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-2026-025606 CMS-1500 · 2026-10-18 | Lawrence Watson UHC-48583-08 | 2026-10-04 Office | Desert Cardiovascular Associates Cardiology · in network | 93224, 99214 | $516.00 | — | Left for review CO97 | — | Needs review |
| 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-2026-034606 CMS-1500 · 2026-10-16 | Evelyn Ramos UHC-70497-07 | 2026-09-25 Office | Evergreen Medical Group Family Medicine · in network | 99395, 99213 | $411.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-017481 CMS-1500 · 2026-10-16 | Jeremy Bishop UHC-33995-12 | 2026-10-04 Office | Northgate Medical Group Family Medicine · in network | 99213, 99214 | $434.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-013282 CMS-1500 · 2026-10-15 | Mason Porter UHC-76399-31 | 2026-09-20 Office | Canyon Cardiovascular Associates Cardiology · in network | 93224, 99214 | $740.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-004162 CMS-1500 · 2026-10-15 | Virginia Wong UHC-96611-25 | 2026-10-12 Office | Evergreen Medical Group Family Medicine · in network | 99203, 99213 | $351.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-011191 CMS-1500 · 2026-10-14 | Christopher Cooper UHC-06864-83 | 2026-10-09 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 99214, 99215 | $537.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-031767 CMS-1500 · 2026-10-12 | Lawrence Young UHC-86523-36 | 2026-09-23 Office | Pinecrest Medical Group Family Medicine · in network | 99395, 99213 | $502.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023112 CMS-1500 · 2026-10-11 | Melissa Tran UHC-46772-18 | 2026-09-22 Office | Heritage Primary Care Associates Family Medicine · in network | 99395, 99213 | $443.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023701 CMS-1500 · 2026-10-10 | Sarah Banks UHC-19530-96 | 2026-09-22 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 80053, 85025 | $121.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-017366 CMS-1500 · 2026-10-09 | John Sims UHC-98485-42 | 2026-08-28 Office | Mesa Family Practice Family Medicine · in network | 36415, 90471 | $55.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-026952 CMS-1500 · 2026-10-08 | David Wang UHC-66449-08 | 2026-09-11 Office | Canyon Medical Group Internal Medicine · in network | 99214, 80053 | $370.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-013701 CMS-1500 · 2026-10-08 | Elijah Gray UHC-73436-77 | 2026-08-26 Office | Evergreen Medical Group Family Medicine · in network | 90471, 99213 | $246.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-028678 CMS-1500 · 2026-10-06 | Christopher Yang UHC-11124-73 | 2026-10-02 Telehealth | Sunrise Counseling Center Behavioral Health · in network | 99214, 90834 | $463.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-009541 CMS-1500 · 2026-10-06 | Gary Vargas UHC-01629-87 | 2026-09-10 Office | Heritage Primary Care Associates Family Medicine · in network | 99214, 36415, 99203 | $512.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-000356 CMS-1500 · 2026-10-06 | Gary Espinoza UHC-09582-44 | 2026-08-24 Office | Riverside Digestive Health Center Gastroenterology · in network | 99214, 43239 | $2,617.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-026705 CMS-1500 · 2026-10-05 | Michelle Walker UHC-76125-07 | 2026-09-18 Office | Heritage Medical Group Family Medicine · in network | 99203, 99213 | $358.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-033123 CMS-1500 · 2026-10-04 | Noah Oliver UHC-49295-92 | 2026-09-06 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 80061, 80053 | $94.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-016997 CMS-1500 · 2026-10-04 | Abigail Reynolds UHC-56842-65 | 2026-09-14 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 83036, 80053 | $104.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-013455 CMS-1500 · 2026-10-04 | Carolyn Jordan UHC-84537-40 | 2026-09-24 Office | Pinecrest Medical Group Internal Medicine · in network | 93000, 80053, 99215 | $396.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-021310 CMS-1500 · 2026-10-02 | Hannah Gilbert UHC-12376-13 | 2026-09-30 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 80061, 87086 | $97.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-011073 CMS-1500 · 2026-10-02 | Richard Bishop UHC-11474-59 | 2026-08-20 Office | Mesa Dermatology Clinic Dermatology · in network | 99213, 11102 | $390.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-025692 CMS-1500 · 2026-10-01 | Gregory Wagner UHC-51627-22 | 2026-09-28 Office | Pinecrest Medical Group Internal Medicine · in network | 99214, 80053 | $308.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-022396 CMS-1500 · 2026-10-01 | Virginia Ross UHC-66259-56 | 2026-09-07 Office | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 99213, 20610 | $457.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-031127 CMS-1500 · 2026-09-27 | Sarah Hamilton UHC-22904-19 | 2026-09-08 Office | Mesa Family Practice Family Medicine · in network | 90471, 99395, 99214 | $527.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-031389 CMS-1500 · 2026-09-26 | Martha Bailey UHC-06979-99 | 2026-09-11 Office | Pinecrest Medical Group Family Medicine · in network | 90471, 99213 | $224.