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-2026-027767 CMS-1500 · 2026-10-18 | Larson Gary no member ID | 2026-09-24 Office | Lakeside Medical Group Family Medicine · out of network | 90471, 36415 | $52.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-018925 CMS-1500 · 2026-10-17 | Gerald Campbell no member ID | 2026-08-25 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 83036 | $67.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-027474 CMS-1500 · 2026-10-13 | Scott Simmons no member ID | 2026-09-12 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 80061, 87086, 83036 | $177.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-027083 CMS-1500 · 2026-10-12 | Amanda Santiiago no member ID | 2026-09-29 Office | Unity Primary Care Associates Family Medicine · out of network | 99213 | $176.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-013499 CMS-1500 · 2026-10-12 | Samuel Tucker no member ID | 2026-08-30 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $187.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-011280 CMS-1500 · 2026-10-08 | Teresa Johnson no member ID | 2026-09-05 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 85025, 83036 | $138.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-029961 CMS-1500 · 2026-10-07 | Zachary Thompson no member ID | 2026-09-02 Office | Sunrise Medical Group Internal Medicine · out of network | 93000 | $98.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-031968 CMS-1500 · 2026-10-03 | Hart Sofia no member ID | 2026-09-20 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · out of network | 87086, 80061 | $144.00 | — | Pended by rule N30 | — | 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-2026-011216 CMS-1500 · 2026-10-01 | Helen Gibosn UHC-11787-25 | 2026-09-08 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053 | $44.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-018924 CMS-1500 · 2026-09-28 | Gerald Campbell no member ID | 2026-08-25 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 83036 | $67.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-000450 CMS-1500 · 2026-09-28 | Brittany Estrada UHC-82467-80 | 2026-09-02 Office | Canyon Counseling Center Behavioral Health · out of network | 90837 | $294.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-006664 CMS-1500 · 2026-09-26 | Rachel Brooks UHC-42063-06 | 2026-08-16 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · out of network | 83036, 85025 | $115.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010515 CMS-1500 · 2026-09-25 | Anna Carpenter no member ID | 2026-09-23 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 93000 | $85.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-019861 CMS-1500 · 2026-09-23 | Nicole Guerrero no member ID | 2026-09-06 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $228.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-018153 CMS-1500 · 2026-09-22 | Mariana Hansen no member ID | 2026-09-04 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97140, 97161 | $576.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-005334 CMS-1500 · 2026-09-22 | Santiago Crawford no member ID | 2026-08-17 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 83036, 80053, 85025 | $179.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-005459 CMS-1500 · 2026-09-21 | Lisa Chapman no member ID | 2026-09-16 Office | Heritage Medical Group Family Medicine · out of network | 90471, 99214 | $259.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-008790 CMS-1500 · 2026-09-20 | Eric Burke no member ID | 2026-09-12 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $192.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-008332 CMS-1500 · 2026-09-20 | Carol Munoz no member ID | 2026-08-17 Office | Meadow GI Associates Gastroenterology · out of network | 99214 | $290.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-000323 CMS-1500 · 2026-09-19 | Santiago Crawford no member ID | 2026-09-09 Office | Valley Skin Care Associates Dermatology · out of network | 11102, 17110 | $504.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024178 CMS-1500 · 2026-09-18 | Marcus Warren no member ID | 2026-09-02 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 87086, 85025, 83036 | $172.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-010607 CMS-1500 · 2026-09-14 | Roy Coleman UHC-34187-63 | 2026-08-10 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $180.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-007112 CMS-1500 · 2026-09-14 | Joseph Jimenez no member ID | 2026-09-09 Office | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 20610 | $193.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-023599 CMS-1500 · 2026-09-13 | Adam Obrien UHC-58333-51 | 2026-09-02 Office | Unity Primary Care Associates Family Medicine · out of network | 99203, 90471 | $237.