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-2026-020923 CMS-1500 · 2026-09-21 | Vincent Graham UHC-92478-19 | 2026-09-07 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97140 | $323.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-020127 CMS-1500 · 2026-09-21 | Frances Anderson UHC-49348-09 | 2026-08-16 Office | Evergreen Dermatology Clinic Dermatology · out of network | 11102 | $242.00 | $58.90 | Clean approval | — | Approved |
| CLM-2026-015629 UB-04 · 2026-09-21 | Austin Nelson UHC-77457-34 | 2026-08-21 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $3,114.00 | $1,051.30 | Clean approval | — | Approved |
| CLM-2026-015023 CMS-1500 · 2026-09-21 | Martha Jimenez UHC-80991-11 | 2026-08-13 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97140 | $348.00 | $131.60 | Clean approval | — | Approved |
| CLM-2026-006450 UB-04 · 2026-09-21 | Nathan Tran UHC-26240-33 | 2026-09-19 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378 | $2,766.00 | $344.74 | Clean approval | — | Approved |
| CLM-2026-005459 CMS-1500 · 2026-09-21 | Lisa Chapman no member ID | 2026-09-16 Office | Heritage Medical Group Family Medicine · out of network | 90471, 99214 | $259.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-005430 CMS-1500 · 2026-09-21 | John Lee UHC-76890-70 | 2026-08-24 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · out of network | 80053, 85025 | $129.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-028220 CMS-1500 · 2026-09-20 | Douglas Phillips UHC-74719-65 | 2026-09-05 Telehealth | Canyon Counseling Center Behavioral Health · out of network | 99214 | $207.00 | $43.15 | Clean approval | — | Approved |
| CLM-2026-022023 CMS-1500 · 2026-09-20 | Matthew Vega UHC-91944-19 | 2026-08-23 Office | Canyon Counseling Center Behavioral Health · out of network | 90837 | $260.00 | $42.00 | Clean approval | — | Approved |
| CLM-2026-017081 UB-04 · 2026-09-20 | Christine Powell UHC-91272-76 | 2026-08-17 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285 | $3,007.00 | $1,103.15 | Clean approval | — | Approved |
| CLM-2026-015827 CMS-1500 · 2026-09-20 | Judith Vasquez UHC-02361-56 | 2026-09-17 Office | Unity Primary Care Associates Family Medicine · out of network | 90471, 99214 | $269.00 | $107.10 | Clean approval | — | Approved |
| CLM-2026-015607 CMS-1500 · 2026-09-20 | Mason Rios UHC-34110-11 | 2026-08-28 Office | Valley Skin Care Associates Dermatology · out of network | 99213 | $191.00 | $25.95 | Clean approval | — | Approved |
| CLM-2026-015436 UB-04 · 2026-09-20 | Joshua Harper UHC-85497-41 | 2026-08-19 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 71046, 99283 | $1,059.00 | $381.60 | Clean approval | — | Approved |
| CLM-2026-010822 CMS-1500 · 2026-09-20 | Kyle Li UHC-25227-10 | 2026-08-30 Office | Harbor Medical Group Internal Medicine · out of network | 99215 | $370.00 | $146.50 | Clean approval | — | Approved |
| CLM-2026-008964 CMS-1500 · 2026-09-20 | Philip Ortiz UHC-37413-99 | 2026-09-13 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 83036 | $112.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-008790 CMS-1500 · 2026-09-20 | Eric Burke no member ID | 2026-09-12 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $192.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-008332 CMS-1500 · 2026-09-20 | Carol Munoz no member ID | 2026-08-17 Office | Meadow GI Associates Gastroenterology · out of network | 99214 | $290.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002614 CMS-1500 · 2026-09-20 | Heather Vazquez UHC-60010-83 | 2026-08-17 Office | Lakeside Medical Group Family Medicine · out of network | 36415, 99203, 90471 | $291.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032028 UB-04 · 2026-09-19 | Hannah Wlliams UHC-36369-69 | 2026-09-03 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285, 99284, 96374 | $4,065.00 | — | Left for review NET | — | Needs review |
| CLM-2026-026786 CMS-1500 · 2026-09-19 | Jesse Weaver UHC-76848-80 | 2026-08-15 Office | Lakeside Endocrine Associates Endocrinology · out of network | 83036 | $42.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-018770 CMS-1500 · 2026-09-19 | Stephanie Oliver UHC-40061-23 | 2026-08-15 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 80053, 80061 | $156.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-015257 CMS-1500 · 2026-09-19 | Donna Bell UHC-23412-40 | 2026-08-27 Office | Harbor Medical Group Internal Medicine · out of network | 80053, 93000 | $143.00 | $39.35 | Clean approval | — | Approved |
| CLM-2026-015245 UB-04 · 2026-09-19 | Camila Santos UHC-31286-37 | 2026-09-10 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 76700 | $3,424.00 | $565.80 | Clean approval | — | Approved |
| CLM-2026-015095 CMS-1500 · 2026-09-19 | Christina Obrien UHC-57093-33 | 2026-09-15 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $291.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-014429 UB-04 · 2026-09-19 | Katherine Payne UHC-90245-36 | 2026-09-15 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $49,343.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-014180 CMS-1500 · 2026-09-19 | Mason Ferguson UHC-99590-17 | 2026-09-11 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 99214, 99215 | $527.00 | $212.15 | Clean approval | — | Approved |
