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-2026-024889 UB-04 · 2026-10-24 | Eric Robertson UHC-01745-78 | 2026-08-28 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $31,691.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-029204 UB-04 · 2026-10-21 | Jesse Price UHC-05475-09 | 2026-08-29 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 71046, 99283 | $910.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028764 CMS-1500 · 2026-10-21 | Edward Phillips UHC-73690-84 | 2026-08-21 Office | Lakeside Medical Group Family Medicine · out of network | 90471, 36415 | $58.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-004773 UB-04 · 2026-10-18 | Bryan Ray UHC-15231-85 | 2026-09-28 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,734.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-031999 CMS-1500 · 2026-10-15 | Dorothy Herrera UHC-12392-13 | 2026-09-16 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90834 | $191.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-016413 CMS-1500 · 2026-10-04 | Theresa Hoffman UHC-15893-12 | 2026-08-05 Office | Lakeside Medical Group Family Medicine · out of network | 99203, 36415, 99214 | $451.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-030647 CMS-1500 · 2026-10-02 | Billy Bennett UHC-96082-25 | 2026-08-20 Office | Heritage Medical Group Family Medicine · out of network | 99395 | $231.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-023859 CMS-1500 · 2026-10-01 | Joseph Day UHC-62916-46 | 2026-09-12 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086, 80053 | $88.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-005335 CMS-1500 · 2026-09-27 | Santiago Crawford no member ID | 2026-08-17 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 83036, 80053, 85025 | $179.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-027093 CMS-1500 · 2026-09-26 | Billy Welch UHC-99018-57 | 2026-09-04 Telehealth | Canyon Counseling Center Behavioral Health · out of network | 99214 | $288.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-021558 CMS-1500 · 2026-09-16 | Don Richardson UHC-97967-62 | 2026-08-11 Office | Harbor Primary Care Associates Family Medicine · out of network | 99203 | $260.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-029966 CMS-1500 · 2026-09-11 | Joan Maldonado UHC-93987-64 | 2026-07-24 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 93000 | $83.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-001449 CMS-1500 · 2026-09-10 | Amy Myers UHC-78281-86 | 2026-08-29 Office | Valley Skin Care Associates Dermatology · out of network | 11403, 11102 | $705.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-012142 CMS-1500 · 2026-09-08 | Dylan Smith UHC-24470-31 | 2026-08-13 Office | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 99213, 20610 | $491.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-034426 CMS-1500 · 2026-08-27 | Roger Edwards UHC-27243-62 | 2026-07-20 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 83036 | $73.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-021776 CMS-1500 · 2026-08-24 | Logan Williams UHC-25542-30 | 2026-08-01 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 87086, 80061 | $166.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-021022 UB-04 · 2026-08-24 | Elijah Cox UHC-15378-08 | 2026-07-03 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285 | $1,695.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-032678 UB-04 · 2026-08-21 | Gabriel Gray UHC-14318-72 | 2026-07-15 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99283 | $694.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014415 CMS-1500 · 2026-08-21 | Rebecca Mitchell UHC-70908-34 | 2026-06-25 Office | Unity Internal Medicine Associates Internal Medicine · out of network | 99215 | $331.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-026466 CMS-1500 · 2026-08-16 | Carl Bryant UHC-04665-45 | 2026-06-18 Office | Cornerstone Family Practice Family Medicine · out of network | 99214 | $271.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-023771 CMS-1500 · 2026-08-15 | Juan Williams UHC-25722-63 | 2026-07-05 Office | Evergreen Dermatology Clinic Dermatology · out of network | 17110 | $285.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-012328 CMS-1500 · 2026-08-12 | Kyle Powell no member ID | 2026-06-26 Office | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 20610 | $263.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-019104 UB-04 · 2026-08-10 | Olivia Campbell no member ID | 2026-06-30 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 99284, 71046 | $1,628.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-017302 CMS-1500 · 2026-07-29 | Fatima Butler UHC-49073-83 | 2026-07-08 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80061, 83036 | $97.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-018074 CMS-1500 · 2026-07-19 | Carlos Franklin no member ID | 2026-06-15 Office | Harbor Medical Group Internal Medicine · out of network | 80053 | $82.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024264 UB-04 · 2026-07-17 | Jerry Dominguez UHC-34607-27 | 2026-06-05 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 77067, 70553 | $3,381.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-021302 CMS-1500 · 2026-07-17 | Shirley Simpson UHC-57924-01 | 2026-06-04 Office | Unity Primary Care Associates Family Medicine · out of network | 99214 | $299.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007384 CMS-1500 · 2026-07-16 | Sean Taylor UHC-43430-10 | 2026-06-18 Office | Lakeside Medical Group Family Medicine · out of network | 99203 | $247.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024616 CMS-1500 · 2026-07-13 | Timothy Walsh UHC-68781-22 | 2026-07-02 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 83036 | $160.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-012754 UB-04 · 2026-07-09 | Maria Edwadrs UHC-34778-96 | 2026-06-03 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177, 76700 | $1,881.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-011979 CMS-1500 · 2026-07-05 | Peter Ford UHC-45344-03 | 2026-06-08 Office | Unity Primary Care Associates Family Medicine · out of network | 90471, 99203 | $269.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-015337 CMS-1500 · 2026-07-04 | Samantha Cruz UHC-37990-57 | 2026-05-26 Office | Valley Primary Care Associates Family Medicine · out of network | 90471 | $33.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-021936 CMS-1500 · 2026-07-03 | Stephen Mason UHC-44082-35 | 2026-06-02 Office | Sunrise Dermatology Clinic Dermatology · out of network | 99213 | $227.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-031344 UB-04 · 2026-07-01 | Donald Castro UHC-60762-21 | 2026-05-10 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93306, 93015 | $1,690.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-032236 CMS-1500 · 2026-06-28 | Billy Griffin UHC-51997-76 | 2026-06-20 Office | Unity Internal Medicine Associates Internal Medicine · out of network | 99214, 80053, 99215 | $531.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028291 CMS-1500 · 2026-06-28 | Dylan Burns UHC-47416-37 | 2026-05-14 Office | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 99213 | $205.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-015056 UB-04 · 2026-06-27 | Joshua Armstrong UHC-90508-70 | 2026-06-06 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93458 | $5,638.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-016912 UB-04 · 2026-06-18 | Sott Jensen UHC-67218-05 | 2026-05-19 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283, 96374 | $1,059.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028656 CMS-1500 · 2026-06-17 | Jeffrey Bryant no member ID | 2026-04-23 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 87086, 80053 | $109.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-008209 CMS-1500 · 2026-06-14 | Elijah Hayes UHC-25480-96 | 2026-05-03 Office | Sunrise Digestive Health Center Gastroenterology · out of network | 99214 | $263.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022390 CMS-1500 · 2026-06-11 | Kayla Hunter UHC-85413-02 | 2026-05-25 Office | Unity Primary Care Associates Family Medicine · out of network | 99214, 99213 | $408.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-011382 CMS-1500 · 2026-06-10 | Bradley Sims UHC-24731-14 | 2026-04-29 Office | Canyon Counseling Center Behavioral Health · out of network | 90791, 90834 | $531.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-018581 CMS-1500 · 2026-06-06 | Brenda Carpenter UHC-50968-55 | 2026-05-03 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97014 | $326.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-004271 UB-04 · 2026-06-06 | Mateo Espinoza UHC-22304-73 | 2026-04-24 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 71046, 99285 | $2,135.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-003973 UB-04 · 2026-06-05 | Ruth Black UHC-63053-46 | 2026-05-20 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93306 | $1,039.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-005538 CMS-1500 · 2026-05-30 | Shirley Baker UHC-45715-13 | 2026-04-12 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 80061 | $94.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-012745 UB-04 · 2026-05-13 | Tyler Fisher UHC-12257-40 | 2026-04-07 Outpatient hospital | Unity Imaging Center Radiology · out of network | 77067, 71046 | $464.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-009713 UB-04 · 2026-05-12 | Jack Kelley no member ID | 2026-04-25 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,840.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-025501 CMS-1500 · 2026-05-10 | Kelly Jensen UHC-89135-52 | 2026-05-01 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 99215 | $409.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-012658 UB-04 · 2026-05-07 | Yuki Boyd UHC-23434-82 | 2026-04-11 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285, 96374 | $2,675.00 | — | Denied by rule CO18 | — | Denied |
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.