Synthetic demonstration · No PHI · Not for clinical use · Active development · All organizations and identifiers are fictional

C_Verified: Denial reason conflicts with the submission receipt

Mercy Regional Medical Center · Inpatient EHR
Chart
Orders
Prior Auth
Meds
Notes
Dr. Anjali Patel · Intensivist | 4-East
Carter, James
MRN: 44218 DOB: 03/04/1968 (58 y M) Loc: 4-East (Room 412) Adm: 2026-05-06 Attg: A. Patel MD
Septic Shock AKI ICU NKDA
Admissions › Inpatient Authorization › New request
Inpatient Admission Authorization Request

Admission & level of care

Concurrent review · HealthCorp Plan A · ICU admission
Requested service
Inpatient admission · ICU level of care
Expected length of stay: 5–7 days
Severity criteria invoked: MCG ISC ICU Admission (hemodynamic instability requiring vasopressors + multi-organ dysfunction)
Diagnoses (ICD-10)
A41.9 Sepsis, unspecified organism
R57.2 Septic shock
N17.9 Acute kidney injury (early)
Clinical setting
ICU, inpatient (admitted via ED)
Insurer
HealthCorp Plan A (member ID HC-44218-A)

Pertinent labs

drawn 2026-05-06 13:42
Synthetic laboratory fields included in the modeled authorization submission
TestValueReferenceFlag
WBC22.3 ×10³/µL4.0–11.0High
Procalcitonin28.4 ng/mL< 0.10Critical high
ESR87 mm/hr< 22High
Lactate4.1 mmol/L0.5–2.2High
BUN42 mg/dL7–20High
Creatinine2.4 mg/dL0.7–1.3High (baseline 1.0)
Blood cultureGram-negative rods, ID pendingn/aPositive

Vitals (current)

recorded 2026-05-06 14:12
Synthetic vital-sign fields included in the modeled authorization submission
HRBPTemp
11888 / 52 (on norepi 0.15 mcg/kg/min)39.2 °C

Clinician sign-off

required for inpatient admission authorization
Statement
"Synthetic clinician statement for this demo: ICU level-of-care fields, severity criteria, vasopressor support, lactate, acute kidney injury labs, and expected length of stay are included in the submitted packet. C_Verified records that this statement was submitted; it does not decide whether the clinical judgment is right."
Signed
A. Patel MD · NPI 1245678901 · 2026-05-06 14:18:42 UTC
Ready to run the synthetic submission. 14 fields will be fingerprinted locally for the modeled HealthCorp Plan A request ADM-44218-A. C_Verified local receipt demo
Mercy Regional Medical Center · Inpatient EHR
Chart
Orders
Prior Auth
Meds
Notes
Dr. Anjali Patel | 4-East
Carter, James
MRN: 44218 Loc: 4-East (Room 412) Attg: A. Patel MD
Septic Shock AKI ICU
Admissions › Inpatient Authorization › ADM-44218-A
Submission complete
✓

Synthetic ADM-44218-A submission prepared for HealthCorp Plan A

Local fingerprints computed for the illustrative 2026-05-06 14:18:53 UTC event. Browser-generated receipt ID: rcpt-0001-ADM-44218-A.
C_Verified receipt ready

Submission receipt

browser-generated, illustrative, and locally verifiable
From
Mercy Regional Medical Center · NPI 1992345678
To
HealthCorp Plan A
Patient
Carter, James · MRN 44218
Service
Inpatient admission · ICU level of care · expected LOS 5–7 days
Submitted
2026-05-06 14:18:53.214 UTC
Fields fingerprinted
14 (patient + service and criteria + diagnosis + 7 labs + 3 vitals + clinician sign-off)
Sender hash (SHA-256)
computing…
Demo witness label
tsa.example.org · fictional label used to generate a local witness digest at 14:18:53.700 UTC
Status
Local demo digests ready
PDF download is not included in this browser demo.
Mercy Regional Medical Center · Inpatient EHR
Chart
Orders
Prior Auth
Meds
Notes
Dr. Anjali Patel | 4-East
Carter, James
MRN: 44218 Loc: 4-East (Room 412)
Septic Shock AKI ICU
Admissions › Inpatient Authorization › ADM-44218-A
Determination received · 2026-05-06 14:26:51 UTC
!

