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-2026-007661 CMS-1500 · 2026-08-23 | Bradley Elliott no member ID | 2026-07-11 Office | Meadow Primary Care Associates Family Medicine · in network | 90471 | $39.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-004124 CMS-1500 · 2026-08-23 | Sandra George no member ID | 2026-07-27 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110 | $248.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024393 CMS-1500 · 2026-08-22 | Melissa Collins UHC-84977-60 | 2026-08-06 Office | Canyon Medical Group Internal Medicine · in network | 99214, 80053 | $369.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-023748 CMS-1500 · 2026-08-22 | Heather Hart UHC-02743-92 | 2026-07-12 Office | Harbor Physical Therapy Physical Therapy · in network | 97110 | $189.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-020034 CMS-1500 · 2026-08-22 | Ahmed Senders no member ID | 2026-08-12 Office | Unity Medical Group Internal Medicine · in network | 99215 | $293.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-013226 CMS-1500 · 2026-08-22 | Stephanie Campbell UHC-60143-31 | 2026-07-28 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 80053 | $52.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-011879 CMS-1500 · 2026-08-22 | Kayla Graham UHC-57842-30 | 2026-08-17 Office | Pinecrest Primary Care Associates Family Medicine · in network | 90471 | $33.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010482 CMS-1500 · 2026-08-22 | Julia Powell UHC-20456-59 | 2026-07-22 Independent laboratory | Valley Reference Lab Clinical Laboratory · in network | 83036, 80061, 85025 | $123.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-007831 UB-04 · 2026-08-22 | Joyce Tran UHC-45030-13 | 2026-07-09 Outpatient hospital | Riverside Cardiovascular Associates Cardiology · in network | 93306, 93015 | $2,232.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-006957 CMS-1500 · 2026-08-22 | Not attached | 2026-08-17 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $431.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-027747 CMS-1500 · 2026-08-21 | Ethan Ramos UHC-96236-46 | 2026-07-28 Office | Evergreen Medical Group Family Medicine · in network | 99213 | $217.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-020244 CMS-1500 · 2026-08-21 | Walter Mrrison UHC-11655-25 | 2026-07-07 Office | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 20610 | $226.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-014870 CMS-1500 · 2026-08-21 | Ralph Rodriguez UHC-39276-85 | 2026-07-01 Independent laboratory | Valley Reference Lab Clinical Laboratory · in network | 80053, 80061, 87086 | $148.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-011270 CMS-1500 · 2026-08-21 | Daniel Grreene no member ID | 2026-08-15 Independent laboratory | Harbor Reference Lab Clinical Laboratory · in network | 80061, 87086 | $98.00 | — | Pended by rule IDQ 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-2026-029936 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-2026-029727 UB-04 · 2026-08-20 | Jacob Lucas UHC-13277-60 | 2026-07-13 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · in network | 88305, 45378, 43239 | $3,645.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-028887 CMS-1500 · 2026-08-20 | Rebecca Warren UHC-69309-05 | 2026-07-10 Independent laboratory | Sunrise Clinical Laboratories Clinical Laboratory · in network | 80053, 85025, 83036 | $210.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-027581 UB-04 · 2026-08-20 | Martha Kim UHC-00401-49 | 2026-08-09 Outpatient hospital | Pinecrest GI Associates Gastroenterology · in network | 43239, 45378 | $4,544.00 | — | Pended by rule IDQ | — | 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-2026-022874 CMS-1500 · 2026-08-20 | Jennifer McCoy UHC-92337-58 | 2026-07-07 Office | Pinecrest Medical Group Family Medicine · in network | 99203, 99214 | $482.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-017334 CMS-1500 · 2026-08-20 | Not attached | 2026-07-31 Independent laboratory | Cornerstone Clinical Laboratories Clinical Laboratory · in network | 83036, 80053 | $141.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-016511 UB-04 · 2026-08-20 | Amber Rose UHC-92898-42 | 2026-07-06 Outpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 29881 | $7,937.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-006341 CMS-1500 · 2026-08-20 | Nicole Bryant UHC-87960-16 | 2026-07-11 Office | Evergreen Dermatology Clinic Dermatology · in network | 99213 | $225.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-018508 CMS-1500 · 2026-08-19 | Omar Peters no member ID | 2026-08-01 Office | Meadow Internal Medicine Associates Internal Medicine · in network | 99215 | $404.