Claims
Claims workbench
Every claim is attached to a resolved member identity, checked by the rules engine under CLAIMS-ADJ v1 (version 1), priced, and either finalised, pended, or handed to the AI adjudicator and an examiner.
Claims received
34,646
$54,707,511.00 billed
Needs review
3,663
89 with an AI recommendation
Pended
2,587
awaiting information or identity
Approved
23,942
$6,757,768.45 plan paid
Denied
4,454
with remittance reason codes
Examiner decided
1
167 not attached to an identity
| Claim | Member | Service | Provider | Procedures | Billed | Plan pays | Rules | AI | Status |
|---|---|---|---|---|---|---|---|---|---|
| CLM-2026-010612 CMS-1500 · 2026-10-26 | Not attached | 2026-09-05 Office | Canyon Counseling Center Behavioral Health · out of network | 90791 | $375.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-022570 CMS-1500 · 2026-10-21 | Not attached | 2026-10-04 Office | Mesa Family Practice Family Medicine · in network | 99214, 36415, 90471 | $348.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-010611 CMS-1500 · 2026-10-18 | Not attached | 2026-09-05 Office | Northgate Counseling Center Behavioral Health · in network | 90791 | $375.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-024558 CMS-1500 · 2026-10-16 | Not attached | 2026-10-03 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 99214, 99215, 80053 | $712.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-022569 CMS-1500 · 2026-10-09 | Not attached | 2026-10-04 Office | Riverside Medical Group Family Medicine · in network | 99214, 36415, 90471 | $348.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-030480 CMS-1500 · 2026-10-08 | Not attached | 2026-09-01 Office | Valley Cardiovascular Associates Cardiology · in network | 99214 | $220.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-015560 UB-04 · 2026-10-06 | Not attached | 2026-09-26 Outpatient hospital | Pinecrest Heart Institute Cardiology · in network | 93015 | $689.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-017095 CMS-1500 · 2026-10-05 | Not attached | 2026-09-02 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97161, 97014 | $613.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-000032 UB-04 · 2026-10-05 | Not attached | 2026-09-25 Outpatient hospital | Pinecrest Heart Institute Cardiology · in network | 93306 | $1,401.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-022552 CMS-1500 · 2026-10-02 | Not attached | 2026-09-23 Office | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $217.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-008131 CMS-1500 · 2026-10-01 | Not attached | 2026-09-15 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97014 | $379.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-018189 UB-04 · 2026-09-29 | Not attached | 2026-08-16 Outpatient hospital | Valley Heart Institute Cardiology · in network | 70553 | $2,348.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-008130 CMS-1500 · 2026-09-25 | Not attached | 2026-09-15 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97014 | $379.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-013429 CMS-1500 · 2026-09-22 | Not attached | 2026-09-04 Office | Desert Heart Institute Cardiology · in network | 93224 | $275.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-005361 UB-04 · 2026-09-22 | Not attached | 2026-09-19 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285 | $3,094.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-029002 UB-04 · 2026-09-21 | Not attached | 2026-08-31 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,744.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-014466 CMS-1500 · 2026-09-19 | Not attached | 2026-08-30 Office | Evergreen Medical Group Family Medicine · in network | 36415, 99395 | $290.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-029001 UB-04 · 2026-09-09 | Not attached | 2026-08-31 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,744.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-025592 CMS-1500 · 2026-09-07 | Not attached | 2026-08-22 Office | Pinecrest Medical Group Family Medicine · in network | 99213, 99203 | $402.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-022108 CMS-1500 · 2026-09-02 | Not attached | 2026-08-08 Office | Desert Internal Medicine Associates Internal Medicine · in network | 93000 | $91.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-017762 CMS-1500 · 2026-09-01 | Not attached | 2026-07-27 Office | Valley Medical Group Internal Medicine · in network | 99214 | $261.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-024682 UB-04 · 2026-08-29 | Not attached | 2026-07-31 Outpatient hospital | Lakeside Medical Group Internal Medicine · in network | 70553 | $2,959.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-005265 UB-04 · 2026-08-28 | Not attached | 2026-08-25 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 71046 | $225.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-025033 UB-04 · 2026-08-27 | Not attached | 2026-07-26 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99285, 71046 | $2,179.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-006957 CMS-1500 · 2026-08-22 | Not attached | 2026-08-17 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $431.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-017334 CMS-1500 · 2026-08-20 | Not attached | 2026-07-31 Independent laboratory | Cornerstone Clinical Laboratories Clinical Laboratory · in network | 83036, 80053 | $141.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-009573 CMS-1500 · 2026-08-19 | Not attached | 2026-08-13 Office | Sunrise Internal Medicine Associates Internal Medicine · in network | 93000, 99215 | $447.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-002422 CMS-1500 · 2026-08-18 | Not attached | 2026-07-28 Office | Lakeside Medical Group Family Medicine · in network | 99203, 99395 | $455.