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-2026-027728 UB-04 · 2026-09-17 | Carlos Nguyen UHC-33573-55 | 2026-08-23 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 71046 | $226.00 | — | Left for review NET | — | Needs review |
| CLM-2026-027327 CMS-1500 · 2026-09-17 | Thomas Morales UHC-74441-71 | 2026-07-28 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11403 | $719.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-027209 CMS-1500 · 2026-09-17 | Angela Marquez UHC-98892-42 | 2026-09-03 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 20610, 99213 | $515.00 | $191.75 | Clean approval | — | Approved |
| CLM-2026-018860 UB-04 · 2026-09-17 | Ahmed Wallace UHC-37460-16 | 2026-08-23 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553 | $2,270.00 | $635.67 | Clean approval | — | Approved |
| CLM-2026-017107 UB-04 · 2026-09-17 | Jeffrey Phillips UHC-08341-30 | 2026-08-24 Inpatient hospital | Sunrise Medical Group Internal Medicine · out of network | 99232 | $209.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-016646 UB-04 · 2026-09-17 | Arjun Sullivan UHC-69356-13 | 2026-08-16 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285 | $2,470.00 | — | Left for review NET | — | Needs review |
| CLM-2026-016201 UB-04 · 2026-09-17 | Noah Burton UHC-87151-33 | 2026-08-13 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $2,395.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010883 CMS-1500 · 2026-09-17 | Keith Collins UHC-13066-46 | 2026-09-04 Office | Harbor Primary Care Associates Family Medicine · out of network | 36415, 99203 | $243.00 | $101.70 | Clean approval | — | Approved |
| CLM-2026-010850 CMS-1500 · 2026-09-17 | Michelle Peters UHC-18230-13 | 2026-09-11 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $225.00 | $51.25 | Clean approval | — | Approved |
| CLM-2026-010511 CMS-1500 · 2026-09-17 | Jean Marquez UHC-24571-43 | 2026-08-16 Office | Cornerstone Family Practice Family Medicine · out of network | 90471, 99214 | $349.00 | $141.75 | Clean approval | — | Approved |
| CLM-2026-008834 UB-04 · 2026-09-17 | Terry Le UHC-29632-13 | 2026-08-29 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378 | $1,643.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-006520 CMS-1500 · 2026-09-17 | Samuel Gray UHC-28025-58 | 2026-08-07 Office | Heritage Medical Group Family Medicine · out of network | 99203, 99213, 99395 | $671.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-005951 UB-04 · 2026-09-17 | George Sims UHC-90175-74 | 2026-08-10 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93306, 93015 | $1,865.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003573 UB-04 · 2026-09-17 | Dylan Robinson UHC-25806-40 | 2026-09-13 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 77067 | $330.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003001 CMS-1500 · 2026-09-17 | Carl Bennett UHC-25577-22 | 2026-08-22 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 83036, 87086 | $76.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-001413 UB-04 · 2026-09-17 | Teresa Cunningham UHC-56407-99 | 2026-08-30 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,969.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-033136 CMS-1500 · 2026-09-16 | David Long UHC-02750-47 | 2026-09-08 Office | Sunrise Medical Group Internal Medicine · out of network | 99214 | $212.00 | $70.40 | Clean approval | — | Approved |
| CLM-2026-031826 CMS-1500 · 2026-09-16 | Natalie Ryan UHC-61600-45 | 2026-08-24 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 83036, 85025, 80061 | $209.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-028118 CMS-1500 · 2026-09-16 | Maria Jenkins UHC-97871-08 | 2026-08-25 Office | Harbor Medical Group Internal Medicine · out of network | 99215 | $358.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026367 UB-04 · 2026-09-16 | Denise Jackson UHC-63308-42 | 2026-08-13 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306, 93015 | $1,845.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-023406 CMS-1500 · 2026-09-16 | Lawrence Garza UHC-41043-26 | 2026-08-12 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $352.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-021558 CMS-1500 · 2026-09-16 | Don Richardson UHC-97967-62 | 2026-08-11 Office | Harbor Primary Care Associates Family Medicine · out of network | 99203 | $260.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-020637 UB-04 · 2026-09-16 | Julie Hudson UHC-36730-68 | 2026-08-05 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 70553 | $3,334.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-016270 UB-04 · 2026-09-16 | Judy Schmidt UHC-10609-39 | 2026-09-10 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285, 96374, 99283 | $3,005.00 | $1,202.25 | Clean approval | — | Approved |
