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SL-2026-WL-15Gathering docs

C. Wilson

Member M-04113 · Spinal Surgery · Heartland Foods

Member workspace
SP
Sarah Park
Assigned owner
Summary
Member
C. Wilson
Diagnosis
Spinal Surgery
M48.062
Carrier
Sun Life Financial
Total claims
$80,000
Spec deductible
$100,000
New eligible paid
$0
below $500 threshold
Source: Javelina
Packet 22 days old — stale, refresh before submitting
Packet checklist1/7
Filing threshold watch
Not ready to file yet
Claim ledger
SL-2026-WL-15-submission-1-claim-ledger.xlsx
Paid claims from Jan 1, 2026 to May 24, 2026
Combined PDF
SL-2026-WL-15-submission-1-filing-packet.pdf
Auto cover sheet + checklist supporting documents
Submission 1 · Initial filing
No filing draft yet. New eligible paid is $0, below the configured $500 filing creation threshold. Template: Platform reimbursement request form.
Current cumulative paid
$80,000
Last filed cumulative paid
None yet
New eligible paid
$0
Filing creation threshold
$500
Current filing record
SL-2026-WL-15-F01 · Initial filing
Watching
Paid periodJan 1, 2026 to May 24, 2026
Spec applied$100,000
New eligible paidNo new paid claims yet
Cumulative paid through$80,000
Filing threshold$500
Printed claim threshold$10,000

Member is over spec, but only $0 is newly eligible; wait until the configured $500 filing creation threshold is met.

Claim detail
Claim Details
DateProviderDx codeAmount
2026-02-19Mayo Clinic — NeurosurgeryM48.062$49,600
2026-04-05Mayo Outpatient PTM48.062$17,600
2026-05-05Walgreens PharmacyM48.062$12,800
Total$80,000
Pre-stage monitoring
Member is at 80% of the $100,000 spec deductible. No filing yet — system is pre-assembling docs so we can file the moment cumulative claims cross spec.
Pre-staged docs1/7
Activity
  1. Member at 80% of spec — watchlist add
    May 20, 2026
  2. Reviewed pending claims
    May 24, 2026·Sarah Park
    Found $48K hospital itemization request from Mar 8 — chasing now
  3. Stalled · multiple blockers, packet at risk of going stale
    UM 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