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
3,664
50 with an AI recommendation
Pended
2,586
awaiting information or identity
Approved
23,942
$6,757,768.45 plan paid
Denied
4,454
with remittance reason codes
Examiner decided
0
167 not attached to an identity
| Claim | Member | Service | Provider | Procedures | Billed | Plan pays | Rules | AI | Status |
|---|---|---|---|---|---|---|---|---|---|
| CLM-2026-013357 CMS-1500 · 2026-10-18 | Maria Russll UHC-17012-96 | 2026-09-04 Office | Harbor Diabetes Center Endocrinology · in network | 95251 | $201.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013139 CMS-1500 · 2026-10-18 | Joan Mason UHC-00755-30 | 2026-09-18 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99203, 99213 | $376.00 | $193.12 | Clean approval | — | Approved |
| CLM-2026-013042 CMS-1500 · 2026-10-18 | Sara Ortiz UHC-96234-58 | 2026-09-18 Office | Evergreen Internal Medicine Associates Internal Medicine · in network | 80053 | $43.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-012815 CMS-1500 · 2026-10-18 | Aaron Johnston UHC-54160-30 | 2026-09-13 Office | Evergreen Family Practice Family Medicine · in network | 99395 | $307.00 | $165.34 | Clean approval | — | Approved |
| CLM-2026-012577 UB-04 · 2026-10-18 | Steven Brooks UHC-72425-74 | 2026-09-25 Outpatient hospital | Pinecrest Cardiovascular Associates Cardiology · in network | 93458 | $7,698.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-012567 UB-04 · 2026-10-18 | Melissa Gardner UHC-62350-59 | 2026-09-07 Inpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 27447 | $39,811.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-012388 UB-04 · 2026-10-18 | Catherine Simpson UHC-22875-45 | 2026-09-18 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458, 93015 | $9,810.00 | $4,160.71 | Clean approval | — | Approved |
| CLM-2026-012046 CMS-1500 · 2026-10-18 | Maria Jordan UHC-32080-45 | 2026-09-07 Office | Riverside Family Practice Family Medicine · in network | 90471 | $42.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011634 CMS-1500 · 2026-10-18 | John Graham UHC-03219-23 | 2026-10-07 Office | Meadow Internal Medicine Associates Internal Medicine · in network | 99214, 80053, 99215 | $610.00 | $348.20 | Clean approval | — | Approved |
| CLM-2026-010644 UB-04 · 2026-10-18 | Zachary Baker UHC-62292-08 | 2026-09-09 Outpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $9,591.00 | $1,952.59 | Clean approval | — | Approved |
| CLM-2026-010611 CMS-1500 · 2026-10-18 | Not attached | 2026-09-05 Office | Northgate Counseling Center Behavioral Health · in network | 90791 | $375.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-009966 CMS-1500 · 2026-10-18 | Abbby Wong UHC-74228-68 | 2026-09-20 Office | Canyon Medical Group Internal Medicine · in network | 80053, 99214 | $317.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-009790 CMS-1500 · 2026-10-18 | Jacob Carr UHC-36540-95 | 2026-10-10 Office | Heritage Primary Care Associates Family Medicine · in network | 36415 | $13.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-009314 CMS-1500 · 2026-10-18 | Laura Rogers UHC-88922-66 | 2026-09-30 Independent laboratory | Pinecrest Reference Lab Clinical Laboratory · in network | 87086, 83036, 80061 | $173.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-008492 CMS-1500 · 2026-10-18 | Sophia Nunez UHC-17485-17 | 2026-09-25 Independent laboratory | Desert Reference Lab Clinical Laboratory · in network | 80053, 85025, 87086 | $185.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-007716 CMS-1500 · 2026-10-18 | Jacqueline Mitchell UHC-85622-08 | 2026-08-23 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99214, 80053 | $350.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007711 CMS-1500 · 2026-10-18 | Aaron Vazquez UHC-12265-62 | 2026-09-25 Office | Unity Medical Group Family Medicine · in network | 99395, 36415 | $313.00 | $164.06 | Clean approval | — | Approved |
| CLM-2026-007459 CMS-1500 · 2026-10-18 | Priya Nelson UHC-65947-09 | 2026-09-28 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 80061, 87086 | $85.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-007172 CMS-1500 · 2026-10-18 | Luis Ford UHC-53020-24 | 2026-10-03 Office | Evergreen Medical Group Family Medicine · in network | 36415, 99214 | $309.00 | $177.94 | Clean approval | — | Approved |
| CLM-2026-006143 UB-04 · 2026-10-18 | Emma McDonald UHC-14703-77 | 2026-10-05 Outpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $8,786.00 | $3,046.11 | Clean approval | — | Approved |
| CLM-2026-005878 UB-04 · 2026-10-18 | Sara Welch UHC-01909-90 | 2026-09-24 Emergency room | Riverside Community Hospital Emergency Medicine · in network | 96374, 99284 | $1,809.00 | $910.25 | Clean approval | — | Approved |
| CLM-2026-005773 UB-04 · 2026-10-18 | Emily Silva UHC-43687-71 | 2026-09-30 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 74177 | $2,419.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-005535 CMS-1500 · 2026-10-18 | Luri Bryant UHC-70153-08 | 2026-09-17 Office | Canyon Skin Care Associates Dermatology · in network | 99213 | $158.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-004819 CMS-1500 · 2026-10-18 | Steven Estrada UHC-77984-19 | 2026-09-07 Office | Cornerstone Diabetes Center Endocrinology · in network | 99215, 99214 | $725.00 | $399.50 | Clean approval | — | Approved |
