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-2026-020798 CMS-1500 · 2026-09-08 | Emily Washington no member ID | 2026-09-02 Office | Lakeside Medical Group Family Medicine · out of network | 99203, 99395 | $473.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-006105 CMS-1500 · 2026-09-08 | Kelly Richardson UHC-69622-24 | 2026-09-05 Office | Valley Skin Care Associates Dermatology · out of network | 11102, 17110 | $604.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-024620 UB-04 · 2026-09-07 | Danel Mejia no member ID | 2026-08-19 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374 | $150.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-002550 UB-04 · 2026-09-05 | Lawrence Tucker no member ID | 2026-08-10 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99285 | $3,080.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-028238 CMS-1500 · 2026-09-04 | Hannah Martin UHC-93034-52 | 2026-08-18 Office | Harbor Medical Group Internal Medicine · out of network | 99214, 93000 | $320.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-011842 UB-04 · 2026-09-04 | Victoria Cruz no member ID | 2026-08-03 Outpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $2,267.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-030127 UB-04 · 2026-09-01 | Isabella Reed UHC-03809-38 | 2026-08-05 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,532.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010043 CMS-1500 · 2026-09-01 | Jennifer Matthews no member ID | 2026-07-25 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 83036, 80053 | $129.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-006378 UB-04 · 2026-09-01 | Vincnet McDonald no member ID | 2026-08-22 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $7,230.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-011106 CMS-1500 · 2026-08-28 | Peter Fowler UHC-94395-87 | 2026-07-15 Office | Evergreen Dermatology Clinic Dermatology · out of network | 11403, 99213 | $856.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-034149 CMS-1500 · 2026-08-26 | Pamela Santiago UHC-24033-67 | 2026-08-02 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $195.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-026011 CMS-1500 · 2026-08-23 | Susan Gardner no member ID | 2026-07-20 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 99214 | $239.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-006100 UB-04 · 2026-08-21 | Joan Lane no member ID | 2026-08-10 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $48,364.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-029936 CMS-1500 · 2026-08-20 | Kayla Roojas no member ID | 2026-08-09 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 93000 | $90.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-024618 UB-04 · 2026-08-20 | Kevin Rice no member ID | 2026-07-21 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93458 | $8,839.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-010676 CMS-1500 · 2026-08-19 | Brandon Warren UHC-89576-83 | 2026-07-15 Office | Harbor Primary Care Associates Family Medicine · out of network | 99214, 99395 | $569.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025599 CMS-1500 · 2026-08-18 | Sophia Larson UHC-69834-51 | 2026-08-16 Office | Canyon Heart Institute Cardiology · out of network | 99214 | $268.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-022227 CMS-1500 · 2026-08-18 | Omar Obrien no member ID | 2026-08-01 Office | Valley Skin Care Associates Dermatology · out of network | 99213, 11403 | $800.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-015006 CMS-1500 · 2026-08-16 | Kelly Silva no member ID | 2026-07-31 Telehealth | Canyon Counseling Center Behavioral Health · out of network | 99214 | $244.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-001785 UB-04 · 2026-08-16 | Gerald Hudson no member ID | 2026-07-08 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99285, 99283 | $2,726.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-012972 CMS-1500 · 2026-08-12 | Justin Murphy no member ID | 2026-07-19 Office | Harbor Primary Care Associates Family Medicine · out of network | 99214, 99203 | $406.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-006840 UB-04 · 2026-08-10 | Frances Jacobs no member ID | 2026-07-06 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99283 | $836.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-022409 CMS-1500 · 2026-08-09 | Dylan Munoz no member ID | 2026-07-16 Office | Evergreen Medical Group Internal Medicine · out of network | 99214, 93000, 99215 | $636.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-014416 UB-04 · 2026-08-08 | Mason Wells UHC-76605-77 | 2026-07-18 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 76700, 77067 | $604.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-001537 UB-04 · 2026-08-08 | Ryan Santos UHC-94423-25 | 2026-07-10 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 96374, 99285, 99283 | $2,930.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-022826 CMS-1500 · 2026-08-07 | Timothy Alexander UHC-78547-89 | 2026-07-18 Office | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 20610 | $246.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-007432 UB-04 · 2026-08-07 | Bobby Garcia UHC-37947-67 | 2026-07-30 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 76700 | $489.00 | — | Pended by rule IDQ | — | Pended |
| 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-2026-003305 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-2026-032111 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-2026-028556 UB-04 · 2026-08-04 | Daniel Austin UHC-34567-10 | 2026-06-27 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 77067 | $301.00 | — | Pended by rule IDQ | — | 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-2026-029504 UB-04 · 2026-07-30 | Randy Long UHC-89497-69 | 2026-07-24 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99283 | $914.00 | — | Pended by rule IDQ | — | 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-2026-015723 UB-04 · 2026-07-28 | Nancy Peters UHC-86599-46 | 2026-07-14 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 71046 | $160.00 | — | Pended by rule IDQ | — | 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-2026-019099 CMS-1500 · 2026-07-25 | Vincent Wilson UHC-04051-03 | 2026-07-22 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80053 | $47.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-021470 CMS-1500 · 2026-07-24 | Roger Banks UHC-95733-48 | 2026-07-11 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 80053, 85025 | $145.00 | — | Pended by rule IDQ | — | 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-2026-001793 UB-04 · 2026-07-22 | Jeremy Singh UHC-23990-52 | 2026-07-05 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 71046, 99283, 99285 | $3,594.00 | — | Pended by rule IDQ | — | 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 |
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.