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-2026-015357 UB-04 · 2026-07-31 | Andrew Soto no member ID | 2026-06-19 Inpatient hospital | Sunrise Medical Group Internal Medicine · in network | 99232 | $228.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-014765 UB-04 · 2026-07-31 | Austin Kennedy no member ID | 2026-07-02 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 74177 | $1,764.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-014760 UB-04 · 2026-07-31 | Nicole Nunez no member ID | 2026-06-28 Emergency room | Sunrise Community Hospital Emergency Medicine · in network | 96374 | $237.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-010935 CMS-1500 · 2026-07-31 | Mateo Shaw UHC-17274-05 | 2026-06-22 Independent laboratory | Evergreen Clinical Laboratories Clinical Laboratory · in network | 83036 | $44.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-009410 CMS-1500 · 2026-07-31 | Nicole Nunez no member ID | 2026-06-23 Office | Sunrise Dermatology Clinic Dermatology · in network | 11403 | $387.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-005311 UB-04 · 2026-07-31 | Juan Ellis no member ID | 2026-07-03 Outpatient hospital | Pinecrest GI Associates Gastroenterology · in network | 88305 | $360.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-001760 CMS-1500 · 2026-07-31 | Not attached | 2026-07-17 Office | Mesa Family Practice Family Medicine · in network | 36415 | $25.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-031303 CMS-1500 · 2026-07-30 | Sofia Collins no member ID | 2026-07-14 Office | Cornerstone Family Practice Family Medicine · out of network | 36415, 99213, 99395 | $484.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-030321 CMS-1500 · 2026-07-30 | Logan Ford no member ID | 2026-06-26 Office | Heritage Primary Care Associates Family Medicine · in network | 99203 | $185.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029504 UB-04 · 2026-07-30 | Randy Long UHC-89497-69 | 2026-07-24 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99283 | $914.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-026992 CMS-1500 · 2026-07-30 | Harold Castillo UHC-59339-91 | 2026-07-25 Office | Riverside Primary Care Associates Family Medicine · in network | 99214 | $214.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025060 UB-04 · 2026-07-30 | Kelly King no member ID | 2026-07-27 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $30,321.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-024471 CMS-1500 · 2026-07-30 | Frank Diaz UHC-91487-75 | 2026-06-24 Independent laboratory | Northgate Reference Lab Clinical Laboratory · in network | 87086 | $64.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-020204 CMS-1500 · 2026-07-30 | Aisha Fowler no member ID | 2026-07-24 Office | Sunrise Diabetes Center Endocrinology · in network | 83036 | $56.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-017432 CMS-1500 · 2026-07-30 | Madison Carllson no member ID | 2026-06-27 Office | Riverside Medical Group Family Medicine · in network | 36415, 99395 | $251.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-006481 CMS-1500 · 2026-07-30 | Not attached | 2026-06-19 Office | Valley Primary Care Associates Family Medicine · in network | 36415 | $24.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-002209 CMS-1500 · 2026-07-30 | Brandon Kennedy no member ID | 2026-07-27 Office | Evergreen Family Practice Family Medicine · in network | 99213, 99395 | $456.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-030354 UB-04 · 2026-07-29 | Jessica Romero UHC-07054-03 | 2026-07-15 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 45378 | $2,512.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-024706 CMS-1500 · 2026-07-29 | Santiago Carter UHC-88240-79 | 2026-07-21 Office | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 99213 | $175.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-023113 CMS-1500 · 2026-07-29 | Jacob Vazquez UHC-80829-54 | 2026-07-07 Office | Mesa Medical Group Family Medicine · in network | 99395, 99214 | $625.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-022995 CMS-1500 · 2026-07-29 | Mei Stevens no member ID | 2026-07-07 Office | Pinecrest Medical Group Family Medicine · in network | 99395, 90471, 36415 | $324.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-020510 CMS-1500 · 2026-07-29 | Santiago Munoz UHC-00179-07 | 2026-06-17 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110 | $168.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-019820 UB-04 · 2026-07-29 | Mari Green no member ID | 2026-06-18 Inpatient hospital | Mesa Internal Medicine Associates Internal Medicine · in network | 99232 | $193.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-012165 CMS-1500 · 2026-07-29 | Albert Wells no member ID | 2026-07-07 Office | Canyon Medical Group Internal Medicine · in network | 99214, 93000 | $298.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-008345 CMS-1500 · 2026-07-29 | Michelle Smith UHC-47865-40 | 2026-05-30 Office | Unity Primary Care Associates Family Medicine · in network | 36415 | $16.