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-2026-005385 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-2026-015560 UB-04 · 2026-10-06 | Not attached | 2026-09-26 Outpatient hospital | Pinecrest Heart Institute Cardiology · in network | 93015 | $689.00 | — | Pended by rule CO16 | — | 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-2026-008932 UB-04 · 2026-10-06 | Theresa Johnson UHC-20217-08 | 2026-08-31 Outpatient hospital | Unity Community Hospital Emergency Medicine · in network | 70553 | $2,567.00 | — | Pended by rule IDQ | — | 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-2026-018012 UB-04 · 2026-10-05 | Sandra Dominguez UHC-22951-96 | 2026-08-22 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99285 | $2,591.00 | — | 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-2026-009121 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-2026-017143 UB-04 · 2026-10-04 | Joan Robertson UHC-80182-89 | 2026-09-02 Outpatient hospital | Evergreen Digestive Health Center Gastroenterology · in network | 88305 | $233.00 | — | Pended by rule IDQ | — | 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-2026-030652 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-2026-026268 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-2026-022203 UB-04 · 2026-10-03 | Carl Morrison UHC-22994-76 | 2026-09-10 Outpatient hospital | Valley Heart Institute Cardiology · in network | 93458, 93306 | $6,534.00 | — | Pended by rule IDQ | — | 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-2026-010133 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-2026-032925 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-2026-012108 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-2026-002997 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-2026-002822 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-2026-031670 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-2026-021168 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-2026-019142 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 |
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.