Claims workbench/CLM-2026-031143

Institutional claim · UB-04 · EDI 837I

CLM-2026-031143

Sunrise Community Hospital, Emergency Medicine. Service 2026-06-18 at emergency room (POS 23). Received 2026-07-16.

PendedOut of network

Billed

$3,800.00

2 lines

Allowed

$1,710.00

if approved

Plan pays

—

Pended

Member owes

—

no coverage

Rules engine

Pend

N30

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Omar Perez
Member ID: none on golden record
Date of birth: 1976-02-05
Identity: Verified4 records, confidence 1.00
Claim record: CLMCLM-424386
Relationship: Self, Las Vegas, NV

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Sunrise Community Hospital
Emergency Medicine · taxonomy 207P00000X
NPI: 2411187117
Network: Out of network
Rendering NPI: 2411187117
Location: Tempe, AZ · TIN 19-3902018
Authorisation / referral: none / REF538439

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	$2,281.00	$1,026.45	—	—	PendedN30
2	99284 rev 0450	Emergency department visit, high severity	—	1	1	$1,519.00	$683.55	—	—	PendedN30
Totals						$3,800.00	$1,710.00	—	—

Diagnoses (ICD-10-CM)

1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal

Claim header

Patient account: PA-202569
Frequency code: 1 (original)
Accident: Yes
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-007611 (verified, link confidence 1.00).
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 28 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	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: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Sunrise Community Hospital2026-06-18 12:42
Follow-up for sprain of unspecified ligament of right ankle, initial encounter. Plan discussed, medications reconciled. Patient presented to the nearest emergency department with acute symptoms; care could not safely be delayed to reach an in-network facility.
SystemSystem: Claims system2026-07-16 06:42
Out-of-network emergency visit. Emergency services are payable at the in-network level when the prudent-layperson standard is met.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-16 17:02
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Itemized billitemized_PA-202569.pdf6 pages
Itemised statement totalling $3800.00 across 2 lines.
Er reported_report_PA-202569.pdf5 pages
Emergency department record: triage acuity 3, chief complaint sprain of unspecified ligament of right ankle, initial encounter.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Eligibility: No coverage segment found for the member ID on this claim. 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

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