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-2026-002965 CMS-1500 · 2026-07-26 | Chriistian Gonzales UHC-94858-35 | 2026-06-28 Office | Evergreen Dermatology Clinic Dermatology · in network | 99213, 11102 | $427.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-002046 CMS-1500 · 2026-07-26 | Mary Murray no member ID | 2026-07-13 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 83036, 85025, 87086 | $155.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-001563 CMS-1500 · 2026-07-26 | Philip Rios no member ID | 2026-06-13 Independent laboratory | Desert Reference Lab Clinical Laboratory · in network | 80053, 80061, 87086 | $167.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-001386 UB-04 · 2026-07-26 | Ana Coleman UHC-92968-09 | 2026-07-05 Outpatient hospital | Cornerstone Imaging Center Radiology · in network | 74177, 71046 | $2,115.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-001231 CMS-1500 · 2026-07-26 | Abigail Vargas no member ID | 2026-07-12 Office | Unity Medical Group Family Medicine · in network | 99203, 99214, 99213 | $640.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-000115 CMS-1500 · 2026-07-26 | Henry Johnson UHC-39549-73 | 2026-07-01 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 80053 | $52.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-033297 CMS-1500 · 2026-07-25 | Gomez Betty no member ID | 2026-07-09 Office | Sunrise Behavioral Health Behavioral Health · in network | 90791 | $381.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-019099 CMS-1500 · 2026-07-25 | Vincent Wilson UHC-04051-03 | 2026-07-22 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80053 | $47.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-016454 CMS-1500 · 2026-07-25 | Henry Harper no member ID | 2026-07-23 Office | Harbor Primary Care Associates Family Medicine · in network | 99395, 36415 | $283.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-007046 CMS-1500 · 2026-07-25 | Teresa Sims UHC-68801-10 | 2026-06-30 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97140 | $217.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-003254 CMS-1500 · 2026-07-25 | Jerry Snyder no member ID | 2026-07-03 Office | Unity Primary Care Associates Family Medicine · in network | 36415, 99203 | $212.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-003020 CMS-1500 · 2026-07-25 | Karen Elliott UHC-05863-63 | 2026-07-13 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $114.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-001458 CMS-1500 · 2026-07-25 | Frank Ramireez UHC-97290-10 | 2026-06-18 Office | Sunrise Heart Institute Cardiology · in network | 99214, 93224 | $705.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-034474 CMS-1500 · 2026-07-24 | Benjamin Cruz UHC-75309-67 | 2026-06-27 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99215 | $302.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-031944 UB-04 · 2026-07-24 | Sophia Roajs no member ID | 2026-07-17 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · in network | 93458 | $6,600.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-021470 CMS-1500 · 2026-07-24 | Roger Banks UHC-95733-48 | 2026-07-11 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 80053, 85025 | $145.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-019103 UB-04 · 2026-07-24 | Olivia Campbell no member ID | 2026-06-30 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 99284, 71046 | $1,628.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-015412 CMS-1500 · 2026-07-24 | Kyle Sism no member ID | 2026-07-12 Office | Lakeside Medical Group Family Medicine · in network | 99395, 99213 | $494.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-006051 UB-04 · 2026-07-24 | Not attached | 2026-06-23 Outpatient hospital | Summit Digestive Health Center Gastroenterology · in network | 88305 | $256.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-001980 UB-04 · 2026-07-24 | Katherine Jenkins no member ID | 2026-07-17 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 71046 | $203.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-001255 CMS-1500 · 2026-07-24 | Pamela Vargas no member ID | 2026-06-28 Office | Riverside Internal Medicine Associates Internal Medicine · in network | 93000, 80053, 99215 | $446.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-033704 CMS-1500 · 2026-07-23 | Not attached | 2026-06-20 Office | Desert Medical Group Internal Medicine · in network | 99214 | $254.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-030726 CMS-1500 · 2026-07-23 | Brian Allen no member ID | 2026-06-29 Office | Evergreen Family Practice Family Medicine · in network | 99395, 90471 | $271.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-030265 UB-04 · 2026-07-23 | Eric Bishop UHC-06958-31 | 2026-07-16 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $38,678.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-029362 CMS-1500 · 2026-07-23 | Timothy Santos no member ID | 2026-07-15 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $177.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-027873 CMS-1500 · 2026-07-23 | Aaron Cole no member ID | 2026-07-21 Office | Valley Cardiovascular Associates Cardiology · in network | 93224, 99214 | $630.