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-2026-014431 UB-04 · 2026-08-28 | Lori Mejia UHC-54236-13 | 2026-08-08 Outpatient hospital | Riverside GI Associates Gastroenterology · in network | 45378, 43239 | $3,243.00 | — | Pended by rule IDQ | — | 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-2026-009006 UB-04 · 2026-08-28 | Justin Rogers no member ID | 2026-07-17 Outpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 73721 | $2,376.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-005265 UB-04 · 2026-08-28 | Not attached | 2026-08-25 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 71046 | $225.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-000150 UB-04 · 2026-08-28 | Jacob Kelly UHC-59781-92 | 2026-08-03 Outpatient hospital | Meadow GI Associates Gastroenterology · in network | 45378, 43239 | $4,486.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-034053 UB-04 · 2026-08-27 | David Yang UHC-06564-81 | 2026-08-10 Outpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 29881 | $9,062.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-032156 UB-04 · 2026-08-27 | Samuel Santiago UHC-56570-42 | 2026-07-20 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $259.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-032150 CMS-1500 · 2026-08-27 | John Hayes UHC-59901-87 | 2026-08-19 Office | Valley Family Practice Family Medicine · in network | 90471 | $29.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-032140 CMS-1500 · 2026-08-27 | Gerald Arnold UHC-27129-15 | 2026-08-18 Office | Sunrise Diabetes Center Endocrinology · in network | 95251 | $203.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025384 UB-04 · 2026-08-27 | Wayne Roberts UHC-07588-16 | 2026-08-07 Emergency room | Valley Regional Medical Center Emergency Medicine · in network | 71046, 99284, 99285 | $3,532.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025033 UB-04 · 2026-08-27 | Not attached | 2026-07-26 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99285, 71046 | $2,179.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-024773 CMS-1500 · 2026-08-27 | Angela Cole UHC-48801-96 | 2026-08-01 Office | Valley Medical Group Internal Medicine · in network | 93000 | $73.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-021485 CMS-1500 · 2026-08-27 | Carlos Daniels no member ID | 2026-08-05 Office | Meadow Primary Care Associates Family Medicine · in network | 90471, 99213 | $194.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-018245 CMS-1500 · 2026-08-27 | Betty Stephens no member ID | 2026-07-17 Office | Sunrise Internal Medicine Associates Internal Medicine · in network | 99214 | $234.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-015058 UB-04 · 2026-08-27 | Terry Laane no member ID | 2026-08-16 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 96374 | $192.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-013894 CMS-1500 · 2026-08-27 | Charles Medina UHC-94822-28 | 2026-07-18 Office | Heritage Medical Group Family Medicine · in network | 90471 | $28.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-011916 CMS-1500 · 2026-08-27 | Greegory Valdez no member ID | 2026-07-16 Office | Riverside Bone and Joint Center Orthopedic Surgery · in network | 20610 | $278.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-002471 CMS-1500 · 2026-08-27 | Kathryn Austin UHC-56978-49 | 2026-07-21 Office | Summit Digestive Health Center Gastroenterology · in network | 99214 | $302.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-002242 UB-04 · 2026-08-27 | Rachel Payne no member ID | 2026-08-21 Emergency room | Cornerstone Regional Medical Center Emergency Medicine · in network | 71046, 96374, 99285 | $2,754.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002127 CMS-1500 · 2026-08-27 | Fatima Delgado no member ID | 2026-07-29 Office | Harbor Medical Group Family Medicine · in network | 99203, 99395, 99213 | $631.00 | — | Pended by rule N30 | — | 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-2026-029131 UB-04 · 2026-08-26 | Brandon Bryant UHC-60328-88 | 2026-08-12 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99283, 99285 | $2,680.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-027696 CMS-1500 · 2026-08-26 | Joshua Wood no member ID | 2026-08-04 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 83036, 80053 | $123.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-027551 UB-04 · 2026-08-26 | Jeffrey Green no member ID | 2026-08-18 Outpatient hospital | Meadow Primary Care Associates Family Medicine · in network | 70553 | $3,003.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024065 UB-04 · 2026-08-26 | Paul Herrera no member ID | 2026-07-23 Outpatient hospital | Pinecrest Primary Care Associates Family Medicine · in network | 70553 | $3,148.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-023799 CMS-1500 · 2026-08-26 | Julia Gomez no member ID | 2026-07-25 Office | Unity Dermatology Clinic Dermatology · in network | 11102, 17110 | $580.