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
3,664
50 with an AI recommendation
Pended
2,586
awaiting information or identity
Approved
23,942
$6,757,768.45 plan paid
Denied
4,454
with remittance reason codes
Examiner decided
0
167 not attached to an identity
| Claim | Member | Service | Provider | Procedures | Billed | Plan pays | Rules | AI | Status |
|---|---|---|---|---|---|---|---|---|---|
| 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-2026-012860 UB-04 · 2026-07-19 | Nicole Barnes UHC-03627-37 | 2026-06-04 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284, 99285, 99283 | $5,471.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-019355 UB-04 · 2026-07-18 | Wei Andrews UHC-89962-52 | 2026-06-04 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 71046, 70553, 74177 | $5,144.00 | — | Pended by rule IDQ | — | 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-2026-029325 UB-04 · 2026-07-14 | Patricia Hernandez UHC-44396-50 | 2026-06-17 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99284 | $1,416.00 | — | Pended by rule IDQ | — | 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-2026-010748 CMS-1500 · 2026-07-08 | Christopher Reynolds UHC-61478-29 | 2026-06-16 Office | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 99213 | $201.00 | — | Pended by rule IDQ | — | 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-2026-024295 UB-04 · 2026-07-07 | Thomas Cox UHC-43029-59 | 2026-06-01 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99285, 71046, 99283 | $3,441.00 | — | Pended by rule IDQ | — | 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-2026-021935 CMS-1500 · 2026-06-28 | Stephen Mason UHC-44082-35 | 2026-06-02 Office | Sunrise Dermatology Clinic Dermatology · out of network | 99213 | $227.00 | — | Pended by rule IDQ | — | 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-2026-030617 UB-04 · 2026-06-26 | Christina Garza UHC-89482-73 | 2026-05-14 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99283 | $806.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010180 UB-04 · 2026-06-26 | Donna Hunter UHC-21504-45 | 2026-05-24 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 71046 | $336.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-017446 CMS-1500 · 2026-06-25 | Christina Moreno UHC-88160-56 | 2026-06-18 Telehealth | Canyon Counseling Center Behavioral Health · out of network | 99214 | $255.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013413 UB-04 · 2026-06-25 | Charlotte Hansen UHC-81644-64 | 2026-05-14 Inpatient hospital | Mesa Internal Medicine Associates Internal Medicine · out of network | 99232 | $182.00 | — | Pended by rule IDQ | — | 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-2026-025873 CMS-1500 · 2026-06-23 | Alan Estrada UHC-27147-66 | 2026-05-15 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90791, 90837 | $517.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-023698 CMS-1500 · 2026-06-23 | Diego Chavez UHC-14045-39 | 2026-06-20 Office | Canyon Counseling Center Behavioral Health · out of network | 90791 | $448.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-018102 UB-04 · 2026-06-22 | Ahmed Sanders UHC-57673-12 | 2026-06-09 Outpatient hospital | Unity Imaging Center Radiology · out of network | 77067, 74177 | $1,900.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-022955 UB-04 · 2026-06-21 | Ruth Vazquez UHC-11615-56 | 2026-05-19 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 96374, 71046 | $390.00 | — | Pended by rule IDQ | — | 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-2026-018709 UB-04 · 2026-06-19 | Debra Jensen UHC-06981-22 | 2026-06-09 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285 | $1,766.00 | — | Pended by rule IDQ | — | 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-2026-022320 UB-04 · 2026-06-16 | Keith Baker UHC-75693-01 | 2026-05-22 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $2,009.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-015234 CMS-1500 · 2026-06-16 | Angela Wagner UHC-74137-63 | 2026-05-25 Office | Lakeside Endocrine Associates Endocrinology · out of network | 83036, 99215 | $467.00 | — | Pended by rule IDQ | — | 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-2026-015923 CMS-1500 · 2026-06-12 | Catherine Graham UHC-44692-74 | 2026-05-11 Telehealth | Canyon Counseling Center Behavioral Health · out of network | 99214 | $210.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030596 CMS-1500 · 2026-06-11 | Lucia Guerrero UHC-27035-87 | 2026-05-02 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 99215 | $347.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025243 UB-04 · 2026-06-11 | Lisa Campbell UHC-60740-82 | 2026-05-03 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 71046, 77067 | $576.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-021712 UB-04 · 2026-06-11 | Not attached | 2026-04-17 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $1,220.00 | — | Pended by rule CO16 | — | 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 |
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.