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SL-2026-0174Gathering docs Advance funded

I. Bennett

Member M-09501 · Transplant · Cascade Manufacturing

Member workspace
MC
Maria Chen
Assigned owner
Summary
Member
I. Bennett
Diagnosis
Transplant
C92.00
Carrier
Tokio Marine HCC
Total claims
$295,000
Spec deductible
$150,000
Amount to file
$145,000
claims above spec deductible
Source: Javelina
Packet 34 days old — stale, refresh before submitting
Packet checklist5/7
Draft filing packet
Packet ready to file
Claim ledger
SL-2026-0174-submission-1-claim-ledger.xlsx
Paid claims from Jan 1, 2026 to May 12, 2026
Combined PDF
SL-2026-0174-submission-1-filing-packet.pdf
Auto cover sheet + checklist supporting documents
Submission 1 · Initial filing
Ready-to-file draft packet. Applies the $150,000 spec deductible and requests $145,000 above deductible. Template: Platform reimbursement request form.
Current cumulative paid
$295,000
Last filed cumulative paid
None yet
New eligible paid
$145,000
Filing creation threshold
$0
Current filing record
SL-2026-0174-F01 · Initial filing
Draft
Paid periodJan 1, 2026 to May 12, 2026
Spec applied$150,000
Amount to request$145,000
Cumulative paid through$295,000
Filing threshold$0
Printed claim threshold$10,000

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

Claim detail
Claim Details
DateProviderDx codeAmount
2026-01-22Memorial Sloan KetteringC92.00$162,250
2026-02-06MSK OutpatientC92.00$53,100
2026-03-13Accredo Specialty PharmacyC92.00$35,400
2026-04-22MSK Follow-up ClinicC92.00$44,250
Total$295,000
Submit packet to carrier
Advance-funded · 15 days late
Provider check is on hold pending carrier approval. Every day this stays unfiled, the provider has been waiting on payment.
Documents5/7 required
Pushback risk cleared2/3 cleared
1 carrier pushback risk flagged for review below
Stuck on
Member
Waiting on COB attestation / Medicare carve-out waiver
15 days since last meaningful update
Activity
  1. Filing packet auto-assembled
    May 12, 2026
    Claim ledger, pre-cert, AAW, and case-mgmt pulled. COB query fired in parallel.
  2. COB query returned ambiguous result
    May 12, 2026
    Insurance discovery API flagged possible Medicare Part B — member-signed Medicare carve-out waiver required before submission
  3. Member outreach sent
    May 12, 2026
    Email + SMS to member requesting Medicare waiver signature via member portal
  4. Auto follow-up #1 sent to member — no response yet
    May 16, 2026
  5. Auto follow-up #2 sent to member — still no response
    May 20, 2026
  6. Called member directly
    May 25, 2026·Maria Chen
    Left voicemail; will retry tomorrow. Considering employer-side escalation if no reply by Friday.
  7. COB ambiguous · need member attestation before filing
    Insurance discovery API flagged possible Medicare Part B — member-signed Medicare carve-out waiver required before submission
Carrier risk checks
Carrier pushback risk