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-2026-013148 UB-04 · 2026-10-17 | Christine Cook no member ID | 2026-09-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $1,157.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013940 UB-04 · 2026-10-14 | Sarah Gomez no member ID | 2026-10-06 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700, 71046, 74177 | $2,353.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013714 UB-04 · 2026-10-09 | Gerald Bowman no member ID | 2026-10-05 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553 | $2,319.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013746 UB-04 · 2026-10-07 | Joe Dean no member ID | 2026-08-31 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 71046 | $220.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-010133 UB-04 · 2026-10-03 | Pamela Harvey no member ID | 2026-09-01 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99284, 99283, 99285 | $3,759.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-027763 UB-04 · 2026-09-25 | Olivia Padilla no member ID | 2026-09-08 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283 | $862.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-005200 UB-04 · 2026-09-24 | Sara Jimenez no member ID | 2026-08-25 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 74177, 71046 | $1,693.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-010132 UB-04 · 2026-09-14 | Pamela Harvey no member ID | 2026-09-01 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99284, 99283, 99285 | $3,759.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-023496 UB-04 · 2026-09-13 | Christine Hawkins no member ID | 2026-09-05 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $1,185.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-010002 UB-04 · 2026-09-09 | Gary Peters no member ID | 2026-08-28 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99283, 99285 | $3,978.00 | — | Pended by rule N30 | — | 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-2026-011842 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-2026-006378 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-2026-006100 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-2026-024618 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-2026-001785 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-2026-006840 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-2026-009269 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-2026-004912 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-2026-019103 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-2026-016927 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 |
| 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-2026-029381 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-2026-001683 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-2026-025987 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-2026-015682 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-2026-029999 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-2026-028366 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 |
| 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-2026-027673 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-2026-012803 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-2026-006922 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-2026-003027 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-2026-014514 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-2026-030661 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-2026-024871 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-2026-024873 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-2026-009712 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-2026-030898 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-2026-012244 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-2026-015139 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 |
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.