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-2026-014661 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-2026-011216 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 |
| 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-2026-010042 CMS-1500 · 2026-09-30 | William Morales no member ID | 2026-08-18 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99203, 99395 | $430.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-009984 CMS-1500 · 2026-09-30 | Barbara Carroll no member ID | 2026-09-06 Office | Sunrise Medical Group Internal Medicine · in network | 99215, 99214 | $560.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-009796 CMS-1500 · 2026-09-30 | Keith Vega no member ID | 2026-09-27 Office | Desert Medical Group Internal Medicine · in network | 99215 | $368.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-007181 CMS-1500 · 2026-09-30 | Susan Burns no member ID | 2026-09-18 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 83036, 80061 | $143.00 | — | Pended by rule IDQ N30 | — | 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-2026-001985 CMS-1500 · 2026-09-30 | Paul Gordon no member ID | 2026-09-13 Office | Valley Medical Group Family Medicine · in network | 99213, 99203, 99395 | $639.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-000700 CMS-1500 · 2026-09-30 | Priya Ward no member ID | 2026-09-06 Office | Heritage Family Practice Family Medicine · in network | 90471 | $33.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-032368 CMS-1500 · 2026-09-29 | Randy Montgomery no member ID | 2026-09-05 Office | Mesa Cardiovascular Associates Cardiology · in network | 93224 | $338.00 | — | Pended by rule N30 | — | 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-2026-010251 CMS-1500 · 2026-09-29 | Susan Armstrong UHC-24801-37 | 2026-08-28 Office | Harbor Medical Group Family Medicine · in network | 36415, 99213 | $169.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-009806 CMS-1500 · 2026-09-29 | Diana Miills no member ID | 2026-09-16 Office | Northgate Medical Group Internal Medicine · in network | 99214 | $279.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-004671 CMS-1500 · 2026-09-29 | Racchel Maldonado UHC-71621-23 | 2026-09-25 Office | Northgate Heart Institute Cardiology · in network | 99214, 93224 | $688.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-003734 CMS-1500 · 2026-09-29 | Teresa Hudson no member ID | 2026-08-26 Telehealth | Evergreen Counseling Center Behavioral Health · in network | 99214 | $313.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-000358 CMS-1500 · 2026-09-29 | Roy Payne UHC-52043-76 | 2026-09-01 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 85025, 87086 | $106.00 | — | Pended by rule IDQ | — | Pended |
| 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-2026-023758 CMS-1500 · 2026-09-28 | Dorothy Alexander UHC-81221-87 | 2026-09-14 Office | Pinecrest Family Practice Family Medicine · in network | 36415, 99395, 90471 | $295.00 | — | Pended by rule IDQ | — | 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-2026-020813 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-2026-020092 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-2026-000450 CMS-1500 · 2026-09-28 | Brittany Estrada UHC-82467-80 | 2026-09-02 Office | Canyon Counseling Center Behavioral Health · out of network | 90837 | $294.00 | — | Pended by rule IDQ | — | 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-2026-009072 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-2026-004186 CMS-1500 · 2026-09-27 | Natalie Hoffman UHC-91848-90 | 2026-08-30 Office | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 99213 | $170.00 | — | 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-2026-020930 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-2026-008519 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-2026-006664 CMS-1500 · 2026-09-26 | Rachel Brooks UHC-42063-06 | 2026-08-16 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · out of network | 83036, 85025 | $115.00 | — | 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-2026-000508 CMS-1500 · 2026-09-26 | Marilyn Munoz UHC-62924-41 | 2026-09-04 Office | Valley Medical Group Internal Medicine · in network | 99214, 99215, 93000 | $631.00 | — | Pended by rule IDQ | — | 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 |
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.