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-2026-017564 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-2026-002809 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-2026-026161 CMS-1500 · 2026-10-16 | Carol Owens UHC-59852-07 | 2026-05-21 Office | Harbor Endocrine Associates Endocrinology · in network | 95251, 99214 | $439.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-011470 CMS-1500 · 2026-10-16 | Valentina Coleman UHC-82461-63 | 2026-07-09 Office | Riverside Internal Medicine Associates Internal Medicine · in network | 80053 | $54.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-002334 CMS-1500 · 2026-10-16 | Juan Banks no member ID | 2026-06-19 Office | Harbor Diabetes Center Endocrinology · in network | 99214, 95251 | $350.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-030080 CMS-1500 · 2026-10-15 | Rebecca Carlson UHC-32126-56 | 2026-04-23 Office | Meadow Primary Care Associates Family Medicine · in network | 99395 | $285.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-034029 UB-04 · 2026-10-14 | Ryan Li UHC-59343-89 | 2026-06-24 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 88305 | $352.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-023532 UB-04 · 2026-10-14 | Andrew Hicks UHC-20492-19 | 2026-03-30 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 70553, 71046 | $2,750.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-028031 CMS-1500 · 2026-10-13 | Lucia Gomez UHC-42126-16 | 2026-03-20 Office | Meadow Heart Institute Cardiology · in network | 99214, 93224 | $630.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-003566 CMS-1500 · 2026-10-12 | Mark Gomez UHC-29262-82 | 2026-06-26 Office | Valley Internal Medicine Associates Internal Medicine · in network | 99215 | $420.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-032440 CMS-1500 · 2026-10-11 | Robert Garcia UHC-56494-97 | 2026-06-29 Office | Canyon Primary Care Associates Family Medicine · in network | 99213, 99214 | $440.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-027111 CMS-1500 · 2026-10-11 | Natalie Fernandez UHC-04526-89 | 2026-07-01 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $228.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-002072 CMS-1500 · 2026-10-10 | Billy Jacobs UHC-33970-88 | 2026-04-22 Office | Harbor Primary Care Associates Family Medicine · in network | 99395, 99213 | $444.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-022094 CMS-1500 · 2026-10-09 | Kathryn Gonzalez UHC-91606-76 | 2026-06-28 Office | Harbor Medical Group Family Medicine · in network | 99214, 99213, 99203 | $570.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-019620 CMS-1500 · 2026-10-09 | Sophia White UHC-42195-58 | 2026-05-15 Independent laboratory | Valley Reference Lab Clinical Laboratory · in network | 87086, 83036 | $128.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-017156 CMS-1500 · 2026-10-09 | Steven Rios UHC-51797-42 | 2026-06-28 Office | Lakeside Dermatology Clinic Dermatology · in network | 11102, 99213, 17110 | $666.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-009820 UB-04 · 2026-10-09 | Walter Weber UHC-22039-25 | 2026-03-31 Outpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,142.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-030444 UB-04 · 2026-10-08 | Kenneth Hughes no member ID | 2026-05-06 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 96374, 99285 | $2,613.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-021362 CMS-1500 · 2026-10-08 | Christian Castillo UHC-97898-44 | 2026-03-19 Office | Mesa Family Practice Family Medicine · in network | 99203, 99395 | $560.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-006058 CMS-1500 · 2026-10-08 | Timothy Reynolds UHC-76724-37 | 2026-03-19 Office | Meadow Medical Group Family Medicine · in network | 99395, 36415 | $329.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-021406 CMS-1500 · 2026-10-05 | Wei Fields UHC-62961-20 | 2026-03-10 Office | Pinecrest Medical Group Internal Medicine · in network | 93000, 80053, 99215 | $533.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-024504 CMS-1500 · 2026-10-04 | Alexander Davis UHC-21797-46 | 2026-06-14 Office | Cornerstone Digestive Health Center Gastroenterology · in network | 99214 | $212.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-022760 CMS-1500 · 2026-10-04 | Samuel Daniels UHC-88956-84 | 2026-06-02 Office | Summit Family Practice Family Medicine · in network | 99213 | $210.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-010646 CMS-1500 · 2026-10-02 | Charles Hunter UHC-17944-90 | 2026-04-27 Office | Heritage Medical Group Family Medicine · in network | 99214, 99395, 99213 | $736.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-002851 CMS-1500 · 2026-10-02 | Helen Garcia UHC-38530-83 | 2026-04-07 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 83036, 87086, 80061 | $140.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-022429 CMS-1500 · 2026-10-01 | Bryan Stevens UHC-54937-27 | 2026-06-16 Office | Meadow Medical Group Family Medicine · in network | 99203 | $240.