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-2026-028367 UB-04 · 2026-09-08 | Walter Clark UHC-73064-35 | 2026-08-25 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285 | $1,736.00 | — | Left for review NET | — | Needs review |
| CLM-2026-027779 CMS-1500 · 2026-09-08 | Jeffrey Carlson UHC-10902-45 | 2026-07-28 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 87086, 80061, 80053, 83036 | $236.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-023555 CMS-1500 · 2026-09-08 | Cynthia Perkins UHC-19178-80 | 2026-08-23 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053 | $66.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-022632 UB-04 · 2026-09-08 | Christopher Cunningham UHC-92637-64 | 2026-07-26 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 88305, 45378 | $2,490.00 | $168.10 | Clean approval | — | Approved |
| CLM-2026-022423 CMS-1500 · 2026-09-08 | Hannah Harris UHC-42317-04 | 2026-08-09 Office | Evergreen Medical Group Internal Medicine · out of network | 93000, 99215, 99214 | $744.00 | $309.80 | Clean approval | — | Approved |
| CLM-2026-021848 CMS-1500 · 2026-09-08 | Betty Rose UHC-23050-58 | 2026-08-22 Office | Heritage Medical Group Family Medicine · out of network | 36415, 99214 | $306.00 | $126.45 | Clean approval | — | Approved |
| CLM-2026-021557 CMS-1500 · 2026-09-08 | Don Richardson UHC-97967-62 | 2026-08-11 Office | Harbor Primary Care Associates Family Medicine · out of network | 99203 | $260.00 | $97.00 | Clean approval | — | Approved |
| CLM-2026-020798 CMS-1500 · 2026-09-08 | Emily Washington no member ID | 2026-09-02 Office | Lakeside Medical Group Family Medicine · out of network | 99203, 99395 | $473.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-015883 CMS-1500 · 2026-09-08 | Joyce Duncan UHC-27486-99 | 2026-08-19 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $243.00 | $59.35 | Clean approval | — | Approved |
| CLM-2026-013047 CMS-1500 · 2026-09-08 | Gabriel Chen UHC-95467-99 | 2026-09-01 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053 | $68.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-012511 CMS-1500 · 2026-09-08 | Joyce Hunt UHC-86921-20 | 2026-07-26 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 93000 | $62.00 | $2.90 | Clean approval | — | Approved |
| CLM-2026-012142 CMS-1500 · 2026-09-08 | Dylan Smith UHC-24470-31 | 2026-08-13 Office | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 99213, 20610 | $491.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-006105 CMS-1500 · 2026-09-08 | Kelly Richardson UHC-69622-24 | 2026-09-05 Office | Valley Skin Care Associates Dermatology · out of network | 11102, 17110 | $604.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-005985 CMS-1500 · 2026-09-08 | Diane Howell UHC-24431-19 | 2026-09-03 Office | Evergreen Medical Group Internal Medicine · out of network | 80053 | $45.00 | $0.25 | Clean approval | — | Approved |
| CLM-2026-004817 UB-04 · 2026-09-08 | Sara Ramos UHC-90845-02 | 2026-08-13 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,515.00 | $331.75 | Clean approval | — | Approved |
| CLM-2026-034231 UB-04 · 2026-09-07 | Jonathan Johnston UHC-00925-87 | 2026-08-17 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283, 96374 | $1,045.00 | $220.25 | Clean approval | — | Approved |
| CLM-2026-031652 UB-04 · 2026-09-07 | Jack Contreras UHC-93423-21 | 2026-08-12 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 76700 | $526.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030220 CMS-1500 · 2026-09-07 | Murray Pamela UHC-21642-27 | 2026-08-26 Office | Unity Primary Care Associates Family Medicine · out of network | 36415 | $21.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-024620 UB-04 · 2026-09-07 | Danel Mejia no member ID | 2026-08-19 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374 | $150.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-023957 UB-04 · 2026-09-07 | Kyle Simpson UHC-10810-94 | 2026-08-17 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 77067 | $3,226.00 | $161.12 | Clean approval | — | Approved |
| CLM-2026-019575 UB-04 · 2026-09-07 | Carlos Ryan UHC-94370-95 | 2026-07-24 Inpatient hospital | Harbor Medical Group Internal Medicine · out of network | 99232 | $197.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-017563 CMS-1500 · 2026-09-07 | Susan Hill UHC-93575-40 | 2026-08-13 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97161, 97014 | $519.00 | $203.55 | Clean approval | — | Approved |
