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-2026-019544 UB-04 · 2026-10-12 | Daina Ran no member ID | 2026-10-03 Outpatient hospital | Evergreen Reference Lab Clinical Laboratory · in network | 70553 | $1,956.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017763 CMS-1500 · 2026-10-12 | Bryan Ortiz UHC-46023-57 | 2026-09-14 Office | Heritage Primary Care Associates Family Medicine · in network | 99203, 99395 | $463.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-014798 CMS-1500 · 2026-10-12 | Adam Green UHC-08215-14 | 2026-10-09 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 99214 | $201.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013526 CMS-1500 · 2026-10-12 | Joseph Wheeler UHC-76888-73 | 2026-09-16 Office | Mesa Medical Group Family Medicine · in network | 99203, 99213 | $387.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013499 CMS-1500 · 2026-10-12 | Samuel Tucker no member ID | 2026-08-30 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $187.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-013417 UB-04 · 2026-10-12 | John Cunningham UHC-37758-42 | 2026-08-16 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553 | $2,471.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010416 CMS-1500 · 2026-10-12 | Katleen Tran no member ID | 2026-10-05 Office | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 99213 | $160.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-010090 UB-04 · 2026-10-12 | Fatima Ford UHC-30941-57 | 2026-09-29 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99283 | $790.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-001970 CMS-1500 · 2026-10-12 | Jacob Jimenez no member ID | 2026-10-04 Office | Desert Medical Group Internal Medicine · in network | 93000 | $95.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-033519 CMS-1500 · 2026-10-11 | Martha Powell UHC-78239-03 | 2026-09-19 Office | Meadow Primary Care Associates Family Medicine · in network | 99203, 99395 | $469.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-021102 CMS-1500 · 2026-10-11 | Thomaas Johnston no member ID | 2026-10-07 Office | Valley Medical Group Family Medicine · in network | 99213, 90471, 99214 | $454.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-003724 CMS-1500 · 2026-10-11 | Kenneth Santos UHC-35521-44 | 2026-09-15 Office | Canyon Cardiovascular Associates Cardiology · in network | 99214 | $222.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-001234 CMS-1500 · 2026-10-11 | Bobby Wilson UHC-41416-73 | 2026-08-31 Office | Lakeside Medical Group Family Medicine · in network | 99213, 36415, 90471 | $257.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-032682 UB-04 · 2026-10-10 | Frank Phillips no member ID | 2026-09-22 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 74177 | $1,730.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-032439 UB-04 · 2026-10-10 | Ralph Burns UHC-63658-24 | 2026-09-30 Outpatient hospital | Lakeside Skin Care Associates Dermatology · in network | 70553 | $2,987.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-031633 CMS-1500 · 2026-10-10 | Aaron Nunez UHC-75381-08 | 2026-08-30 Office | Sunrise GI Associates Gastroenterology · in network | 99214 | $284.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030069 CMS-1500 · 2026-10-10 | Pamela Snadoval UHC-52330-59 | 2026-09-14 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99203 | $242.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-027261 UB-04 · 2026-10-10 | Brittany Holmes UHC-82722-34 | 2026-10-01 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93015 | $438.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-026157 CMS-1500 · 2026-10-10 | Stephanie Vargas no member ID | 2026-09-06 Office | Desert Primary Care Associates Family Medicine · in network | 99395, 99214 | $519.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-017157 CMS-1500 · 2026-10-10 | Alice Butler no member ID | 2026-09-20 Telehealth | Evergreen Counseling Center Behavioral Health · in network | 99214 | $233.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-012964 CMS-1500 · 2026-10-10 | Julia Rose no member ID | 2026-08-27 Office | Evergreen Medical Group Family Medicine · in network | 36415, 99395 | $362.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-007224 UB-04 · 2026-10-10 | Sean Carpenter UHC-27165-58 | 2026-10-04 Emergency room | Meadow Regional Medical Center Emergency Medicine · in network | 99283, 99285 | $3,896.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-034553 UB-04 · 2026-10-09 | Mason Williams no member ID | 2026-09-04 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 70553 | $2,139.