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-2026-023776 UB-04 · 2026-09-02 | Karen Li no member ID | 2026-08-10 Outpatient hospital | Evergreen Digestive Health Center Gastroenterology · in network | 88305, 45378 | $3,014.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-022108 CMS-1500 · 2026-09-02 | Not attached | 2026-08-08 Office | Desert Internal Medicine Associates Internal Medicine · in network | 93000 | $91.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-022000 CMS-1500 · 2026-09-02 | Alice Armstrong no member ID | 2026-08-02 Office | Sunrise GI Associates Gastroenterology · in network | 99214 | $293.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017119 CMS-1500 · 2026-09-02 | Sharon Woods UHC-33271-36 | 2026-07-22 Office | Mesa Dermatology Clinic Dermatology · in network | 99213 | $205.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-012568 CMS-1500 · 2026-09-02 | Jean Jones no member ID | 2026-08-19 Office | Heritage Digestive Health Center Gastroenterology · in network | 99214 | $276.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-010592 UB-04 · 2026-09-02 | Jesse Reyes UHC-88973-05 | 2026-08-26 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 71046, 77067 | $484.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-004066 UB-04 · 2026-09-02 | Diego Gray UHC-18868-12 | 2026-08-27 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 77067, 70553 | $3,093.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-001779 CMS-1500 · 2026-09-02 | Sam Andrews no member ID | 2026-08-04 Office | Valley Cardiovascular Associates Cardiology · in network | 99214 | $254.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-030127 UB-04 · 2026-09-01 | Isabella Reed UHC-03809-38 | 2026-08-05 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,532.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030020 CMS-1500 · 2026-09-01 | Fatima Jordan UHC-31084-55 | 2026-08-18 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97014 | $336.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-026476 CMS-1500 · 2026-09-01 | Marcus Valdez UHC-18011-42 | 2026-08-21 Independent laboratory | Desert Reference Lab Clinical Laboratory · in network | 83036, 80053 | $106.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-024927 CMS-1500 · 2026-09-01 | Randy Cok no member ID | 2026-08-05 Office | Meadow Primary Care Associates Family Medicine · in network | 99395 | $285.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-022417 CMS-1500 · 2026-09-01 | Melissa Phillips no member ID | 2026-08-15 Office | Evergreen Family Practice Family Medicine · in network | 99203 | $209.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017762 CMS-1500 · 2026-09-01 | Not attached | 2026-07-27 Office | Valley Medical Group Internal Medicine · in network | 99214 | $261.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-014377 CMS-1500 · 2026-09-01 | Sophia Morris no member ID | 2026-08-30 Office | Mesa Diabetes Center Endocrinology · in network | 99214 | $272.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-010043 CMS-1500 · 2026-09-01 | Jennifer Matthews no member ID | 2026-07-25 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 83036, 80053 | $129.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-009582 CMS-1500 · 2026-09-01 | Randy Green no member ID | 2026-08-28 Office | Meadow GI Associates Gastroenterology · in network | 99214 | $228.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-006378 UB-04 · 2026-09-01 | Vincnet McDonald no member ID | 2026-08-22 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $7,230.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-000485 CMS-1500 · 2026-09-01 | Patricia Lawson no member ID | 2026-08-10 Office | Riverside Family Practice Family Medicine · in network | 99214, 99213, 99203 | $718.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-026864 UB-04 · 2026-08-31 | Pat Herrera no member ID | 2026-07-28 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 71046, 77067 | $468.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-018935 CMS-1500 · 2026-08-31 | Jeffrey Richardson no member ID | 2026-07-28 Office | Heritage Family Practice Family Medicine · in network | 99395, 36415 | $255.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-012828 CMS-1500 · 2026-08-31 | Arjun Hunt no member ID | 2026-07-17 Office | Desert Diabetes Center Endocrinology · in network | 83036 | $68.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-007207 CMS-1500 · 2026-08-31 | Carol Guzman no member ID | 2026-07-18 Office | Harbor Medical Group Family Medicine · in network | 36415, 99213, 99395 | $451.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-005588 CMS-1500 · 2026-08-31 | Sara Adams no member ID | 2026-07-27 Office | Desert Primary Care Associates Family Medicine · in network | 99213 | $220.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-001402 CMS-1500 · 2026-08-31 | Angela Gray no member ID | 2026-08-19 Office | Pinecrest Medical Group Internal Medicine · in network | 80053, 99214 | $356.