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-2026-024970 CMS-1500 · 2026-08-06 | Helen Graay no member ID | 2026-07-03 Office | Canyon Counseling Center Behavioral Health · out of network | 90791, 90837 | $574.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-032111 CMS-1500 · 2026-08-04 | Maria Garcia no member ID | 2026-07-10 Office | Lakeside Endocrine Associates Endocrinology · out of network | 83036, 95251 | $236.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-009269 UB-04 · 2026-08-04 | Michael Willis no member ID | 2026-06-25 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 70553 | $3,584.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-032721 UB-04 · 2026-08-03 | Charlees Murray no member ID | 2026-06-24 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700, 74177 | $2,717.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-019725 CMS-1500 · 2026-07-31 | Beverly Rogers no member ID | 2026-07-06 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $307.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-031303 CMS-1500 · 2026-07-30 | Sofia Collins no member ID | 2026-07-14 Office | Cornerstone Family Practice Family Medicine · out of network | 36415, 99213, 99395 | $484.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-004912 UB-04 · 2026-07-29 | Carol Li no member ID | 2026-07-10 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $1,284.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-030047 CMS-1500 · 2026-07-28 | Jordna Diana no member ID | 2026-07-03 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $271.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-014332 CMS-1500 · 2026-07-26 | Joan Santiago no member ID | 2026-07-03 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 87086, 85025, 83036 | $231.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-019103 UB-04 · 2026-07-24 | Olivia Campbell no member ID | 2026-06-30 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 99284, 71046 | $1,628.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-007328 CMS-1500 · 2026-07-23 | Christine Gutierrez no member ID | 2026-06-17 Office | Heritage Medical Group Family Medicine · out of network | 99203 | $240.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-030132 CMS-1500 · 2026-07-22 | Grace Taylor no member ID | 2026-07-17 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80053, 87086 | $125.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-012327 CMS-1500 · 2026-07-22 | Kyle Powell no member ID | 2026-06-26 Office | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 20610 | $263.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-016927 UB-04 · 2026-07-21 | Gregory Smith no member ID | 2026-06-05 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 71046, 96374, 99284 | $2,028.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-016407 UB-04 · 2026-07-21 | Ethan Walsh no member ID | 2026-07-07 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99283, 99285 | $2,842.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-015655 UB-04 · 2026-07-21 | Roy Nichols no member ID | 2026-07-08 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 77067, 74177 | $4,593.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-027140 CMS-1500 · 2026-07-20 | Markus Singh no member ID | 2026-07-02 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061, 83036 | $131.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-033068 CMS-1500 · 2026-07-17 | Christina Jimenez no member ID | 2026-06-26 Office | Sunrise Medical Group Internal Medicine · out of network | 80053, 99214 | $355.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-031143 UB-04 · 2026-07-16 | Omar Perez no member ID | 2026-06-18 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285, 99284 | $3,800.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-023192 CMS-1500 · 2026-07-15 | Lucia Armstrong no member ID | 2026-06-02 Office | Lakeside Medical Group Family Medicine · out of network | 99214, 99395, 90471 | $557.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-020516 CMS-1500 · 2026-07-13 | Kathleen Cox no member ID | 2026-07-09 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 87086, 85025, 80061 | $144.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029381 UB-04 · 2026-07-12 | Sarah Perkins no member ID | 2026-06-12 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 74177, 71046 | $1,433.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-007699 UB-04 · 2026-07-11 | Shaorn Nunez no member ID | 2026-07-05 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99283, 96374 | $1,228.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-018073 CMS-1500 · 2026-07-09 | Carlos Franklin no member ID | 2026-06-15 Office | Harbor Medical Group Internal Medicine · out of network | 80053 | $82.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-028086 CMS-1500 · 2026-07-08 | Jeffrey Warren no member ID | 2026-06-27 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $300.