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-2026-002997 UB-04 · 2026-10-02 | Betty Mendez UHC-07773-92 | 2026-09-08 Outpatient hospital | Pinecrest Physical Therapy Physical Therapy · in network | 70553 | $6,768.00 | — | Pended by rule IDQ | — | 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-2026-021168 UB-04 · 2026-10-01 | Gerald Knight UHC-94266-68 | 2026-09-07 Inpatient hospital | Evergreen Internal Medicine Associates Internal Medicine · in network | 99232 | $247.00 | — | Pended by rule IDQ | — | 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-2026-028943 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-2026-025549 UB-04 · 2026-09-30 | Alexis Price UHC-80433-48 | 2026-09-21 Emergency room | Cornerstone Regional Medical Center Emergency Medicine · in network | 99283 | $757.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-003493 UB-04 · 2026-09-30 | Russell Espinoza UHC-97721-25 | 2026-09-13 Outpatient hospital | Evergreen Cardiovascular Associates Cardiology · in network | 93458, 93015 | $7,162.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-018189 UB-04 · 2026-09-29 | Not attached | 2026-08-16 Outpatient hospital | Valley Heart Institute Cardiology · in network | 70553 | $2,348.00 | — | Pended by rule CO16 | — | 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-2026-020813 UB-04 · 2026-09-28 | Debra Obrien UHC-76374-56 | 2026-09-20 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99283, 99285 | $3,622.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-009887 UB-04 · 2026-09-28 | Kayla Schmidt no member ID | 2026-09-05 Inpatient hospital | Pinecrest Medical Group Internal Medicine · in network | 99232, 99215 | $495.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-027740 UB-04 · 2026-09-27 | Arthur Anderson no member ID | 2026-09-16 Outpatient hospital | Canyon Medical Group Internal Medicine · in network | 70553 | $2,038.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-012781 UB-04 · 2026-09-27 | Jean White no member ID | 2026-08-20 Emergency room | Lakeside Regional Medical Center Emergency Medicine · in network | 71046 | $170.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-009072 UB-04 · 2026-09-27 | Isabella Andrews UHC-83174-58 | 2026-09-10 Emergency room | Desert Regional Medical Center Emergency Medicine · in network | 99285, 99284, 99283 | $5,395.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-023715 UB-04 · 2026-09-26 | John Schmidt UHC-63438-99 | 2026-08-15 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 77067, 74177 | $1,529.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-008519 UB-04 · 2026-09-26 | Lori Contreras UHC-12717-94 | 2026-09-22 Outpatient hospital | Mesa Dermatology Clinic Dermatology · in network | 70553 | $2,697.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-004320 UB-04 · 2026-09-26 | Lisa Williamson no member ID | 2026-08-30 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 71046 | $195.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-033663 UB-04 · 2026-09-25 | Fatima Schmidt no member ID | 2026-09-13 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99284 | $1,547.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-028112 UB-04 · 2026-09-25 | Emmma White no member ID | 2026-09-03 Outpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 29881, 73721 | $11,916.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-027763 UB-04 · 2026-09-25 | Olivia Padilla no member ID | 2026-09-08 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283 | $862.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-026913 UB-04 · 2026-09-25 | Gerald Bowman no member ID | 2026-08-20 Outpatient hospital | Lakeside Medical Group Internal Medicine · in network | 70553 | $2,269.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-020728 UB-04 · 2026-09-25 | Jean Nunez no member ID | 2026-08-22 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99285, 96374, 99283 | $3,666.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-007499 UB-04 · 2026-09-25 | Fatima Price no member ID | 2026-08-24 Outpatient hospital | Valley Digestive Health Center Gastroenterology · in network | 43239 | $1,552.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024740 UB-04 · 2026-09-24 | Valentina Ausstin no member ID | 2026-08-30 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 71046 | $236.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-024598 UB-04 · 2026-09-24 | Kenneth Ryan no member ID | 2026-08-25 Outpatient hospital | Desert Heart Institute Cardiology · in network | 93458, 93306 | $8,073.