2,265.00	$1,245.75	—	—	DeniedCO29
2	96374 rev 0260	IV push, single drug	—	1	1,2	$243.00	$133.65	—	—	DeniedCO29
Totals						$2,508.00	$1,379.40	—	—

Diagnoses (ICD-10-CM)

1. R10.9 Unspecified abdominal painprincipal
2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter

Claim header

Patient account: PA-923009
Frequency code: 1 (original)
Accident: Yes
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-034055 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-02-28: CORE-HMO (HMO), effective 2024-07-01.
Timely filing	Fail	CO29	Received 117 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	Pass		In-network provider Harbor Regional Medical Center (9303939968).
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: Harbor Regional Medical Center2026-02-28 15:24
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-06-25 03:35
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.

Attachments

Documents received with the claim

Itemized billitemized_PA-923009.pdf9 pages
Itemised statement totalling $2508.00 across 2 lines.
Er reported_report_PA-923009.pdf5 pages
Emergency department record: triage acuity 2, chief complaint unspecified abdominal pain.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Timely filing: Received 117 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-022106	2026-05-18	Northgate Internal Medicine Associates	$101.00	Needs review
CLM-2026-022105	2026-05-18	Northgate Internal Medicine Associates	$101.00	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