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-2026-019733 CMS-1500 · 2026-10-18 | Daniel Le no member ID | 2026-09-12 Office | Harbor Medical Group Family Medicine · in network | 99203 | $230.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-013357 CMS-1500 · 2026-10-18 | Maria Russll UHC-17012-96 | 2026-09-04 Office | Harbor Diabetes Center Endocrinology · in network | 95251 | $201.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025433 CMS-1500 · 2026-10-17 | Christian Cruz UHC-81334-28 | 2026-10-06 Office | Pinecrest Family Practice Family Medicine · in network | 36415, 99203 | $251.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-019537 CMS-1500 · 2026-10-17 | Priya Chavez UHC-11128-20 | 2026-10-14 Office | Northgate Medical Group Family Medicine · in network | 90471, 99213, 99395 | $498.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-015282 CMS-1500 · 2026-10-17 | Aaron Shaw no member ID | 2026-09-19 Independent laboratory | Pinecrest Reference Lab Clinical Laboratory · in network | 85025, 83036, 87086 | $135.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-011604 CMS-1500 · 2026-10-16 | Andrea Lee no member ID | 2026-09-19 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110, 97140 | $243.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-004387 CMS-1500 · 2026-10-16 | Bryan Mitchell UHC-04861-43 | 2026-10-01 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 83036, 80061 | $98.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000169 CMS-1500 · 2026-10-16 | Ahmed Wright UHC-78812-39 | 2026-09-27 Office | Evergreen Primary Care Associates Family Medicine · in network | 99213, 99214 | $426.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-029991 CMS-1500 · 2026-10-15 | Nancy Welch UHC-74613-35 | 2026-09-20 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97014, 97161 | $545.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-011274 CMS-1500 · 2026-10-15 | Nancy Welch UHC-74613-35 | 2026-09-13 Telehealth | Pinecrest Behavioral Health Behavioral Health · in network | 99214 | $279.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000946 CMS-1500 · 2026-10-15 | Matthew Jones UHC-41159-40 | 2026-09-13 Office | Unity Medical Group Internal Medicine · in network | 93000 | $113.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000486 CMS-1500 · 2026-10-15 | Jason Hunt UHC-16244-46 | 2026-09-22 Independent laboratory | Pinecrest Clinical Laboratories Clinical Laboratory · in network | 83036 | $71.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-027164 CMS-1500 · 2026-10-14 | Joyce Cole no member ID | 2026-09-20 Office | Harbor Physical Therapy Physical Therapy · in network | 97110 | $236.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-022211 CMS-1500 · 2026-10-14 | Steve Scott no member ID | 2026-09-05 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140 | $379.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-012386 CMS-1500 · 2026-10-14 | Albert Flores UHC-31435-25 | 2026-09-26 Office | Sunrise Cardiovascular Associates Cardiology · in network | 99214 | $329.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-003388 CMS-1500 · 2026-10-14 | Natalie Palmer UHC-30236-51 | 2026-08-31 Office | Meadow Bone and Joint Center Orthopedic Surgery · in network | 20610 | $261.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025541 CMS-1500 · 2026-10-13 | Frances Jensen no member ID | 2026-10-03 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 83036 | $74.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-023759 CMS-1500 · 2026-10-13 | Dorothy Alexander UHC-81221-87 | 2026-09-14 Office | Pinecrest Family Practice Family Medicine · in network | 36415, 99395, 90471 | $295.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-027083 CMS-1500 · 2026-10-12 | Amanda Santiiago no member ID | 2026-09-29 Office | Unity Primary Care Associates Family Medicine · out of network | 99213 | $176.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-017763 CMS-1500 · 2026-10-12 | Bryan Ortiz UHC-46023-57 | 2026-09-14 Office | Heritage Primary Care Associates Family Medicine · in network | 99203, 99395 | $463.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-014798 CMS-1500 · 2026-10-12 | Adam Green UHC-08215-14 | 2026-10-09 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 99214 | $201.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013526 CMS-1500 · 2026-10-12 | Joseph Wheeler UHC-76888-73 | 2026-09-16 Office | Mesa Medical Group Family Medicine · in network | 99203, 99213 | $387.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013499 CMS-1500 · 2026-10-12 | Samuel Tucker no member ID | 2026-08-30 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $187.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-010416 CMS-1500 · 2026-10-12 | Katleen Tran no member ID | 2026-10-05 Office | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 99213 | $160.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-033519 CMS-1500 · 2026-10-11 | Martha Powell UHC-78239-03 | 2026-09-19 Office | Meadow Primary Care Associates Family Medicine · in network | 99203, 99395 | $469.