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-2026-032717 UB-04 · 2026-10-17 | Victoria Padilla UHC-84331-08 | 2026-09-27 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 76700, 71046 | $614.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032479 UB-04 · 2026-10-17 | Ralph Garza UHC-69417-14 | 2026-09-30 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $203.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-031941 UB-04 · 2026-10-17 | Mark Riley UHC-38683-19 | 2026-10-01 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 96374, 99284 | $1,564.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-031465 UB-04 · 2026-10-17 | Steven Guzman UHC-15163-18 | 2026-10-01 Outpatient hospital | Valley Imaging Center Radiology · in network | 71046 | $143.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030816 UB-04 · 2026-10-17 | Carl Smith UHC-10143-60 | 2026-10-02 Outpatient hospital | Heritage Digestive Health Center Gastroenterology · in network | 45378 | $2,697.00 | $154.38 | Clean approval | — | Approved |
| CLM-2026-030671 UB-04 · 2026-10-17 | Peter Lane UHC-22452-89 | 2026-09-28 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $35,985.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-029651 CMS-1500 · 2026-10-17 | Rachel Coleman UHC-34040-77 | 2026-09-26 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99215, 80053 | $437.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-028704 CMS-1500 · 2026-10-17 | Pamela Scott UHC-72353-94 | 2026-10-07 Office | Sunrise Internal Medicine Associates Internal Medicine · in network | 99215 | $353.00 | $198.86 | Clean approval | — | Approved |
| CLM-2026-028673 CMS-1500 · 2026-10-17 | Dylan Robertson UHC-45403-96 | 2026-10-11 Office | Valley Rehabilitation Center Physical Therapy · in network | 97110 | $225.00 | $109.50 | Clean approval | — | Approved |
| CLM-2026-028489 CMS-1500 · 2026-10-17 | Deborah Vasquez UHC-04821-42 | 2026-09-23 Office | Desert Medical Group Internal Medicine · in network | 99215, 80053, 93000 | $440.00 | $232.80 | Clean approval | — | Approved |
| CLM-2026-028432 CMS-1500 · 2026-10-17 | Mary Jordan UHC-43821-91 | 2026-09-08 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 93000 | $69.00 | $12.78 | Clean approval | — | Approved |
| CLM-2026-028403 CMS-1500 · 2026-10-17 | Bobby Dominguez UHC-26590-88 | 2026-10-07 Office | Sunrise Skin Care Associates Dermatology · in network | 99213, 17110, 11403 | $858.00 | $456.96 | Clean approval | — | Approved |
| CLM-2026-028239 UB-04 · 2026-10-17 | Christopher Mendez UHC-78590-93 | 2026-10-01 Outpatient hospital | Meadow Regional Medical Center Emergency Medicine · in network | 70553 | $2,335.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-028236 CMS-1500 · 2026-10-17 | Maria Evans UHC-09452-22 | 2026-10-05 Office | Canyon Skin Care Associates Dermatology · in network | 17110 | $222.00 | $97.64 | Clean approval | — | Approved |
| CLM-2026-027168 UB-04 · 2026-10-17 | Sharon Patterson UHC-01025-68 | 2026-10-07 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99283, 71046 | $1,247.00 | $535.85 | Clean approval | — | Approved |
| CLM-2026-026788 CMS-1500 · 2026-10-17 | Michael Campbell UHC-94863-84 | 2026-09-07 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97161, 97014 | $335.00 | $187.70 | Clean approval | — | Approved |
| CLM-2026-026667 UB-04 · 2026-10-17 | Vincent Castillo UHC-39871-55 | 2026-10-13 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $203.00 | $10.80 | Clean approval | — | Approved |
| CLM-2026-025433 CMS-1500 · 2026-10-17 | Christian Cruz UHC-81334-28 | 2026-10-06 Office | Pinecrest Family Practice Family Medicine · in network | 36415, 99203 | $251.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025372 CMS-1500 · 2026-10-17 | Willie Martin UHC-69388-74 | 2026-09-18 Office | Heritage Medical Group Family Medicine · in network | 99395, 36415 | $323.00 | $175.26 | Clean approval | — | Approved |
| CLM-2026-024880 UB-04 · 2026-10-17 | Ruth Dunn UHC-79382-41 | 2026-09-24 Inpatient hospital | Cornerstone Internal Medicine Associates Internal Medicine · in network | 99232 | $189.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-024477 CMS-1500 · 2026-10-17 | Christian Henry UHC-60838-89 | 2026-10-02 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 87086 | $40.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023184 UB-04 · 2026-10-17 | Joshua Campbell UHC-12728-30 | 2026-09-13 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 74177 | $1,255.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-023019 CMS-1500 · 2026-10-17 | William Contreras UHC-63728-04 | 2026-10-11 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 87086 | $60.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-022893 CMS-1500 · 2026-10-17 | Vincent Lewis UHC-59903-89 | 2026-09-09 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $276.00 | $131.12 | Clean approval | — | Approved |
| CLM-2026-022643 CMS-1500 · 2026-10-17 | Jacqueline Jimenez UHC-16993-83 | 2026-10-04 Office | Meadow Primary Care Associates Family Medicine · in network | 99395, 99214 | $506.00 | $293.72 | Clean approval | — | Approved |
