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JT
James Torres
Assigned owner
Summary
Member
J. Riley
Diagnosis
NICU
P07.25
Carrier
Berkley Accident & Health
Total claims
$175,000
Spec deductible
$100,000
Amount to file
$75,000
claims above spec deductible
Source: Cigna
Packet 30 days old — stale, refresh before submitting
Packet checklist1/7
Draft filing packet
Packet ready to file
Claim ledger
SL-2026-0170-submission-1-claim-ledger.xlsx
Paid claims from Jan 1, 2026 to May 16, 2026
Combined PDF
SL-2026-0170-submission-1-filing-packet.pdf
Auto cover sheet + checklist supporting documents
Submission 1 · Initial filing
Ready-to-file draft packet. Applies the $100,000 spec deductible and requests $75,000 above deductible. Template: Platform reimbursement request form.
Current cumulative paid
$175,000
Last filed cumulative paid
None yet
New eligible paid
$75,000
Filing creation threshold
$1,000
Current filing record
SL-2026-0170-F01 · Initial filing
DraftPaid periodJan 1, 2026 to May 16, 2026
Spec applied$100,000
Amount to request$75,000
Cumulative paid through$175,000
Filing threshold$1,000
Printed claim threshold$10,000
Initial filing applies the specific deductible; request amount is paid claims above deductible.
Claim detail
Claim Details
| Date | Provider | Dx code | Amount |
|---|---|---|---|
| 2026-02-11 | UCSF Benioff Children's — NICU | P07.25 | $126,000 |
| 2026-02-26 | UCSF Imaging | P07.25 | $28,000 |
| 2026-04-12 | BabySteps Pediatric Specialty | P07.25 | $21,000 |
| Total | $175,000 | ||
Submit packet to carrier
Blocked — deductible not funded
Underlying claims haven't been paid yet — employer is short on the plan-account wire. We can't file for spec reimbursement until the plan has actually paid out the $12K.
Documents1/7 required
Pushback risk cleared3/3 cleared
Stuck on
UM and HR
Waiting on pre-cert + active-at-work attestation
11 days since last meaningful update
Activity
- Active-at-work email sent to Northern Logistics HRMay 7, 2026
- Pre-cert auto follow-up sent — UM still has not respondedMay 12, 2026
- AAW auto follow-up #1 sentMay 14, 2026
- Plan account short on deductible wire — Accounting notifiedMay 16, 2026Employer is short on the deposit needed to fund underlying claims; cannot file until plan pays
- Escalated to Accounting leadMay 19, 2026·James TorresPinged finance contact at Northern Logistics; expecting wire by end of week
- AAW auto follow-up #2 sent — still no response from HRMay 23, 2026
- Stalled · multiple blockers, packet at risk of going staleUM has not responded to pre-cert; HR has not replied to active-at-work follow-ups. Manual escalation needed.
Carrier risk checks
Carrier pushback risk