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-003724 CMS-1500 · 2026-10-11 | Kenneth Santos UHC-35521-44 | 2026-09-15 Office | Canyon Cardiovascular Associates Cardiology · in network | 99214 | $222.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-001234 CMS-1500 · 2026-10-11 | Bobby Wilson UHC-41416-73 | 2026-08-31 Office | Lakeside Medical Group Family Medicine · in network | 99213, 36415, 90471 | $257.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-031633 CMS-1500 · 2026-10-10 | Aaron Nunez UHC-75381-08 | 2026-08-30 Office | Sunrise GI Associates Gastroenterology · in network | 99214 | $284.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030069 CMS-1500 · 2026-10-10 | Pamela Snadoval UHC-52330-59 | 2026-09-14 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99203 | $242.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-026157 CMS-1500 · 2026-10-10 | Stephanie Vargas no member ID | 2026-09-06 Office | Desert Primary Care Associates Family Medicine · in network | 99395, 99214 | $519.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-017157 CMS-1500 · 2026-10-10 | Alice Butler no member ID | 2026-09-20 Telehealth | Evergreen Counseling Center Behavioral Health · in network | 99214 | $233.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-032934 CMS-1500 · 2026-10-09 | Bradley Carlson UHC-48617-01 | 2026-09-29 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 80053, 87086, 80061, 83036 | $272.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-029523 CMS-1500 · 2026-10-09 | Julie Fernandez no member ID | 2026-09-27 Office | Mesa Diabetes Center Endocrinology · in network | 83036 | $48.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-006247 CMS-1500 · 2026-10-09 | Matthew Ryan no member ID | 2026-10-07 Office | Meadow Primary Care Associates Family Medicine · in network | 90471, 99395 | $358.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-000842 CMS-1500 · 2026-10-09 | Joe Graham UHC-51875-48 | 2026-09-20 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 83036 | $69.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000342 CMS-1500 · 2026-10-09 | Jennifer Carr no member ID | 2026-09-23 Office | Mesa Behavioral Health Behavioral Health · in network | 90834, 90791 | $550.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-011280 CMS-1500 · 2026-10-08 | Teresa Johnson no member ID | 2026-09-05 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 85025, 83036 | $138.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-003468 CMS-1500 · 2026-10-08 | Russell Jacobs UHC-03633-88 | 2026-10-04 Office | Meadow Primary Care Associates Family Medicine · in network | 99395, 99203 | $431.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-020093 CMS-1500 · 2026-10-07 | Joseph Lawson no member ID | 2026-09-19 Office | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 20610 | $228.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-018381 CMS-1500 · 2026-10-07 | Amber Rose UHC-92898-42 | 2026-08-23 Office | Northgate Medical Group Internal Medicine · in network | 80053, 93000 | $133.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-005515 CMS-1500 · 2026-10-07 | Randy Morris no member ID | 2026-09-15 Office | Sunrise Medical Group Internal Medicine · in network | 80053 | $42.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-005385 CMS-1500 · 2026-10-07 | Nathan Turner UHC-08557-62 | 2026-09-05 Office | Sunrise Cardiovascular Associates Cardiology · in network | 99214 | $236.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-004289 CMS-1500 · 2026-10-06 | Camila Russell no member ID | 2026-08-31 Office | Evergreen Family Practice Family Medicine · in network | 99214 | $265.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-019839 CMS-1500 · 2026-10-05 | Kyle Harper UHC-68942-57 | 2026-08-24 Office | Mesa Family Practice Family Medicine · in network | 99203 | $235.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013336 CMS-1500 · 2026-10-05 | Jacqueline Yang UHC-73644-33 | 2026-09-26 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110 | $180.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010419 CMS-1500 · 2026-10-05 | Gerald Gordon UHC-42317-69 | 2026-09-30 Office | Sunrise Skin Care Associates Dermatology · in network | 11102 | $189.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-008945 CMS-1500 · 2026-10-05 | Julia Reyes no member ID | 2026-08-30 Independent laboratory | Summit Clinical Laboratories Clinical Laboratory · in network | 83036, 80061 | $153.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-006185 CMS-1500 · 2026-10-04 | Karen Barnes UHC-87810-76 | 2026-08-25 Office | Desert Primary Care Associates Family Medicine · in network | 99214 | $257.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000533 CMS-1500 · 2026-10-04 | Tyler Wilson UHC-59252-11 | 2026-09-02 Independent laboratory | Evergreen Clinical Laboratories Clinical Laboratory · in network | 85025, 80053, 83036 | $172.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-026268 CMS-1500 · 2026-10-03 | David Moreno UHC-71942-05 | 2026-09-12 Independent laboratory | Summit Clinical Laboratories Clinical Laboratory · in network | 80053, 80061, 85025 | $138.00 | — | 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.