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-2026-026769 CMS-1500 · 2026-08-05 | Jason Thompson no member ID | 2026-06-28 Independent laboratory | Summit Clinical Laboratories Clinical Laboratory · in network | 80053 | $64.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-021844 UB-04 · 2026-08-05 | Jesse Stewart no member ID | 2026-08-03 Emergency room | Meadow Regional Medical Center Emergency Medicine · in network | 96374, 71046 | $331.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-018847 CMS-1500 · 2026-08-05 | George Li no member ID | 2026-07-16 Office | Harbor Endocrine Associates Endocrinology · in network | 99215, 83036 | $445.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-016426 CMS-1500 · 2026-08-05 | Joseph Simpson UHC-40911-71 | 2026-07-09 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90837 | $260.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013935 CMS-1500 · 2026-08-05 | Brandon Payne UHC-55907-96 | 2026-07-10 Office | Unity Family Practice Family Medicine · in network | 99213 | $178.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-006129 CMS-1500 · 2026-08-05 | Samuel Bennett no member ID | 2026-06-22 Office | Meadow Medical Group Family Medicine · in network | 90471, 36415 | $39.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-005631 CMS-1500 · 2026-08-05 | Jerry Meyer UHC-94668-47 | 2026-07-01 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 87086, 80053, 85025 | $211.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-005292 CMS-1500 · 2026-08-05 | Laura Weber UHC-70400-26 | 2026-06-28 Office | Pinecrest Medical Group Internal Medicine · in network | 93000, 80053 | $131.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-034499 UB-04 · 2026-08-04 | Ronald Espinoza no member ID | 2026-07-16 Emergency room | Valley Regional Medical Center Emergency Medicine · in network | 99283, 96374 | $934.00 | — | 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-2026-031483 UB-04 · 2026-08-04 | Randy Coko no member ID | 2026-06-25 Emergency room | Meadow Regional Medical Center Emergency Medicine · in network | 99283, 99285 | $3,380.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-028556 UB-04 · 2026-08-04 | Daniel Austin UHC-34567-10 | 2026-06-27 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 77067 | $301.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025975 CMS-1500 · 2026-08-04 | Sarah Howell UHC-91177-68 | 2026-07-29 Office | Summit Internal Medicine Associates Internal Medicine · in network | 80053 | $64.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-022468 UB-04 · 2026-08-04 | Not attached | 2026-07-15 Outpatient hospital | Summit Imaging Center Radiology · in network | 77067, 70553 | $2,817.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-019361 UB-04 · 2026-08-04 | Anna Ortega no member ID | 2026-07-21 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 45378 | $2,027.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-017169 UB-04 · 2026-08-04 | Maria Garcia no member ID | 2026-08-01 Inpatient hospital | Lakeside Medical Group Internal Medicine · in network | 99232 | $249.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013032 CMS-1500 · 2026-08-04 | Frank Carter UHC-96878-77 | 2026-06-24 Office | Meadow Physical Therapy Physical Therapy · in network | 97110, 97014 | $315.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-009269 UB-04 · 2026-08-04 | Michael Willis no member ID | 2026-06-25 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 70553 | $3,584.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-008766 CMS-1500 · 2026-08-04 | Diane Hunt no member ID | 2026-07-30 Office | Desert Medical Group Internal Medicine · in network | 93000, 99215 | $459.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-006902 CMS-1500 · 2026-08-04 | Andrea Powell no member ID | 2026-06-23 Office | Northgate Medical Group Family Medicine · in network | 36415, 99214 | $224.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-002902 CMS-1500 · 2026-08-04 | Brandon Warren no member ID | 2026-07-06 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99214 | $319.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-034626 UB-04 · 2026-08-03 | Ana Allen UHC-40301-04 | 2026-07-03 Emergency room | Cornerstone Regional Medical Center Emergency Medicine · in network | 71046, 99283 | $748.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-032721 UB-04 · 2026-08-03 | Charlees Murray no member ID | 2026-06-24 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700, 74177 | $2,717.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-025608 UB-04 · 2026-08-03 | Scott Romero no member ID | 2026-07-08 Outpatient hospital | Riverside Imaging Center Radiology · in network | 70553 | $2,023.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-025444 UB-04 · 2026-08-03 | Garry Rice no member ID | 2026-06-20 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 70553, 74177, 76700 | $6,220.