Claims & billing

Denial prediction is the core of this screen: every pending claim is scored by the denial-risk model before adjudication, from the payer and service-line history in the Data Store — each score advisory, each factor cited to the real counts it came from. Every read is audited under the payment purpose the same way a chart view is audited under treatment.

59,347

claims stored — across the corpus

$24,781,728.33

billed

$15,678,236.01

paid by payers

5,977

denied claims

$2,197,976.09

patient responsibility

Pending queue — scored before submission

Highest predicted denial risk first. A score never blocks a claim; it tells a biller where attention pays before the payer decides.

Risk	Claim	Patient	Payer	Billed	Top factors (from the adjudication history)
24/99	CLM-20261044007	Stacie Mari Miller	Medicaid	$16,330.97	Medicaid denial history: 1589 of 8709 claims denied (18%) High-dollar claim ($16,330.97 billed) — history shows elevated review rates
24/99	CLM-20261149002	Wilbert Leannon	Medicaid	$14,411.41	Medicaid denial history: 1589 of 8709 claims denied (18%) High-dollar claim ($14,411.41 billed) — history shows elevated review rates
24/99	CLM-2026960006	Rosina Jalisa Hamill	Medicaid	$14,218.18	Medicaid denial history: 1589 of 8709 claims denied (18%) High-dollar claim ($14,218.18 billed) — history shows elevated review rates
23/99	CLM-2026862004	Ouida Lourdes Daniel	Medicaid	$34,500.09	Medicaid denial history: 1589 of 8709 claims denied (18%) High-dollar claim ($34,500.09 billed) — history shows elevated review rates
23/99	CLM-2026883005	Pinkie Celestine Grady	Medicaid	$33,951.24	Medicaid denial history: 1589 of 8709 claims denied (18%) High-dollar claim ($33,951.24 billed) — history shows elevated review rates
23/99	CLM-20261177004	Zella Mohr	Medicaid	$19,039.82	Medicaid denial history: 1589 of 8709 claims denied (18%) High-dollar claim ($19,039.82 billed) — history shows elevated review rates
23/99	CLM-2026148001	Cameron Esperanza Leuschke	Medicaid	$15,783.94	Medicaid denial history: 1589 of 8709 claims denied (18%) High-dollar claim ($15,783.94 billed) — history shows elevated review rates
23/99	CLM-2026750001	Mario Benito Concepción	Medicaid	$14,373.73	Medicaid denial history: 1589 of 8709 claims denied (18%) High-dollar claim ($14,373.73 billed) — history shows elevated review rates
23/99	CLM-20261072003	Tawny Shenita Ryan	Medicaid	$12,104.00	Medicaid denial history: 1589 of 8709 claims denied (18%) High-dollar claim ($12,104.00 billed) — history shows elevated review rates
21/99	CLM-2026234007	Sihu Littlebear	UnitedHealthcare	$14,347.12	UnitedHealthcare denial history: 1318 of 8195 claims denied (16%) High-dollar claim ($14,347.12 billed) — history shows elevated review rates
18/99	CLM-20261020001	Adriana Paloma Gomez	Cigna	$12,472.20	High-dollar claim ($12,472.20 billed) — history shows elevated review rates Service 312608009 (Laceration - injury (disorder)): 7 of 39 historically denied (18%)
17/99	CLM-20261006005	Elena Pilar Gomez	Cigna	$11,451.02	High-dollar claim ($11,451.02 billed) — history shows elevated review rates Cigna denial history: 765 of 6166 claims denied (12%)

Denial patterns the model has learned

The strongest payer × service denial clusters in the adjudication history — where process fixes beat resubmission.

Payer	Service	Denied	Of	Rate
Medicaid	62 · HPV, quadrivalent	5	13	38%
Medicaid	371883000 · Outpatient procedure (procedure)	6	17	35%
Medicaid	180256009 · Subcutaneous immunotherapy (procedure)	6	17	35%
Cigna	121 · zoster vaccine, live	4	12	33%
Cigna	10509002 · Acute bronchitis (disorder)	4	14	29%
Medicaid	D0120 · periodic oral evaluation established patient	6	23	26%

By payer

Payer	Claims	Billed	Paid	Denied
Medicaid	10,256	$4,237,337.74	$2,445,846.70	1,589
Blue Cross Blue Shield	10,171	$4,005,116.07	$2,596,463.01	888
UnitedHealthcare	9,618	$3,634,829.55	$2,114,270.78	1,318
Medicare	9,304	$3,536,792.42	$2,466,649.06	514
Aetna	8,082	$3,451,404.58	$2,222,024.62	627
Cigna	7,259	$3,315,698.11	$2,020,774.75	765
Humana	4,657	$2,600,549.86	$1,812,207.09	276

