Claims workbench/CLM-2026-034430
Institutional claim · UB-04 · EDI 837I

CLM-2026-034430

Desert Regional Medical Center, Emergency Medicine. Service 2026-02-03 at emergency room (POS 23). Received 2026-02-12.

Pended
Billed
$1,029.00
1 line
Allowed
$565.95
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Pend
CO16
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

The claim record could not be attached to a resolved identity. Resolve it in the steward queue first.

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-7600
Coverage period
2022-05-01 to present
Deductible
$2,704.12 of $3,500.0077%
Out-of-pocket maximum
$2,303.29 of $10,500.0022%
Copays
office $20.00, specialist $50.00, emergency $150.00
Physical therapy visits
3 of 20 used

Provider

Billing and rendering

Billing provider
Desert Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI
8317237419
Network
In network
Rendering NPI
8317237419
Location
Austin, TX · TIN 55-6992539
Authorisation / referral
none / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199283
rev 0450
Emergency department visit, moderate severity—11$1,029.00$565.95——PendedCO16
Totals$1,029.00$565.95——
Diagnoses (ICD-10-CM)
  • 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
Claim header
Patient account
PA-669325
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityFailCO16Claim record is not attached to a resolved identity.
Claim lacks information needed for adjudication
EligibilityPassActive on 2026-02-03: UNKNOWN (PPO), effective 2022-05-01.
Timely filingPassReceived 9 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Desert Regional Medical Center (8317237419).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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: Desert Regional Medical Center2026-02-03 15:06

    Follow-up for sprain of unspecified ligament of right ankle, initial encounter. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-669325.pdf3 pages

    Itemised statement totalling $1029.00 across 1 line.

  • Er reported_report_PA-669325.pdf3 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

  1. Rules enginePended2026-10-21 13:43
    Member identity: Claim record is not attached to a resolved identity.

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
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: Clean

Clean claim, priced at contract rate.

Review queue