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-2026-029523 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-2026-006247 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-2026-000842 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-2026-032325 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-2026-011280 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-2026-029961 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-2026-020093 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-2026-005515 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-2026-005385 CMS-1500 · 2026-10-07 | Nathan Turner UHC-08557-62 | 2026-09-05 Office | Sunrise Cardiovascular Associates Cardiology · in network | 99214 | $236.00 | — | Pended by rule IDQ | — | 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-2026-004289 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-2026-019839 CMS-1500 · 2026-10-05 | Kyle Harper UHC-68942-57 | 2026-08-24 Office | Mesa Family Practice Family Medicine · in network | 99203 | $235.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-017095 CMS-1500 · 2026-10-05 | Not attached | 2026-09-02 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97161, 97014 | $613.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-013336 CMS-1500 · 2026-10-05 | Jacqueline Yang UHC-73644-33 | 2026-09-26 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110 | $180.00 | — | Pended by rule IDQ | — | 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-2026-010419 CMS-1500 · 2026-10-05 | Gerald Gordon UHC-42317-69 | 2026-09-30 Office | Sunrise Skin Care Associates Dermatology · in network | 11102 | $189.00 | — | Pended by rule IDQ | — | 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-2026-006185 CMS-1500 · 2026-10-04 | Karen Barnes UHC-87810-76 | 2026-08-25 Office | Desert Primary Care Associates Family Medicine · in network | 99214 | $257.00 | — | Pended by rule IDQ | — | 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-2026-000533 CMS-1500 · 2026-10-04 | Tyler Wilson UHC-59252-11 | 2026-09-02 Independent laboratory | Evergreen Clinical Laboratories Clinical Laboratory · in network | 85025, 80053, 83036 | $172.00 | — | Pended by rule IDQ | — | 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-2026-026268 CMS-1500 · 2026-10-03 | David Moreno UHC-71942-05 | 2026-09-12 Independent laboratory | Summit Clinical Laboratories Clinical Laboratory · in network | 80053, 80061, 85025 | $138.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-022725 CMS-1500 · 2026-10-03 | Ana Carr UHC-99021-58 | 2026-08-22 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99215 | $285.00 | — | Pended by rule IDQ | — | 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-2026-012499 CMS-1500 · 2026-10-03 | Jess Johnson UHC-65449-18 | 2026-09-21 Office | Evergreen Medical Group Family Medicine · in network | 36415, 99395, 99203 | $527.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-032925 CMS-1500 · 2026-10-02 | Brenda Harris UHC-30691-44 | 2026-09-10 Office | Meadow Skin Care Associates Dermatology · in network | 17110, 99213 | $398.00 | — | Pended by rule IDQ | — | 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-2026-002822 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-2026-031670 CMS-1500 · 2026-10-01 | Randy Webb UHC-16139-40 | 2026-09-05 Office | Mesa Family Practice Family Medicine · in network | 36415, 99395, 99214 | $519.00 | — | Pended by rule IDQ | — | 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-2026-011216 CMS-1500 · 2026-10-01 | Helen Gibosn UHC-11787-25 | 2026-09-08 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053 | $44.00 | — | Pended by rule IDQ | — | 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-2026-032397 CMS-1500 · 2026-09-30 | Maria Russell UHC-17012-96 | 2026-09-09 Independent laboratory | Unity Reference Lab Clinical Laboratory · in network | 80053 | $83.00 | — | Pended by rule IDQ | — | 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 |
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.