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-2026-001654 CMS-1500 · 2026-10-20 | Ana Robinson UHC-45904-17 | 2026-10-02 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99214 | $236.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-031649 CMS-1500 · 2026-10-19 | Jonathan Marquez UHC-57626-40 | 2026-10-03 Office | Valley Skin Care Associates Dermatology · in network | 17110 | $215.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-020910 CMS-1500 · 2026-10-19 | James Rodriguez UHC-66449-14 | 2026-09-18 Office | Evergreen Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $444.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-019167 CMS-1500 · 2026-10-19 | Emily Martin UHC-23423-50 | 2026-08-30 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 80061, 83036, 85025 | $145.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-000819 CMS-1500 · 2026-10-19 | Carol Fowler UHC-12538-47 | 2026-09-26 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 99215 | $344.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-034142 CMS-1500 · 2026-10-18 | Wayne Ward UHC-86507-79 | 2026-09-17 Office | Meadow Medical Group Family Medicine · in network | 36415, 99203, 99214 | $452.00 | $272.80 | Clean approval | — | Approved |
| CLM-2026-033652 CMS-1500 · 2026-10-18 | Tyler Moore UHC-71756-75 | 2026-09-03 Office | Evergreen Dermatology Clinic Dermatology · out of network | 11403, 99213 | $902.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-033340 CMS-1500 · 2026-10-18 | Donald Stewart UHC-62097-19 | 2026-09-05 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 85025 | $40.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032967 CMS-1500 · 2026-10-18 | Amber Howell UHC-88592-44 | 2026-09-18 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11403, 17110 | $956.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032473 CMS-1500 · 2026-10-18 | Arjun Cruz UHC-63818-91 | 2026-09-03 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140 | $401.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-032335 CMS-1500 · 2026-10-18 | James Delgado UHC-83159-99 | 2026-09-29 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $186.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-031983 CMS-1500 · 2026-10-18 | Valentina Mejia UHC-96174-01 | 2026-09-17 Office | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 20610 | $276.00 | $96.12 | Clean approval | — | Approved |
| CLM-2026-031368 CMS-1500 · 2026-10-18 | Donald Griffin UHC-74616-95 | 2026-10-16 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $240.00 | $128.80 | Clean approval | — | Approved |
| CLM-2026-030928 CMS-1500 · 2026-10-18 | Alexis Long UHC-64773-95 | 2026-10-10 Office | Unity Physical Therapy Physical Therapy · in network | 97110, 97014, 97161 | $540.00 | $309.80 | Clean approval | — | Approved |
| CLM-2026-030554 CMS-1500 · 2026-10-18 | Mateo Castro UHC-93344-27 | 2026-09-20 Independent laboratory | Unity Clinical Laboratories Clinical Laboratory · in network | 80053 | $52.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030299 CMS-1500 · 2026-10-18 | Frances Reed UHC-43006-53 | 2026-10-14 Office | Cornerstone Cardiovascular Associates Cardiology · in network | 99214 | $272.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-029993 CMS-1500 · 2026-10-18 | Lori Duncan UHC-77386-40 | 2026-10-01 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99215, 80053 | $377.00 | $213.74 | Clean approval | — | Approved |
| CLM-2026-029255 CMS-1500 · 2026-10-18 | Matthew Carpenter UHC-33751-82 | 2026-10-14 Office | Desert Medical Group Internal Medicine · in network | 93000 | $113.00 | $30.06 | Clean approval | — | Approved |
| CLM-2026-027767 CMS-1500 · 2026-10-18 | Larson Gary no member ID | 2026-09-24 Office | Lakeside Medical Group Family Medicine · out of network | 90471, 36415 | $52.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-027511 CMS-1500 · 2026-10-18 | Kimberly George UHC-06108-11 | 2026-09-09 Independent laboratory | Unity Clinical Laboratories Clinical Laboratory · in network | 83036, 87086, 80053 | $194.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-026808 CMS-1500 · 2026-10-18 | Megan Davis UHC-00007-16 | 2026-10-12 Office | Northgate Cardiovascular Associates Cardiology · in network | 99214 | $309.00 | $151.58 | Clean approval | — | Approved |
| CLM-2026-026696 CMS-1500 · 2026-10-18 | Paul Kelley UHC-55115-85 | 2026-10-04 Office | Harbor Physical Therapy Physical Therapy · in network | 97110, 97161 | $449.00 | $248.38 | Clean approval | — | Approved |
| CLM-2026-026691 CMS-1500 · 2026-10-18 | Gabriel Sanders UHC-13138-62 | 2026-09-03 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99214, 93000 | $392.00 | $223.04 | Clean approval | — | Approved |
| CLM-2026-025903 CMS-1500 · 2026-10-18 | Jason Garrett UHC-04664-80 | 2026-09-18 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99215, 80053 | $385.00 | $213.70 | Clean approval | — | Approved |
| CLM-2026-025758 CMS-1500 · 2026-10-18 | Joseph Olson UHC-17116-81 | 2026-09-28 Office | Mesa Behavioral Health Behavioral Health · in network | 90837 | $221.00 | $87.02 | Clean approval | — | Approved |