Recent claims

Claim	Patient	Payer	Date	Status	Billed	Paid
CLM-G0149602	Mateo Miguel Gomez	Cigna	Aug 30, 2026	paid	$277.78	$184.69	Lines
CLM-G0147450	Ali Weber	Medicaid	Aug 30, 2026	paid	$88.48	$64.95	Lines
CLM-G0146402	Jasmine Smith	UnitedHealthcare	Aug 30, 2026	paid	$545.11	$417.21	Lines
CLM-G0146105	Aarav Stern	Medicare	Aug 30, 2026	denied	$112.63	$0.00	Lines
CLM-G0145392	Sebastian Antonio Gomez	UnitedHealthcare	Aug 30, 2026	paid	$512.57	$348.54	Lines
CLM-G0145225	Henry Rossi	Medicare	Aug 30, 2026	paid	$51.75	$23.95	Lines
CLM-G0145108	Sofya Gomez	Aetna	Aug 30, 2026	paid	$71.08	$41.57	Lines
CLM-G0143728	Hiroshi Mark Jefferson	Medicare	Aug 30, 2026	paid	$253.45	$162.00	Lines
CLM-G0143591	Koda Ross Benally	Medicaid	Aug 30, 2026	paid	$159.56	$78.08	Lines
CLM-G0143427	Jun Santos	Medicaid	Aug 30, 2026	paid	$400.40	$247.99	Lines
CLM-G0143224	Maria Nelson	Blue Cross Blue Shield	Aug 30, 2026	paid	$296.91	$212.88	Lines
CLM-G0140889	Carol Olivia Ivanov	Medicaid	Aug 30, 2026	paid	$406.13	$233.98	Lines
CLM-G0140864	Rafael Gomez	UnitedHealthcare	Aug 30, 2026	denied	$26.16	$0.00	Lines
CLM-G0139854	Alexei William OConnor	Blue Cross Blue Shield	Aug 30, 2026	paid	$89.31	$41.86	Lines
CLM-G0139132	Kenneth Costa	Humana	Aug 30, 2026	paid	$381.08	$219.60	Lines
CLM-G0138964	Kimana Louise Blackhorse	Medicaid	Aug 30, 2026	denied	$432.08	$0.00	Lines
CLM-G0137486	Guadalupe Battle	Blue Cross Blue Shield	Aug 30, 2026	paid	$53.75	$43.19	Lines
CLM-G0136680	Min-Jun Allen	UnitedHealthcare	Aug 30, 2026	paid	$24.18	$13.30	Lines
CLM-G0135780	Kiara Ramirez	UnitedHealthcare	Aug 30, 2026	denied	$343.91	$0.00	Lines
CLM-G0134294	Cheyenne Louise Spottedeagle	Medicaid	Aug 30, 2026	paid	$109.48	$85.43	Lines
CLM-G0133180	Oliver Jung	Blue Cross Blue Shield	Aug 30, 2026	paid	$59.87	$42.99	Lines
CLM-G0131948	Isaiah Andrew Kelly	Cigna	Aug 30, 2026	paid	$287.47	$192.07	Lines
CLM-G0131327	Viktor Xavier Kowalski	Blue Cross Blue Shield	Aug 30, 2026	pending	$87.04	$0.00	Lines
CLM-G0131277	Gabriela Gomez	UnitedHealthcare	Aug 30, 2026	paid	$317.11	$215.64	Lines
CLM-G0130003	Sofya Raisa Gomez	Medicare	Aug 30, 2026	paid	$297.16	$190.64	Lines
CLM-G0129823	Natalia Esperanza Gomez	Medicare	Aug 30, 2026	pending	$62.32	$0.00	Lines
CLM-G0128996	Dawit Cohen	Humana	Aug 30, 2026	denied	$363.22	$0.00	Lines
CLM-G0126733	Mei Cho	Humana	Aug 30, 2026	paid	$37.84	$22.31	Lines
CLM-G0126280	Malik Cillian Cho	Medicare	Aug 30, 2026	paid	$520.47	$250.92	Lines
CLM-G0125178	Francisco Redcloud	Blue Cross Blue Shield	Aug 30, 2026	paid	$40.82	$26.06	Lines
CLM-G0125076	Duc Merriweather	UnitedHealthcare	Aug 30, 2026	denied	$259.29	$0.00	Lines
CLM-G0124206	Ebony Zhao	Medicare	Aug 30, 2026	paid	$419.31	$241.49	Lines
CLM-G0124057	Alessia Elena Marino	Blue Cross Blue Shield	Aug 30, 2026	paid	$265.23	$135.96	Lines
CLM-G0121203	Kseniya Galya Gomez	Blue Cross Blue Shield	Aug 30, 2026	paid	$316.65	$171.41	Lines
CLM-G0120859	Samir Sebastian Slaughter	Aetna	Aug 30, 2026	paid	$296.56	$162.35	Lines
CLM-G0120851	Chen Kim	UnitedHealthcare	Aug 30, 2026	paid	$134.99	$95.85	Lines
CLM-G0119477	Charles Gupta	Medicare	Aug 30, 2026	pending	$26.57	$0.00	Lines
CLM-G0117899	Adriana Paloma Gomez	UnitedHealthcare	Aug 30, 2026	paid	$323.37	$201.32	Lines
CLM-G0116836	Thi Min Yang	Humana	Aug 30, 2026	paid	$266.23	$166.91	Lines
CLM-G0116542	Emma Yasmin Esposito	Aetna	Aug 30, 2026	paid	$181.45	$94.85	Lines