| CLM-2026-022494 UB-04 · 2026-10-17 | Juan Jimenez UHC-84918-36 | 2026-09-06 Emergency room | Summit Community Hospital Emergency Medicine · in network | 71046 | $242.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-022113 UB-04 · 2026-10-17 | Maria Moore UHC-93684-85 | 2026-10-07 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 76700, 74177 | $1,965.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-022095 CMS-1500 · 2026-10-17 | Robert Soto UHC-74389-69 | 2026-09-05 Independent laboratory | Desert Clinical Laboratories Clinical Laboratory · in network | 83036 | $39.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-021612 CMS-1500 · 2026-10-17 | Adam Garrett UHC-27878-40 | 2026-10-01 Office | Evergreen Medical Group Family Medicine · in network | 90471, 99203, 99214 | $538.00 | $314.96 | Clean approval | — | Approved |
| CLM-2026-021605 CMS-1500 · 2026-10-17 | Jacob Snyder UHC-83953-23 | 2026-09-06 Office | Cornerstone Diabetes Center Endocrinology · in network | 99214, 99215 | $597.00 | $320.14 | Clean approval | — | Approved |
| CLM-2026-021037 CMS-1500 · 2026-10-17 | Jeremy Mendez UHC-21632-60 | 2026-09-20 Office | Harbor Family Practice Family Medicine · in network | 36415, 90471 | $51.00 | $18.60 | Clean approval | — | Approved |
| CLM-2026-020933 UB-04 · 2026-10-17 | Julie Alvarez UHC-08988-72 | 2026-09-04 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 45378 | $2,116.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-019537 CMS-1500 · 2026-10-17 | Priya Chavez UHC-11128-20 | 2026-10-14 Office | Northgate Medical Group Family Medicine · in network | 90471, 99213, 99395 | $498.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-018303 CMS-1500 · 2026-10-17 | Carol Rogers UHC-29452-56 | 2026-09-18 Office | Valley Medical Group Family Medicine · in network | 36415, 90471 | $67.00 | $27.90 | Clean approval | — | Approved |
| CLM-2026-018111 CMS-1500 · 2026-10-17 | Kenneth Coleman UHC-07479-77 | 2026-09-28 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 93000 | $93.00 | $27.66 | Clean approval | — | Approved |
| CLM-2026-017884 UB-04 · 2026-10-17 | Wallace Betty UHC-94593-87 | 2026-09-03 Outpatient hospital | Meadow GI Associates Gastroenterology · in network | 88305 | $290.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-017765 CMS-1500 · 2026-10-17 | Thomas Luna UHC-14024-11 | 2026-10-15 Office | Riverside Medical Group Family Medicine · in network | 90471 | $29.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-017719 CMS-1500 · 2026-10-17 | Olivia Ramos UHC-74736-34 | 2026-09-25 Office | Heritage Behavioral Health Behavioral Health · in network | 90791, 90834 | $525.00 | $250.50 | Clean approval | — | Approved |
| CLM-2026-017715 CMS-1500 · 2026-10-17 | Amber Delgado UHC-52060-85 | 2026-09-24 Independent laboratory | Unity Clinical Laboratories Clinical Laboratory · in network | 80053, 80061 | $147.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-017662 CMS-1500 · 2026-10-17 | Maria Cruz UHC-56006-43 | 2026-09-04 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 80053, 93000 | $174.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-017614 CMS-1500 · 2026-10-17 | Harold Murphy UHC-22265-13 | 2026-09-10 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90791 | $428.00 | $205.36 | Clean approval | — | Approved |
| CLM-2026-017402 CMS-1500 · 2026-10-17 | Marilyn Kelly UHC-08484-93 | 2026-09-27 Telehealth | Summit Counseling Center Behavioral Health · in network | 99214 | $218.00 | $85.16 | Clean approval | — | Approved |
| CLM-2026-017348 CMS-1500 · 2026-10-17 | Katherine Castillo no member ID | 2026-09-28 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99214 | $318.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017192 CMS-1500 · 2026-10-17 | Kenneth Morgan UHC-50444-71 | 2026-09-28 Office | Cornerstone Diabetes Center Endocrinology · in network | 99215 | $406.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-017124 UB-04 · 2026-10-17 | Jose Weber UHC-75597-59 | 2026-10-09 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93015 | $424.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-017001 UB-04 · 2026-10-17 | Bryan Guerrero UHC-44575-81 | 2026-10-06 Emergency room | Summit Community Hospital Emergency Medicine · in network | 99283, 71046 | $928.00 | $260.40 | Clean approval | — | Approved |
| CLM-2026-016699 CMS-1500 · 2026-10-17 | William Diaz UHC-98786-04 | 2026-09-07 Office | Sunrise Skin Care Associates Dermatology · in network | 11102, 11403 | $758.00 | $394.96 | Clean approval | — | Approved |
| CLM-2026-016486 CMS-1500 · 2026-10-17 | Karen Wells UHC-21724-15 | 2026-09-17 Office | Harbor Physical Therapy Physical Therapy · in network | 97110 | $261.00 | $121.82 | Clean approval | — | Approved |
| CLM-2026-016432 CMS-1500 · 2026-10-17 | Diana Stephens UHC-94285-82 | 2026-09-04 Office | Northgate Medical Group Family Medicine · in network | 36415 | $25.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-016322 CMS-1500 · 2026-10-17 | Aelxander Young UHC-08174-22 | 2026-09-15 Office | Summit Primary Care Associates Family Medicine · in network | 99213, 36415 | $188.00 | $86.56 | 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.