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-2026-011565 CMS-1500 · 2026-09-15 | Andrea Powell no member ID | 2026-08-25 Office | Meadow Heart Institute Cardiology · in network | 93224, 99214 | $748.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-010294 CMS-1500 · 2026-09-15 | Deborah Fox no member ID | 2026-09-10 Office | Northgate Medical Group Family Medicine · in network | 99203 | $218.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-010607 CMS-1500 · 2026-09-14 | Roy Coleman UHC-34187-63 | 2026-08-10 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $180.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010132 UB-04 · 2026-09-14 | 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-2026-008386 CMS-1500 · 2026-09-14 | Roger Hawkins UHC-17742-30 | 2026-08-17 Office | Evergreen Medical Group Family Medicine · in network | 99214 | $301.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-007382 UB-04 · 2026-09-14 | Marilyn Hart no member ID | 2026-08-15 Outpatient hospital | Riverside Imaging Center Radiology · in network | 74177, 77067 | $2,561.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-007112 CMS-1500 · 2026-09-14 | Joseph Jimenez no member ID | 2026-09-09 Office | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 20610 | $193.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-026341 CMS-1500 · 2026-09-13 | Becky Clark no member ID | 2026-09-08 Office | Sunrise Behavioral Health Behavioral Health · in network | 90837 | $204.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-023808 CMS-1500 · 2026-09-13 | Carl Montgomery UHC-57349-54 | 2026-08-21 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110 | $110.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-023599 CMS-1500 · 2026-09-13 | Adam Obrien UHC-58333-51 | 2026-09-02 Office | Unity Primary Care Associates Family Medicine · out of network | 99203, 90471 | $237.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-023496 UB-04 · 2026-09-13 | Christine Hawkins no member ID | 2026-09-05 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $1,185.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-018818 CMS-1500 · 2026-09-13 | Brenda Mills UHC-64046-69 | 2026-08-13 Office | Heritage Primary Care Associates Family Medicine · in network | 36415, 99214, 90471 | $352.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-018469 UB-04 · 2026-09-13 | Ryan Moore UHC-30429-82 | 2026-08-30 Inpatient hospital | Pinecrest Internal Medicine Associates Internal Medicine · in network | 99232 | $178.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-031311 UB-04 · 2026-09-12 | Juan Munoz UHC-06071-85 | 2026-09-03 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 45378 | $1,885.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030096 CMS-1500 · 2026-09-12 | Petar Rice no member ID | 2026-08-24 Office | Canyon Primary Care Associates Family Medicine · in network | 99395 | $300.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-019254 UB-04 · 2026-09-12 | Nicole Nunez no member ID | 2026-07-30 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93306 | $1,055.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017510 UB-04 · 2026-09-12 | Julie Alexander no member ID | 2026-08-10 Inpatient hospital | Desert Internal Medicine Associates Internal Medicine · in network | 99232 | $200.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-005497 CMS-1500 · 2026-09-12 | Carol Munoz no member ID | 2026-08-28 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $229.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002198 CMS-1500 · 2026-09-12 | Tyler Li UHC-77075-77 | 2026-09-10 Office | Unity Medical Group Internal Medicine · in network | 93000, 99214 | $390.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-033163 UB-04 · 2026-09-11 | Cynthia Dunn UHC-08495-02 | 2026-09-08 Emergency room | Riverside Community Hospital Emergency Medicine · in network | 71046 | $206.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-031759 CMS-1500 · 2026-09-11 | Elizabeth Ray no member ID | 2026-08-09 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 80053 | $55.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-031269 UB-04 · 2026-09-11 | Sofia Bowman no member ID | 2026-08-29 Outpatient hospital | Riverside Primary Care Associates Family Medicine · in network | 70553 | $3,460.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-030699 CMS-1500 · 2026-09-11 | Henry Harper no member ID | 2026-08-08 Office | Unity Family Practice Family Medicine · in network | 99395, 99214 | $483.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-026940 CMS-1500 · 2026-09-11 | Elijah Stone no member ID | 2026-08-13 Office | Canyon Cardiovascular Associates Cardiology · out of network | 99214, 93224 | $677.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-025824 UB-04 · 2026-09-11 | Amber Maldonado no member ID | 2026-08-24 Outpatient hospital | Unity Community Hospital Emergency Medicine · in network | 70553 | $3,344.