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-015488 CMS-1500 · 2026-08-26 | Mason Obrien no member ID | 2026-07-21 Office | Canyon Medical Group Internal Medicine · in network | 80053 | $80.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-008223 CMS-1500 · 2026-08-26 | Juan Lewis no member ID | 2026-07-02 Independent laboratory | Summit Clinical Laboratories Clinical Laboratory · in network | 87086, 85025, 80053 | $141.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-006145 UB-04 · 2026-08-26 | Carolyn Martin UHC-41069-52 | 2026-07-29 Outpatient hospital | Valley Imaging Center Radiology · in network | 76700, 74177 | $2,597.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-020496 CMS-1500 · 2026-08-25 | Yuki Ramos no member ID | 2026-08-11 Office | Heritage Primary Care Associates Family Medicine · in network | 90471, 99395 | $275.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-013137 CMS-1500 · 2026-08-25 | Robert Howell no member ID | 2026-08-03 Office | Heritage GI Associates Gastroenterology · in network | 99214 | $284.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-012895 UB-04 · 2026-08-25 | Kathleen Santiago no member ID | 2026-07-15 Outpatient hospital | Unity Cardiovascular Associates Cardiology · in network | 70553 | $3,415.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-008217 CMS-1500 · 2026-08-25 | Timothy Howell UHC-30686-19 | 2026-08-08 Office | Pinecrest Medical Group Family Medicine · in network | 36415 | $22.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-007713 CMS-1500 · 2026-08-25 | Judith Espinoza no member ID | 2026-07-29 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 80053 | $59.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-005203 UB-04 · 2026-08-25 | Margaret Roberts no member ID | 2026-07-12 Outpatient hospital | Riverside GI Associates Gastroenterology · in network | 45378, 88305 | $2,507.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-033326 UB-04 · 2026-08-24 | Susan Adams no member ID | 2026-07-10 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 71046 | $117.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-030702 UB-04 · 2026-08-24 | Priay Hunter no member ID | 2026-07-12 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 70553, 77067 | $3,635.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-028666 UB-04 · 2026-08-24 | Christian Porter UHC-10085-76 | 2026-07-12 Outpatient hospital | Valley Imaging Center Radiology · in network | 77067, 70553 | $3,519.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-012345 CMS-1500 · 2026-08-24 | Laura Evans no member ID | 2026-08-08 Office | Meadow Medical Group Family Medicine · in network | 99203 | $255.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-005121 UB-04 · 2026-08-24 | Aaron Ortiz no member ID | 2026-07-19 Outpatient hospital | Meadow Cardiovascular Associates Cardiology · in network | 93015 | $548.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-002591 CMS-1500 · 2026-08-24 | Betty Evans UHC-40645-66 | 2026-07-30 Office | Canyon Medical Group Internal Medicine · in network | 80053, 99215 | $367.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000953 CMS-1500 · 2026-08-24 | Lisa Reid no member ID | 2026-07-22 Independent laboratory | Meadow Clinical Laboratories Clinical Laboratory · in network | 83036, 80061, 85025 | $149.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-032162 CMS-1500 · 2026-08-23 | Gerald Foster no member ID | 2026-08-12 Office | Valley Primary Care Associates Family Medicine · in network | 99214 | $219.00 | — | Pended by rule IDQ N30 | — | 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-2026-025931 CMS-1500 · 2026-08-23 | Patrick Gibson UHC-07243-35 | 2026-07-09 Office | Summit Family Practice Family Medicine · in network | 99213 | $184.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-021996 UB-04 · 2026-08-23 | Cheryl Parker no member ID | 2026-08-03 Emergency room | Sunrise Community Hospital Emergency Medicine · in network | 71046, 99285, 99284 | $4,522.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-018041 UB-04 · 2026-08-23 | Pamela Gardner UHC-65974-65 | 2026-07-24 Outpatient hospital | Pinecrest Medical Group Family Medicine · in network | 70553 | $2,098.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-015494 CMS-1500 · 2026-08-23 | Alexys Duncan no member ID | 2026-08-17 Office | Riverside Family Practice Family Medicine · in network | 36415, 99203 | $240.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-012818 CMS-1500 · 2026-08-23 | Adam Nunez no member ID | 2026-08-09 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110, 97014 | $204.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-008873 CMS-1500 · 2026-08-23 | Samuel Tucker UHC-63335-10 | 2026-08-15 Office | Meadow Medical Group Family Medicine · in network | 99203 | $193.00 | — | Pended by rule IDQ | — | 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.