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-2026-029399 CMS-1500 · 2026-01-09 | Tyler Campbell UHC-99970-10 | 2026-01-07 Office | Mesa Dermatology Clinic Dermatology · in network | 11403, 17110 | $782.00 | — | Left for review CO97 | Approved confidence 0.95 | Needs review |
| CLM-2026-028245 CMS-1500 · 2026-01-09 | Daniel Vargas UHC-13090-50 | 2025-12-19 Independent laboratory | Unity Reference Lab Clinical Laboratory · in network | 80053, 87086, 80061 | $166.00 | — | Left for review CO16 | Pended confidence 0.95 | Needs review |
| CLM-2026-025496 CMS-1500 · 2026-01-09 | Ronald Valdez UHC-61056-55 | 2025-12-19 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 83036, 85025 | $108.00 | — | Left for review REPL | Approved confidence 0.95 | Needs review |
| CLM-2026-024408 UB-04 · 2026-01-09 | Nancy Price UHC-34209-49 | 2026-01-01 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $1,206.00 | — | Left for review NET | Approved confidence 0.95 | Needs review |
| CLM-2026-016985 CMS-1500 · 2026-01-09 | George Medina UHC-11140-35 | 2025-12-14 Office | Evergreen Family Practice Family Medicine · in network | 99203 | $197.00 | — | Left for review CO16 | Pended confidence 0.95 | Needs review |
| CLM-2026-032646 UB-04 · 2026-01-08 | Camila Rios UHC-12493-59 | 2025-12-13 Outpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 70553, 73721 | $3,864.00 | — | Left for review CO50 | Approved confidence 0.95 | Needs review |
| CLM-2026-030098 UB-04 · 2026-01-08 | Joyce Carter UHC-28186-60 | 2025-11-29 Outpatient hospital | Evergreen Medical Group Family Medicine · in network | 70553 | $2,667.00 | — | Left for review CO50 | Denied confidence 0.95 | Needs review |
| CLM-2026-029037 CMS-1500 · 2026-01-08 | Willie Martin UHC-69388-74 | 2025-12-26 Office | Desert Family Practice Family Medicine · in network | 99214 | $315.00 | — | Left for review REPL | Approved confidence 0.95 | Needs review |
| CLM-2026-028277 UB-04 · 2026-01-08 | Gary Matthews UHC-27209-51 | 2025-12-19 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177 | $1,935.00 | — | Left for review CO16 | Pended confidence 0.80 | Needs review |
| CLM-2026-023429 CMS-1500 · 2026-01-08 | Gregory Pierce UHC-34020-29 | 2025-12-07 Independent laboratory | Desert Clinical Laboratories Clinical Laboratory · in network | 87086, 85025 | $86.00 | — | Left for review REPL | Approved confidence 0.95 | Needs review |
| CLM-2026-021043 CMS-1500 · 2026-01-08 | Aisha Gardner UHC-26182-08 | 2025-12-24 Office | Summit Family Practice Family Medicine · in network | 99214, 99213 | $470.00 | — | Left for review CO97 | Denied confidence 0.95 | Needs review |
| CLM-2026-019207 CMS-1500 · 2026-01-08 | Ann Murray UHC-04228-65 | 2025-12-29 Office | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 99213 | $229.00 | — | Left for review REPL | Approved confidence 0.95 | Needs review |
| CLM-2026-019170 CMS-1500 · 2026-01-08 | Jennifer Nguyen UHC-98317-01 | 2025-11-29 Office | Riverside Primary Care Associates Family Medicine · in network | 99203, 99213 | $460.00 | — | Left for review CO97 | Denied confidence 0.95 | Needs review |
| CLM-2026-017415 CMS-1500 · 2026-01-08 | Cheryl Johnson UHC-75959-53 | 2025-12-23 Office | Sunrise Physical Therapy Physical Therapy · in network | 97110 | $93.00 | — | Left for review REPL | Approved confidence 0.95 | Needs review |
| CLM-2026-017072 UB-04 · 2026-01-08 | Emma Henry UHC-50050-99 | 2025-12-01 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $32,757.00 | — | Left for review HIGH | Approved confidence 0.95 | Needs review |
| CLM-2026-015936 UB-04 · 2026-01-08 | Peter Kelly UHC-28833-25 | 2025-12-15 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700, 74177 | $2,069.00 | — | Left for review CO50 | Pended confidence 0.80 | Needs review |
| CLM-2026-015028 UB-04 · 2026-01-08 | Emma Simpson UHC-49747-10 | 2025-12-23 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 76700, 70553 | $2,822.00 | — | Left for review CO50 | Pended confidence 0.80 | Needs review |