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-030157 CMS-1500 · 2026-09-26 | Peter Smith UHC-20983-31 | 2026-09-09 Office | Northgate Medical Group Internal Medicine · in network | 93000, 99214 | $371.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-013570 CMS-1500 · 2026-09-26 | Debra Elliott UHC-29655-41 | 2026-09-02 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $288.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-000825 CMS-1500 · 2026-09-26 | Kayla Williamson UHC-28782-70 | 2026-08-21 Independent laboratory | Sunrise Clinical Laboratories Clinical Laboratory · in network | 80061, 87086, 80053 | $166.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-021220 CMS-1500 · 2026-09-25 | Santiago Allen UHC-39555-75 | 2026-09-18 Office | Valley Medical Group Family Medicine · in network | 99203, 90471 | $264.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-029923 CMS-1500 · 2026-09-24 | Kyle Harrison UHC-34852-96 | 2026-08-25 Office | Desert Primary Care Associates Family Medicine · in network | 36415, 99213 | $175.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-001137 CMS-1500 · 2026-09-24 | George Holmes UHC-85048-47 | 2026-09-01 Office | Pinecrest Medical Group Family Medicine · in network | 99214, 36415, 90471 | $272.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-000045 CMS-1500 · 2026-09-23 | Marcus Wong UHC-03574-75 | 2026-08-20 Office | Harbor Primary Care Associates Family Medicine · in network | 99203, 90471, 99213 | $446.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-003349 CMS-1500 · 2026-09-20 | Kenneth Dunn UHC-30577-22 | 2026-09-08 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 80053, 80061 | $140.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-004438 CMS-1500 · 2026-09-17 | Kimberly Payne UHC-83579-91 | 2026-08-26 Office | Evergreen Medical Group Family Medicine · in network | 36415, 99203 | $246.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-011862 CMS-1500 · 2026-09-16 | Joseph Obrien UHC-03406-45 | 2026-09-14 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $273.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-007573 CMS-1500 · 2026-09-16 | Vincent Armstrong UHC-92198-01 | 2026-09-08 Office | Unity Dermatology Clinic Dermatology · in network | 11403, 11102 | $896.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-029699 CMS-1500 · 2026-09-15 | Zachary Carlson UHC-05862-91 | 2026-08-08 Office | Unity Medical Group Internal Medicine · in network | 93000, 99214 | $341.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-008985 CMS-1500 · 2026-09-15 | David Ford UHC-92766-36 | 2026-08-07 Office | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 20610, 99213 | $508.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-018637 CMS-1500 · 2026-09-13 | Karen Elliott UHC-05863-63 | 2026-08-08 Office | Harbor Primary Care Associates Family Medicine · in network | 36415, 90471 | $53.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-013791 CMS-1500 · 2026-09-13 | Victoria Flores UHC-25370-92 | 2026-08-30 Office | Valley Family Practice Family Medicine · in network | 99203, 99213 | $456.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-021328 CMS-1500 · 2026-09-12 | Karen Foster UHC-09837-69 | 2026-07-30 Office | Unity Dermatology Clinic Dermatology · in network | 11403, 11102 | $781.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023951 CMS-1500 · 2026-09-11 | Valentina Guerrero UHC-71193-02 | 2026-08-28 Office | Lakeside Medical Group Family Medicine · in network | 90471, 99213 | $223.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-015094 CMS-1500 · 2026-09-11 | Evelyn Fisher UHC-52353-84 | 2026-07-29 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $287.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-011344 CMS-1500 · 2026-09-11 | Christine Harvey UHC-40603-08 | 2026-08-23 Office | Harbor Physical Therapy Physical Therapy · in network | 97110, 97161, 97014 | $483.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-028713 CMS-1500 · 2026-09-10 | Lori Hawkins UHC-55156-14 | 2026-07-31 Office | Heritage Digestive Health Center Gastroenterology · in network | 99214, 43239 | $2,848.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-007154 CMS-1500 · 2026-09-10 | Chris Ferguson UHC-41567-67 | 2026-08-31 Office | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 20610, 99213 | $530.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-030639 CMS-1500 · 2026-09-09 | Jonathan Marquez UHC-57626-40 | 2026-08-04 Independent laboratory | Desert Reference Lab Clinical Laboratory · in network | 87086, 85025, 80061 | $166.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-026724 CMS-1500 · 2026-09-09 | Heather Estrada UHC-14837-83 | 2026-08-28 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 80061, 83036, 85025 | $187.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-000838 CMS-1500 · 2026-09-08 | Sean Reynolds UHC-33152-78 | 2026-08-21 Office | Heritage Medical Group Internal Medicine · in network | 99215, 99214 | $562.00 | — | Left for review CO97 | — | 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.