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-005497 CMS-1500 · 2026-09-12 | Carol Munoz no member ID | 2026-08-28 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $229.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-026940 CMS-1500 · 2026-09-11 | Elijah Stone no member ID | 2026-08-13 Office | Canyon Cardiovascular Associates Cardiology · out of network | 99214, 93224 | $677.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002999 CMS-1500 · 2026-09-11 | Jacob Vazquez no member ID | 2026-09-02 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 85025 | $48.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-007936 CMS-1500 · 2026-09-10 | Sara Padilla UHC-35197-28 | 2026-09-05 Office | Unity Primary Care Associates Family Medicine · out of network | 99213 | $172.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-026954 CMS-1500 · 2026-09-09 | Gary Hoffman no member ID | 2026-08-10 Office | Northgate Primary Care Associates Family Medicine · out of network | 99214, 36415 | $333.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-020798 CMS-1500 · 2026-09-08 | Emily Washington no member ID | 2026-09-02 Office | Lakeside Medical Group Family Medicine · out of network | 99203, 99395 | $473.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-006105 CMS-1500 · 2026-09-08 | Kelly Richardson UHC-69622-24 | 2026-09-05 Office | Valley Skin Care Associates Dermatology · out of network | 11102, 17110 | $604.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-028238 CMS-1500 · 2026-09-04 | Hannah Martin UHC-93034-52 | 2026-08-18 Office | Harbor Medical Group Internal Medicine · out of network | 99214, 93000 | $320.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010043 CMS-1500 · 2026-09-01 | Jennifer Matthews no member ID | 2026-07-25 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 83036, 80053 | $129.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-011106 CMS-1500 · 2026-08-28 | Peter Fowler UHC-94395-87 | 2026-07-15 Office | Evergreen Dermatology Clinic Dermatology · out of network | 11403, 99213 | $856.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-034149 CMS-1500 · 2026-08-26 | Pamela Santiago UHC-24033-67 | 2026-08-02 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $195.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-026011 CMS-1500 · 2026-08-23 | Susan Gardner no member ID | 2026-07-20 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 99214 | $239.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029936 CMS-1500 · 2026-08-20 | Kayla Roojas no member ID | 2026-08-09 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 93000 | $90.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-010676 CMS-1500 · 2026-08-19 | Brandon Warren UHC-89576-83 | 2026-07-15 Office | Harbor Primary Care Associates Family Medicine · out of network | 99214, 99395 | $569.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025599 CMS-1500 · 2026-08-18 | Sophia Larson UHC-69834-51 | 2026-08-16 Office | Canyon Heart Institute Cardiology · out of network | 99214 | $268.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-022227 CMS-1500 · 2026-08-18 | Omar Obrien no member ID | 2026-08-01 Office | Valley Skin Care Associates Dermatology · out of network | 99213, 11403 | $800.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-015006 CMS-1500 · 2026-08-16 | Kelly Silva no member ID | 2026-07-31 Telehealth | Canyon Counseling Center Behavioral Health · out of network | 99214 | $244.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-012972 CMS-1500 · 2026-08-12 | Justin Murphy no member ID | 2026-07-19 Office | Harbor Primary Care Associates Family Medicine · out of network | 99214, 99203 | $406.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-022409 CMS-1500 · 2026-08-09 | Dylan Munoz no member ID | 2026-07-16 Office | Evergreen Medical Group Internal Medicine · out of network | 99214, 93000, 99215 | $636.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-022826 CMS-1500 · 2026-08-07 | Timothy Alexander UHC-78547-89 | 2026-07-18 Office | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 20610 | $246.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-024970 CMS-1500 · 2026-08-06 | Helen Graay no member ID | 2026-07-03 Office | Canyon Counseling Center Behavioral Health · out of network | 90791, 90837 | $574.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-032111 CMS-1500 · 2026-08-04 | Maria Garcia no member ID | 2026-07-10 Office | Lakeside Endocrine Associates Endocrinology · out of network | 83036, 95251 | $236.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-019725 CMS-1500 · 2026-07-31 | Beverly Rogers no member ID | 2026-07-06 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $307.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-031303 CMS-1500 · 2026-07-30 | Sofia Collins no member ID | 2026-07-14 Office | Cornerstone Family Practice Family Medicine · out of network | 36415, 99213, 99395 | $484.00 | — | 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.