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
3,663
89 with an AI recommendation
Pended
2,587
awaiting information or identity
Approved
23,942
$6,757,768.45 plan paid
Denied
4,454
with remittance reason codes
Examiner decided
1
167 not attached to an identity
| Claim | Member | Service | Provider | Procedures | Billed | Plan pays | Rules | AI | Status |
|---|---|---|---|---|---|---|---|---|---|
| CLM-2026-020093 CMS-1500 · 2026-10-07 | Joseph Lawson no member ID | 2026-09-19 Office | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 20610 | $228.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-018410 CMS-1500 · 2026-10-07 | Brenda Nichols no member ID | 2026-09-14 Office | Unity Dermatology Clinic Dermatology · in network | 11403, 99213 | $579.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013746 UB-04 · 2026-10-07 | Joe Dean no member ID | 2026-08-31 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 71046 | $220.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-005515 CMS-1500 · 2026-10-07 | Randy Morris no member ID | 2026-09-15 Office | Sunrise Medical Group Internal Medicine · in network | 80053 | $42.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-004600 CMS-1500 · 2026-10-07 | Samuel Richards no member ID | 2026-08-24 Office | Sunrise Skin Care Associates Dermatology · in network | 99213, 11403 | $846.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-009493 UB-04 · 2026-10-06 | George Lewis no member ID | 2026-09-06 Outpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 29881 | $8,543.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-004289 CMS-1500 · 2026-10-06 | Camila Russell no member ID | 2026-08-31 Office | Evergreen Family Practice Family Medicine · in network | 99214 | $265.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-012283 CMS-1500 · 2026-10-05 | Mark Patterson no member ID | 2026-10-01 Office | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 99213 | $188.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-011551 CMS-1500 · 2026-10-05 | Chris Phillisp no member ID | 2026-09-28 Office | Desert Medical Group Internal Medicine · in network | 93000 | $71.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-009121 UB-04 · 2026-10-05 | Jacob Herrera no member ID | 2026-09-16 Inpatient hospital | Cornerstone Internal Medicine Associates Internal Medicine · in network | 99232 | $240.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-008945 CMS-1500 · 2026-10-05 | Julia Reyes no member ID | 2026-08-30 Independent laboratory | Summit Clinical Laboratories Clinical Laboratory · in network | 83036, 80061 | $153.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-000032 UB-04 · 2026-10-05 | Not attached | 2026-09-25 Outpatient hospital | Pinecrest Heart Institute Cardiology · in network | 93306 | $1,401.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-034094 UB-04 · 2026-10-04 | Jacqueline Black no member ID | 2026-09-27 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 74177, 77067 | $1,850.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-001937 CMS-1500 · 2026-10-04 | Jack Paterson no member ID | 2026-09-02 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 85025 | $39.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-031968 CMS-1500 · 2026-10-03 | Hart Sofia no member ID | 2026-09-20 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · out of network | 87086, 80061 | $144.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-030652 UB-04 · 2026-10-03 | Joe Medina no member ID | 2026-08-19 Outpatient hospital | Evergreen Dermatology Clinic Dermatology · in network | 70553 | $1,900.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-022383 CMS-1500 · 2026-10-03 | Mason McDonald no member ID | 2026-09-01 Independent laboratory | Riverside Clinical Laboratories Clinical Laboratory · in network | 83036 | $75.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-021053 CMS-1500 · 2026-10-03 | Benjamin Dean no member ID | 2026-09-28 Office | Riverside Cardiovascular Associates Cardiology · in network | 93224 | $259.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-010133 UB-04 · 2026-10-03 | Pamela Harvey no member ID | 2026-09-01 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99284, 99283, 99285 | $3,759.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-009809 UB-04 · 2026-10-03 | Santiago Prike no member ID | 2026-08-31 Outpatient hospital | Northgate Cardiovascular Associates Cardiology · in network | 93015 | $521.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-003351 UB-04 · 2026-10-03 | Amy Simpson no member ID | 2026-08-25 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $235.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-028970 CMS-1500 · 2026-10-02 | Cynthia Brooks no member ID | 2026-09-10 Office | Harbor Bone and Joint Center Orthopedic Surgery · in network | 99213 | $216.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-023231 CMS-1500 · 2026-10-02 | Sophia Russell no member ID | 2026-09-01 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 80053, 99215 | $474.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-022552 CMS-1500 · 2026-10-02 | Not attached | 2026-09-23 Office | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $217.