| CLM-2026-012810 UB-04 · 2026-01-08 | Patricia Le UHC-15651-83 | 2025-12-11 Inpatient hospital | Sunrise Internal Medicine Associates Internal Medicine · in network | 99232, 99215 | $503.00 | — | Left for review CO97 | Denied confidence 0.95 | Needs review |
| CLM-2026-011954 UB-04 · 2026-01-08 | Diana Carroll UHC-85368-85 | 2026-01-02 Outpatient hospital | Lakeside Skin Care Associates Dermatology · in network | 70553 | $2,654.00 | — | Left for review CO50 | Approved confidence 0.95 | Needs review |
| CLM-2026-030093 CMS-1500 · 2026-01-07 | Linda Davis UHC-55392-40 | 2025-12-11 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 99214, 93000 | $278.00 | — | Left for review CO16 | Pended confidence 0.95 | Needs review |
| CLM-2026-029085 UB-04 · 2026-01-07 | Cynthia Hunter UHC-66546-30 | 2025-12-28 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 70553 | $2,420.00 | — | Left for review CO50 | Approved confidence 0.95 | Needs review |
| CLM-2026-027894 CMS-1500 · 2026-01-07 | Joseph Richardson UHC-87640-10 | 2025-12-11 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90834, 90837 | $375.00 | — | Left for review CO97 | Denied confidence 0.95 | Needs review |
| CLM-2026-027610 UB-04 · 2026-01-07 | Dorothy Fulelr UHC-32368-14 | 2025-12-15 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 70553 | $1,862.00 | — | Left for review CO50 | Approved confidence 0.95 | Needs review |
| CLM-2026-027283 UB-04 · 2026-01-07 | Eugene Evans UHC-97992-74 | 2025-12-17 Outpatient hospital | Canyon Medical Group Internal Medicine · in network | 70553 | $2,600.00 | — | Left for review CO50 | Denied confidence 0.95 | Needs review |
| CLM-2026-020306 UB-04 · 2026-01-07 | Mateo Sims UHC-98861-75 | 2025-11-24 Outpatient hospital | Lakeside Skin Care Associates Dermatology · in network | 70553 | $2,404.00 | — | Left for review CO50 | Denied confidence 0.95 | Needs review |
| CLM-2026-020258 UB-04 · 2026-01-07 | Larry Perez UHC-26253-85 | 2025-12-01 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $48,120.00 | — | Left for review HIGH | Approved confidence 0.95 | Needs review |
| CLM-2026-016575 CMS-1500 · 2026-01-07 | Sharon Gomez UHC-34933-75 | 2025-12-16 Office | Canyon Counseling Center Behavioral Health · out of network | 90834 | $140.00 | — | Left for review REPL | Approved confidence 0.95 | Needs review |
| CLM-2026-012934 CMS-1500 · 2026-01-07 | Larry Black UHC-35995-09 | 2025-12-26 Office | Heritage Physical Therapy Physical Therapy · in network | 97110, 97140 | $244.00 | — | Left for review CO97 | Denied confidence 0.95 | Needs review |
| CLM-2026-011193 UB-04 · 2026-01-07 | Lisa Graham UHC-27955-94 | 2025-12-05 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $45,350.00 | — | Left for review HIGH | Approved confidence 0.95 | Needs review |
| CLM-2026-002281 UB-04 · 2026-01-07 | Andrew Harper UHC-15603-56 | 2025-12-25 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $47,343.00 | — | Left for review HIGH | Approved confidence 0.95 | Needs review |
| CLM-2026-001225 CMS-1500 · 2026-01-07 | Janice Hunt UHC-70664-95 | 2025-12-27 Independent laboratory | Unity Clinical Laboratories Clinical Laboratory · in network | 87086, 80061, 80053 | $177.00 | — | Left for review CO97 | Approved confidence 0.95 | Needs review |
| CLM-2026-033567 UB-04 · 2026-01-06 | Philip Holmes UHC-83762-30 | 2025-12-22 Outpatient hospital | Canyon Regional Medical Center Emergency Medicine · in network | 70553 | $3,435.00 | — | Left for review CO50 | Approved confidence 0.95 | Needs review |
| CLM-2026-028463 CMS-1500 · 2026-01-06 | Logan Bailey UHC-62349-08 | 2025-12-24 Office | Valley Digestive Health Center Gastroenterology · in network | 99214 | $269.00 | — | Left for review CO16 | Pended confidence 0.95 | Needs review |
| CLM-2026-027075 CMS-1500 · 2026-01-06 | Roy Alexander UHC-29043-03 | 2025-12-30 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 80061, 80053 | $101.00 | — | Left for review CO97 | Denied confidence 0.95 | Needs review |
