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SL-2026-0160Gathering docs

N. Ito

Member M-06701 · NICU · Pacific Health Network

Member workspace
DN
David Nguyen
Assigned owner
Summary
Member
N. Ito
Diagnosis
NICU
P07.25
Carrier
Sun Life Financial
Total claims
$178,000
Spec deductible
$175,000
Amount to file
$3,000
claims above spec deductible
Source: Javelina
Packet 28 days old — stale, refresh before submitting
Packet checklist5/7
Draft filing packet
Packet ready to file
Claim ledger
SL-2026-0160-submission-1-claim-ledger.xlsx
Paid claims from Jan 1, 2026 to May 18, 2026
Combined PDF
SL-2026-0160-submission-1-filing-packet.pdf
Auto cover sheet + checklist supporting documents
Submission 1 · Initial filing
Ready-to-file draft packet. Applies the $175,000 spec deductible and requests $3,000 above deductible. Template: Platform reimbursement request form.
Current cumulative paid
$178,000
Last filed cumulative paid
None yet
New eligible paid
$3,000
Filing creation threshold
$500
Current filing record
SL-2026-0160-F01 · Initial filing
Draft
Paid periodJan 1, 2026 to May 18, 2026
Spec applied$175,000
Amount to request$3,000
Cumulative paid through$178,000
Filing threshold$500
Printed claim threshold$10,000

Initial filing applies the specific deductible; request amount is paid claims above deductible.

Claim detail
Claim Details
DateProviderDx codeAmount
2026-02-13Texas Children's Hospital — NICUP07.25$128,160
2026-02-28Texas Children's ImagingP07.25$28,480
2026-04-14Pediatrix Medical GroupP07.25$21,360
Total$178,000
Submit packet to carrier
Funded — ready to submit
Plan has paid the underlying claims through the spec deductible. Ready to file for reimbursement of the amount above spec.
Documents5/7 required
Pushback risk cleared3/3 cleared
Stuck on
Member
Waiting on COB attestation / Medicare carve-out waiver
9 days since last meaningful update
Activity
  1. Spec deductible triggered
    May 9, 2026
  2. Filing packet auto-assembled
    May 9, 2026
  3. COB query returned ambiguous result
    May 9, 2026
    Insurance discovery API flagged possible secondary coverage through spouse plan — manual verification required
  4. Member outreach sent
    May 9, 2026
    Requested confirmation of spouse coverage status via member portal
  5. Called member
    May 24, 2026·David Nguyen
    Member confirmed no other coverage; need attestation in writing per carrier requirements
  6. COB ambiguous · need member attestation before filing
    Insurance discovery API flagged possible secondary coverage through spouse plan — manual verification required
Carrier risk checks
Carrier pushback risk