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-032934 CMS-1500 · 2026-10-09 | Bradley Carlson UHC-48617-01 | 2026-09-29 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 80053, 87086, 80061, 83036 | $272.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-029523 CMS-1500 · 2026-10-09 | Julie Fernandez no member ID | 2026-09-27 Office | Mesa Diabetes Center Endocrinology · in network | 83036 | $48.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-022569 CMS-1500 · 2026-10-09 | Not attached | 2026-10-04 Office | Riverside Medical Group Family Medicine · in network | 99214, 36415, 90471 | $348.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-017566 UB-04 · 2026-10-09 | Gabriel Shew no member ID | 2026-09-28 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 43239 | $1,993.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013714 UB-04 · 2026-10-09 | Gerald Bowman no member ID | 2026-10-05 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553 | $2,319.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-006247 CMS-1500 · 2026-10-09 | Matthew Ryan no member ID | 2026-10-07 Office | Meadow Primary Care Associates Family Medicine · in network | 90471, 99395 | $358.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-001306 UB-04 · 2026-10-09 | Larry Willis UHC-23228-90 | 2026-09-04 Outpatient hospital | Desert Cardiovascular Associates Cardiology · in network | 93306 | $1,517.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000842 CMS-1500 · 2026-10-09 | Joe Graham UHC-51875-48 | 2026-09-20 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 83036 | $69.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000342 CMS-1500 · 2026-10-09 | Jennifer Carr no member ID | 2026-09-23 Office | Mesa Behavioral Health Behavioral Health · in network | 90834, 90791 | $550.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-000033 UB-04 · 2026-10-09 | Lynda Greene no member ID | 2026-10-01 Outpatient hospital | Riverside Imaging Center Radiology · in network | 76700 | $485.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-032325 CMS-1500 · 2026-10-08 | James Riley no member ID | 2026-09-22 Office | Harbor Physical Therapy Physical Therapy · in network | 97110, 97161 | $536.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-030480 CMS-1500 · 2026-10-08 | Not attached | 2026-09-01 Office | Valley Cardiovascular Associates Cardiology · in network | 99214 | $220.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-028937 UB-04 · 2026-10-08 | Olivia Soto no member ID | 2026-09-21 Outpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,512.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-025648 UB-04 · 2026-10-08 | Dennis Murphy UHC-72122-15 | 2026-09-28 Outpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 29881 | $8,955.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-019215 UB-04 · 2026-10-08 | Bryan Ortiz UHC-46023-57 | 2026-09-10 Outpatient hospital | Meadow Imaging Center Radiology · in network | 77067 | $390.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-011280 CMS-1500 · 2026-10-08 | Teresa Johnson no member ID | 2026-09-05 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 85025, 83036 | $138.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-003468 CMS-1500 · 2026-10-08 | Russell Jacobs UHC-03633-88 | 2026-10-04 Office | Meadow Primary Care Associates Family Medicine · in network | 99395, 99203 | $431.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-002869 UB-04 · 2026-10-08 | Camila Munoz no member ID | 2026-09-30 Outpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 70553 | $2,983.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029961 CMS-1500 · 2026-10-07 | Zachary Thompson no member ID | 2026-09-02 Office | Sunrise Medical Group Internal Medicine · out of network | 93000 | $98.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-026732 UB-04 · 2026-10-07 | Lori George UHC-37487-27 | 2026-08-29 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 76700 | $383.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-026491 UB-04 · 2026-10-07 | Lucia Holmes UHC-11141-74 | 2026-09-11 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 74177 | $1,305.00 | — | Pended by rule IDQ | — | Pended |
| 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-2026-018381 CMS-1500 · 2026-10-07 | Amber Rose UHC-92898-42 | 2026-08-23 Office | Northgate Medical Group Internal Medicine · in network | 80053, 93000 | $133.00 | — | Pended by rule IDQ | — | 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-2026-005660 UB-04 · 2026-10-07 | Ashley Nunez UHC-90338-03 | 2026-10-04 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 88305 | $262.00 | — | Pended by rule IDQ | — | 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 |
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.