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-014051 UB-04 · 2026-09-24 | Maggie Turner UHC-64447-70 | 2026-08-13 Outpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 29881 | $6,962.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-012341 UB-04 · 2026-09-24 | Dorothy Richards no member ID | 2026-09-04 Outpatient hospital | Evergreen Digestive Health Center Gastroenterology · in network | 43239 | $1,512.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-005200 UB-04 · 2026-09-24 | Sara Jimenez no member ID | 2026-08-25 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 74177, 71046 | $1,693.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-003779 UB-04 · 2026-09-24 | Jeffrey Park no member ID | 2026-09-01 Emergency room | Meadow Regional Medical Center Emergency Medicine · in network | 99285, 71046 | $2,024.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029799 UB-04 · 2026-09-23 | Janice Rose no member ID | 2026-08-29 Outpatient hospital | Valley Digestive Health Center Gastroenterology · in network | 43239, 88305 | $2,009.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-028821 UB-04 · 2026-09-23 | Scott Romero no member ID | 2026-09-07 Outpatient hospital | Sunrise GI Associates Gastroenterology · in network | 45378 | $2,229.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-014697 UB-04 · 2026-09-23 | Andrea Patel no member ID | 2026-08-18 Outpatient hospital | Riverside Imaging Center Radiology · in network | 77067, 70553 | $2,666.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-018157 UB-04 · 2026-09-22 | William Lynch no member ID | 2026-09-18 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $163.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013416 UB-04 · 2026-09-22 | 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-2026-011029 UB-04 · 2026-09-22 | Janice Santiago no member ID | 2026-09-03 Outpatient hospital | Valley Digestive Health Center Gastroenterology · in network | 88305, 45378 | $1,783.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-008077 UB-04 · 2026-09-22 | Michael Pena UHC-91542-65 | 2026-09-08 Outpatient hospital | Unity Diagnostic Imaging Radiology · in network | 76700 | $401.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-005361 UB-04 · 2026-09-22 | Not attached | 2026-09-19 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285 | $3,094.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-029002 UB-04 · 2026-09-21 | Not attached | 2026-08-31 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,744.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-011782 UB-04 · 2026-09-21 | Joe Thomas UHC-78254-13 | 2026-09-08 Emergency room | Valley Regional Medical Center Emergency Medicine · in network | 99284, 71046 | $1,357.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030272 UB-04 · 2026-09-20 | Alice Montgomery no member ID | 2026-08-10 Inpatient hospital | Canyon Medical Group Internal Medicine · in network | 99232 | $223.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-028928 UB-04 · 2026-09-20 | Walter Burns no member ID | 2026-09-17 Outpatient hospital | Sunrise Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $8,235.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-011348 UB-04 · 2026-09-20 | Ssan Hansen no member ID | 2026-09-18 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 77067 | $282.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-007500 UB-04 · 2026-09-20 | Donna Torres UHC-22870-14 | 2026-08-25 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 77067, 76700 | $639.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-016463 UB-04 · 2026-09-19 | Maria Yang no member ID | 2026-09-06 Outpatient hospital | Evergreen Digestive Health Center Gastroenterology · in network | 43239 | $1,849.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-027615 UB-04 · 2026-09-18 | Valentina Scott UHC-56762-01 | 2026-08-12 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 96374, 99283 | $922.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025198 UB-04 · 2026-09-18 | Christina Rios UHC-96267-36 | 2026-09-13 Emergency room | Valley Regional Medical Center Emergency Medicine · in network | 71046, 99284 | $1,300.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-009511 UB-04 · 2026-09-18 | Christian Gomez no member ID | 2026-08-15 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · in network | 88305, 43239 | $2,509.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-020121 UB-04 · 2026-09-17 | Brian Wells UHC-78951-31 | 2026-08-22 Outpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 73721 | $2,085.00 | — | Pended by rule IDQ | — | 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.