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-031027 UB-04 · 2026-09-30 | Alan Lee no member ID | 2026-02-25 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99283, 96374 | $956.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-009750 CMS-1500 · 2026-09-29 | Jerry Crawford UHC-60376-73 | 2026-06-22 Office | Meadow Primary Care Associates Family Medicine · in network | 99213, 36415 | $188.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-008191 CMS-1500 · 2026-09-29 | Anthony Harris UHC-93261-88 | 2026-05-07 Office | Heritage Primary Care Associates Family Medicine · in network | 99203 | $231.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-020906 CMS-1500 · 2026-09-28 | Julie Simmos no member ID | 2026-04-15 Office | Riverside GI Associates Gastroenterology · in network | 99214 | $211.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-012976 UB-04 · 2026-09-28 | Samuel Ray UHC-71219-67 | 2026-03-21 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 45378, 43239 | $4,467.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-006010 CMS-1500 · 2026-09-28 | Zachary Ray UHC-38123-88 | 2026-04-19 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97161 | $382.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-008711 CMS-1500 · 2026-09-27 | Julie Ryan UHC-73740-43 | 2026-03-27 Independent laboratory | Desert Reference Lab Clinical Laboratory · in network | 85025, 87086 | $118.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-028548 CMS-1500 · 2026-09-26 | Alexis Elliott UHC-73306-15 | 2026-03-27 Independent laboratory | Meadow Reference Lab Clinical Laboratory · in network | 80053, 80061 | $138.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-025001 CMS-1500 · 2026-09-26 | Stephanie Ross UHC-04168-70 | 2026-04-16 Office | Heritage Digestive Health Center Gastroenterology · in network | 99214 | $227.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-017572 CMS-1500 · 2026-09-26 | Roy Wright UHC-76478-99 | 2026-04-22 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97014 | $197.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-013553 CMS-1500 · 2026-09-26 | Alan Ferguson UHC-70793-11 | 2026-05-26 Office | Canyon Cardiovascular Associates Cardiology · in network | 99214 | $317.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-009481 CMS-1500 · 2026-09-26 | Diana Bailey UHC-96404-93 | 2026-03-03 Office | Desert Medical Group Family Medicine · in network | 36415, 90471, 99213 | $212.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-026832 CMS-1500 · 2026-09-25 | Marcus Hoffman UHC-57280-21 | 2026-03-11 Office | Meadow Primary Care Associates Family Medicine · in network | 36415 | $15.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-024213 CMS-1500 · 2026-09-25 | Camila Ortiz UHC-05912-11 | 2026-06-05 Office | Pinecrest Heart Institute Cardiology · in network | 99214 | $273.00 | — | Denied by rule CO27 CO29 | — | Denied |
| CLM-2026-005747 CMS-1500 · 2026-09-24 | Hiroshi Green UHC-29732-52 | 2026-04-07 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97014 | $392.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-002594 CMS-1500 · 2026-09-24 | Jonathan Pierce UHC-45594-56 | 2026-02-19 Independent laboratory | Desert Clinical Laboratories Clinical Laboratory · in network | 83036, 80053, 80061 | $159.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-019445 CMS-1500 · 2026-09-23 | Cheryl Banks UHC-00187-29 | 2026-06-19 Office | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 20610 | $206.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-008505 CMS-1500 · 2026-09-23 | Kathleen Soto UHC-10461-05 | 2026-04-11 Office | Valley Internal Medicine Associates Internal Medicine · in network | 93000 | $96.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-000147 CMS-1500 · 2026-09-22 | Camila Rios UHC-12493-59 | 2026-03-18 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 93000, 99215 | $371.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-033531 UB-04 · 2026-09-21 | Carol Henry UHC-64577-07 | 2026-05-27 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 77067, 74177, 71046 | $3,177.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-026244 UB-04 · 2026-09-20 | Jackie Diaz UHC-15009-91 | 2026-03-11 Outpatient hospital | Desert Heart Institute Cardiology · in network | 93458 | $5,581.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-021737 CMS-1500 · 2026-09-20 | Bruce Reynolds UHC-33418-96 | 2026-06-13 Office | Evergreen Family Practice Family Medicine · in network | 90471 | $25.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-016107 CMS-1500 · 2026-09-20 | Ronald Reid UHC-15374-37 | 2026-05-15 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 80053 | $76.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-000583 UB-04 · 2026-09-20 | Bruce Martinez UHC-23802-99 | 2026-02-23 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 43239, 88305 | $2,709.00 | — | Denied by rule CO29 | — | Denied |
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.