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SL-2026-0098Carrier denied Advance funded

L. Okafor

Member M-09114 · Oncology · Cascade Manufacturing

Member workspace
MC
Maria Chen
Assigned owner
Summary
Member
L. Okafor
Diagnosis
Oncology
C50.912
Carrier
Berkley Accident & Health
Total claims
$220,000
Spec deductible
$150,000
Amount to file
$70,000
claims above spec deductible
Filed
$70,000
Reimbursed
$0
Outstanding
$70,000
Source: Javelina
Packet 30 days old — stale, refresh before submitting
Packet checklist7/7
Filing output and history
Filing output
Claim ledger
SL-2026-0098-submission-2-claim-ledger.xlsx
Paid claims from Apr 8, 2026 to May 16, 2026
Combined PDF
SL-2026-0098-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
$220,000
Last filed cumulative paid
$220,000
New eligible paid
$0
Filing creation threshold
$1,000
Filing records for this member
SL-2026-0098-F01 · Initial filing
Submitted
Paid periodJan 1, 2026 to Apr 7, 2026
Spec applied$150,000
Filed amount$70,000
Cumulative paid through$220,000
Filing threshold$1,000
Printed claim threshold$10,000

Initial filing applied the specific deductible and set the last filed cumulative paid amount for future filings.

SL-2026-0098-F02 · Subsequent filing
Watching
Paid periodApr 8, 2026 to May 16, 2026
Spec applied$0
New eligible paidNo new paid claims yet
Cumulative paid through$220,000
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
DateProviderDx codeAmount
2025-12-13Mayo Clinic — OncologyC50.912$136,400
2026-01-27Mayo InfusionC50.912$48,400
2026-02-26Optum Specialty PharmacyC50.912$35,200
Total$220,000
Communication history
Communication4 messages
From usclaims@berkleyaccidenthealth.com
Apr 7, 2026
[SL-2026-0098] Oncology stop-loss filing — L. Okafor

Stop-loss claim filing for L. Okafor (M-09114). Attached: claim ledger flat file plus combined PDF packet with supporting docs.

SL-2026-0098-claim-ledger.xlsx SL-2026-0098-filing-packet.pdf fee-invoices.pdf um-case-management-notes.pdf aaw-cob-forms.pdf
From carrierclaims@berkleyaccidenthealth.com
Apr 22, 2026
Re: [SL-2026-0098] Oncology stop-loss filing — L. Okafor

Carrier asked for the COB / no-subrogation result.

Action: Forward COB discovery PDF
From usclaims@berkleyaccidenthealth.com
May 7, 2026
Re: [SL-2026-0098] Oncology stop-loss filing — L. Okafor

COB confirmation submitted

From carrierclaims@berkleyaccidenthealth.com
May 16, 2026
Re: [SL-2026-0098] Oncology stop-loss filing — L. Okafor

Reason: "Service not covered by contract" — citing exclusion 4.2(c). Appeal window 60 days.

Action: Open appeal within window
Carrier denied — appeal
Denied 11 days ago
Reason: Reason: "Service not covered by contract" — citing exclusion 4.2(c). Appeal window 60 days.
Standard appeal window: 60 days from denial.
System has the rebuttal pack pre-assembled — review and send.
Stuck on
Carrier
Waiting on denial — appeal needs to be filed
11 days since last meaningful update
Activity
  1. Filed to carrier
    Apr 7, 2026·Maria Chen
  2. Request for COB documentation
    Apr 22, 2026·Berkley A&H
  3. COB confirmation submitted
    May 7, 2026·Maria Chen
  4. Denial received
    May 16, 2026·Berkley A&H
    Reason: "Service not covered by contract" — citing exclusion 4.2(c). Appeal window 60 days.
  5. Denial parsed — appeal pack auto-assembled
    May 18, 2026
    System pulled plan-doc Section 4.2 in full plus comparable approved cases at the same carrier; rebuttal cites direct contradiction of exclusion 4.2(c)
  6. Reviewed appeal pack
    May 24, 2026·Maria Chen
    Adding two prior approval references from same carrier before submitting; targeting tomorrow
  7. Carrier denied · rep needs to review appeal path
    Reason: "Service not covered by contract" — citing exclusion 4.2(c). Appeal window 60 days.
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