Claims workbench/CLM-2026-030620

Institutional claim · UB-04 · Paper

CLM-2026-030620

Mesa Regional Medical Center, Emergency Medicine. Service 2026-05-27 at emergency room (POS 23). Received 2026-06-09.

DeniedOut of network

Billed

$3,001.00

2 lines

Allowed

$1,650.55

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Andrew Wagn
Member ID: UHC-05635-36
Date of birth: 1968-03-11
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-402365
Relationship: Child, Nashville, TN

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-6259
Coverage period: 2021-05-01 to 2026-02-06
Deductible: $289.13 of $1,500.0019%
Out-of-pocket maximum: $1,706.17 of $4,500.0038%
Copays: office $20.00, specialist $60.00, emergency $250.00
Physical therapy visits: 8 of 20 used

Provider

Billing and rendering

Billing provider: Mesa Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI: 3600007819
Network: Out of network
Rendering NPI: 3600007819
Location: Tampa, FL · TIN 90-5702951
Authorisation / referral: none / REF324879

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	$1,874.00	$1,030.70	—	—	DeniedCO27
2	99284 rev 0450	Emergency department visit, high severity	—	1	1,2	$1,127.00	$619.85	—	—	DeniedCO27
Totals						$3,001.00	$1,650.55	—	—

Diagnoses (ICD-10-CM)

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

Claim header

Patient account: PA-120891
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-034302 (provisional, link confidence 1.00).
Eligibility	Fail	CO27	Date of service 2026-05-27 is after coverage terminated on 2026-02-06. Expenses incurred after coverage terminated
Timely filing	Pass		Received 13 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 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Mesa Regional Medical Center2026-05-27 14:21
Follow-up for sprain of unspecified ligament of right ankle, initial encounter. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-06-09 05:39

Attachments

Documents received with the claim

Itemized billitemized_PA-120891.pdf7 pages
Itemised statement totalling $3001.00 across 2 lines.
Er reported_report_PA-120891.pdf3 pages
Emergency department record: triage acuity 4, chief complaint sprain of unspecified ligament of right ankle, initial encounter.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Eligibility: Date of service 2026-05-27 is after coverage terminated on 2026-02-06. 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

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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity