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-2026-007805 UB-04 · 2026-09-09 | Melissa Soto UHC-47899-58 | 2026-07-27 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 70553, 77067 | $3,685.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-007526 CMS-1500 · 2026-09-09 | Christina Green no member ID | 2026-08-30 Office | Lakeside Heart Institute Cardiology · in network | 93224 | $340.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002628 CMS-1500 · 2026-09-09 | Juan Ellis no member ID | 2026-08-03 Office | Canyon Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $361.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-034316 CMS-1500 · 2026-09-08 | Abigail Gray UHC-91906-99 | 2026-07-26 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 85025 | $39.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-020798 CMS-1500 · 2026-09-08 | Emily Washington no member ID | 2026-09-02 Office | Lakeside Medical Group Family Medicine · out of network | 99203, 99395 | $473.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017452 UB-04 · 2026-09-08 | Brittany Campbell no member ID | 2026-08-19 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 77067 | $258.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013169 UB-04 · 2026-09-08 | Logan Wang UHC-66376-95 | 2026-08-30 Outpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 73721 | $1,264.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010489 CMS-1500 · 2026-09-08 | Sophia Lee no member ID | 2026-08-11 Office | Meadow Family Practice Family Medicine · in network | 99203 | $241.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-007734 CMS-1500 · 2026-09-08 | William Brooks no member ID | 2026-08-02 Office | Desert Internal Medicine Associates Internal Medicine · in network | 93000 | $70.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-006105 CMS-1500 · 2026-09-08 | Kelly Richardson UHC-69622-24 | 2026-09-05 Office | Valley Skin Care Associates Dermatology · out of network | 11102, 17110 | $604.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-003691 CMS-1500 · 2026-09-08 | Roger Gibzon no member ID | 2026-09-03 Office | Harbor Family Practice Family Medicine · in network | 99213 | $211.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-025592 CMS-1500 · 2026-09-07 | Not attached | 2026-08-22 Office | Pinecrest Medical Group Family Medicine · in network | 99213, 99203 | $402.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-024620 UB-04 · 2026-09-07 | Danel Mejia no member ID | 2026-08-19 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374 | $150.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-023967 CMS-1500 · 2026-09-07 | Lucia Young no member ID | 2026-08-09 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99215, 80053, 93000 | $487.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-022914 UB-04 · 2026-09-07 | David Ortiz no member ID | 2026-08-26 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · in network | 99283 | $772.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-019796 CMS-1500 · 2026-09-07 | Scott Garcia UHC-93685-32 | 2026-08-20 Office | Desert Internal Medicine Associates Internal Medicine · in network | 80053, 99214 | $331.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-019216 CMS-1500 · 2026-09-07 | 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-2026-003935 CMS-1500 · 2026-09-07 | Scott Sulivan UHC-79551-82 | 2026-08-10 Office | Summit Primary Care Associates Family Medicine · in network | 99395, 99203 | $501.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-001822 UB-04 · 2026-09-07 | Alice Baker UHC-01066-48 | 2026-08-22 Emergency room | Unity Community Hospital Emergency Medicine · in network | 71046, 99285 | $2,122.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-033471 UB-04 · 2026-09-06 | Diane Alvarez no member ID | 2026-08-28 Outpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 29881 | $7,145.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-025262 CMS-1500 · 2026-09-06 | Jennifer Jackson no member ID | 2026-07-24 Office | Northgate Dermatology Clinic Dermatology · in network | 11102 | $289.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024847 CMS-1500 · 2026-09-06 | Katherine Russell no member ID | 2026-09-03 Office | Desert Internal Medicine Associates Internal Medicine · in network | 93000, 99215 | $467.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-014866 UB-04 · 2026-09-06 | Wei Medina no member ID | 2026-08-02 Outpatient hospital | Desert Imaging Center Radiology · in network | 74177, 76700 | $2,267.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-011955 CMS-1500 · 2026-09-06 | Madison Fields UHC-58583-07 | 2026-08-29 Office | Sunrise Cardiovascular Associates Cardiology · in network | 99214, 93224 | $656.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010170 CMS-1500 · 2026-09-06 | Keith Washington no member ID | 2026-08-16 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 99215 | $369.