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-2026-010612 CMS-1500 · 2026-10-26 | Not attached | 2026-09-05 Office | Canyon Counseling Center Behavioral Health · out of network | 90791 | $375.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-022552 CMS-1500 · 2026-10-02 | Not attached | 2026-09-23 Office | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $217.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-005361 UB-04 · 2026-09-22 | Not attached | 2026-09-19 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285 | $3,094.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-029002 UB-04 · 2026-09-21 | Not attached | 2026-08-31 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,744.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-029001 UB-04 · 2026-09-09 | Not attached | 2026-08-31 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,744.00 | — | Pended by rule CO16 | — | 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-2026-008280 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-2026-021712 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-2026-018742 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-2026-021711 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-2026-012552 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-2026-007158 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-2026-008812 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-2026-031742 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-2026-005913 CMS-1500 · 2026-01-25 | Not attached | 2026-01-18 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 93000 | $117.00 | — | Pended by rule CO16 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.