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-2026-020225 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-2026-019748 UB-04 · 2026-06-04 | Pamela Lawson UHC-19051-72 | 2026-05-18 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283 | $1,070.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000568 CMS-1500 · 2026-06-04 | Paul Valdez UHC-95327-83 | 2026-05-11 Office | Heritage Medical Group Family Medicine · out of network | 99395, 99214, 99203 | $760.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-023809 UB-04 · 2026-06-03 | Amber Soto UHC-45707-34 | 2026-04-24 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285 | $2,801.00 | — | Pended by rule IDQ | — | 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-2026-000425 UB-04 · 2026-06-03 | Brittany Kelley UHC-07098-28 | 2026-05-10 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283, 99284 | $2,369.00 | — | Pended by rule IDQ | — | 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 |
| CLM-2026-028655 CMS-1500 · 2026-05-30 | Jeffrey Bryant no member ID | 2026-04-23 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 87086, 80053 | $109.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-027673 UB-04 · 2026-05-29 | Elizabeth Robinson no member ID | 2026-04-14 Outpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $9,371.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-022476 CMS-1500 · 2026-05-28 | Patrick Spencer no member ID | 2026-04-27 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80053 | $55.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-012803 UB-04 · 2026-05-27 | Karen Li no member ID | 2026-04-16 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 88305, 43239 | $2,583.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-001298 UB-04 · 2026-05-27 | Roger Franklin no member ID | 2026-04-20 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 29881 | $6,890.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-018742 CMS-1500 · 2026-05-26 | Not attached | 2026-05-04 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 85025, 80053, 83036 | $199.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-007988 UB-04 · 2026-05-25 | Mason Carter UHC-49290-17 | 2026-04-23 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 77067, 76700, 71046 | $892.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-006922 UB-04 · 2026-05-23 | 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-2026-004983 CMS-1500 · 2026-05-23 | Barbara Johnston UHC-24731-68 | 2026-05-08 Office | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 20610 | $211.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-021711 UB-04 · 2026-05-22 | 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-2026-004917 CMS-1500 · 2026-05-21 | Jacob Williams no member ID | 2026-05-18 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11403, 11102, 17110 | $1,002.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-003559 CMS-1500 · 2026-05-20 | George Padilla no member ID | 2026-05-07 Office | Valley Primary Care Associates Family Medicine · out of network | 90471, 99395 | $286.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-001405 CMS-1500 · 2026-05-20 | Noah Bowman no member ID | 2026-04-24 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 83036, 85025, 80053 | $187.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-003027 UB-04 · 2026-05-19 | Lawrence Cunningham no member ID | 2026-04-09 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 77067, 74177 | $1,893.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002441 CMS-1500 · 2026-05-19 | Camila Oriz no member ID | 2026-05-08 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $306.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-010994 CMS-1500 · 2026-05-18 | Kelly Willis no member ID | 2026-04-29 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 99214, 80053, 99215 | $685.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-025441 CMS-1500 · 2026-05-17 | Bryan Henderson UHC-39534-92 | 2026-05-14 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 85025, 87086 | $67.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-002875 CMS-1500 · 2026-05-17 | Adam Riley no member ID | 2026-04-23 Office | Harbor Primary Care Associates Family Medicine · out of network | 90471 | $41.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-032198 CMS-1500 · 2026-05-16 | Bryant Jeffrey no member ID | 2026-04-13 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 83036, 87086, 80053 | $193.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-030041 CMS-1500 · 2026-05-16 | Wei Murphy UHC-71874-98 | 2026-05-08 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086, 83036 | $115.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-017076 CMS-1500 · 2026-05-16 | Camila Ortiz no member ID | 2026-04-10 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 85025 | $61.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-009542 CMS-1500 · 2026-05-15 | Jennifer Scott no member ID | 2026-04-04 Office | Unity Primary Care Associates Family Medicine · out of network | 99395, 90471 | $286.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-034330 CMS-1500 · 2026-05-14 | Justin Reyes no member ID | 2026-05-02 Office | Evergreen Dermatology Clinic Dermatology · out of network | 99213, 11102 | $405.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-002251 CMS-1500 · 2026-05-13 | Bruce Alvarez UHC-31238-59 | 2026-04-03 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 85025, 80061, 83036 | $139.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-014514 UB-04 · 2026-05-11 | Joseph Flors no member ID | 2026-04-22 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 71046, 70553 | $3,773.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-004987 CMS-1500 · 2026-05-11 | Kathy Duncan no member ID | 2026-04-01 Telehealth | Lakeside Behavioral Health Behavioral Health · out of network | 99214 | $314.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-026394 UB-04 · 2026-05-10 | Angela Wagner UHC-74137-63 | 2026-04-14 Outpatient hospital | Pinecrest Regional Medical Center Emergency Medicine · out of network | 70553 | $2,131.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-015036 CMS-1500 · 2026-05-10 | Ashley Murphy UHC-51930-08 | 2026-04-28 Office | Lakeside Medical Group Family Medicine · out of network | 36415, 99214 | $259.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-012552 UB-04 · 2026-05-10 | Not attached | 2026-04-02 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378 | $2,234.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-023145 UB-04 · 2026-05-09 | Virginia Ray UHC-17642-30 | 2026-04-12 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 71046 | $137.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030661 UB-04 · 2026-05-08 | Mariana Cook no member ID | 2026-04-17 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 74177, 71046 | $2,238.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-012408 CMS-1500 · 2026-05-08 | Sean Howell UHC-57319-58 | 2026-04-24 Office | Evergreen Dermatology Clinic Dermatology · out of network | 11102 | $246.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-022982 CMS-1500 · 2026-05-07 | Martha Ferguson UHC-39212-39 | 2026-04-28 Office | Harbor Medical Group Internal Medicine · out of network | 80053, 99215 | $413.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-024871 UB-04 · 2026-05-06 | Dennis Woods no member ID | 2026-04-26 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 71046 | $128.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-001100 UB-04 · 2026-05-06 | Billy Bailey UHC-36394-37 | 2026-03-27 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285 | $2,832.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-034167 CMS-1500 · 2026-05-05 | Jesse Reyes no member ID | 2026-04-30 Office | Unity Primary Care Associates Family Medicine · out of network | 90471 | $37.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-024873 UB-04 · 2026-05-05 | Daniel Bailey no member ID | 2026-04-27 Outpatient hospital | Riverside Regional Medical Center Emergency Medicine · out of network | 70553 | $2,003.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-022981 CMS-1500 · 2026-05-04 | Martha Ferguson UHC-39212-39 | 2026-04-28 Office | Harbor Medical Group Internal Medicine · out of network | 80053, 99215 | $413.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-009712 UB-04 · 2026-05-04 | Jack Kelley no member ID | 2026-04-25 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,840.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-018940 CMS-1500 · 2026-05-03 | Janice Rose no member ID | 2026-03-30 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 99214, 99215 | $540.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-031232 CMS-1500 · 2026-05-02 | Gray Rodriguez no member ID | 2026-04-26 Office | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 99213, 20610 | $374.00 | — | 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.