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-2026-015560 UB-04 · 2026-10-06 | Not attached | 2026-09-26 Outpatient hospital | Pinecrest Heart Institute Cardiology · in network | 93015 | $689.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-000032 UB-04 · 2026-10-05 | Not attached | 2026-09-25 Outpatient hospital | Pinecrest Heart Institute Cardiology · in network | 93306 | $1,401.00 | — | Pended by rule CO16 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-2026-005361 UB-04 · 2026-09-22 | Not attached | 2026-09-19 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285 | $3,094.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-029002 UB-04 · 2026-09-21 | 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-2026-029001 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-2026-024682 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-2026-005265 UB-04 · 2026-08-28 | Not attached | 2026-08-25 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 71046 | $225.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-025033 UB-04 · 2026-08-27 | Not attached | 2026-07-26 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99285, 71046 | $2,179.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-000866 UB-04 · 2026-08-09 | Not attached | 2026-07-25 Outpatient hospital | Riverside Imaging Center Radiology · in network | 76700 | $611.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-021178 UB-04 · 2026-08-06 | Not attached | 2026-07-26 Outpatient hospital | Desert Imaging Center Radiology · in network | 71046 | $200.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-003305 UB-04 · 2026-08-06 | Not attached | 2026-07-10 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283 | $917.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-000539 UB-04 · 2026-08-06 | Not attached | 2026-06-27 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · in network | 93306, 93015 | $1,820.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-022468 UB-04 · 2026-08-04 | Not attached | 2026-07-15 Outpatient hospital | Summit Imaging Center Radiology · in network | 77067, 70553 | $2,817.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-021633 UB-04 · 2026-07-31 | Not attached | 2026-06-18 Inpatient hospital | Heritage Internal Medicine Associates Internal Medicine · in network | 99232 | $216.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-011469 UB-04 · 2026-07-26 | Not attached | 2026-06-19 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,113.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-006051 UB-04 · 2026-07-24 | Not attached | 2026-06-23 Outpatient hospital | Summit Digestive Health Center Gastroenterology · in network | 88305 | $256.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-021091 UB-04 · 2026-07-20 | Not attached | 2026-06-15 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $213.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-001574 UB-04 · 2026-07-15 | Not attached | 2026-06-15 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 77067, 70553 | $2,837.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-012305 UB-04 · 2026-07-10 | Not attached | 2026-07-08 Outpatient hospital | Valley Regional Medical Center Emergency Medicine · in network | 70553 | $3,121.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-030457 UB-04 · 2026-07-05 | Not attached | 2026-06-15 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $37,882.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-022726 UB-04 · 2026-07-05 | Not attached | 2026-06-18 Emergency room | Lakeside Regional Medical Center Emergency Medicine · in network | 71046, 99284 | $1,264.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-004698 UB-04 · 2026-07-05 | Not attached | 2026-05-22 Inpatient hospital | Summit Medical Group Internal Medicine · in network | 99232 | $162.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-018862 UB-04 · 2026-06-30 | Not attached | 2026-06-09 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,271.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-030288 UB-04 · 2026-06-19 | Not attached | 2026-06-14 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99283, 71046, 99284 | $2,329.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-003297 UB-04 · 2026-06-17 | Not attached | 2026-05-20 Outpatient hospital | Pinecrest Physical Therapy Physical Therapy · in network | 70553 | $10,944.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-021712 UB-04 · 2026-06-11 | Not attached | 2026-04-17 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $1,220.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-006969 UB-04 · 2026-06-11 | Not attached | 2026-05-18 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 76700 | $351.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-026339 UB-04 · 2026-06-09 | Not attached | 2026-05-16 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 88305 | $264.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-028400 UB-04 · 2026-06-07 | Not attached | 2026-06-05 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 77067 | $267.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-017953 UB-04 · 2026-06-06 | Not attached | 2026-04-26 Outpatient hospital | Meadow GI Associates Gastroenterology · in network | 45378 | $1,904.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-004372 UB-04 · 2026-05-29 | Not attached | 2026-05-07 Emergency room | Desert Regional Medical Center Emergency Medicine · in network | 96374, 99285 | $2,299.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-021200 UB-04 · 2026-05-27 | Not attached | 2026-05-22 Emergency room | Canyon Regional Medical Center Emergency Medicine · in network | 99283, 99284 | $1,958.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-021372 UB-04 · 2026-05-25 | Not attached | 2026-04-10 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 77067, 74177 | $2,366.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-021711 UB-04 · 2026-05-22 | Not attached | 2026-04-17 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $1,220.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-010875 UB-04 · 2026-05-15 | Not attached | 2026-04-20 Outpatient hospital | Northgate Reference Lab Clinical Laboratory · in network | 70553 | $2,229.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-012552 UB-04 · 2026-05-10 | Not attached | 2026-04-02 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378 | $2,234.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-001813 UB-04 · 2026-05-05 | Not attached | 2026-03-27 Inpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 27447 | $42,721.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-032820 UB-04 · 2026-04-26 | Not attached | 2026-03-25 Emergency room | Desert Regional Medical Center Emergency Medicine · in network | 96374 | $237.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-027593 UB-04 · 2026-04-13 | Not attached | 2026-03-02 Inpatient hospital | Riverside Internal Medicine Associates Internal Medicine · in network | 99232 | $224.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-026722 UB-04 · 2026-04-09 | Not attached | 2026-03-20 Outpatient hospital | Desert Imaging Center Radiology · in network | 71046 | $175.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-004114 UB-04 · 2026-03-30 | Not attached | 2026-02-21 Outpatient hospital | Unity Cardiovascular Associates Cardiology · in network | 93458 | $9,311.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-029643 UB-04 · 2026-03-26 | Not attached | 2026-02-07 Outpatient hospital | Evergreen Cardiovascular Associates Cardiology · in network | 93458 | $7,517.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-029642 UB-04 · 2026-03-20 | Not attached | 2026-02-07 Outpatient hospital | Evergreen Cardiovascular Associates Cardiology · in network | 93458 | $7,517.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-022489 UB-04 · 2026-03-19 | Not attached | 2026-03-14 Inpatient hospital | Sunrise Internal Medicine Associates Internal Medicine · in network | 99232 | $257.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-029261 UB-04 · 2026-03-04 | Not attached | 2026-01-13 Outpatient hospital | Heritage Digestive Health Center Gastroenterology · in network | 43239 | $2,390.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-027273 UB-04 · 2026-03-04 | Not attached | 2026-02-11 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 77067 | $364.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-029260 UB-04 · 2026-02-27 | Not attached | 2026-01-13 Outpatient hospital | Heritage Digestive Health Center Gastroenterology · in network | 43239 | $2,390.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-034430 UB-04 · 2026-02-12 | Not attached | 2026-02-03 Emergency room | Desert Regional Medical Center Emergency Medicine · in network | 99283 | $1,029.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-027206 UB-04 · 2026-02-10 | Not attached | 2026-01-08 Outpatient hospital | Desert Imaging Center Radiology · in network | 70553, 76700 | $3,400.00 | — | Pended by rule CO16 | — | 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.