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-2026-033685 UB-04 · 2026-08-16 | Heather Austin UHC-79946-28 | 2026-08-11 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 71046 | $122.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-033022 CMS-1500 · 2026-08-16 | Alice Sanders no member ID | 2026-07-13 Office | Riverside Primary Care Associates Family Medicine · in network | 99395 | $269.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-031884 CMS-1500 · 2026-08-16 | Terry Tran UHC-88172-96 | 2026-08-05 Telehealth | Pinecrest Behavioral Health Behavioral Health · in network | 99214 | $242.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-023139 CMS-1500 · 2026-08-16 | Douglas Salazar no member ID | 2026-07-24 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 83036, 80061 | $152.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-023078 UB-04 · 2026-08-16 | Julia Ortega no member ID | 2026-07-09 Outpatient hospital | Riverside Imaging Center Radiology · in network | 76700 | $445.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-021934 CMS-1500 · 2026-08-16 | Robert Jenkins UHC-46816-23 | 2026-07-03 Office | Evergreen Rehabilitation Center Physical Therapy · in network | 97110, 97140 | $217.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-020869 CMS-1500 · 2026-08-16 | Deborah Wilils no member ID | 2026-07-13 Office | Summit Internal Medicine Associates Internal Medicine · in network | 99214, 99215 | $543.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017435 UB-04 · 2026-08-16 | Carolyn Ruiz no member ID | 2026-08-01 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99285, 99283, 99284 | $5,160.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-015429 CMS-1500 · 2026-08-16 | Evelyn Castro UHC-23520-64 | 2026-07-08 Office | Lakeside Medical Group Internal Medicine · in network | 99214, 80053 | $307.00 | — | Pended by rule IDQ | — | 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-2026-014725 CMS-1500 · 2026-08-16 | Roy Hansen UHC-85927-31 | 2026-08-01 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 83036, 80061 | $134.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013073 CMS-1500 · 2026-08-16 | Madison Flores UHC-36145-14 | 2026-07-09 Office | Valley Medical Group Family Medicine · in network | 36415 | $25.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010861 CMS-1500 · 2026-08-16 | Tyler Anderson UHC-60331-66 | 2026-08-02 Office | Summit Endocrine Associates Endocrinology · in network | 83036, 99215 | $455.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-008272 CMS-1500 · 2026-08-16 | Andrew Crawford UHC-51292-90 | 2026-08-08 Office | Sunrise Dermatology Clinic Dermatology · in network | 11403, 17110 | $910.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-004700 UB-04 · 2026-08-16 | Emma Washington UHC-20115-01 | 2026-07-26 Inpatient hospital | Cornerstone Internal Medicine Associates Internal Medicine · in network | 99232 | $243.00 | — | Pended by rule IDQ | — | 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-2026-032199 UB-04 · 2026-08-15 | Melissa Anderson UHC-80083-70 | 2026-08-11 Outpatient hospital | Summit Heart Institute Cardiology · in network | 93015, 93306 | $1,749.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-029480 CMS-1500 · 2026-08-15 | Jessica Roemro no member ID | 2026-07-28 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99214, 36415 | $260.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-024562 CMS-1500 · 2026-08-15 | Elizabeth Patterson no member ID | 2026-07-12 Office | Mesa Family Practice Family Medicine · in network | 99214, 99213 | $396.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-021939 UB-04 · 2026-08-15 | Wang Lisa no member ID | 2026-07-13 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93458 | $6,633.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-021548 CMS-1500 · 2026-08-15 | Jack Sanchez UHC-31828-64 | 2026-08-04 Office | Meadow Medical Group Family Medicine · in network | 99214, 99203 | $483.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-021227 CMS-1500 · 2026-08-15 | Bruce Porter UHC-09068-81 | 2026-07-21 Office | Lakeside Digestive Health Center Gastroenterology · in network | 99214 | $287.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-016149 UB-04 · 2026-08-15 | Omar Vasquez UHC-98026-90 | 2026-07-06 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 77067 | $244.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-014869 CMS-1500 · 2026-08-15 | Ralph Rodriguez UHC-39276-85 | 2026-07-01 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 80053, 80061, 87086 | $148.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-012237 UB-04 · 2026-08-15 | Doglas Lawence UHC-50395-41 | 2026-07-03 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 74177 | $2,241.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-007472 UB-04 · 2026-08-15 | Melissa Allen UHC-41301-70 | 2026-07-15 Outpatient hospital | Harbor Digestive Health Center Gastroenterology · in network | 43239 | $1,305.