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-2026-030898 UB-04 · 2026-04-30 | Sophia Cole no member ID | 2026-03-27 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $28,051.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-018611 CMS-1500 · 2026-04-29 | Timothy Delgado UHC-37717-31 | 2026-04-09 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 87086, 83036 | $110.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-012244 UB-04 · 2026-04-29 | Teresa Larson no member ID | 2026-04-10 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285, 99284, 99283 | $4,969.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-020574 CMS-1500 · 2026-04-25 | Victoria Burke no member ID | 2026-04-12 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 85025, 83036, 87086 | $159.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-018610 CMS-1500 · 2026-04-22 | Timothy Delgado UHC-37717-31 | 2026-04-09 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 87086, 83036 | $110.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-005690 CMS-1500 · 2026-04-22 | Diiego Fields no member ID | 2026-04-17 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 93000, 80053 | $152.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-015139 UB-04 · 2026-04-21 | Watson Austin no member ID | 2026-03-18 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 74177 | $2,370.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-005401 UB-04 · 2026-04-20 | Laura Alvarado no member ID | 2026-04-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283 | $891.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-011548 UB-04 · 2026-04-19 | Thomas Ruiz no member ID | 2026-03-21 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284, 96374, 99283 | $2,407.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-018617 CMS-1500 · 2026-04-18 | Frank Willis no member ID | 2026-04-13 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90837 | $182.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-014476 CMS-1500 · 2026-04-18 | Jose Griffin UHC-35738-01 | 2026-04-02 Office | Valley Primary Care Associates Family Medicine · out of network | 99395, 99214, 36415 | $655.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-006827 UB-04 · 2026-04-18 | Chreyl Carlson no member ID | 2026-04-09 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285, 96374 | $2,137.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-014834 UB-04 · 2026-04-15 | Charles Fowler no member ID | 2026-03-26 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700 | $422.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-025249 CMS-1500 · 2026-04-14 | Carlos Stevens no member ID | 2026-03-30 Office | Cornerstone Family Practice Family Medicine · out of network | 99203 | $224.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-020488 CMS-1500 · 2026-04-14 | Julie Peters UHC-18844-54 | 2026-03-15 Office | Meadow GI Associates Gastroenterology · out of network | 99214 | $271.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-016770 UB-04 · 2026-04-14 | Gary Rice UHC-62341-88 | 2026-04-04 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93306, 93015 | $2,053.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-018480 CMS-1500 · 2026-04-12 | Emma Soto no member ID | 2026-03-09 Office | Valley Primary Care Associates Family Medicine · out of network | 90471 | $33.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-015858 CMS-1500 · 2026-04-12 | Lori Webb no member ID | 2026-03-14 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 85025, 80053, 83036 | $187.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-007158 CMS-1500 · 2026-04-12 | Not attached | 2026-03-24 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 85025, 87086 | $74.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-019297 CMS-1500 · 2026-04-11 | Logan Hamilton UHC-24877-82 | 2026-03-19 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $228.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-009078 UB-04 · 2026-04-11 | Roy Marshall UHC-12603-94 | 2026-02-28 Outpatient hospital | Unity Primary Care Associates Family Medicine · out of network | 70553 | $2,809.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-019768 CMS-1500 · 2026-04-09 | Thomas Jordan UHC-61772-32 | 2026-03-07 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 93000 | $95.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-004503 CMS-1500 · 2026-04-09 | Sofia Hughes no member ID | 2026-03-02 Office | Cornerstone Family Practice Family Medicine · out of network | 99203, 99395, 99213 | $731.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-004897 CMS-1500 · 2026-04-06 | Elizabeth Dunn UHC-90095-72 | 2026-03-01 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 80061, 85025, 87086 | $146.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030447 CMS-1500 · 2026-04-04 | Cruz Rachel no member ID | 2026-03-24 Office | Harbor Medical Group Internal Medicine · out of network | 99214 | $283.