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-2026-033658 CMS-1500 · 2026-09-28 | Edward Maldonado no member ID | 2026-09-09 Office | Meadow Medical Group Family Medicine · in network | 36415 | $21.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-022244 CMS-1500 · 2026-09-28 | Stephen Patel no member ID | 2026-09-13 Office | Canyon Medical Group Internal Medicine · in network | 93000, 99214 | $348.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-020092 CMS-1500 · 2026-09-28 | 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-2026-018924 CMS-1500 · 2026-09-28 | Gerald Campbell no member ID | 2026-08-25 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 83036 | $67.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-016469 CMS-1500 · 2026-09-28 | Ralph Lee no member ID | 2026-09-24 Office | Meadow Primary Care Associates Family Medicine · in network | 99214 | $229.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-012630 CMS-1500 · 2026-09-28 | Ashley Sandoval no member ID | 2026-09-05 Office | Evergreen Family Practice Family Medicine · in network | 36415, 99203 | $228.00 | — | Pended by rule N30 | — | 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-2026-002324 CMS-1500 · 2026-09-28 | 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-2026-027740 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-2026-020675 CMS-1500 · 2026-09-27 | Brittany Riley no member ID | 2026-09-22 Office | Northgate Cardiovascular Associates Cardiology · in network | 99214 | $230.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-019217 CMS-1500 · 2026-09-27 | Sandra Tucker no member ID | 2026-08-14 Office | Meadow Bone and Joint Center Orthopedic Surgery · in network | 99213 | $156.00 | — | Pended by rule 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-2026-020930 CMS-1500 · 2026-09-26 | Sarah Perkins no member ID | 2026-09-09 Office | Sunrise Skin Care Associates Dermatology · in network | 11102 | $320.00 | — | Pended by rule N30 | — | 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-2026-028248 CMS-1500 · 2026-09-25 | Deborah Dominguez no member ID | 2026-09-15 Office | Meadow GI Associates Gastroenterology · in network | 99214 | $324.00 | — | Pended by rule IDQ 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-2026-025218 CMS-1500 · 2026-09-25 | Emily Schultz no member ID | 2026-09-16 Telehealth | Unity Counseling Center Behavioral Health · in network | 99214 | $277.00 | — | 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-2026-020081 CMS-1500 · 2026-09-25 | Samuel Ray no member ID | 2026-09-19 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 80053 | $55.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-010515 CMS-1500 · 2026-09-25 | Anna Carpenter no member ID | 2026-09-23 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 93000 | $85.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-009905 CMS-1500 · 2026-09-25 | Sandra Russell no member ID | 2026-08-29 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 93000 | $75.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-008130 CMS-1500 · 2026-09-25 | Not attached | 2026-09-15 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97014 | $379.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-007499 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-2026-019612 CMS-1500 · 2026-09-24 | Helen Alexander no member ID | 2026-08-16 Office | Sunrise Behavioral Health Behavioral Health · in network | 90834, 90791 | $527.00 | — | Pended by rule N30 | — | 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-2026-006997 CMS-1500 · 2026-09-24 | Jacob Herrera no member ID | 2026-08-14 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 80053, 83036, 80061 | $165.00 | — | Pended by rule 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-2026-001631 CMS-1500 · 2026-09-24 | Doris McDonald no member ID | 2026-09-01 Telehealth | Summit Counseling Center Behavioral Health · in network | 99214 | $309.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-034030 CMS-1500 · 2026-09-23 | Shirley Matthews no member ID | 2026-09-19 Office | Valley Medical Group Internal Medicine · in network | 99214, 99215 | $547.00 | — | 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-2026-027269 CMS-1500 · 2026-09-23 | Gloria Peters no member ID | 2026-09-09 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99214, 93000, 80053 | $416.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-019861 CMS-1500 · 2026-09-23 | Nicole Guerrero no member ID | 2026-09-06 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $228.00 | — | 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-2026-013741 CMS-1500 · 2026-09-23 | Steven Maldonado no member ID | 2026-09-03 Independent laboratory | Valley Reference Lab Clinical Laboratory · in network | 80053 | $76.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-028859 CMS-1500 · 2026-09-22 | Margaret Ramirez no member ID | 2026-08-09 Office | Heritage Medical Group Internal Medicine · in network | 99215, 99214 | $543.00 | — | 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-2026-018153 CMS-1500 · 2026-09-22 | Mariana Hansen no member ID | 2026-09-04 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97140, 97161 | $576.00 | — | Pended by rule IDQ N30 | — | 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-2026-005334 CMS-1500 · 2026-09-22 | Santiago Crawford no member ID | 2026-08-17 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 83036, 80053, 85025 | $179.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-001478 CMS-1500 · 2026-09-22 | Stephen Henry no member ID | 2026-09-02 Office | Meadow Family Practice Family Medicine · in network | 99203, 99213 | $421.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-026965 CMS-1500 · 2026-09-21 | Laura Guzman no member ID | 2026-09-04 Office | Sunrise Counseling Center Behavioral Health · in network | 90837 | $272.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-017044 CMS-1500 · 2026-09-21 | Bobby Ross no member ID | 2026-08-29 Office | Heritage Primary Care Associates Family Medicine · in network | 36415, 99213 | $204.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-005459 CMS-1500 · 2026-09-21 | Lisa Chapman no member ID | 2026-09-16 Office | Heritage Medical Group Family Medicine · out of network | 90471, 99214 | $259.00 | — | 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.