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013841 CMS-1500 · 2026-08-19 | Christina Silva no member ID | 2026-08-12 Independent laboratory | Meadow Reference Lab Clinical Laboratory · in network | 80061 | $45.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-010813 UB-04 · 2026-08-19 | Ryan Pena UHC-20316-03 | 2026-08-17 Outpatient hospital | Evergreen GI Associates Gastroenterology · in network | 43239, 45378 | $3,610.00 | — | Pended by rule IDQ | — | 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-2026-010488 CMS-1500 · 2026-08-19 | Sophia Lee no member ID | 2026-08-11 Office | Lakeside Medical Group Family Medicine · in network | 99203 | $241.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-009573 CMS-1500 · 2026-08-19 | Not attached | 2026-08-13 Office | Sunrise Internal Medicine Associates Internal Medicine · in network | 93000, 99215 | $447.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-004278 UB-04 · 2026-08-19 | Evelyn Perry no member ID | 2026-08-17 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 74177 | $2,091.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029795 UB-04 · 2026-08-18 | Joan Young UHC-85977-17 | 2026-07-14 Outpatient hospital | Riverside GI Associates Gastroenterology · in network | 45378 | $2,005.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-027154 UB-04 · 2026-08-18 | Maria Watkins no member ID | 2026-08-07 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 74177 | $1,918.00 | — | Pended by rule N30 | — | 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-2026-024301 CMS-1500 · 2026-08-18 | George Howell no member ID | 2026-07-14 Office | Pinecrest Medical Group Family Medicine · in network | 99395, 99213 | $435.00 | — | Pended by rule IDQ N30 | — | 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-2026-017595 UB-04 · 2026-08-18 | Randy Armstrng no member ID | 2026-08-01 Emergency room | Canyon Regional Medical Center Emergency Medicine · in network | 96374 | $251.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-012125 UB-04 · 2026-08-18 | Danielle Wang no member ID | 2026-07-13 Outpatient hospital | Meadow Cardiovascular Associates Cardiology · in network | 93015 | $414.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-011285 CMS-1500 · 2026-08-18 | Bradley Caarroll no member ID | 2026-08-04 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110, 97140 | $354.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-007215 CMS-1500 · 2026-08-18 | Sophia Murphy no member ID | 2026-07-25 Office | Meadow Primary Care Associates Family Medicine · in network | 99203 | $227.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-006460 UB-04 · 2026-08-18 | Jack Taylor UHC-47608-49 | 2026-07-24 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 76700, 70553 | $3,357.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-004567 UB-04 · 2026-08-18 | Jerry Dean no member ID | 2026-07-13 Inpatient hospital | Mesa Internal Medicine Associates Internal Medicine · in network | 99232 | $222.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002422 CMS-1500 · 2026-08-18 | Not attached | 2026-07-28 Office | Lakeside Medical Group Family Medicine · in network | 99203, 99395 | $455.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-033633 CMS-1500 · 2026-08-17 | Aaron Nunez no member ID | 2026-08-07 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 99214, 80053 | $359.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-031879 UB-04 · 2026-08-17 | Lisa Reid no member ID | 2026-07-28 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $28,943.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013183 CMS-1500 · 2026-08-17 | Kayla Schmidt no member ID | 2026-07-09 Office | Summit Counseling Center Behavioral Health · in network | 90837 | $279.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-010558 UB-04 · 2026-08-17 | Petr Morgan no member ID | 2026-08-10 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 74177 | $1,978.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-008260 CMS-1500 · 2026-08-17 | Bobby Ferguson UHC-85211-32 | 2026-07-29 Independent laboratory | Evergreen Reference Lab Clinical Laboratory · in network | 80053, 83036, 80061 | $196.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000952 CMS-1500 · 2026-08-17 | 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-2026-034007 CMS-1500 · 2026-08-16 | Stephen Mills UHC-08024-69 | 2026-07-29 Office | Unity Digestive Health Center Gastroenterology · in network | 99214 | $261.00 | — | 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.