Authorization DENIED · Reason given: required fields missing

Simulated HealthCorp Plan A response, eight minutes after the modeled submission.

Determination details

Authorization
ADM-44218-A
Service
Inpatient admission · ICU level of care · expected LOS 5–7 days
Decision
DENIED · stated reason: required fields missing
Decided by
ClaimSavr v4.7.2 (HealthCorp third-party AI)
Decision time
2026-05-06 14:26:51 UTC
Reason
"Required severity, lab, and vital-sign fields were not present in the submitted record."
!
C_Verified flagged a receipt conflict. The denial cites missing fields. The local illustrative receipt (rcpt-0001-ADM-44218-A) records those fields in the modeled submission. This demo makes the case available in the Appeals & Grievances workqueue for human review. It does not prove payer delivery or decide medical necessity.
Mercy Regional · Appeals & Grievances Workqueue
L. Romero, RN · Appeals lead

Open cases

Synthetic appeals workqueue
Case Patient Drug / Service Insurer Reason cited Urgency Evidence
APP-44218-A Carter, James ICU admission (concurrent review) HealthCorp Plan A Required fields missing High C_Verified bundle ready
APP-44181-C Nguyen, Hoa SNF rehab post-discharge BlueLine PPO Skilled-care criteria Medium manual review Not included in demo
APP-44192-B Khalil, Yara Inpatient stay extension HealthCorp Plan B LOS beyond benchmark Low manual review Not included in demo
APP-44209-A Mendoza, Carlos Home health 60d State Medicaid Plan-of-care documentation Low manual review Not included in demo
Mercy Regional · Appeals & Grievances Case APP-44218-A
L. Romero, RN

Carter, James · ICU Admission Authorization Appeal

Insurer: HealthCorp Plan A Decision by: ClaimSavr v4.7.2 Submitted: 2026-05-06 14:18:53 UTC Denied: 2026-05-06 14:26:51 UTC
High urgency · Active patient (septic shock + AKI) C_Verified evidence ready
ClaimSavr's stated denial reason · required fields missing
Required severity and service fields
claimed missing in the submitted record
✕
Required lab and vital-sign fields
claimed missing in the submitted record
✕
Local illustrative receipt · fields included in the modeled submission
Diagnoses
A41.9 Sepsis · R57.2 Septic shock · N17.9 AKI
✓
Submitted hemodynamic fields
Blood pressure
88 / 52 mmHg, on norepinephrine 0.15 mcg/kg/min
✓
Heart rate
118 bpm, sinus tachycardia
✓
Lactate
4.1 mmol/L · submitted value
✓
Submitted renal laboratory fields
Creatinine
2.4 mg/dL · baseline field 1.0
✓
BUN
42 mg/dL · submitted value
✓
Other submitted laboratory fields
Procalcitonin
28.4 ng/mL · submitted value
✓
WBC
22.3 ×10³/µL · submitted value
✓
ESR
87 mm/hr · submitted value
✓
Blood culture
Gram-negative rods, ID pending
✓
Additional submitted fields
Temperature
39.2 °C · febrile
✓
Clinician sign-off
A. Patel MD, NPI 1245678901 · submitted with the packet
✓

The denial reason needs review.

ClaimSavr's simulated denial stated that the submission lacked required fields. The browser-generated receipt records the vasopressor, lactate, BUN, creatinine, and vital-sign fields in the modeled submission, each with a local SHA-256 digest. A separate browser recomputation produces the same composite value. That local match does not prove delivery to HealthCorp. A human appeals or compliance team decides what to do next.
Sender hash
computing…
Simulated receiver replay hash
computing…
LOCAL MATCH · A separate browser recomputation used the same synthetic package bytes. No external receipt is claimed.
Case APP-44218-A › Evidence › rcpt-0001-ADM-44218-A
PDF download is not included.
Illustrative Browser-Generated Submission Receipt

rcpt-0001-ADM-44218-A

Local SHA-256 evidence of what this synthetic authorization package contains

Parties

Submitting entity
Mercy Regional Medical Center · NPI 1992345678
Modeled receiving entity
HealthCorp Plan A · Member ID HC-44218-A
Subject patient
Carter, James · MRN 44218 · DOB 03/04/1968
Subject service
Inpatient admission · ICU level of care · expected LOS 5–7 days
ICD-10: A41.9 Sepsis · R57.2 Septic shock · N17.9 Acute kidney injury
Severity criteria: MCG ISC ICU Admission

