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-2026-004590 CMS-1500 · 2026-09-21 | Hiroshi Hudson no member ID | 2026-09-08 Office | Pinecrest Primary Care Associates Family Medicine · in network | 90471 | $39.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002861 CMS-1500 · 2026-09-21 | Ruth Rice no member ID | 2026-09-02 Office | Sunrise Behavioral Health Behavioral Health · in network | 90837 | $216.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-033842 CMS-1500 · 2026-09-20 | Mariana Morrison UHC-95112-56 | 2026-09-03 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · in network | 87086, 85025, 83036 | $142.00 | — | 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-2026-018772 CMS-1500 · 2026-09-20 | Judy Miller UHC-09658-23 | 2026-08-29 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 80061, 85025 | $103.00 | — | Pended by rule IDQ | — | 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-2026-008790 CMS-1500 · 2026-09-20 | Eric Burke no member ID | 2026-09-12 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $192.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-008332 CMS-1500 · 2026-09-20 | Carol Munoz no member ID | 2026-08-17 Office | Meadow GI Associates Gastroenterology · out of network | 99214 | $290.00 | — | Pended by rule 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-2026-001492 CMS-1500 · 2026-09-20 | Santiago Washington UHC-82320-39 | 2026-09-13 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 83036, 80053 | $109.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030226 CMS-1500 · 2026-09-19 | Kelly Miller no member ID | 2026-08-10 Office | Sunrise Dermatology Clinic Dermatology · in network | 11403, 17110 | $910.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-023636 CMS-1500 · 2026-09-19 | Keith Collins no member ID | 2026-09-02 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 80061, 85025 | $91.00 | — | Pended by rule IDQ N30 | — | 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-2026-014466 CMS-1500 · 2026-09-19 | Not attached | 2026-08-30 Office | Evergreen Medical Group Family Medicine · in network | 36415, 99395 | $290.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-000341 CMS-1500 · 2026-09-19 | Justin Ruiz no member ID | 2026-07-29 Office | Lakeside Heart Institute Cardiology · in network | 99214 | $258.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-000323 CMS-1500 · 2026-09-19 | Santiago Crawford no member ID | 2026-09-09 Office | Valley Skin Care Associates Dermatology · out of network | 11102, 17110 | $504.00 | — | 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-2026-025044 CMS-1500 · 2026-09-18 | Madison Taylor no member ID | 2026-08-07 Independent laboratory | Pinecrest Clinical Laboratories Clinical Laboratory · in network | 83036 | $61.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-024178 CMS-1500 · 2026-09-18 | Marcus Warren no member ID | 2026-09-02 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 87086, 85025, 83036 | $172.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-022478 CMS-1500 · 2026-09-18 | Logan Green no member ID | 2026-08-13 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110, 97140 | $329.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-014948 CMS-1500 · 2026-09-18 | Fatima Jordan UHC-31084-55 | 2026-08-29 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 83036 | $75.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-011207 CMS-1500 · 2026-09-18 | Carlos Greene no member ID | 2026-08-08 Office | Meadow Medical Group Family Medicine · in network | 36415, 99214 | $333.00 | — | Pended by rule N30 | — | 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-2026-003210 CMS-1500 · 2026-09-18 | Gerald Foster no member ID | 2026-09-05 Office | Riverside GI Associates Gastroenterology · in network | 99214 | $305.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-030338 CMS-1500 · 2026-09-17 | Michele Luna no member ID | 2026-08-25 Independent laboratory | Harbor Reference Lab Clinical Laboratory · in network | 87086, 85025, 83036 | $160.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-020757 CMS-1500 · 2026-09-17 | Andrew Morales no member ID | 2026-09-08 Office | Harbor Medical Group Family Medicine · in network | 99395 | $281.00 | — | 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 |
| CLM-2026-017748 UB-04 · 2026-09-17 | Brian Wells UHC-78951-31 | 2026-08-11 Outpatient hospital | Northgate Cardiovascular Associates Cardiology · in network | 93306, 93458 | $9,359.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-016201 UB-04 · 2026-09-17 | Noah Burton UHC-87151-33 | 2026-08-13 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $2,395.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-012983 CMS-1500 · 2026-09-17 | Stephanie Snyder no member ID | 2026-08-26 Office | Meadow Physical Therapy Physical Therapy · in network | 97110, 97014 | $333.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-003552 CMS-1500 · 2026-09-17 | Debra Matthews no member ID | 2026-09-03 Office | Evergreen Primary Care Associates Family Medicine · in network | 90471, 99213 | $235.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-001879 CMS-1500 · 2026-09-17 | Arthur Grant UHC-68341-63 | 2026-08-27 Independent laboratory | Desert Reference Lab Clinical Laboratory · in network | 83036, 80053 | $119.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-028911 CMS-1500 · 2026-09-16 | Patrick Singh UHC-86192-10 | 2026-08-31 Office | Valley Rehabilitation Center Physical Therapy · in network | 97110 | $280.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-020834 UB-04 · 2026-09-16 | Janice Banks no member ID | 2026-08-24 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285 | $2,240.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-011801 UB-04 · 2026-09-16 | Michael Duncan UHC-46296-78 | 2026-08-20 Outpatient hospital | Heritage Community Hospital Emergency Medicine · in network | 70553 | $3,554.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-008900 CMS-1500 · 2026-09-16 | Contreras Mark no member ID | 2026-09-14 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $156.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-004338 CMS-1500 · 2026-09-16 | Christine Pierce UHC-02916-39 | 2026-09-08 Office | Riverside Bone and Joint Center Orthopedic Surgery · in network | 20610 | $190.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-001790 UB-04 · 2026-09-16 | Juan Alexander no member ID | 2026-08-24 Outpatient hospital | Cornerstone Imaging Center Radiology · in network | 77067 | $379.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-029869 CMS-1500 · 2026-09-15 | Mateo Espinoza UHC-22304-73 | 2026-08-31 Office | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 99213 | $239.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025631 CMS-1500 · 2026-09-15 | Julie Romero no member ID | 2026-08-04 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110 | $195.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-023868 CMS-1500 · 2026-09-15 | Barbara Hill no member ID | 2026-08-18 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97014, 97140 | $364.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-021773 CMS-1500 · 2026-09-15 | Arjun Wang no member ID | 2026-09-13 Office | Evergreen Family Practice Family Medicine · in network | 36415 | $13.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-018487 UB-04 · 2026-09-15 | Sarah Howell UHC-91177-68 | 2026-09-02 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99283, 96374, 99284 | $2,602.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-017827 UB-04 · 2026-09-15 | Rachel Young UHC-25987-45 | 2026-08-27 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 70553 | $3,153.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-017768 UB-04 · 2026-09-15 | Emma Hamilon no member ID | 2026-08-10 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 76700 | $336.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017496 UB-04 · 2026-09-15 | Emma Ruiz no member ID | 2026-09-12 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99285, 71046 | $2,208.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-016385 CMS-1500 · 2026-09-15 | Denise Carroll UHC-30539-11 | 2026-08-21 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 80053 | $80.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-011638 UB-04 · 2026-09-15 | Harold Hall UHC-71225-35 | 2026-08-20 Outpatient hospital | Harbor Diagnostic Imaging Radiology · in network | 70553, 71046 | $2,855.00 | — | 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.