| CLM-2026-025606 CMS-1500 · 2026-10-18 | Lawrence Watson UHC-48583-08 | 2026-10-04 Office | Desert Cardiovascular Associates Cardiology · in network | 93224, 99214 | $516.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-025088 CMS-1500 · 2026-10-18 | Julie Hart UHC-16029-61 | 2026-09-02 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $310.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024186 CMS-1500 · 2026-10-18 | Joyce Guerrero UHC-29388-20 | 2026-09-15 Independent laboratory | Unity Reference Lab Clinical Laboratory · in network | 85025 | $56.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-024142 CMS-1500 · 2026-10-18 | Helen Hicks UHC-81077-42 | 2026-09-16 Office | Evergreen Medical Group Family Medicine · in network | 99213 | $171.00 | $66.02 | Clean approval | — | Approved |
| CLM-2026-024000 CMS-1500 · 2026-10-18 | Lawrence George UHC-17614-13 | 2026-10-03 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80061, 83036 | $137.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-023751 CMS-1500 · 2026-10-18 | Samantha Washington UHC-17963-87 | 2026-09-21 Office | Pinecrest Medical Group Family Medicine · in network | 99203, 99213 | $386.00 | $199.32 | Clean approval | — | Approved |
| CLM-2026-023733 CMS-1500 · 2026-10-18 | Isabella Burton UHC-09055-50 | 2026-09-21 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 93000, 80053, 99214 | $416.00 | $232.92 | Clean approval | — | Approved |
| CLM-2026-023692 CMS-1500 · 2026-10-18 | Sofia Guerrero UHC-42523-31 | 2026-09-06 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 80061, 87086 | $164.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023016 CMS-1500 · 2026-10-18 | Joe Weaver UHC-65868-91 | 2026-09-10 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 85025, 87086, 80053 | $163.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-021847 CMS-1500 · 2026-10-18 | Tony Luna UHC-56014-62 | 2026-09-30 Office | Evergreen Family Practice Family Medicine · in network | 99213, 90471, 99395 | $525.00 | $295.50 | Clean approval | — | Approved |
| CLM-2026-021441 CMS-1500 · 2026-10-18 | Jeremy Fernandez UHC-50658-84 | 2026-09-19 Office | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 99213 | $205.00 | $67.10 | Clean approval | — | Approved |
| CLM-2026-020561 CMS-1500 · 2026-10-18 | John Maldonado UHC-79682-77 | 2026-10-05 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97161 | $403.00 | $219.86 | Clean approval | — | Approved |
| CLM-2026-020330 CMS-1500 · 2026-10-18 | Emma McDonald UHC-14703-77 | 2026-10-04 Office | Pinecrest Family Practice Family Medicine · in network | 99203, 36415, 99214 | $460.00 | $265.20 | Clean approval | — | Approved |
| 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-2026-019418 CMS-1500 · 2026-10-18 | Lori Jones UHC-48852-57 | 2026-10-02 Office | Riverside Primary Care Associates Family Medicine · in network | 99213, 99395 | $497.00 | $278.14 | Clean approval | — | Approved |
| CLM-2026-019413 CMS-1500 · 2026-10-18 | Samuel Wheeler UHC-26647-40 | 2026-09-21 Office | Evergreen Medical Group Family Medicine · in network | 99214, 90471, 99213 | $462.00 | $266.44 | Clean approval | — | Approved |
| CLM-2026-018460 CMS-1500 · 2026-10-18 | Joyce Carr UHC-88883-33 | 2026-09-29 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 80053, 93000, 99214 | $340.00 | $185.80 | Clean approval | — | Approved |
| CLM-2026-018402 CMS-1500 · 2026-10-18 | Sara Jones UHC-75451-48 | 2026-09-14 Office | Lakeside Medical Group Family Medicine · in network | 99395, 90471, 99214 | $594.00 | $338.28 | Clean approval | — | Approved |
| CLM-2026-017708 CMS-1500 · 2026-10-18 | Noah Rogers UHC-89314-56 | 2026-10-11 Office | Heritage Internal Medicine Associates Internal Medicine · in network | 80053, 93000 | $168.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-017673 CMS-1500 · 2026-10-18 | Betty Jones UHC-95087-33 | 2026-09-24 Office | Sunrise Medical Group Family Medicine · in network | 90471, 99203, 99214 | $455.00 | $266.60 | Clean approval | — | Approved |
| CLM-2026-017564 CMS-1500 · 2026-10-18 | Henry Espinoza UHC-50850-98 | 2026-05-19 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 93000 | $90.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-017491 CMS-1500 · 2026-10-18 | Joyce Roberts UHC-91571-60 | 2026-10-16 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $180.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-017139 CMS-1500 · 2026-10-18 | Eirc Foster UHC-97726-64 | 2026-09-09 Office | Meadow Family Practice Family Medicine · in network | 36415, 99214, 99395 | $539.00 | $318.68 | Clean approval | — | Approved |
| CLM-2026-016564 CMS-1500 · 2026-10-18 | Jeremy Harper UHC-46303-79 | 2026-09-11 Office | Harbor Physical Therapy Physical Therapy · in network | 97110 | $320.00 | $168.40 | Clean approval | — | Approved |
| CLM-2026-016547 CMS-1500 · 2026-10-18 | Bobby Campbell UHC-12188-14 | 2026-09-22 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 80053 | $51.00 | $1.62 | Clean approval | — | Approved |
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.