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-2026-034095 UB-04 · 2026-10-24 | Jacqueline Black no member ID | 2026-09-27 Outpatient hospital | Riverside Imaging Center Radiology · in network | 74177, 77067 | $1,850.00 | — | Pended by rule IDQ N30 | — | 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-2026-027767 CMS-1500 · 2026-10-18 | Larson Gary no member ID | 2026-09-24 Office | Lakeside Medical Group Family Medicine · out of network | 90471, 36415 | $52.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-019733 CMS-1500 · 2026-10-18 | Daniel Le no member ID | 2026-09-12 Office | Harbor Medical Group Family Medicine · in network | 99203 | $230.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-014170 UB-04 · 2026-10-18 | Justin Crawford UHC-67392-45 | 2026-10-02 Inpatient hospital | Meadow Medical Group Internal Medicine · in network | 99232 | $235.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013357 CMS-1500 · 2026-10-18 | Maria Russll UHC-17012-96 | 2026-09-04 Office | Harbor Diabetes Center Endocrinology · in network | 95251 | $201.00 | — | Pended by rule IDQ | — | 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-2026-025433 CMS-1500 · 2026-10-17 | Christian Cruz UHC-81334-28 | 2026-10-06 Office | Pinecrest Family Practice Family Medicine · in network | 36415, 99203 | $251.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-019537 CMS-1500 · 2026-10-17 | Priya Chavez UHC-11128-20 | 2026-10-14 Office | Northgate Medical Group Family Medicine · in network | 90471, 99213, 99395 | $498.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-018925 CMS-1500 · 2026-10-17 | Gerald Campbell no member ID | 2026-08-25 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 83036 | $67.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017348 CMS-1500 · 2026-10-17 | Katherine Castillo no member ID | 2026-09-28 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99214 | $318.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017124 UB-04 · 2026-10-17 | Jose Weber UHC-75597-59 | 2026-10-09 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93015 | $424.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-015282 CMS-1500 · 2026-10-17 | Aaron Shaw no member ID | 2026-09-19 Independent laboratory | Pinecrest Reference Lab Clinical Laboratory · in network | 85025, 83036, 87086 | $135.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-014171 UB-04 · 2026-10-17 | Amy Collins UHC-11297-50 | 2026-10-06 Outpatient hospital | Harbor Digestive Health Center Gastroenterology · in network | 45378 | $1,594.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013148 UB-04 · 2026-10-17 | Christine Cook no member ID | 2026-09-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $1,157.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002739 UB-04 · 2026-10-17 | William Howard no member ID | 2026-09-19 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99283 | $1,082.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024854 CMS-1500 · 2026-10-16 | Rebecca Aguilar no member ID | 2026-09-26 Office | Mesa Dermatology Clinic Dermatology · in network | 11102, 17110, 11403 | $1,057.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024821 UB-04 · 2026-10-16 | Angela Sullivan no member ID | 2026-09-27 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285 | $2,083.00 | — | Pended by rule N30 | — | 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-2026-011604 CMS-1500 · 2026-10-16 | Andrea Lee no member ID | 2026-09-19 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110, 97140 | $243.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-008054 UB-04 · 2026-10-16 | Terry Cooper no member ID | 2026-09-26 Emergency room | Harbor Regional Medical Center Emergency Medicine · in network | 71046 | $246.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-004387 CMS-1500 · 2026-10-16 | Bryan Mitchell UHC-04861-43 | 2026-10-01 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 83036, 80061 | $98.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-001738 CMS-1500 · 2026-10-16 | Susan Burns no member ID | 2026-09-16 Office | Sunrise Diabetes Center Endocrinology · in network | 83036, 99214 | $337.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-000169 CMS-1500 · 2026-10-16 | Ahmed Wright UHC-78812-39 | 2026-09-27 Office | Evergreen Primary Care Associates Family Medicine · in network | 99213, 99214 | $426.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-029991 CMS-1500 · 2026-10-15 | Nancy Welch UHC-74613-35 | 2026-09-20 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97014, 97161 | $545.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025255 CMS-1500 · 2026-10-15 | Bobby Thomas no member ID | 2026-09-27 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90837 | $295.