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-2026-021923 CMS-1500 · 2026-08-11 | Hawkins Lucia no member ID | 2026-08-01 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $312.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-020292 CMS-1500 · 2026-08-11 | Gary Butler no member ID | 2026-07-28 Independent laboratory | Summit Clinical Laboratories Clinical Laboratory · in network | 80061, 83036, 80053 | $189.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-016674 CMS-1500 · 2026-08-11 | Joyce Weber no member ID | 2026-07-02 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 83036 | $57.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-015562 CMS-1500 · 2026-08-11 | Albert Davis UHC-32845-52 | 2026-08-08 Office | Unity Primary Care Associates Family Medicine · in network | 99203, 36415 | $253.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-005129 CMS-1500 · 2026-08-11 | Lisa Pena UHC-45922-33 | 2026-06-28 Office | Riverside Family Practice Family Medicine · in network | 99214, 99203 | $454.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-031488 CMS-1500 · 2026-08-10 | George Gomez no member ID | 2026-07-09 Independent laboratory | Pinecrest Reference Lab Clinical Laboratory · in network | 80061, 80053 | $115.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029245 UB-04 · 2026-08-10 | Frank Kelley no member ID | 2026-07-13 Emergency room | Unity Community Hospital Emergency Medicine · in network | 71046 | $221.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-028902 CMS-1500 · 2026-08-10 | Santiago Edwards no member ID | 2026-07-15 Office | Harbor Primary Care Associates Family Medicine · in network | 99213 | $201.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-022190 UB-04 · 2026-08-10 | Cheryl Ray UHC-15687-67 | 2026-07-20 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $39,509.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-011202 CMS-1500 · 2026-08-10 | George Delgado no member ID | 2026-07-07 Office | Sunrise Dermatology Clinic Dermatology · in network | 17110 | $242.00 | — | 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-2026-030404 CMS-1500 · 2026-08-09 | Brenda Phillips UHC-75690-49 | 2026-07-12 Office | Riverside Digestive Health Center Gastroenterology · in network | 99214 | $304.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030245 CMS-1500 · 2026-08-09 | Melissa Mendez UHC-41965-57 | 2026-07-21 Office | Sunrise Behavioral Health Behavioral Health · in network | 90837, 90791 | $598.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-026895 UB-04 · 2026-08-09 | Brittany Rios no member ID | 2026-07-06 Outpatient hospital | Desert Imaging Center Radiology · in network | 70553, 77067, 71046 | $2,577.00 | — | Pended by rule IDQ 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-2026-020184 CMS-1500 · 2026-08-09 | Austin Hansen UHC-79692-72 | 2026-06-27 Independent laboratory | Unity Reference Lab Clinical Laboratory · in network | 87086, 85025 | $129.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000866 UB-04 · 2026-08-09 | Not attached | 2026-07-25 Outpatient hospital | Riverside Imaging Center Radiology · in network | 76700 | $611.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-033021 CMS-1500 · 2026-08-08 | 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-2026-029609 UB-04 · 2026-08-08 | Denise Dunn UHC-66614-26 | 2026-08-02 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 74177, 77067 | $2,191.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-022100 UB-04 · 2026-08-08 | Betty Perkins no member ID | 2026-07-22 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $42,072.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-019879 CMS-1500 · 2026-08-08 | Daniel Davis no member ID | 2026-06-28 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $312.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017488 UB-04 · 2026-08-08 | Eric Jimenez UHC-94818-41 | 2026-07-25 Outpatient hospital | Meadow Cardiovascular Associates Cardiology · in network | 93015 | $544.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-014676 UB-04 · 2026-08-08 | Stephen Harvey no member ID | 2026-07-12 Outpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $5,716.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-014416 UB-04 · 2026-08-08 | Mason Wells UHC-76605-77 | 2026-07-18 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 76700, 77067 | $604.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-005595 CMS-1500 · 2026-08-08 | Mark Phillisp no member ID | 2026-08-06 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · in network | 87086, 85025 | $122.