| CLM-2026-004759 CMS-1500 · 2026-10-18 | Frank Woods UHC-50088-36 | 2026-09-23 Office | Meadow Medical Group Family Medicine · in network | 99395, 99213, 99203 | $775.00 | $450.50 | Clean approval | — | Approved |
| CLM-2026-004744 CMS-1500 · 2026-10-18 | Albert Weaver UHC-17326-17 | 2026-10-13 Office | Unity Medical Group Internal Medicine · in network | 80053 | $45.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-004489 UB-04 · 2026-10-18 | Thomas Walker UHC-98355-06 | 2026-09-25 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 77067, 76700 | $759.00 | $105.86 | Clean approval | — | Approved |
| CLM-2026-004216 UB-04 · 2026-10-18 | Alexander Reid UHC-77022-69 | 2026-09-16 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 71046, 70553 | $3,057.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-003839 CMS-1500 · 2026-10-18 | Ahmed Wallace UHC-37460-16 | 2026-09-10 Office | Valley Medical Group Family Medicine · in network | 99214, 90471 | $274.00 | $149.88 | Clean approval | — | Approved |
| CLM-2026-003431 UB-04 · 2026-10-18 | Emily Palmer UHC-80821-83 | 2026-09-08 Outpatient hospital | Pinecrest Heart Institute Cardiology · in network | 93458 | $5,465.00 | $888.96 | Clean approval | — | Approved |
| CLM-2026-003319 CMS-1500 · 2026-10-18 | Keith Vazquez UHC-01356-46 | 2026-10-06 Office | Unity Dermatology Clinic Dermatology · in network | 99213, 11403 | $760.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-003164 UB-04 · 2026-10-18 | Nancy Wong UHC-74984-66 | 2026-09-13 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 88305, 45378 | $2,851.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-002928 UB-04 · 2026-10-18 | Roy Burns UHC-22217-24 | 2026-09-07 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $178.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-002915 CMS-1500 · 2026-10-18 | Joan Murphy UHC-51326-26 | 2026-10-16 Office | Sunrise Counseling Center Behavioral Health · in network | 90791, 90834 | $611.00 | $328.82 | Clean approval | — | Approved |
| CLM-2026-002809 UB-04 · 2026-10-18 | Olivia Armstrong UHC-25797-48 | 2026-05-27 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458, 93015 | $5,527.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-002469 CMS-1500 · 2026-10-18 | Brian Gonzalez UHC-11415-22 | 2026-09-18 Office | Unity Bone and Joint Center Orthopedic Surgery · in network | 99213 | $232.00 | $83.84 | Clean approval | — | Approved |
| CLM-2026-002464 CMS-1500 · 2026-10-18 | Raymond Washington UHC-78812-89 | 2026-09-03 Office | Harbor Medical Group Family Medicine · in network | 90471, 99203 | $276.00 | $146.12 | Clean approval | — | Approved |
| CLM-2026-002357 CMS-1500 · 2026-10-18 | Charles Nguyen UHC-11107-77 | 2026-09-12 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 85025, 80061 | $106.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-001670 CMS-1500 · 2026-10-18 | Anthony Johnston UHC-39804-89 | 2026-09-20 Office | Sunrise Medical Group Family Medicine · in network | 99213, 99395, 90471 | $506.00 | $273.72 | Clean approval | — | Approved |
| CLM-2026-001442 UB-04 · 2026-10-18 | Sophia Howell UHC-51733-01 | 2026-09-26 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 43239, 45378, 88305 | $4,193.00 | $1,058.91 | Clean approval | — | Approved |
| CLM-2026-001208 UB-04 · 2026-10-18 | Alexander Robertson UHC-20832-08 | 2026-09-29 Outpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,651.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-000165 UB-04 · 2026-10-18 | Bradley Russell UHC-45171-11 | 2026-09-28 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $38,503.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-034428 CMS-1500 · 2026-10-17 | Omar Ortiz UHC-62827-27 | 2026-09-27 Office | Evergreen Family Practice Family Medicine · in network | 99395, 99214 | $433.00 | $243.46 | Clean approval | — | Approved |
| CLM-2026-033635 CMS-1500 · 2026-10-17 | Ashley Garza UHC-69569-85 | 2026-09-27 Office | Harbor Physical Therapy Physical Therapy · in network | 97110, 97140 | $308.00 | $165.96 | Clean approval | — | Approved |
| CLM-2026-033620 CMS-1500 · 2026-10-17 | Helen Johnson UHC-28850-11 | 2026-09-10 Office | Evergreen Primary Care Associates Family Medicine · in network | 99395 | $334.00 | $187.08 | Clean approval | — | Approved |
| CLM-2026-033611 CMS-1500 · 2026-10-17 | Sofa Weaver UHC-57114-29 | 2026-10-02 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97161 | $459.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-032856 CMS-1500 · 2026-10-17 | Bruce Weaver UHC-97693-66 | 2026-09-25 Office | Riverside Bone and Joint Center Orthopedic Surgery · in network | 20610, 99213 | $461.00 | $210.82 | Clean approval | — | Approved |
| CLM-2026-032839 CMS-1500 · 2026-10-17 | Gregory Torres UHC-36621-45 | 2026-09-15 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 87086, 85025 | $71.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032797 CMS-1500 · 2026-10-17 | Noah Pena UHC-91234-26 | 2026-09-24 Office | Evergreen Dermatology Clinic Dermatology · in network | 11403 | $398.00 | $186.76 | Clean approval | — | Approved |
| CLM-2026-032764 UB-04 · 2026-10-17 | Diana Williamson UHC-93292-52 | 2026-10-07 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 71046 | $172.00 | $0.00 | 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.