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024257 UB-04 · 2026-09-11 | Amber Maldonado no member ID | 2026-08-09 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 45378, 88305 | $2,951.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-022086 CMS-1500 · 2026-09-11 | Frances Henry no member ID | 2026-08-19 Office | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 20610 | $242.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-020960 CMS-1500 · 2026-09-11 | Stephen Burke no member ID | 2026-08-31 Office | Evergreen Primary Care Associates Family Medicine · in network | 36415 | $13.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-016732 UB-04 · 2026-09-11 | Maria Ortiz no member ID | 2026-08-26 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 77067 | $255.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-005909 CMS-1500 · 2026-09-11 | George Riley UHC-93048-03 | 2026-09-09 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99215 | $387.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-002999 CMS-1500 · 2026-09-11 | Jacob Vazquez no member ID | 2026-09-02 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 85025 | $48.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-001993 CMS-1500 · 2026-09-11 | Julia Nguyen UHC-90442-51 | 2026-08-29 Office | Riverside Medical Group Family Medicine · in network | 99213 | $142.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030357 CMS-1500 · 2026-09-10 | Nicholas Tran no member ID | 2026-07-28 Office | Meadow Family Practice Family Medicine · in network | 99214, 99395 | $504.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-028879 UB-04 · 2026-09-10 | Emma Rodriguez no member ID | 2026-08-25 Emergency room | Desert Regional Medical Center Emergency Medicine · in network | 71046 | $239.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-021771 UB-04 · 2026-09-10 | Anna Colman no member ID | 2026-08-23 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99285, 99284 | $3,364.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017240 UB-04 · 2026-09-10 | Aisha Turner no member ID | 2026-09-07 Outpatient hospital | Unity Digestive Health Center Gastroenterology · in network | 43239 | $2,252.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-012883 CMS-1500 · 2026-09-10 | Steven Park no member ID | 2026-08-08 Office | Riverside Primary Care Associates Family Medicine · in network | 99214, 99395 | $469.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-011362 CMS-1500 · 2026-09-10 | Sofia Montgomery no member ID | 2026-08-31 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97161 | $431.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-007936 CMS-1500 · 2026-09-10 | Sara Padilla UHC-35197-28 | 2026-09-05 Office | Unity Primary Care Associates Family Medicine · out of network | 99213 | $172.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-006961 CMS-1500 · 2026-09-10 | Keith Long no member ID | 2026-08-28 Office | Unity Physical Therapy Physical Therapy · in network | 97110 | $276.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-005036 CMS-1500 · 2026-09-10 | Joan Montgomery no member ID | 2026-07-30 Office | Valley Medical Group Internal Medicine · in network | 99215, 93000, 99214 | $743.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-000511 CMS-1500 · 2026-09-10 | Marilyn Reyes UHC-39493-80 | 2026-09-05 Office | Unity Primary Care Associates Family Medicine · in network | 99214, 99203 | $482.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000480 UB-04 · 2026-09-10 | Gabriel Bennett no member ID | 2026-08-15 Outpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $10,599.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-000306 CMS-1500 · 2026-09-10 | Mary George UHC-99908-37 | 2026-07-31 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $376.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030509 CMS-1500 · 2026-09-09 | George Reynolds no member ID | 2026-08-03 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 93000 | $81.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-030090 UB-04 · 2026-09-09 | Kyle Garrett no member ID | 2026-09-01 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 76700 | $421.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-029001 UB-04 · 2026-09-09 | Not attached | 2026-08-31 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,744.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-026954 CMS-1500 · 2026-09-09 | Gary Hoffman no member ID | 2026-08-10 Office | Northgate Primary Care Associates Family Medicine · out of network | 99214, 36415 | $333.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013600 CMS-1500 · 2026-09-09 | Sofia Nunez UHC-92875-98 | 2026-08-16 Office | Sunrise Dermatology Clinic Dermatology · in network | 99213, 11403 | $764.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010002 UB-04 · 2026-09-09 | Gary Peters no member ID | 2026-08-28 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99283, 99285 | $3,978.00 | — | 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.