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-000671 UB-04 · 2026-08-31 | Chris Bishop UHC-37211-39 | 2026-08-02 Outpatient hospital | Sunrise GI Associates Gastroenterology · in network | 45378, 43239 | $4,014.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-027971 UB-04 · 2026-08-30 | Justin Walker no member ID | 2026-08-08 Outpatient hospital | Pinecrest GI Associates Gastroenterology · in network | 45378, 43239 | $3,696.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-025460 CMS-1500 · 2026-08-30 | Emma Ortiz UHC-56096-77 | 2026-07-21 Office | Evergreen Internal Medicine Associates Internal Medicine · in network | 93000 | $62.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-023535 CMS-1500 · 2026-08-30 | Nathan Gonzalez UHC-46783-10 | 2026-07-20 Office | Heritage Primary Care Associates Family Medicine · in network | 99213, 99214, 99395 | $726.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-023394 CMS-1500 · 2026-08-30 | Linda Payne UHC-07120-79 | 2026-08-12 Office | Unity Primary Care Associates Family Medicine · in network | 99395 | $334.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-012991 CMS-1500 · 2026-08-30 | Kathleen Bailey UHC-81568-33 | 2026-08-05 Office | Mesa Medical Group Family Medicine · in network | 90471 | $35.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-012103 UB-04 · 2026-08-30 | Raymond Walsh no member ID | 2026-08-16 Outpatient hospital | Lakeside Clinical Laboratories Clinical Laboratory · in network | 70553 | $3,433.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-011927 CMS-1500 · 2026-08-30 | Roger Nguyen no member ID | 2026-08-10 Office | Desert Primary Care Associates Family Medicine · in network | 36415 | $13.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-008607 CMS-1500 · 2026-08-30 | Abigail Palmer UHC-54190-01 | 2026-07-31 Office | Summit Counseling Center Behavioral Health · in network | 90834 | $163.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-031472 CMS-1500 · 2026-08-29 | Alan Cole UHC-30570-34 | 2026-08-27 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · in network | 87086, 80053 | $99.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030441 UB-04 · 2026-08-29 | Alice Hernandez no member ID | 2026-08-02 Outpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 73721 | $2,323.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024724 CMS-1500 · 2026-08-29 | Joseph Kennedy no member ID | 2026-07-25 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97140 | $240.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024682 UB-04 · 2026-08-29 | Not attached | 2026-07-31 Outpatient hospital | Lakeside Medical Group Internal Medicine · in network | 70553 | $2,959.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-023275 CMS-1500 · 2026-08-29 | Jordan Kelley UHC-93333-68 | 2026-08-03 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 80053 | $56.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-021807 CMS-1500 · 2026-08-29 | Jooyce Vargas no member ID | 2026-08-21 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 85025 | $66.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-020768 UB-04 · 2026-08-29 | Brenda Wells no member ID | 2026-07-30 Outpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 29881, 73721 | $12,450.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-019143 CMS-1500 · 2026-08-29 | Sharon Walsh UHC-08844-89 | 2026-08-11 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110 | $232.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-017596 UB-04 · 2026-08-29 | Randy Armstrng no member ID | 2026-08-01 Emergency room | Sunrise Community Hospital Emergency Medicine · in network | 96374 | $251.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-014270 CMS-1500 · 2026-08-29 | Diego Larson no member ID | 2026-08-23 Office | Pinecrest GI Associates Gastroenterology · in network | 99214 | $311.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-005942 CMS-1500 · 2026-08-29 | Fatima Anderson no member ID | 2026-08-21 Office | Lakeside Medical Group Family Medicine · in network | 99203, 99213 | $401.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-032476 CMS-1500 · 2026-08-28 | Gregory Carroll no member ID | 2026-08-17 Office | Sunrise Family Practice Family Medicine · in network | 99203, 99395, 90471 | $564.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029764 UB-04 · 2026-08-28 | Hiroshi Miller no member ID | 2026-07-24 Outpatient hospital | Harbor Rehabilitation Center Physical Therapy · in network | 70553 | $7,893.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-027425 CMS-1500 · 2026-08-28 | Priya Smith UHC-16634-84 | 2026-08-06 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97161 | $572.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-023317 CMS-1500 · 2026-08-28 | Grreene Carlos no member ID | 2026-07-19 Office | Riverside Primary Care Associates Family Medicine · in network | 36415, 99213 | $217.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017990 CMS-1500 · 2026-08-28 | Juan Santos no member ID | 2026-07-15 Office | Harbor Medical Group Family Medicine · in network | 90471 | $25.00 | — | 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.