Transmission

Submitted at
2026-05-06T14:18:53.214Z (UTC)
Modeled channel
X12-278 over a fictional HealthCorp payer interface (concurrent review)
Field count
14 fields (patient + service and criteria + diagnosis + seven labs + three vitals + clinician sign-off)

Per-field SHA-256 digests

Local SHA-256 digest for each synthetic submitted field
FieldSHA-256 digest
computing…

Composite sender hash

computing…

Simulated receiver replay hash, generated locally

computing…

Simulated witness digest

Witness label: tsa.example.org (fictional demo label)
Digest method: Local SHA-256 over the witness label, sender hash, and illustrative timestamp
Witness digest: computing…
Illustrative timestamp: 2026-05-06T14:18:53.700Z
This browser can re-derive the per-field digests, composite sender hash, simulated receiver replay hash, linked local receipt digests, and simulated witness digest from the synthetic values shown here. No transmission, payer acknowledgement, independent witness, digital signature, or external timestamp is established by this page.

Draft compliance reports · Case APP-44218-A

Each report is a local illustrative draft. Nothing is sent from this page. A human hospital team would decide whether to approve an external delivery, and a configured production workflow would need separate delivery evidence. The demo links local draft records into its browser-generated bundle.
Hospital appeals lead internal appeal review
Prior-authorization denial reason conflicts with the submission receipt
The simulated insurer AI response says required fields were missing. The browser-generated submission receipt records those fields in the modeled package. Prepared as an internal draft for the hospital's appeals team to review.
tracking: PA-REVIEW-2026-44218A · receipt: rcpt-0003-APPEAL
Prepared 14:32:18 UTC
Draft, awaiting sign-off
Compliance team escalation decision
Review whether the receipt conflict should be escalated
The simulated HealthCorp response denies an authorization on the stated basis that required fields were missing. The local illustrative receipt contains those fields and carries an earlier modeled timestamp. Prepared as a draft; the hospital decides whether any external escalation is appropriate.
tracking: ESC-2026-MA-44218A · receipt: rcpt-0004-REVIEW
Prepared 14:32:18 UTC
Draft, awaiting sign-off
ClaimSavr, Inc. third-party AI vendor
Receipt evidence and corrective-action request
The synthetic model response denied an authorization citing missing fields that the local demo receipt records in the package. This draft asks the vendor to review the mismatch. It is not sent from this page.
tracking: AIV-44218A · receipt: rcpt-0005-AIV
Prepared 14:32:18 UTC
Draft, awaiting sign-off
Audit bundle · Case APP-44218-A

Local illustrative evidence package is ready.

This browser-generated bundle models evidence an appeals or compliance reviewer could inspect. It contains the synthetic submission receipt, local draft records, a simulated receiver replay record, and a simulated witness digest. The verifier below recomputes the exact local hashes shown on this page. It does not establish payer delivery, an independent witness, a signed certificate, or production readiness.

Bundle ID
BND-44218-A
Generated
2026-05-06 14:32:25 UTC
Receipts included
5
Demo witness
1 local simulated witness digest using the fictional label tsa.example.org
Local integrity check
READY
Format
Browser-generated data illustration · no download included

Contents

✓ rcpt-0001-ADM-44218-AOriginal ICU admission auth submission …
✓ rcpt-0002-REPLAYLocal simulated receiver replay record …
✓ rcpt-0003-APPEALAppeal review draft …
✓ rcpt-0004-REVIEWEscalation review draft …
✓ rcpt-0005-AIVClaimSavr corrective-action notice …
✓ witness-0001Local simulated witness digest (fictional label) …
Bundle download is not included in this demo. Verify recomputes the exact local hashes shown in this browser demo.
This verifier checks local consistency only. It recomputes 14 per-field digests, both composite package computations, five linked receipt digests, and one simulated witness digest. Independent assurance would require separately retained evidence from the relevant systems or witness.
Step 1 of 8 Clinician submits ICU admission authorization
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