| CLM-2026-026357 UB-04 · 2026-01-06 | Grace Valdez UHC-35478-16 | 2025-12-17 Outpatient hospital | Summit Cardiovascular Associates Cardiology · in network | 70553 | $3,501.00 | — | Left for review CO50 | Denied confidence 0.95 | Needs review |
| CLM-2026-024024 UB-04 · 2026-01-06 | Teresa Howell UHC-92058-49 | 2025-12-25 Inpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 27447 | $32,041.00 | — | Left for review HIGH | Approved confidence 0.95 | Needs review |
| CLM-2026-023750 UB-04 · 2026-01-06 | Matthew Ward UHC-15822-54 | 2025-12-27 Emergency room | Valley Regional Medical Center Emergency Medicine · in network | 71046, 99283, 99284 | $2,043.00 | — | Left for review CO97 | Denied confidence 0.95 | Needs review |
| CLM-2026-022823 UB-04 · 2026-01-06 | Carl Rivera UHC-16910-17 | 2025-12-22 Outpatient hospital | Unity Medical Group Internal Medicine · in network | 70553 | $3,569.00 | — | Left for review CO50 | Approved confidence 0.95 | Needs review |
| CLM-2026-017330 CMS-1500 · 2026-01-06 | Andrew Lee UHC-17562-92 | 2026-01-01 Office | Harbor Endocrine Associates Endocrinology · in network | 99214, 83036 | $292.00 | — | Left for review CO97 | Approved confidence 0.95 | Needs review |
| CLM-2026-011814 UB-04 · 2026-01-06 | Patricia Sandoval UHC-68939-94 | 2025-12-15 Outpatient hospital | Meadow Physical Therapy Physical Therapy · out of network | 70553 | $4,716.00 | — | Left for review CO50 | Denied confidence 0.95 | Needs review |
| CLM-2026-008128 UB-04 · 2026-01-06 | Gregory Reid UHC-65879-07 | 2025-12-06 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99284, 99283 | $2,491.00 | — | Left for review NET | Approved confidence 0.95 | Needs review |
| CLM-2026-003253 UB-04 · 2026-01-06 | Gabriel Robertson UHC-65311-64 | 2025-12-25 Outpatient hospital | Desert Internal Medicine Associates Internal Medicine · in network | 70553 | $2,210.00 | — | Left for review CO50 | Denied confidence 0.95 | Needs review |
| CLM-2026-032202 CMS-1500 · 2026-01-05 | Jeremy Torres UHC-01486-09 | 2026-01-02 Office | Canyon Medical Group Internal Medicine · in network | 99214, 99215 | $654.00 | — | Left for review CO16 | Pended confidence 0.95 | Needs review |
| CLM-2026-032124 UB-04 · 2026-01-05 | Bryan McDonald UHC-55577-57 | 2025-12-08 Outpatient hospital | Unity Medical Group Family Medicine · in network | 70553 | $2,231.00 | — | Left for review CO50 | Approved confidence 0.95 | Needs review |
| CLM-2026-031007 CMS-1500 · 2026-01-05 | Heather Gomez UHC-98871-36 | 2025-11-23 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 87086, 83036, 85025, 80061 | $251.00 | — | Left for review CO97 | Denied confidence 0.95 | Needs review |
| CLM-2026-024777 UB-04 · 2026-01-05 | Amanda Mendoza UHC-89922-24 | 2025-12-14 Outpatient hospital | Meadow Regional Medical Center Emergency Medicine · in network | 70553 | $3,089.00 | — | Left for review CO50 | Denied confidence 0.95 | Needs review |
| CLM-2026-012107 CMS-1500 · 2026-01-05 | Andrea Wagner UHC-53110-13 | 2025-12-19 Office | Lakeside Medical Group Family Medicine · in network | 99203, 99395 | $491.00 | — | Left for review CO97 | Approved confidence 0.95 | Needs review |
| CLM-2026-009416 UB-04 · 2026-01-05 | Joseph Flores UHC-70640-04 | 2025-12-04 Outpatient hospital | Northgate Medical Group Family Medicine · in network | 70553 | $2,513.00 | — | Left for review CO50 | Approved confidence 0.95 | Needs review |
| CLM-2026-007671 UB-04 · 2026-01-05 | Tyler Morris UHC-22612-53 | 2025-12-20 Outpatient hospital | Harbor Rehabilitation Center Physical Therapy · in network | 70553 | $9,804.00 | — | Left for review CO50 | Denied confidence 0.95 | Needs review |
| CLM-2026-005994 CMS-1500 · 2026-01-05 | Lori Ferguson UHC-87498-51 | 2025-12-04 Office | Evergreen Family Practice Family Medicine · in network | 90471, 99213 | $224.00 | — | Left for review CO97 | Approved confidence 0.95 | Needs review |
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.