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-2026-022605 UB-04 · 2026-09-11 | Jeffrey Santos UHC-37212-67 | 2026-08-08 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 71046, 74177 | $1,502.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-021464 CMS-1500 · 2026-09-11 | Omar Santiago UHC-90592-10 | 2026-08-21 Office | Canyon Counseling Center Behavioral Health · out of network | 90837 | $290.00 | $70.50 | Clean approval | — | Approved |
| CLM-2026-019267 CMS-1500 · 2026-09-11 | Melissa Palmer UHC-34264-24 | 2026-08-22 Office | Unity Primary Care Associates Family Medicine · out of network | 99213 | $159.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-016330 UB-04 · 2026-09-11 | Denise Adams no member ID | 2026-08-18 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 70553 | $1,975.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-013609 CMS-1500 · 2026-09-11 | Jennfier Carroll UHC-60488-61 | 2026-08-10 Office | Evergreen Dermatology Clinic Dermatology · out of network | 99213, 11102 | $474.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006139 CMS-1500 · 2026-09-11 | Sara Scott UHC-06212-17 | 2026-08-29 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90834, 90837 | $404.00 | $141.80 | Clean approval | — | Approved |
| CLM-2026-002999 CMS-1500 · 2026-09-11 | Jacob Vazquez no member ID | 2026-09-02 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 85025 | $48.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-031913 CMS-1500 · 2026-09-10 | Helen Mills UHC-72226-56 | 2026-09-07 Office | Northgate Primary Care Associates Family Medicine · out of network | 36415 | $21.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-031053 CMS-1500 · 2026-09-10 | Ryan Mendez UHC-79204-52 | 2026-08-13 Office | Valley Primary Care Associates Family Medicine · out of network | 99213, 99214 | $434.00 | $170.30 | Clean approval | — | Approved |
| CLM-2026-030434 CMS-1500 · 2026-09-10 | Beverly Payne UHC-24738-29 | 2026-08-16 Office | Harbor Primary Care Associates Family Medicine · out of network | 90471 | $41.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030223 CMS-1500 · 2026-09-10 | Susan Vazquez UHC-65517-83 | 2026-08-06 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 87086 | $69.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-029710 UB-04 · 2026-09-10 | Isabella Bell UHC-68295-82 | 2026-08-06 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · out of network | 99232 | $200.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-025712 CMS-1500 · 2026-09-10 | Austin Johnston UHC-13663-84 | 2026-09-03 Office | Canyon Counseling Center Behavioral Health · out of network | 90837 | $283.00 | $77.35 | Clean approval | — | Approved |
| CLM-2026-023164 CMS-1500 · 2026-09-10 | Kenneth Kennedy UHC-75623-35 | 2026-08-28 Office | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $199.00 | $29.55 | Clean approval | — | Approved |
| CLM-2026-020448 UB-04 · 2026-09-10 | Amanda Fox UHC-00623-39 | 2026-05-04 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721, 29881 | $8,998.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-014812 CMS-1500 · 2026-09-10 | Ethan Weber UHC-74911-42 | 2026-09-06 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 83036 | $69.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-013078 CMS-1500 · 2026-09-10 | Roy Wilson UHC-47553-11 | 2026-09-01 Office | Sunrise Dermatology Clinic Dermatology · out of network | 99213 | $206.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-011917 CMS-1500 · 2026-09-10 | Rebecca Collins UHC-41980-63 | 2026-08-30 Office | Heritage Medical Group Family Medicine · out of network | 99213 | $205.00 | $52.25 | Clean approval | — | Approved |
| CLM-2026-010587 UB-04 · 2026-09-10 | Ryan Richards UHC-91216-27 | 2026-08-10 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $8,803.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-010357 CMS-1500 · 2026-09-10 | Bruce Morris UHC-06635-80 | 2026-08-05 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 87086, 83036 | $110.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-010253 CMS-1500 · 2026-09-10 | Amy Vasquez UHC-05827-31 | 2026-08-15 Office | Lakeside Medical Group Family Medicine · out of network | 99203 | $229.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-009892 CMS-1500 · 2026-09-10 | Chris Park UHC-85719-74 | 2026-08-30 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 87086, 80061, 83036 | $166.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009786 UB-04 · 2026-09-10 | Elijah Clark UHC-58917-79 | 2026-08-09 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 43239 | $2,081.00 | $11.46 | Clean approval | — | Approved |
| CLM-2026-007936 CMS-1500 · 2026-09-10 | Sara Padilla UHC-35197-28 | 2026-09-05 Office | Unity Primary Care Associates Family Medicine · out of network | 99213 | $172.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-004446 CMS-1500 · 2026-09-10 | Michael Patel UHC-44001-21 | 2026-08-31 Office | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $214.00 | $46.30 | Clean approval | — | Approved |
