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SL-2026-0072Approved Advance funded
G. Hayes
Member M-05509 · Transplant · Atlas Tech Group
Member workspaceJT
James Torres
Assigned owner
Summary
Member
G. Hayes
Diagnosis
Transplant
C92.00
Carrier
Voya Financial
Total claims
$195,000
Spec deductible
$125,000
Amount to file
$70,000
claims above spec deductible
Filed
$70,000
Reimbursed
$50,000
Outstanding
$20,000
Source: Cigna
Packet 24 days old — stale, refresh before submitting
Packet checklist7/7
Filing output and history
Filing output
Claim ledger
SL-2026-0072-submission-2-claim-ledger.xlsx
Paid claims from Mar 29, 2026 to May 22, 2026
Combined PDF
SL-2026-0072-submission-2-filing-packet.pdf
Auto cover sheet + checklist supporting documents
Submission 2 · Subsequent incremental filing
Subsequent filing is incremental: new eligible paid claims since the last filed cumulative paid amount. Template: Platform reimbursement request form.
Current cumulative paid
$195,000
Last filed cumulative paid
$195,000
New eligible paid
$0
Filing creation threshold
$1,000
Filing records for this member
SL-2026-0072-F01 · Initial filing
Partial reimbursementPaid periodJan 1, 2026 to Mar 28, 2026
Spec applied$125,000
Filed amount$70,000
Cumulative paid through$195,000
Filing threshold$1,000
Printed claim threshold$10,000
Initial filing is still open: carrier reimbursed part of the request and the remaining dollars need denial/more-info follow-up. New filings still start after this filing’s cumulative paid amount.
SL-2026-0072-F02 · Subsequent filing
WatchingPaid periodMar 29, 2026 to May 22, 2026
Spec applied$0
New eligible paidNo new paid claims yet
Cumulative paid through$195,000
Filing threshold$1,000
Printed claim threshold$10,000
Future treatment would open as a separate filing once new eligible paid claims meet the configured filing creation threshold.
Claim detail
Claim Details
| Date | Provider | Dx code | Amount |
|---|---|---|---|
| 2025-11-08 | Cleveland Clinic — Main | C92.00 | $107,250 |
| 2025-11-23 | Cleveland Clinic — Outpatient | C92.00 | $35,100 |
| 2025-12-28 | Walgreens Specialty Rx | C92.00 | $23,400 |
| 2026-02-06 | Cleveland Clinic — Bone Marrow Clinic | C92.00 | $29,250 |
| Total | $195,000 | ||
Communication history
Communication3 messages
From usclaims@voyafinancial.com
Mar 28, 2026[SL-2026-0072] Transplant stop-loss filing — G. Hayes
Stop-loss claim filing for G. Hayes (M-05509). Attached: claim ledger flat file plus combined PDF packet with supporting docs.
SL-2026-0072-claim-ledger.xlsx SL-2026-0072-filing-packet.pdf fee-invoices.pdf um-case-management-notes.pdf aaw-cob-forms.pdf
From carrierclaims@voyafinancial.com
Apr 22, 2026Re: [SL-2026-0072] Transplant stop-loss filing — G. Hayes
Carrier flagged $20K of surgical fees for UCR (usual, customary, reasonable) review
From carrierclaims@voyafinancial.com
May 12, 2026Re: [SL-2026-0072] Transplant stop-loss filing — G. Hayes
$50K paid against the $70K filed; $20K denied citing UCR review on surgical fees
Action: Sub-appeal on outstanding balance
Partial payment received
Reimbursed$50,000
Outstanding$20,000
Review the outstanding balance and decide whether to appeal or close the variance.
Stuck on
Carrier
Waiting on carrier review
5 days since last meaningful update
Activity
- Spec deductible triggeredFeb 26, 2026
- Filed to carrierMar 28, 2026·James Torres
- Approved with adjustmentApr 22, 2026·VoyaCarrier flagged $20K of surgical fees for UCR (usual, customary, reasonable) review
- Partial payment receivedMay 12, 2026·Voya$50K paid against the $70K filed; $20K denied citing UCR review on surgical fees
- Sub-appeal pack auto-assembledMay 17, 2026System pulled comparable surgical-fee data from prior approved cases at same facility
- Sub-appeal submitted on $20K balanceMay 22, 2026·James Torres
- Partial reimbursement · outstanding balance needs reviewCarrier reimbursed part of the request; review the outstanding balance and decide whether to appeal or write off.
Carrier risk checks
Carrier pushback risk