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-005270 UB-04 · 2026-07-29 | Maria Henderson UHC-96129-77 | 2026-06-19 Outpatient hospital | Heritage Community Hospital Emergency Medicine · in network | 70553 | $2,817.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-004912 UB-04 · 2026-07-29 | Carol Li no member ID | 2026-07-10 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $1,284.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-003746 CMS-1500 · 2026-07-29 | Not attached | 2026-06-25 Independent laboratory | Desert Clinical Laboratories Clinical Laboratory · in network | 83036 | $76.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-030047 CMS-1500 · 2026-07-28 | Jordna Diana no member ID | 2026-07-03 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $271.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-023608 CMS-1500 · 2026-07-28 | Zachary Perkins no member ID | 2026-07-02 Office | Mesa Primary Care Associates Family Medicine · in network | 99214 | $272.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-023502 UB-04 · 2026-07-28 | Roger Nguyen no member ID | 2026-06-21 Outpatient hospital | Valley Heart Institute Cardiology · in network | 93306 | $1,585.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-020050 CMS-1500 · 2026-07-28 | Alexander Walker no member ID | 2026-06-26 Office | Sunrise Skin Care Associates Dermatology · in network | 11403 | $506.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-015723 UB-04 · 2026-07-28 | Nancy Peters UHC-86599-46 | 2026-07-14 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 71046 | $160.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-009252 CMS-1500 · 2026-07-28 | Ray Ray UHC-65599-35 | 2026-07-23 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 85025 | $35.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-008815 UB-04 · 2026-07-28 | Kimbeerly Evans no member ID | 2026-07-22 Outpatient hospital | Cornerstone Imaging Center Radiology · in network | 76700, 77067, 70553 | $3,170.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-007891 CMS-1500 · 2026-07-28 | Anna Chapman no member ID | 2026-06-28 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 80053 | $44.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-033382 CMS-1500 · 2026-07-27 | Jacqueline McCoy no member ID | 2026-06-26 Office | Northgate Medical Group Internal Medicine · in network | 80053 | $49.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-020395 CMS-1500 · 2026-07-27 | Justin Griffin UHC-52595-90 | 2026-07-21 Office | Sunrise Internal Medicine Associates Internal Medicine · in network | 99214 | $282.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-018871 UB-04 · 2026-07-27 | Vincent Jenkins UHC-91130-49 | 2026-07-08 Outpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 73721 | $1,467.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-015660 CMS-1500 · 2026-07-27 | Amy Gonzalez no member ID | 2026-07-12 Office | Valley Family Practice Family Medicine · in network | 99213, 99395 | $415.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-011204 UB-04 · 2026-07-27 | Rachel Fernandez no member ID | 2026-06-16 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 93306 | $1,036.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-005730 CMS-1500 · 2026-07-27 | Keith Cook no member ID | 2026-06-17 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97140 | $258.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002220 UB-04 · 2026-07-27 | Thomas Rsoe UHC-81794-28 | 2026-07-05 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99285, 99284, 71046 | $3,350.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-027754 CMS-1500 · 2026-07-26 | Kyle Rojas no member ID | 2026-07-01 Office | Pinecrest Primary Care Associates Family Medicine · in network | 36415 | $22.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-020747 UB-04 · 2026-07-26 | Gracce Ortea no member ID | 2026-06-13 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 45378, 43239 | $4,584.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-014332 CMS-1500 · 2026-07-26 | Joan Santiago no member ID | 2026-07-03 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 87086, 85025, 83036 | $231.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-013611 CMS-1500 · 2026-07-26 | Lori Hawkins UHC-55156-14 | 2026-07-02 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90837, 90834 | $438.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-011469 UB-04 · 2026-07-26 | Not attached | 2026-06-19 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,113.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-010064 CMS-1500 · 2026-07-26 | Jan Santos UHC-52788-39 | 2026-06-21 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97161 | $532.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-009967 CMS-1500 · 2026-07-26 | Philip Rios no member ID | 2026-07-15 Office | Lakeside Medical Group Family Medicine · in network | 99203, 36415, 99213 | $400.00 | — | 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.