| CLM-2026-017429 UB-04 · 2026-09-07 | Sarah Oliver UHC-32902-31 | 2026-08-20 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 77067, 74177, 71046 | $1,857.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-016024 CMS-1500 · 2026-09-07 | Christine Barnes UHC-70917-32 | 2026-09-01 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $276.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-015668 UB-04 · 2026-09-07 | Thomas Berry UHC-80771-70 | 2026-08-28 Outpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,855.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-010687 UB-04 · 2026-09-07 | Carl Bryant UHC-04665-45 | 2026-08-02 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93458, 93306 | $6,309.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-009743 UB-04 · 2026-09-07 | Gregory Cruz UHC-66888-17 | 2026-08-27 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · out of network | 99232 | $200.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-009196 CMS-1500 · 2026-09-07 | Teresa Fisher UHC-20504-81 | 2026-08-20 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 87086, 85025 | $132.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-004998 CMS-1500 · 2026-09-07 | Omar Thomas UHC-30987-31 | 2026-09-04 Office | Lakeside Medical Group Family Medicine · out of network | 99213 | $201.00 | $70.45 | Clean approval | — | Approved |
| CLM-2026-002032 CMS-1500 · 2026-09-07 | Carol Hughes UHC-70476-15 | 2026-08-11 Office | Cornerstone Family Practice Family Medicine · out of network | 99213, 99214 | $506.00 | $187.70 | Clean approval | — | Approved |
| CLM-2026-000268 CMS-1500 · 2026-09-07 | Keith Larson UHC-83530-31 | 2026-08-14 Office | Sunrise Medical Group Internal Medicine · out of network | 80053 | $70.00 | $6.50 | Clean approval | — | Approved |
| CLM-2026-033090 CMS-1500 · 2026-09-06 | Benjamin McCoy UHC-82674-65 | 2026-08-11 Office | Lakeside Endocrine Associates Endocrinology · out of network | 83036, 99214 | $348.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-030264 CMS-1500 · 2026-09-06 | Cynthia Jenkins UHC-84353-34 | 2026-07-27 Office | Harbor Medical Group Internal Medicine · out of network | 99215, 99214 | $627.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-030206 UB-04 · 2026-09-06 | Isabella Santos UHC-21801-43 | 2026-08-12 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 88305, 45378 | $1,930.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-029965 CMS-1500 · 2026-09-06 | Joan Maldonado UHC-93987-64 | 2026-07-24 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 93000 | $83.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-028605 CMS-1500 · 2026-09-06 | Gabriel Padilla UHC-42797-52 | 2026-08-29 Office | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 99213 | $194.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-026812 CMS-1500 · 2026-09-06 | David Armstrong UHC-36225-03 | 2026-08-24 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11102 | $207.00 | $18.15 | Clean approval | — | Approved |
| CLM-2026-026012 CMS-1500 · 2026-09-06 | Nancy Watkins UHC-11052-08 | 2026-08-08 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97161 | $491.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-020989 CMS-1500 · 2026-09-06 | Michael Porter UHC-50791-32 | 2026-07-25 Office | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 99213 | $189.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-019307 CMS-1500 · 2026-09-06 | Danielle Carpenter UHC-39373-55 | 2026-08-08 Office | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $238.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-017691 CMS-1500 · 2026-09-06 | Aisha Chen UHC-11222-74 | 2026-07-24 Office | Sunrise Dermatology Clinic Dermatology · out of network | 99213, 17110 | $436.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-017635 CMS-1500 · 2026-09-06 | Kayla Vargas UHC-09167-84 | 2026-08-11 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11403, 11102 | $709.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-015793 UB-04 · 2026-09-06 | Terry Lawson UHC-03302-69 | 2026-07-29 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93458, 93306 | $9,149.00 | $2,353.00 | Clean approval | — | Approved |
| CLM-2026-008923 CMS-1500 · 2026-09-06 | Nathan Hall UHC-65209-99 | 2026-08-26 Office | Northgate Primary Care Associates Family Medicine · out of network | 99395 | $312.00 | $110.40 | Clean approval | — | Approved |
| CLM-2026-007877 CMS-1500 · 2026-09-06 | Cheryl Castro UHC-39022-48 | 2026-08-30 Office | Cornerstone Family Practice Family Medicine · out of network | 36415 | $12.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-007091 CMS-1500 · 2026-09-06 | Bobby Riley UHC-22969-34 | 2026-08-06 Office | Harbor Primary Care Associates Family Medicine · out of network | 90471 | $44.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-005076 UB-04 · 2026-09-06 | Paul Knight UHC-66169-12 | 2026-08-19 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 29881 | $10,961.00 | $3,194.74 | Clean approval | — | Approved |
| CLM-2026-000840 UB-04 · 2026-09-06 | Dennis Spencer UHC-48894-38 | 2026-08-16 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 77067, 74177, 71046 | $2,729.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-034111 CMS-1500 · 2026-09-05 | Liz Robinson UHC-80513-60 | 2026-08-21 Office | Harbor Primary Care Associates Family Medicine · out of network | 99213 | $203.00 | $71.35 | Clean approval | — | Approved |
| CLM-2026-032115 CMS-1500 · 2026-09-05 | Kimberly Robertson UHC-53237-67 | 2026-08-04 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 83036, 80061 | $148.00 | $0.00 | 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.