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-008812 CMS-1500 · 2026-04-04 | Not attached | 2026-02-12 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 83036, 87086 | $78.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-033228 UB-04 · 2026-04-02 | Shirley Chavez UHC-09108-69 | 2026-02-17 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99284 | $1,257.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-007979 UB-04 · 2026-04-02 | Jessica Dean UHC-39196-24 | 2026-03-18 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 71046, 76700 | $750.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-019162 UB-04 · 2026-03-31 | Jen Lynch no member ID | 2026-03-12 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 70553, 74177 | $4,606.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-006054 CMS-1500 · 2026-03-31 | Eryc Wheeler no member ID | 2026-03-12 Office | Lakeside Medical Group Family Medicine · out of network | 99214, 99203 | $526.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002104 CMS-1500 · 2026-03-31 | Jeffrey Stewart no member ID | 2026-03-08 Office | Valley Primary Care Associates Family Medicine · out of network | 36415 | $20.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029227 UB-04 · 2026-03-30 | Bobby Robinson no member ID | 2026-02-20 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 29881 | $7,361.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-025222 UB-04 · 2026-03-30 | Jesse Mendez UHC-45205-47 | 2026-03-06 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 96374 | $193.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-023055 CMS-1500 · 2026-03-30 | Joyce Guzman UHC-97902-24 | 2026-03-01 Office | Harbor Primary Care Associates Family Medicine · out of network | 99395, 99203 | $569.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-020449 CMS-1500 · 2026-03-29 | Joseph Thompson UHC-49525-57 | 2026-03-25 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80053, 85025, 83036 | $175.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-007978 UB-04 · 2026-03-29 | Jessica Dean UHC-39196-24 | 2026-03-18 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 71046, 76700 | $750.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-031742 CMS-1500 · 2026-03-28 | Not attached | 2026-02-27 Office | Northgate Primary Care Associates Family Medicine · out of network | 36415, 99395 | $322.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-014100 UB-04 · 2026-03-27 | Thomas Anderson no member ID | 2026-02-19 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285, 71046, 99284 | $3,973.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-011114 UB-04 · 2026-03-27 | Jerry Jordan no member ID | 2026-02-27 Outpatient hospital | Unity Primary Care Associates Family Medicine · out of network | 70553 | $3,319.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-011021 UB-04 · 2026-03-26 | Rachel Black UHC-66404-42 | 2026-03-12 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285, 71046 | $2,993.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-026166 UB-04 · 2026-03-25 | Jessica Henderson no member ID | 2026-03-19 Outpatient hospital | Mesa Clinical Laboratories Clinical Laboratory · out of network | 70553 | $2,165.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-022328 CMS-1500 · 2026-03-25 | Russell Herrera no member ID | 2026-02-22 Office | Sunrise Medical Group Internal Medicine · out of network | 99214 | $263.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-028714 CMS-1500 · 2026-03-24 | Lori Obrien no member ID | 2026-02-08 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 85025, 80053, 83036 | $224.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-008755 UB-04 · 2026-03-23 | Christina Burke no member ID | 2026-03-08 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99284 | $1,346.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-028617 UB-04 · 2026-03-18 | Sharon Patterson no member ID | 2026-02-14 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93306 | $1,451.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017993 CMS-1500 · 2026-03-17 | Wheeler Christian no member ID | 2026-03-04 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 87086 | $32.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-008995 CMS-1500 · 2026-03-17 | Ashley Edwards no member ID | 2026-02-01 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 87086, 83036, 85025 | $153.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-007308 CMS-1500 · 2026-03-17 | Ralph Johnson no member ID | 2026-02-25 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $199.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-019876 CMS-1500 · 2026-03-15 | Aisha Allen no member ID | 2026-03-13 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 87086, 80053 | $153.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-011242 UB-04 · 2026-03-12 | Mei Garcia no member ID | 2026-02-26 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · out of network | 99232 | $255.00 | — | 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.