| CLM-2026-013505 CMS-1500 · 2026-09-16 | Dorothy Padilla UHC-53088-33 | 2026-08-04 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 87086 | $57.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010845 UB-04 · 2026-09-16 | Jenkins Bryan UHC-40066-17 | 2026-09-02 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 74177, 70553, 76700 | $5,626.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-008171 CMS-1500 · 2026-09-16 | Austin Rose UHC-24245-99 | 2026-09-04 Office | Sunrise Medical Group Internal Medicine · out of network | 80053, 99215 | $481.00 | $186.45 | Clean approval | — | Approved |
| CLM-2026-001145 CMS-1500 · 2026-09-16 | Kimberly Hunter UHC-75741-71 | 2026-08-10 Office | Meadow Heart Institute Cardiology · out of network | 99214 | $241.00 | $68.45 | Clean approval | — | Approved |
| CLM-2026-034165 CMS-1500 · 2026-09-15 | Austin Franklin UHC-70952-25 | 2026-08-23 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · out of network | 83036, 87086, 80053 | $159.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032019 UB-04 · 2026-09-15 | Ralph Ruiz UHC-43941-81 | 2026-08-09 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 77067, 71046, 70553 | $2,809.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-031508 CMS-1500 · 2026-09-15 | Elijah Le UHC-95173-48 | 2026-09-12 Office | Sunrise Medical Group Internal Medicine · out of network | 99215 | $323.00 | $125.35 | Clean approval | — | Approved |
| CLM-2026-031226 CMS-1500 · 2026-09-15 | Sara Ortega UHC-33453-03 | 2026-09-06 Office | Canyon Counseling Center Behavioral Health · out of network | 90837 | $246.00 | $35.70 | Clean approval | — | Approved |
| CLM-2026-030902 UB-04 · 2026-09-15 | Karen Warren UHC-82850-96 | 2026-08-24 Outpatient hospital | Cornerstone Reference Lab Clinical Laboratory · out of network | 70553 | $2,169.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-030234 CMS-1500 · 2026-09-15 | Raymond Castro UHC-84200-38 | 2026-08-12 Office | Valley Skin Care Associates Dermatology · out of network | 11102 | $316.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-027577 UB-04 · 2026-09-15 | Angela Johnston UHC-84082-76 | 2026-04-07 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $48,024.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-026488 UB-04 · 2026-09-15 | Stephanie Porter UHC-07006-03 | 2026-08-31 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 71046 | $130.00 | — | Left for review NET | — | Needs review |
| CLM-2026-023090 CMS-1500 · 2026-09-15 | Kelly Carpenter UHC-64131-81 | 2026-08-21 Office | Northgate Primary Care Associates Family Medicine · out of network | 99203, 90471, 99395 | $598.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-018761 UB-04 · 2026-09-15 | Ahmed Sims UHC-36382-81 | 2026-08-02 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93458 | $8,823.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-017373 CMS-1500 · 2026-09-15 | Luis Boyd UHC-14517-04 | 2026-09-05 Office | Unity Internal Medicine Associates Internal Medicine · out of network | 99214 | $207.00 | $68.15 | Clean approval | — | Approved |
| CLM-2026-015672 UB-04 · 2026-09-15 | Debra Collins UHC-86010-85 | 2026-08-28 Inpatient hospital | Sunrise Medical Group Internal Medicine · out of network | 99232 | $235.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-012958 CMS-1500 · 2026-09-15 | Joan Edwards UHC-88614-34 | 2026-09-02 Office | Harbor Medical Group Internal Medicine · out of network | 99215, 99214, 93000 | $651.00 | $272.95 | Clean approval | — | Approved |
| CLM-2026-012671 UB-04 · 2026-09-15 | Bowman Bowman UHC-86900-82 | 2026-08-31 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046, 99283 | $1,318.00 | $485.55 | Clean approval | — | Approved |
| CLM-2026-012191 UB-04 · 2026-09-15 | Margaret Spencer UHC-91658-38 | 2026-08-08 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99284, 99283, 71046 | $2,961.00 | $1,182.45 | Clean approval | — | Approved |
| CLM-2026-006925 CMS-1500 · 2026-09-15 | Alexis Hunt UHC-21311-85 | 2026-08-13 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 20610, 99213 | $473.00 | $137.85 | Clean approval | — | Approved |
| CLM-2026-004663 UB-04 · 2026-09-15 | Randy Robinson UHC-80582-02 | 2026-08-07 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 71046, 99284, 99283 | $2,389.00 | $1,018.35 | Clean approval | — | Approved |
| CLM-2026-033713 UB-04 · 2026-09-14 | Roy Sanders UHC-81923-33 | 2026-08-18 Outpatient hospital | Valley Skin Care Associates Dermatology · out of network | 70553 | $2,149.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-032583 CMS-1500 · 2026-09-14 | Debra Oliver UHC-96451-85 | 2026-08-08 Office | Heritage Medical Group Family Medicine · out of network | 90471, 99213, 99395 | $569.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-031986 CMS-1500 · 2026-09-14 | Thomas Luna UHC-95083-87 | 2026-08-19 Office | Harbor Medical Group Internal Medicine · out of network | 99214 | $241.00 | $83.45 | Clean approval | — | Approved |
| CLM-2026-031315 UB-04 · 2026-09-14 | Debbie Powell UHC-05099-83 | 2026-08-28 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,635.00 | $269.60 | Clean approval | — | Approved |
| CLM-2026-029763 CMS-1500 · 2026-09-14 | Jose Richardson UHC-61622-11 | 2026-08-06 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97014 | $179.00 | — | 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.