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024926 CMS-1500 · 2026-08-03 | Olivia Walker UHC-17212-22 | 2026-06-26 Office | Riverside Primary Care Associates Family Medicine · in network | 36415, 99203 | $209.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-015333 CMS-1500 · 2026-08-03 | Megan Young no member ID | 2026-06-24 Office | Riverside Primary Care Associates Family Medicine · in network | 99203 | $206.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-010802 CMS-1500 · 2026-08-03 | Lawrence Richards UHC-83053-66 | 2026-07-24 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 83036, 80053 | $120.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-009758 CMS-1500 · 2026-08-03 | Andrea Jordan UHC-03898-53 | 2026-07-19 Office | Lakeside Medical Group Family Medicine · in network | 99203, 99395 | $518.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-008975 CMS-1500 · 2026-08-03 | Sharon Burke no member ID | 2026-07-11 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110, 97014, 97140 | $367.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-004482 CMS-1500 · 2026-08-03 | Brian Anderson UHC-99057-57 | 2026-06-20 Office | Canyon Skin Care Associates Dermatology · in network | 11102, 17110, 99213 | $668.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-003723 UB-04 · 2026-08-03 | Roger Bowman no member ID | 2026-06-30 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 70553, 74177, 77067 | $4,757.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-003372 CMS-1500 · 2026-08-03 | Emma Le UHC-99358-95 | 2026-07-03 Office | Riverside Primary Care Associates Family Medicine · in network | 99214 | $221.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-018459 CMS-1500 · 2026-08-02 | Daniel Carter no member ID | 2026-06-27 Office | Mesa Family Practice Family Medicine · in network | 36415, 99203 | $234.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-015575 CMS-1500 · 2026-08-02 | Roger Carroll UHC-21603-47 | 2026-06-19 Office | Unity Medical Group Family Medicine · in network | 90471 | $32.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010855 CMS-1500 · 2026-08-02 | Kathy Jimenez no member ID | 2026-06-21 Office | Evergreen Family Practice Family Medicine · in network | 99213 | $154.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-006635 CMS-1500 · 2026-08-02 | Virginia Morrison no member ID | 2026-06-20 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 80053, 83036 | $109.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029807 CMS-1500 · 2026-08-01 | Jesse Walker no member ID | 2026-07-25 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140 | $223.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-022085 CMS-1500 · 2026-08-01 | Sophia Lee UHC-28248-10 | 2026-07-27 Office | Summit Medical Group Internal Medicine · in network | 99214, 80053 | $275.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-018870 CMS-1500 · 2026-08-01 | Maria Valdez no member ID | 2026-07-01 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 93000, 99214, 99215 | $661.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-016784 CMS-1500 · 2026-08-01 | Katherine Silva no member ID | 2026-07-28 Office | Evergreen Family Practice Family Medicine · in network | 36415, 99214 | $238.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-011393 CMS-1500 · 2026-08-01 | Janice Rodriguez no member ID | 2026-06-23 Office | Lakeside Medical Group Family Medicine · in network | 99203, 36415, 99213 | $425.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-010191 CMS-1500 · 2026-08-01 | Emma Santiago UHC-20832-61 | 2026-06-23 Office | Unity Primary Care Associates Family Medicine · in network | 99213, 36415 | $217.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-033023 UB-04 · 2026-07-31 | Kathleen Fowler no member ID | 2026-07-15 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 70553, 74177 | $5,009.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029637 CMS-1500 · 2026-07-31 | Yuki Elliott UHC-23585-70 | 2026-06-24 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97161 | $502.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-027799 CMS-1500 · 2026-07-31 | Diego Howard no member ID | 2026-07-26 Office | Heritage Medical Group Internal Medicine · in network | 99215, 93000 | $380.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-021633 UB-04 · 2026-07-31 | Not attached | 2026-06-18 Inpatient hospital | Heritage Internal Medicine Associates Internal Medicine · in network | 99232 | $216.00 | — | Pended by rule CO16 | — | 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-2026-018944 UB-04 · 2026-07-31 | Russell Park UHC-27001-48 | 2026-07-16 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 70553, 77067 | $3,693.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-017888 CMS-1500 · 2026-07-31 | Terry Stephens no member ID | 2026-06-29 Office | Evergreen Family Practice Family Medicine · in network | 36415 | $16.00 | — | Pended by rule IDQ 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.