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-005900 UB-04 · 2026-08-15 | Alan Dean UHC-46690-93 | 2026-07-22 Outpatient hospital | Riverside Imaging Center Radiology · in network | 70553 | $2,540.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-005857 UB-04 · 2026-08-15 | Billy Mendez UHC-86409-59 | 2026-07-17 Outpatient hospital | Pinecrest GI Associates Gastroenterology · in network | 70553 | $3,485.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-034508 UB-04 · 2026-08-14 | Paul Aguilar UHC-80837-07 | 2026-07-16 Inpatient hospital | Canyon Medical Group Internal Medicine · in network | 99232 | $243.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-033565 UB-04 · 2026-08-14 | Scott Lee UHC-74686-52 | 2026-08-07 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 71046 | $225.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-033077 CMS-1500 · 2026-08-14 | Sophia Jimenez no member ID | 2026-07-26 Office | Valley Medical Group Internal Medicine · in network | 80053 | $77.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-032835 UB-04 · 2026-08-14 | Melissa Dixon no member ID | 2026-07-03 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 74177, 76700 | $2,941.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-027417 UB-04 · 2026-08-14 | Brandon Payne no member ID | 2026-07-20 Outpatient hospital | Northgate Cardiovascular Associates Cardiology · in network | 93306 | $1,255.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-016728 CMS-1500 · 2026-08-14 | Nicole Murray no member ID | 2026-08-09 Office | Sunrise Counseling Center Behavioral Health · in network | 90837 | $247.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-015238 UB-04 · 2026-08-14 | Yuki Jackson no member ID | 2026-07-09 Outpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 70553 | $2,125.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013641 UB-04 · 2026-08-14 | Victoria Stevens no member ID | 2026-08-11 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 70553, 74177, 77067 | $6,333.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-025202 UB-04 · 2026-08-13 | Alice Herrera no member ID | 2026-07-29 Outpatient hospital | Evergreen GI Associates Gastroenterology · in network | 70553, 88305 | $3,048.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-016363 CMS-1500 · 2026-08-13 | Nicole Rivera UHC-02205-42 | 2026-08-11 Office | Meadow Medical Group Family Medicine · in network | 99395, 90471 | $314.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-031069 CMS-1500 · 2026-08-12 | Kimberly Park no member ID | 2026-07-29 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97161, 97014 | $429.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-025645 CMS-1500 · 2026-08-12 | Jerry Lee no member ID | 2026-07-09 Office | Mesa Dermatology Clinic Dermatology · in network | 11102, 99213 | $404.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024376 UB-04 · 2026-08-12 | Lori Nelson no member ID | 2026-07-22 Emergency room | Lakeside Regional Medical Center Emergency Medicine · in network | 71046, 99285 | $2,112.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-023114 CMS-1500 · 2026-08-12 | Jacob Vazquez UHC-80829-54 | 2026-07-07 Office | Meadow Primary Care Associates Family Medicine · in network | 99395, 99214 | $625.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-021456 UB-04 · 2026-08-12 | Eugene McCoy no member ID | 2026-08-08 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 96374, 99284 | $1,479.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017797 CMS-1500 · 2026-08-12 | Sofia Lopez UHC-91834-08 | 2026-07-25 Office | Summit Primary Care Associates Family Medicine · in network | 99203, 99395 | $471.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-017111 UB-04 · 2026-08-12 | Melissa Hawkins no member ID | 2026-07-09 Outpatient hospital | Valley Imaging Center Radiology · in network | 70553, 74177 | $4,003.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-015296 CMS-1500 · 2026-08-12 | Nathan Guerrero UHC-44163-58 | 2026-07-27 Office | Mesa Family Practice Family Medicine · in network | 99395 | $340.00 | — | Pended by rule IDQ | — | 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-2026-004941 CMS-1500 · 2026-08-12 | Julie Stephens UHC-55281-28 | 2026-07-01 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140 | $307.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-002693 CMS-1500 · 2026-08-12 | Jeremy Dunncan no member ID | 2026-07-27 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 87086, 80053 | $130.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024791 CMS-1500 · 2026-08-11 | Mariana Wilson no member ID | 2026-07-28 Office | Unity Counseling Center Behavioral Health · in network | 90834 | $219.00 | — | 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.