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-2026-034095 UB-04 · 2026-10-24 | Jacqueline Black no member ID | 2026-09-27 Outpatient hospital | Riverside Imaging Center Radiology · in network | 74177, 77067 | $1,850.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-013148 UB-04 · 2026-10-17 | Christine Cook no member ID | 2026-09-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $1,157.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002739 UB-04 · 2026-10-17 | William Howard no member ID | 2026-09-19 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99283 | $1,082.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024821 UB-04 · 2026-10-16 | Angela Sullivan no member ID | 2026-09-27 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285 | $2,083.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-008054 UB-04 · 2026-10-16 | Terry Cooper no member ID | 2026-09-26 Emergency room | Harbor Regional Medical Center Emergency Medicine · in network | 71046 | $246.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-012574 UB-04 · 2026-10-15 | Juan Graham no member ID | 2026-10-02 Inpatient hospital | Canyon Medical Group Internal Medicine · in network | 99232 | $185.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-006483 UB-04 · 2026-10-15 | John Cox no member ID | 2026-09-24 Outpatient hospital | Summit Heart Institute Cardiology · in network | 93015 | $583.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013940 UB-04 · 2026-10-14 | Sarah Gomez no member ID | 2026-10-06 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700, 71046, 74177 | $2,353.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-001282 UB-04 · 2026-10-14 | Julia Castillo no member ID | 2026-10-06 Inpatient hospital | Canyon Medical Group Internal Medicine · in network | 99232 | $182.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029398 UB-04 · 2026-10-13 | William Carpenter no member ID | 2026-09-06 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 71046, 99283 | $1,129.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-019544 UB-04 · 2026-10-12 | Daina Ran no member ID | 2026-10-03 Outpatient hospital | Evergreen Reference Lab Clinical Laboratory · in network | 70553 | $1,956.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-032682 UB-04 · 2026-10-10 | Frank Phillips no member ID | 2026-09-22 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 74177 | $1,730.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-034553 UB-04 · 2026-10-09 | Mason Williams no member ID | 2026-09-04 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 70553 | $2,139.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-017566 UB-04 · 2026-10-09 | Gabriel Shew no member ID | 2026-09-28 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 43239 | $1,993.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013714 UB-04 · 2026-10-09 | Gerald Bowman no member ID | 2026-10-05 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553 | $2,319.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-000033 UB-04 · 2026-10-09 | Lynda Greene no member ID | 2026-10-01 Outpatient hospital | Riverside Imaging Center Radiology · in network | 76700 | $485.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-028937 UB-04 · 2026-10-08 | Olivia Soto no member ID | 2026-09-21 Outpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,512.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002869 UB-04 · 2026-10-08 | Camila Munoz no member ID | 2026-09-30 Outpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 70553 | $2,983.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013746 UB-04 · 2026-10-07 | Joe Dean no member ID | 2026-08-31 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 71046 | $220.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-009493 UB-04 · 2026-10-06 | George Lewis no member ID | 2026-09-06 Outpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 29881 | $8,543.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-009121 UB-04 · 2026-10-05 | Jacob Herrera no member ID | 2026-09-16 Inpatient hospital | Cornerstone Internal Medicine Associates Internal Medicine · in network | 99232 | $240.00 | — | Pended by rule N30 | — | 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-2026-034094 UB-04 · 2026-10-04 | Jacqueline Black no member ID | 2026-09-27 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 74177, 77067 | $1,850.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-030652 UB-04 · 2026-10-03 | Joe Medina no member ID | 2026-08-19 Outpatient hospital | Evergreen Dermatology Clinic Dermatology · in network | 70553 | $1,900.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-010133 UB-04 · 2026-10-03 | 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-2026-009809 UB-04 · 2026-10-03 | Santiago Prike no member ID | 2026-08-31 Outpatient hospital | Northgate Cardiovascular Associates Cardiology · in network | 93015 | $521.