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-020841 CMS-1500 · 2026-10-02 | Priya Young no member ID | 2026-09-19 Office | Desert Cardiovascular Associates Cardiology · in network | 99214, 93224 | $551.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-018995 CMS-1500 · 2026-10-02 | Joan Wheler no member ID | 2026-09-24 Office | Unity Dermatology Clinic Dermatology · in network | 99213 | $217.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-018194 CMS-1500 · 2026-10-02 | Brenda Stewart no member ID | 2026-09-21 Independent laboratory | Meadow Reference Lab Clinical Laboratory · in network | 80061, 80053, 87086, 83036 | $196.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-012108 UB-04 · 2026-10-02 | Megan Kim no member ID | 2026-09-22 Outpatient hospital | Canyon Primary Care Associates Family Medicine · in network | 70553 | $2,006.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-002822 CMS-1500 · 2026-10-02 | Laura Cruz no member ID | 2026-09-06 Office | Sunrise Dermatology Clinic Dermatology · in network | 17110, 11403 | $875.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002325 CMS-1500 · 2026-10-02 | Lucia Webb no member ID | 2026-09-18 Office | Canyon Medical Group Internal Medicine · in network | 99215 | $290.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-032031 UB-04 · 2026-10-01 | Joe Peters no member ID | 2026-09-23 Outpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 70553 | $2,602.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-027874 CMS-1500 · 2026-10-01 | Diego Vasquez no member ID | 2026-08-19 Office | Riverside Digestive Health Center Gastroenterology · in network | 99214 | $245.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024769 CMS-1500 · 2026-10-01 | Zachary Reyes no member ID | 2026-09-18 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 99215 | $302.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-019142 CMS-1500 · 2026-10-01 | Fatima Cook no member ID | 2026-09-12 Independent laboratory | Evergreen Reference Lab Clinical Laboratory · in network | 87086, 80061 | $110.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-018027 UB-04 · 2026-10-01 | Nicole Park no member ID | 2026-08-18 Outpatient hospital | Heritage Digestive Health Center Gastroenterology · in network | 43239, 88305 | $2,289.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-014661 UB-04 · 2026-10-01 | Austin Chavez no member ID | 2026-09-10 Outpatient hospital | Summit Heart Institute Cardiology · in network | 93306 | $1,059.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-008131 CMS-1500 · 2026-10-01 | Not attached | 2026-09-15 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97014 | $379.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-030435 CMS-1500 · 2026-09-30 | Anggela Hughes no member ID | 2026-09-12 Office | Sunrise Behavioral Health Behavioral Health · in network | 90791 | $382.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-028943 UB-04 · 2026-09-30 | Jack James no member ID | 2026-08-31 Outpatient hospital | Summit Cardiovascular Associates Cardiology · in network | 93458 | $7,054.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-025788 UB-04 · 2026-09-30 | Sarah Smith no member ID | 2026-09-12 Emergency room | Unity Community Hospital Emergency Medicine · in network | 96374 | $220.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-010042 CMS-1500 · 2026-09-30 | William Morales no member ID | 2026-08-18 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99203, 99395 | $430.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-009984 CMS-1500 · 2026-09-30 | Barbara Carroll no member ID | 2026-09-06 Office | Sunrise Medical Group Internal Medicine · in network | 99215, 99214 | $560.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-009796 CMS-1500 · 2026-09-30 | Keith Vega no member ID | 2026-09-27 Office | Desert Medical Group Internal Medicine · in network | 99215 | $368.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-007181 CMS-1500 · 2026-09-30 | Susan Burns no member ID | 2026-09-18 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 83036, 80061 | $143.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-001985 CMS-1500 · 2026-09-30 | Paul Gordon no member ID | 2026-09-13 Office | Valley Medical Group Family Medicine · in network | 99213, 99203, 99395 | $639.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-000700 CMS-1500 · 2026-09-30 | Priya Ward no member ID | 2026-09-06 Office | Heritage Family Practice Family Medicine · in network | 90471 | $33.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-032368 CMS-1500 · 2026-09-29 | Randy Montgomery no member ID | 2026-09-05 Office | Mesa Cardiovascular Associates Cardiology · in network | 93224 | $338.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-014022 UB-04 · 2026-09-29 | Charles Ford no member ID | 2026-09-03 Outpatient hospital | Summit Imaging Center Radiology · in network | 71046, 74177 | $2,223.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-009806 CMS-1500 · 2026-09-29 | Diana Miills no member ID | 2026-09-16 Office | Northgate Medical Group Internal Medicine · in network | 99214 | $279.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-003734 CMS-1500 · 2026-09-29 | Teresa Hudson no member ID | 2026-08-26 Telehealth | Evergreen Counseling Center Behavioral Health · in network | 99214 | $313.00 | — | 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.