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-007335 UB-04 · 2026-09-06 | Abigil Jordan UHC-89089-78 | 2026-07-27 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 70553, 93306 | $4,225.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-004576 CMS-1500 · 2026-09-06 | Maria Yang no member ID | 2026-08-24 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99214, 99395, 90471 | $612.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-030113 UB-04 · 2026-09-05 | Martha Soto no member ID | 2026-08-13 Inpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 27447 | $40,676.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-028158 CMS-1500 · 2026-09-05 | Emily Sanders no member ID | 2026-08-25 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $116.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-026240 CMS-1500 · 2026-09-05 | Richard Morgan UHC-56192-61 | 2026-07-24 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $128.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-024109 UB-04 · 2026-09-05 | Bruce Hudson no member ID | 2026-09-02 Emergency room | Harbor Regional Medical Center Emergency Medicine · in network | 96374, 71046 | $329.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-019126 UB-04 · 2026-09-05 | Stephanie Arnold UHC-99944-03 | 2026-08-31 Outpatient hospital | Pinecrest Cardiovascular Associates Cardiology · in network | 93306, 93015 | $1,992.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-014494 CMS-1500 · 2026-09-05 | Yuki Maldonado no member ID | 2026-08-26 Office | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 99213 | $198.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-011508 CMS-1500 · 2026-09-05 | Jack Gibson no member ID | 2026-07-25 Office | Desert Rehabilitation Center Physical Therapy · in network | 97110, 97140 | $265.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-002550 UB-04 · 2026-09-05 | Lawrence Tucker no member ID | 2026-08-10 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99285 | $3,080.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-000340 CMS-1500 · 2026-09-05 | 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-2026-028238 CMS-1500 · 2026-09-04 | Hannah Martin UHC-93034-52 | 2026-08-18 Office | Harbor Medical Group Internal Medicine · out of network | 99214, 93000 | $320.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-028183 CMS-1500 · 2026-09-04 | Arthur Freeman no member ID | 2026-08-04 Office | Sunrise Skin Care Associates Dermatology · in network | 11403, 17110 | $962.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-011842 UB-04 · 2026-09-04 | Victoria Cruz no member ID | 2026-08-03 Outpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $2,267.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-000553 UB-04 · 2026-09-04 | Austin Lopez UHC-04812-49 | 2026-08-30 Outpatient hospital | Desert Imaging Center Radiology · in network | 71046 | $132.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-033468 CMS-1500 · 2026-09-03 | Christina Park no member ID | 2026-08-01 Office | Canyon Skin Care Associates Dermatology · in network | 17110, 11403 | $798.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-033331 UB-04 · 2026-09-03 | Juan Myers UHC-57612-75 | 2026-07-20 Outpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 29881, 73721 | $8,411.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-023839 CMS-1500 · 2026-09-03 | Lori Nunez UHC-64875-75 | 2026-08-27 Independent laboratory | Evergreen Clinical Laboratories Clinical Laboratory · in network | 85025, 80053 | $95.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-020722 CMS-1500 · 2026-09-03 | Wei Hamilton UHC-96684-93 | 2026-07-28 Office | Lakeside Skin Care Associates Dermatology · in network | 17110 | $249.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-019698 CMS-1500 · 2026-09-03 | Bobby Myers no member ID | 2026-08-22 Office | Meadow Medical Group Family Medicine · in network | 36415, 99395 | $349.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-004332 UB-04 · 2026-09-03 | William Collins UHC-41025-03 | 2026-08-30 Outpatient hospital | Lakeside Reference Lab Clinical Laboratory · in network | 70553 | $2,965.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-003944 CMS-1500 · 2026-09-03 | Sophia Marquez no member ID | 2026-08-28 Office | Northgate Dermatology Clinic Dermatology · in network | 17110, 11102, 99213 | $582.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-034435 CMS-1500 · 2026-09-02 | Pamela Richards UHC-61406-34 | 2026-08-25 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97014, 97161 | $465.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-034166 CMS-1500 · 2026-09-02 | Ralph Johnson no member ID | 2026-07-27 Office | Riverside Primary Care Associates Family Medicine · in network | 99214, 36415 | $258.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024677 CMS-1500 · 2026-09-02 | Olivia Wilzon no member ID | 2026-08-28 Office | Meadow Dermatology Clinic Dermatology · in network | 17110 | $256.00 | — | 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.