| CLM-2026-014002 CMS-1500 · 2026-09-19 | Kenneth Day UHC-80408-04 | 2026-08-12 Office | Harbor Medical Group Internal Medicine · out of network | 80053, 99214 | $345.00 | $128.25 | Clean approval | — | Approved |
| CLM-2026-012455 CMS-1500 · 2026-09-19 | Janet Sanchez UHC-19523-28 | 2026-09-11 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086 | $70.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010561 UB-04 · 2026-09-19 | Michael Stone UHC-84625-12 | 2026-08-24 Inpatient hospital | Unity Internal Medicine Associates Internal Medicine · out of network | 99232 | $188.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-006447 CMS-1500 · 2026-09-19 | Dorothy Gray UHC-49733-88 | 2026-08-19 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 87086, 80061 | $125.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-006152 CMS-1500 · 2026-09-19 | Peter Patel UHC-99963-63 | 2026-08-06 Office | Lakeside Medical Group Family Medicine · out of network | 99214 | $273.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-005350 CMS-1500 · 2026-09-19 | Vincent Palmer UHC-31592-87 | 2026-08-05 Office | Lakeside Medical Group Family Medicine · out of network | 90471, 99395, 99203 | $482.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-003147 CMS-1500 · 2026-09-19 | Lisa Porter UHC-43480-38 | 2026-08-21 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 85025, 83036 | $123.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-000323 CMS-1500 · 2026-09-19 | Santiago Crawford no member ID | 2026-09-09 Office | Valley Skin Care Associates Dermatology · out of network | 11102, 17110 | $504.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-032392 CMS-1500 · 2026-09-18 | Sharon Aguylar UHC-98678-80 | 2026-09-09 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 83036 | $46.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-031359 UB-04 · 2026-09-18 | Maria Carlson UHC-01702-71 | 2026-09-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046 | $130.00 | — | Left for review NET | — | Needs review |
| CLM-2026-030159 CMS-1500 · 2026-09-18 | Linda Wong UHC-06165-19 | 2026-08-17 Office | Meadow Heart Institute Cardiology · out of network | 99214 | $244.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-027615 UB-04 · 2026-09-18 | Valentina Scott UHC-56762-01 | 2026-08-12 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 96374, 99283 | $922.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025915 CMS-1500 · 2026-09-18 | Anrew Ramos UHC-09140-27 | 2026-08-09 Office | Unity Primary Care Associates Family Medicine · out of network | 99213, 99214 | $402.00 | $140.90 | Clean approval | — | Approved |
| CLM-2026-024178 CMS-1500 · 2026-09-18 | Marcus Warren no member ID | 2026-09-02 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 87086, 85025, 83036 | $172.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-018657 CMS-1500 · 2026-09-18 | Virginia Marrtin UHC-82287-41 | 2026-09-07 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 87086 | $145.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-016412 CMS-1500 · 2026-09-18 | Theresa Hoffman UHC-15893-12 | 2026-08-05 Office | Lakeside Medical Group Family Medicine · out of network | 99203, 36415, 99214 | $451.00 | $162.95 | Clean approval | — | Approved |
| CLM-2026-014340 UB-04 · 2026-09-18 | Marcus Alexander UHC-89293-82 | 2026-08-13 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 71046 | $174.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-012822 CMS-1500 · 2026-09-18 | Christopher Harris UHC-90418-51 | 2026-08-24 Office | Canyon Counseling Center Behavioral Health · out of network | 90791, 90837, 90834 | $867.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006755 CMS-1500 · 2026-09-18 | Eugene Spencer UHC-72821-85 | 2026-08-21 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086, 85025 | $113.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003640 CMS-1500 · 2026-09-18 | Billy Weaver UHC-92169-35 | 2026-09-03 Office | Lakeside Endocrine Associates Endocrinology · out of network | 99215 | $359.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-003589 UB-04 · 2026-09-18 | Bryan Black UHC-11439-98 | 2026-09-03 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 74177 | $3,641.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-034583 UB-04 · 2026-09-17 | Donald Mejia UHC-18967-39 | 2026-02-24 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046, 99285 | $2,180.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-030331 CMS-1500 · 2026-09-17 | Michael Bishop UHC-40617-39 | 2026-08-19 Office | Lakeside Medical Group Family Medicine · out of network | 90471 | $45.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-028007 UB-04 · 2026-09-17 | Michael Schultz UHC-55567-38 | 2026-08-03 Outpatient hospital | Unity Imaging Center Radiology · out of network | 74177, 71046 | $1,932.00 | — | Denied by rule CO204 | — | 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.