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024533 CMS-1500 · 2026-10-15 | Amanda Simmons no member ID | 2026-10-12 Office | Summit Family Practice Family Medicine · in network | 36415, 99395, 99213 | $472.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-012574 UB-04 · 2026-10-15 | Juan Graham no member ID | 2026-10-02 Inpatient hospital | Canyon Medical Group Internal Medicine · in network | 99232 | $185.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-011274 CMS-1500 · 2026-10-15 | Nancy Welch UHC-74613-35 | 2026-09-13 Telehealth | Pinecrest Behavioral Health Behavioral Health · in network | 99214 | $279.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-009695 CMS-1500 · 2026-10-15 | Kayla Richards no member ID | 2026-10-02 Office | Sunrise Cardiovascular Associates Cardiology · in network | 93224 | $350.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-006483 UB-04 · 2026-10-15 | John Cox no member ID | 2026-09-24 Outpatient hospital | Summit Heart Institute Cardiology · in network | 93015 | $583.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-005798 CMS-1500 · 2026-10-15 | Martha Simmons no member ID | 2026-10-07 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 87086, 83036 | $72.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-005317 UB-04 · 2026-10-15 | Helen Snyder UHC-08676-93 | 2026-10-01 Outpatient hospital | Meadow Imaging Center Radiology · in network | 70553, 76700 | $3,998.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-004891 CMS-1500 · 2026-10-15 | Cheryl Carr no member ID | 2026-09-30 Office | Sunrise GI Associates Gastroenterology · in network | 99214 | $267.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-001185 UB-04 · 2026-10-15 | Wei Washington UHC-27182-89 | 2026-09-17 Outpatient hospital | Meadow Imaging Center Radiology · in network | 70553, 76700 | $3,938.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000946 CMS-1500 · 2026-10-15 | Matthew Jones UHC-41159-40 | 2026-09-13 Office | Unity Medical Group Internal Medicine · in network | 93000 | $113.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000486 CMS-1500 · 2026-10-15 | Jason Hunt UHC-16244-46 | 2026-09-22 Independent laboratory | Pinecrest Clinical Laboratories Clinical Laboratory · in network | 83036 | $71.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-027164 CMS-1500 · 2026-10-14 | Joyce Cole no member ID | 2026-09-20 Office | Harbor Physical Therapy Physical Therapy · in network | 97110 | $236.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-022211 CMS-1500 · 2026-10-14 | Steve Scott no member ID | 2026-09-05 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140 | $379.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-013940 UB-04 · 2026-10-14 | Sarah Gomez no member ID | 2026-10-06 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700, 71046, 74177 | $2,353.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-012386 CMS-1500 · 2026-10-14 | Albert Flores UHC-31435-25 | 2026-09-26 Office | Sunrise Cardiovascular Associates Cardiology · in network | 99214 | $329.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-003388 CMS-1500 · 2026-10-14 | Natalie Palmer UHC-30236-51 | 2026-08-31 Office | Meadow Bone and Joint Center Orthopedic Surgery · in network | 20610 | $261.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-001282 UB-04 · 2026-10-14 | Julia Castillo no member ID | 2026-10-06 Inpatient hospital | Canyon Medical Group Internal Medicine · in network | 99232 | $182.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029398 UB-04 · 2026-10-13 | William Carpenter no member ID | 2026-09-06 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 71046, 99283 | $1,129.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-027474 CMS-1500 · 2026-10-13 | Scott Simmons no member ID | 2026-09-12 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 80061, 87086, 83036 | $177.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-025541 CMS-1500 · 2026-10-13 | Frances Jensen no member ID | 2026-10-03 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 83036 | $74.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-023759 CMS-1500 · 2026-10-13 | Dorothy Alexander UHC-81221-87 | 2026-09-14 Office | Pinecrest Family Practice Family Medicine · in network | 36415, 99395, 90471 | $295.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-015769 UB-04 · 2026-10-13 | Eugene Bell UHC-07032-53 | 2026-09-21 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · in network | 96374 | $180.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-027083 CMS-1500 · 2026-10-12 | Amanda Santiiago no member ID | 2026-09-29 Office | Unity Primary Care Associates Family Medicine · out of network | 99213 | $176.00 | — | Pended by rule IDQ N30 | — | 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.