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-2026-031025 CMS-1500 · 2026-09-05 | Anna Fisher UHC-66514-15 | 2026-07-25 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 83036, 80053 | $134.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-027533 UB-04 · 2026-09-05 | Priya Williams UHC-70691-50 | 2026-08-05 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378, 88305 | $2,460.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-026043 UB-04 · 2026-09-05 | Mari Montgomery UHC-23118-53 | 2026-08-25 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $786.00 | $270.00 | Clean approval | — | Approved |
| CLM-2026-023251 UB-04 · 2026-09-05 | Bveerly Sandoval UHC-71693-15 | 2026-08-07 Outpatient hospital | Sunrise Community Hospital Emergency Medicine · out of network | 70553 | $3,428.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-020985 UB-04 · 2026-09-05 | Mason Brown UHC-44719-67 | 2026-08-18 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284, 99283, 99285 | $5,231.00 | $2,103.95 | Clean approval | — | Approved |
| CLM-2026-019851 UB-04 · 2026-09-05 | Alexis Little UHC-97948-59 | 2026-08-16 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284, 99283 | $2,435.00 | — | Left for review NET | — | Needs review |
| CLM-2026-015960 UB-04 · 2026-09-05 | Susan Ward UHC-82540-45 | 2026-08-28 Inpatient hospital | Unity Internal Medicine Associates Internal Medicine · out of network | 99232 | $188.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-014633 CMS-1500 · 2026-09-05 | Nancy Kelley UHC-35134-70 | 2026-07-24 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · out of network | 80061 | $75.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-013458 CMS-1500 · 2026-09-05 | Diana Porter UHC-51105-44 | 2026-08-18 Office | Valley Skin Care Associates Dermatology · out of network | 99213, 11403 | $805.00 | $302.25 | Clean approval | — | Approved |
| CLM-2026-011585 CMS-1500 · 2026-09-05 | Valentina Mejia UHC-96174-01 | 2026-07-23 Office | Valley Skin Care Associates Dermatology · out of network | 11102, 17110 | $475.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006006 CMS-1500 · 2026-09-05 | Diego Gibson UHC-11359-80 | 2026-08-03 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 99215, 93000 | $473.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004761 CMS-1500 · 2026-09-05 | Kevin Cunningham UHC-11004-76 | 2026-08-27 Office | Lakeside Endocrine Associates Endocrinology · out of network | 95251 | $150.00 | $7.50 | Clean approval | — | Approved |
| CLM-2026-003146 CMS-1500 · 2026-09-05 | Lisa Porter UHC-43480-38 | 2026-08-21 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 85025, 83036 | $123.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-002550 UB-04 · 2026-09-05 | Lawrence Tucker no member ID | 2026-08-10 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99285 | $3,080.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002202 CMS-1500 · 2026-09-05 | Brittany Munoz UHC-17677-75 | 2026-08-31 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 80061 | $41.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-001897 UB-04 · 2026-09-05 | Janice Sto UHC-96551-62 | 2026-08-14 Inpatient hospital | Harbor Medical Group Internal Medicine · out of network | 99232, 99215 | $507.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-000872 CMS-1500 · 2026-09-05 | Patricia Wood UHC-51254-08 | 2026-08-29 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 80053, 99214 | $305.00 | $116.55 | Clean approval | — | Approved |
| CLM-2026-000677 UB-04 · 2026-09-05 | Juan Richardson UHC-66465-99 | 2026-08-13 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285, 99284 | $2,956.00 | $980.20 | Clean approval | — | Approved |
| CLM-2026-033875 UB-04 · 2026-09-04 | Ann Alexandre UHC-97453-82 | 2026-08-28 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $6,961.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-030999 UB-04 · 2026-09-04 | Frances Williamson UHC-12909-32 | 2026-08-01 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283 | $634.00 | $35.30 | Clean approval | — | Approved |