| CLM-2026-004391 UB-04 · 2026-09-10 | Larry Black UHC-17622-95 | 2026-08-30 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285, 71046 | $3,115.00 | $1,251.75 | Clean approval | — | Approved |
| CLM-2026-002808 CMS-1500 · 2026-09-10 | Susan Vazquez UHC-65517-83 | 2026-08-14 Office | Harbor Primary Care Associates Family Medicine · out of network | 90471, 99213 | $210.00 | $74.25 | Clean approval | — | Approved |
| CLM-2026-001449 CMS-1500 · 2026-09-10 | Amy Myers UHC-78281-86 | 2026-08-29 Office | Valley Skin Care Associates Dermatology · out of network | 11403, 11102 | $705.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-033562 CMS-1500 · 2026-09-09 | Philip Morgan UHC-74681-79 | 2026-08-12 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 85025, 87086, 80053 | $147.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032340 UB-04 · 2026-09-09 | Logan Washington UHC-85073-69 | 2026-08-26 Inpatient hospital | Harbor Medical Group Internal Medicine · out of network | 99232 | $211.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-031217 CMS-1500 · 2026-09-09 | Willie Woods UHC-98244-27 | 2026-09-07 Office | Lakeside Medical Group Family Medicine · out of network | 99395, 99203, 99214 | $799.00 | $319.55 | Clean approval | — | Approved |
| CLM-2026-030177 CMS-1500 · 2026-09-09 | Donald Carr UHC-61234-06 | 2026-08-06 Office | Sunrise Digestive Health Center Gastroenterology · out of network | 99214 | $236.00 | $31.20 | Clean approval | — | Approved |
| CLM-2026-030091 CMS-1500 · 2026-09-09 | Dennis Bradley UHC-87114-24 | 2026-08-17 Office | Northgate Primary Care Associates Family Medicine · out of network | 99395, 90471 | $319.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-029568 UB-04 · 2026-09-09 | Janice Lnae UHC-62285-48 | 2026-08-05 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 77067, 74177 | $2,383.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-029001 UB-04 · 2026-09-09 | Not attached | 2026-08-31 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,744.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-026954 CMS-1500 · 2026-09-09 | Gary Hoffman no member ID | 2026-08-10 Office | Northgate Primary Care Associates Family Medicine · out of network | 99214, 36415 | $333.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-023795 CMS-1500 · 2026-09-09 | Emma Mitchell UHC-83138-42 | 2026-08-18 Office | Harbor Medical Group Internal Medicine · out of network | 93000, 99214 | $354.00 | $132.30 | Clean approval | — | Approved |
| CLM-2026-021275 CMS-1500 · 2026-09-09 | Scott Ward UHC-40403-01 | 2026-09-04 Office | Valley Skin Care Associates Dermatology · out of network | 99213 | $179.00 | $20.55 | Clean approval | — | Approved |
| CLM-2026-021050 UB-04 · 2026-09-09 | Nicole Bryant UHC-87960-16 | 2026-08-05 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93458, 93306 | $9,072.00 | $3,075.99 | Clean approval | — | Approved |
| CLM-2026-020365 CMS-1500 · 2026-09-09 | Ana Banks UHC-34703-52 | 2026-08-27 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 83036, 80061 | $89.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-020064 UB-04 · 2026-09-09 | Christine Hughes UHC-27448-55 | 2026-08-14 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 96374, 99284 | $1,805.00 | $707.85 | Clean approval | — | Approved |
| CLM-2026-017146 UB-04 · 2026-09-09 | Jacob Kelly UHC-59781-92 | 2026-08-22 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $2,203.00 | $697.38 | Clean approval | — | Approved |
| CLM-2026-013695 CMS-1500 · 2026-09-09 | Wayne Carpenter UHC-08752-97 | 2026-08-22 Office | Harbor Medical Group Internal Medicine · out of network | 99215 | $345.00 | $135.25 | Clean approval | — | Approved |
| CLM-2026-013507 CMS-1500 · 2026-09-09 | Jonathan Wang UHC-87057-53 | 2026-08-17 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 93000 | $83.00 | $12.35 | Clean approval | — | Approved |
| CLM-2026-010002 UB-04 · 2026-09-09 | Gary Peters no member ID | 2026-08-28 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99283, 99285 | $3,978.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-009811 CMS-1500 · 2026-09-09 | Abby Arnold UHC-99410-20 | 2026-08-22 Office | Harbor Medical Group Internal Medicine · out of network | 99214, 80053 | $309.00 | $114.05 | Clean approval | — | Approved |
| CLM-2026-004870 CMS-1500 · 2026-09-09 | Jordan Bowman UHC-13738-33 | 2026-08-25 Office | Unity Internal Medicine Associates Internal Medicine · out of network | 99214, 93000, 80053 | $398.00 | $159.10 | Clean approval | — | Approved |
| CLM-2026-000694 UB-04 · 2026-09-09 | Kimberly Munoz UHC-59562-45 | 2026-08-20 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 73721, 29881 | $12,860.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-033482 UB-04 · 2026-09-08 | Mark Fox UHC-99909-59 | 2026-08-13 Inpatient hospital | Harbor Medical Group Internal Medicine · out of network | 99232 | $256.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-029657 UB-04 · 2026-09-08 | Zachary Green UHC-03711-37 | 2026-08-31 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 96374, 71046, 99284 | $1,509.00 | $587.70 | 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.