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-000866 UB-04 · 2026-08-09 | Not attached | 2026-07-25 Outpatient hospital | Riverside Imaging Center Radiology · in network | 76700 | $611.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-032394 CMS-1500 · 2026-08-07 | Not attached | 2026-07-09 Office | Pinecrest Medical Group Family Medicine · in network | 36415 | $24.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-021178 UB-04 · 2026-08-06 | Not attached | 2026-07-26 Outpatient hospital | Desert Imaging Center Radiology · in network | 71046 | $200.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-003305 UB-04 · 2026-08-06 | Not attached | 2026-07-10 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283 | $917.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-000539 UB-04 · 2026-08-06 | Not attached | 2026-06-27 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · in network | 93306, 93015 | $1,820.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-022468 UB-04 · 2026-08-04 | Not attached | 2026-07-15 Outpatient hospital | Summit Imaging Center Radiology · in network | 77067, 70553 | $2,817.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-021633 UB-04 · 2026-07-31 | Not attached | 2026-06-18 Inpatient hospital | Heritage Internal Medicine Associates Internal Medicine · in network | 99232 | $216.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-001760 CMS-1500 · 2026-07-31 | Not attached | 2026-07-17 Office | Mesa Family Practice Family Medicine · in network | 36415 | $25.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-006481 CMS-1500 · 2026-07-30 | Not attached | 2026-06-19 Office | Valley Primary Care Associates Family Medicine · in network | 36415 | $24.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-003746 CMS-1500 · 2026-07-29 | Not attached | 2026-06-25 Independent laboratory | Desert Clinical Laboratories Clinical Laboratory · in network | 83036 | $76.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-011469 UB-04 · 2026-07-26 | Not attached | 2026-06-19 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,113.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-006051 UB-04 · 2026-07-24 | Not attached | 2026-06-23 Outpatient hospital | Summit Digestive Health Center Gastroenterology · in network | 88305 | $256.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-033704 CMS-1500 · 2026-07-23 | Not attached | 2026-06-20 Office | Desert Medical Group Internal Medicine · in network | 99214 | $254.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-021091 UB-04 · 2026-07-20 | Not attached | 2026-06-15 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $213.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-013751 CMS-1500 · 2026-07-18 | Not attached | 2026-06-16 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97014 | $407.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-011823 CMS-1500 · 2026-07-18 | Not attached | 2026-06-20 Office | Sunrise Family Practice Family Medicine · in network | 99203 | $183.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-001574 UB-04 · 2026-07-15 | Not attached | 2026-06-15 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 77067, 70553 | $2,837.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-009319 CMS-1500 · 2026-07-13 | Not attached | 2026-06-06 Office | Riverside Primary Care Associates Family Medicine · in network | 90471, 99213, 36415 | $262.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-012305 UB-04 · 2026-07-10 | Not attached | 2026-07-08 Outpatient hospital | Valley Regional Medical Center Emergency Medicine · in network | 70553 | $3,121.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-024260 CMS-1500 · 2026-07-09 | Not attached | 2026-06-01 Office | Northgate Heart Institute Cardiology · in network | 99214 | $264.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-006345 CMS-1500 · 2026-07-07 | Not attached | 2026-06-20 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110 | $270.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-030457 UB-04 · 2026-07-05 | Not attached | 2026-06-15 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $37,882.00 | — | Pended by rule CO16 | — | Pended |
Top reason codes
Across rules and final decisions
- N30 Patient ineligible for this service1,566
- IDQ Member identity under steward review1,522
- CO50 Not medically necessary per payer policy1,234
- CO204 Service not covered under the member's plan1,223
- CO27 Expenses incurred after coverage terminated1,164
- CO18 Exact duplicate claim or service871
- CO97 Benefit included in another service already adjudicated608
- CO16 Claim lacks information needed for adjudication606
- CO29 Time limit for filing has expired589
- REPL Replacement claim; supersedes the original submission490
- CO197 Precertification or authorization absent481
- HIGH Billed amount above auto-pay ceiling351
How a claim is adjudicated
Deterministic first, AI second, people last
- Attach. The claim's member record is resolved through the identity graph; coverage is found by member ID or, failing that, by name and date of birth.
- Rules. Identity hold, eligibility, timely filing, duplicates, prior authorisation, network, medical-necessity edits, bundling, benefit limits, completeness and the high-dollar ceiling.
- Price. Contract or out-of-network allowance, then copay, deductible and coinsurance from the member's accumulators.
- AI review. Only claims the rules left for review go to the model, with every piece of evidence labelled. Its answer is validated before anyone sees it.
- Examiner. A person records the final decision with reason codes and a rationale; everything is hash-chained in the audit log.