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-001537 UB-04 · 2026-08-08 | Ryan Santos UHC-94423-25 | 2026-07-10 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 96374, 99285, 99283 | $2,930.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-032394 CMS-1500 · 2026-08-07 | Not attached | 2026-07-09 Office | Pinecrest Medical Group Family Medicine · in network | 36415 | $24.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-031172 CMS-1500 · 2026-08-07 | Virginia Hudson no member ID | 2026-07-03 Office | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 99213 | $192.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-026378 UB-04 · 2026-08-07 | Emma Weaver UHC-92616-38 | 2026-07-19 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · in network | 99232, 99215 | $592.00 | — | Pended by rule IDQ | — | 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-2026-016790 CMS-1500 · 2026-08-07 | Elizabeth Mendez no member ID | 2026-06-28 Office | Summit Family Practice Family Medicine · in network | 99395, 90471, 99203 | $564.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-016408 UB-04 · 2026-08-07 | Ethan Walsh no member ID | 2026-07-07 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99283, 99285 | $2,842.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-014888 CMS-1500 · 2026-08-07 | Christopher Robinson no member ID | 2026-07-10 Office | Canyon Internal Medicine Associates Internal Medicine · in network | 99214, 99215 | $604.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-011962 CMS-1500 · 2026-08-07 | Kayla Vazquez UHC-77211-27 | 2026-07-17 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 80061, 87086, 83036 | $209.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-008914 CMS-1500 · 2026-08-07 | Pamela Sanders UHC-11818-05 | 2026-07-29 Office | Pinecrest Family Practice Family Medicine · in network | 99395, 99213, 90471 | $470.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-008222 CMS-1500 · 2026-08-07 | 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-2026-007432 UB-04 · 2026-08-07 | Bobby Garcia UHC-37947-67 | 2026-07-30 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 76700 | $489.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030751 CMS-1500 · 2026-08-06 | Eugene Phillips no member ID | 2026-07-19 Independent laboratory | Summit Clinical Laboratories Clinical Laboratory · in network | 85025, 83036 | $136.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-030750 CMS-1500 · 2026-08-06 | Emily Dominguez no member ID | 2026-07-09 Office | Lakeside Medical Group Family Medicine · in network | 99203 | $232.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029342 UB-04 · 2026-08-06 | Albert Lynch UHC-43210-65 | 2026-07-27 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $250.00 | — | 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-2026-023156 CMS-1500 · 2026-08-06 | Maria Bryant UHC-92112-28 | 2026-06-22 Office | Heritage Behavioral Health Behavioral Health · in network | 90834, 90791 | $603.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-022712 UB-04 · 2026-08-06 | Santiago Jacobs no member ID | 2026-07-03 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 43239 | $2,557.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-021178 UB-04 · 2026-08-06 | Not attached | 2026-07-26 Outpatient hospital | Desert Imaging Center Radiology · in network | 71046 | $200.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-018647 UB-04 · 2026-08-06 | Katherine Spencer UHC-92145-04 | 2026-08-02 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 74177 | $1,802.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-015669 CMS-1500 · 2026-08-06 | Gabriel Woods no member ID | 2026-07-28 Office | Summit Counseling Center Behavioral Health · in network | 90834, 90791 | $497.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-003305 UB-04 · 2026-08-06 | Not attached | 2026-07-10 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283 | $917.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-000539 UB-04 · 2026-08-06 | Not attached | 2026-06-27 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · in network | 93306, 93015 | $1,820.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-032943 UB-04 · 2026-08-05 | Noah Andrews no member ID | 2026-07-03 Outpatient hospital | Summit Imaging Center Radiology · in network | 77067 | $320.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-028796 CMS-1500 · 2026-08-05 | Christian Gomez no member ID | 2026-07-10 Office | Meadow Medical Group Family Medicine · in network | 99214 | $291.00 | — | 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.