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-003351 UB-04 · 2026-10-03 | Amy Simpson no member ID | 2026-08-25 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $235.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-012108 UB-04 · 2026-10-02 | Megan Kim no member ID | 2026-09-22 Outpatient hospital | Canyon Primary Care Associates Family Medicine · in network | 70553 | $2,006.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-032031 UB-04 · 2026-10-01 | Joe Peters no member ID | 2026-09-23 Outpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 70553 | $2,602.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-018027 UB-04 · 2026-10-01 | Nicole Park no member ID | 2026-08-18 Outpatient hospital | Heritage Digestive Health Center Gastroenterology · in network | 43239, 88305 | $2,289.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-014661 UB-04 · 2026-10-01 | Austin Chavez no member ID | 2026-09-10 Outpatient hospital | Summit Heart Institute Cardiology · in network | 93306 | $1,059.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-028943 UB-04 · 2026-09-30 | Jack James no member ID | 2026-08-31 Outpatient hospital | Summit Cardiovascular Associates Cardiology · in network | 93458 | $7,054.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-025788 UB-04 · 2026-09-30 | Sarah Smith no member ID | 2026-09-12 Emergency room | Unity Community Hospital Emergency Medicine · in network | 96374 | $220.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-014022 UB-04 · 2026-09-29 | Charles Ford no member ID | 2026-09-03 Outpatient hospital | Summit Imaging Center Radiology · in network | 71046, 74177 | $2,223.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-009887 UB-04 · 2026-09-28 | Kayla Schmidt no member ID | 2026-09-05 Inpatient hospital | Pinecrest Medical Group Internal Medicine · in network | 99232, 99215 | $495.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-027740 UB-04 · 2026-09-27 | Arthur Anderson no member ID | 2026-09-16 Outpatient hospital | Canyon Medical Group Internal Medicine · in network | 70553 | $2,038.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-012781 UB-04 · 2026-09-27 | Jean White no member ID | 2026-08-20 Emergency room | Lakeside Regional Medical Center Emergency Medicine · in network | 71046 | $170.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-004320 UB-04 · 2026-09-26 | Lisa Williamson no member ID | 2026-08-30 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 71046 | $195.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-033663 UB-04 · 2026-09-25 | Fatima Schmidt no member ID | 2026-09-13 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99284 | $1,547.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-028112 UB-04 · 2026-09-25 | Emmma White no member ID | 2026-09-03 Outpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 29881, 73721 | $11,916.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-027763 UB-04 · 2026-09-25 | Olivia Padilla no member ID | 2026-09-08 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283 | $862.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-026913 UB-04 · 2026-09-25 | Gerald Bowman no member ID | 2026-08-20 Outpatient hospital | Lakeside Medical Group Internal Medicine · in network | 70553 | $2,269.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-020728 UB-04 · 2026-09-25 | Jean Nunez no member ID | 2026-08-22 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99285, 96374, 99283 | $3,666.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-007499 UB-04 · 2026-09-25 | Fatima Price no member ID | 2026-08-24 Outpatient hospital | Valley Digestive Health Center Gastroenterology · in network | 43239 | $1,552.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024740 UB-04 · 2026-09-24 | Valentina Ausstin no member ID | 2026-08-30 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 71046 | $236.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-024598 UB-04 · 2026-09-24 | Kenneth Ryan no member ID | 2026-08-25 Outpatient hospital | Desert Heart Institute Cardiology · in network | 93458, 93306 | $8,073.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-012341 UB-04 · 2026-09-24 | Dorothy Richards no member ID | 2026-09-04 Outpatient hospital | Evergreen Digestive Health Center Gastroenterology · in network | 43239 | $1,512.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-005200 UB-04 · 2026-09-24 | Sara Jimenez no member ID | 2026-08-25 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 74177, 71046 | $1,693.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-003779 UB-04 · 2026-09-24 | Jeffrey Park no member ID | 2026-09-01 Emergency room | Meadow Regional Medical Center Emergency Medicine · in network | 99285, 71046 | $2,024.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029799 UB-04 · 2026-09-23 | Janice Rose no member ID | 2026-08-29 Outpatient hospital | Valley Digestive Health Center Gastroenterology · in network | 43239, 88305 | $2,009.00 | — | Pended by rule IDQ 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.