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-023644 UB-04 · 2026-07-23 | Mei Moreno no member ID | 2026-07-01 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 74177, 77067 | $1,745.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-018743 UB-04 · 2026-07-23 | Maria Daniels no member ID | 2026-06-15 Inpatient hospital | Desert Internal Medicine Associates Internal Medicine · in network | 99232 | $175.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-017448 CMS-1500 · 2026-07-23 | Ryan Li UHC-59343-89 | 2026-06-29 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90791, 90837 | $626.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-014679 CMS-1500 · 2026-07-23 | Carolyn Dominguez UHC-67504-21 | 2026-07-21 Office | Valley Primary Care Associates Family Medicine · in network | 99213 | $145.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-008261 CMS-1500 · 2026-07-23 | Watkins Nathan no member ID | 2026-06-30 Office | Pinecrest Medical Group Internal Medicine · in network | 80053 | $64.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-007328 CMS-1500 · 2026-07-23 | Christine Gutierrez no member ID | 2026-06-17 Office | Heritage Medical Group Family Medicine · out of network | 99203 | $240.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-030132 CMS-1500 · 2026-07-22 | Grace Taylor no member ID | 2026-07-17 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80053, 87086 | $125.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-029216 UB-04 · 2026-07-22 | Ben Parker no member ID | 2026-06-24 Inpatient hospital | Valley Internal Medicine Associates Internal Medicine · in network | 99232 | $218.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-026160 UB-04 · 2026-07-22 | Christian Ortega UHC-60388-18 | 2026-07-02 Outpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,704.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-024963 CMS-1500 · 2026-07-22 | Brittany Estrada UHC-82467-80 | 2026-07-05 Office | Evergreen Internal Medicine Associates Internal Medicine · in network | 99214, 93000 | $384.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-024779 CMS-1500 · 2026-07-22 | Patricia Vazquez no member ID | 2026-07-12 Office | Desert Primary Care Associates Family Medicine · in network | 99395, 99213 | $437.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-021554 CMS-1500 · 2026-07-22 | Brittany Estrada UHC-82467-80 | 2026-06-19 Independent laboratory | Meadow Reference Lab Clinical Laboratory · in network | 80061 | $55.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-015504 CMS-1500 · 2026-07-22 | Camila Vargas no member ID | 2026-06-11 Office | Mesa Primary Care Associates Family Medicine · in network | 99203, 99213 | $398.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-012963 UB-04 · 2026-07-22 | Elizabeth Chhapman no member ID | 2026-07-12 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99284, 96374, 99283 | $2,670.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-012327 CMS-1500 · 2026-07-22 | Kyle Powell no member ID | 2026-06-26 Office | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 20610 | $263.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-010778 CMS-1500 · 2026-07-22 | Dilan Berry no member ID | 2026-06-18 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 80061, 87086, 83036 | $139.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-007821 CMS-1500 · 2026-07-22 | Juan Gordon no member ID | 2026-07-01 Office | Meadow Primary Care Associates Family Medicine · in network | 99395, 99213 | $500.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-003929 CMS-1500 · 2026-07-22 | Hunter Jeff no member ID | 2026-06-21 Office | Sunrise Cardiovascular Associates Cardiology · in network | 93224 | $417.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-003243 CMS-1500 · 2026-07-22 | Donald Sullivan no member ID | 2026-06-12 Office | Meadow Medical Group Family Medicine · in network | 36415, 99214 | $279.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-001793 UB-04 · 2026-07-22 | Jeremy Singh UHC-23990-52 | 2026-07-05 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 71046, 99283, 99285 | $3,594.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-033333 UB-04 · 2026-07-21 | Karen Padilla no member ID | 2026-06-19 Outpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,469.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-028308 CMS-1500 · 2026-07-21 | Christopher Stevens UHC-44226-46 | 2026-06-25 Office | Lakeside Medical Group Family Medicine · in network | 36415, 99203 | $226.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-027138 CMS-1500 · 2026-07-21 | Roy Nichols no member ID | 2026-07-07 Office | Lakeside Skin Care Associates Dermatology · in network | 11403, 99213 | $562.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-026583 CMS-1500 · 2026-07-21 | Virginia Ward no member ID | 2026-06-19 Independent laboratory | Riverside Clinical Laboratories Clinical Laboratory · in network | 80061, 80053, 83036 | $165.00 | — | 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.