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-019871 CMS-1500 · 2026-07-08 | Amber Jimenez no member ID | 2026-06-13 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 83036, 87086 | $103.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-009460 CMS-1500 · 2026-07-08 | Adam Sandoval no member ID | 2026-06-05 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · out of network | 83036, 80053 | $146.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-020571 CMS-1500 · 2026-07-03 | Maria West no member ID | 2026-06-04 Office | Northgate Primary Care Associates Family Medicine · out of network | 99213, 90471 | $177.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-019230 CMS-1500 · 2026-07-03 | Deborah McDonald no member ID | 2026-06-29 Office | Valley Skin Care Associates Dermatology · out of network | 11403 | $606.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-034429 CMS-1500 · 2026-07-02 | Rady Rogers no member ID | 2026-06-22 Office | Lakeside Medical Group Family Medicine · out of network | 99203 | $238.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-032090 CMS-1500 · 2026-07-02 | Janice Rodriguez no member ID | 2026-05-25 Office | Unity Primary Care Associates Family Medicine · out of network | 99213 | $160.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-025672 CMS-1500 · 2026-07-02 | Thomas Sullivan no member ID | 2026-05-24 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80061 | $41.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017859 CMS-1500 · 2026-07-02 | Tyler Perry no member ID | 2026-05-27 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $284.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-017817 CMS-1500 · 2026-06-30 | Don Park no member ID | 2026-05-25 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $146.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-001683 UB-04 · 2026-06-27 | Henry Wayne no member ID | 2026-06-22 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283, 99284 | $2,253.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-023116 CMS-1500 · 2026-06-24 | Patrick Espinoza no member ID | 2026-05-14 Office | Evergreen Medical Group Internal Medicine · out of network | 99215, 93000 | $415.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-008280 CMS-1500 · 2026-06-21 | Not attached | 2026-06-08 Office | Canyon Internal Medicine Associates Internal Medicine · out of network | 99214 | $231.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-025987 UB-04 · 2026-06-19 | Kayla Jenkins no member ID | 2026-05-08 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 29881 | $7,743.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-018609 CMS-1500 · 2026-06-19 | Chris Hamilton no member ID | 2026-05-12 Office | Lakeside Endocrine Associates Endocrinology · out of network | 99215, 95251 | $431.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-016846 CMS-1500 · 2026-06-19 | Steven Clark no member ID | 2026-06-03 Office | Lakeside Medical Group Family Medicine · out of network | 36415 | $20.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-015682 UB-04 · 2026-06-18 | Willie Gomez no member ID | 2026-05-15 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $2,215.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-004948 CMS-1500 · 2026-06-17 | Margaret Mendoza no member ID | 2026-05-23 Office | Harbor Medical Group Internal Medicine · out of network | 99214, 93000 | $415.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029999 UB-04 · 2026-06-14 | Nicholas Wilson no member ID | 2026-05-25 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $1,676.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-028366 UB-04 · 2026-06-08 | David Wheeler no member ID | 2026-04-30 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $6,133.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-013702 UB-04 · 2026-06-07 | Eric Long no member ID | 2026-04-30 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 43239 | $1,555.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-020225 CMS-1500 · 2026-06-06 | Donna Cook no member ID | 2026-05-06 Office | Valley Primary Care Associates Family Medicine · out of network | 99214, 90471, 36415 | $303.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-000412 CMS-1500 · 2026-06-06 | Kenneth Ryan no member ID | 2026-05-10 Office | Canyon Counseling Center Behavioral Health · out of network | 90834, 90791 | $550.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-006923 UB-04 · 2026-06-03 | Janice Kennedy no member ID | 2026-05-10 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553, 71046, 76700 | $3,453.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-027554 CMS-1500 · 2026-06-01 | Brenda Glbert no member ID | 2026-05-05 Office | Harbor Medical Group Internal Medicine · out of network | 99214 | $299.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-012820 CMS-1500 · 2026-06-01 | Steve Jensen no member ID | 2026-05-14 Telehealth | Lakeside Behavioral Health Behavioral Health · out of network | 99214, 90834 | $498.00 | — | Pended by rule 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.