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-2026-028245 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-2026-016985 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-2026-028277 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-2026-030093 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-2026-028463 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-2026-032202 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-2026-016227 UB-04 · 2026-01-04 | Gerald Miller UHC-84890-95 | 2025-11-22 Emergency room | Desert Regional Medical Center Emergency Medicine · in network | 96374 | $213.00 | — | Left for review CO16 | Pended confidence 0.95 | Needs review |
| CLM-2026-014876 CMS-1500 · 2026-01-04 | Anthony Nguyen UHC-17522-25 | 2025-12-23 Office | Pinecrest Medical Group Internal Medicine · in network | 99215 | $316.00 | — | Left for review CO16 | Pended confidence 0.95 | Needs review |
| CLM-2026-030759 UB-04 · 2026-01-02 | Gregory Taylor UHC-40403-19 | 2025-12-31 Outpatient hospital | Meadow Imaging Center Radiology · in network | 70553, 76700, 74177 | $4,904.00 | — | Left for review CO16 | Pended confidence 0.95 | Needs review |
| CLM-2026-026668 CMS-1500 · 2026-01-02 | Alexander Hunt UHC-71385-53 | 2025-12-11 Office | Riverside Family Practice Family Medicine · in network | 99213 | $175.00 | — | Left for review CO16 | Pended confidence 0.95 | Needs review |
| CLM-2026-012596 CMS-1500 · 2026-01-01 | Hannah Willis UHC-29058-11 | 2025-12-20 Independent laboratory | Desert Clinical Laboratories Clinical Laboratory · in network | 85025 | $61.00 | — | Left for review CO16 | Pended confidence 0.80 | Needs review |
| CLM-2026-001501 CMS-1500 · 2026-01-01 | Martha Lewis UHC-83453-88 | 2025-11-26 Office | Unity Primary Care Associates Family Medicine · out of network | 99395 | $313.00 | — | Left for review CO16 | Pended confidence 0.80 | 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.