| CLM-2026-028238 CMS-1500 · 2026-09-04 | Hannah Martin UHC-93034-52 | 2026-08-18 Office | Harbor Medical Group Internal Medicine · out of network | 99214, 93000 | $320.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-020511 CMS-1500 · 2026-09-04 | Linda Sanchez UHC-89911-60 | 2026-07-25 Office | Unity Primary Care Associates Family Medicine · out of network | 99214, 36415 | $312.00 | $115.40 | Clean approval | — | Approved |
| CLM-2026-020506 UB-04 · 2026-09-04 | Jesse Wilson UHC-96437-49 | 2026-08-01 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 88305 | $278.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-019965 UB-04 · 2026-09-04 | Hannah Rose UHC-38319-19 | 2026-08-09 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283, 99285 | $2,618.00 | — | Left for review NET CO97 | — | Needs review |
| CLM-2026-011842 UB-04 · 2026-09-04 | Victoria Cruz no member ID | 2026-08-03 Outpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $2,267.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-010692 UB-04 · 2026-09-04 | Donna Schmidt UHC-88832-04 | 2026-08-30 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $38,434.00 | — | Left for review CO16 HIGH | — | Needs review |
| CLM-2026-010677 UB-04 · 2026-09-04 | Elijah Ryan UHC-60945-02 | 2026-07-27 Inpatient hospital | Riverside Internal Medicine Associates Internal Medicine · out of network | 99232 | $252.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010565 CMS-1500 · 2026-09-04 | Brandon Watson UHC-65481-98 | 2026-07-29 Office | Lakeside Medical Group Family Medicine · out of network | 99395 | $226.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-002936 UB-04 · 2026-09-04 | Julie Lewis UHC-04157-39 | 2026-08-14 Outpatient hospital | Lakeside Endocrine Associates Endocrinology · out of network | 70553 | $1,873.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-030852 UB-04 · 2026-09-03 | Omar Smith UHC-23045-19 | 2026-08-27 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285, 99283 | $3,427.00 | — | Left for review NET | — | Needs review |
| CLM-2026-026616 UB-04 · 2026-09-03 | Sharon Cooper UHC-81455-82 | 2026-08-26 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93015, 93458 | $5,856.00 | $1,432.10 | Clean approval | — | Approved |
| CLM-2026-024176 UB-04 · 2026-09-03 | Andrea Coleman UHC-21993-89 | 2026-08-06 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 74177 | $2,406.00 | $262.17 | Clean approval | — | Approved |
| CLM-2026-018669 CMS-1500 · 2026-09-03 | Frances Graham UHC-93802-82 | 2026-08-05 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 87086, 83036, 80053, 85025 | $275.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-016176 UB-04 · 2026-09-03 | Dorothy Russell UHC-99625-04 | 2026-08-07 Outpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 73721, 29881 | $12,198.00 | $4,675.73 | Clean approval | — | Approved |
| CLM-2026-012141 CMS-1500 · 2026-09-03 | Dylan Smith UHC-24470-31 | 2026-08-13 Office | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 99213, 20610 | $491.00 | $145.95 | Clean approval | — | Approved |
| CLM-2026-011919 UB-04 · 2026-09-03 | Sara Cox UHC-33317-40 | 2026-08-23 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 76700 | $2,603.00 | $328.33 | Clean approval | — | Approved |
| CLM-2026-006333 UB-04 · 2026-09-03 | Maria Tran UHC-91217-99 | 2026-08-14 Outpatient hospital | Valley Skin Care Associates Dermatology · out of network | 70553 | $3,230.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-002920 UB-04 · 2026-09-03 | Alice Lynch UHC-12665-44 | 2026-08-20 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306, 93015 | $1,977.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-002629 CMS-1500 · 2026-09-03 | Amy Washington UHC-41659-76 | 2026-08-13 Office | Lakeside Medical Group Family Medicine · out of network | 99213, 99395 | $545.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001040 UB-04 · 2026-09-03 | Aisha Santos UHC-20680-09 | 2026-08-14 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 71046 | $124.00 | — | Left for review NET | — | Needs review |
| CLM-2026-033677 UB-04 · 2026-09-02 | Tyler Kelley UHC-71559-70 | 2026-08-25 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99284 | $1,050.00 | — | Left for review NET | — | Needs review |
| CLM-2026-033330 CMS-1500 · 2026-09-02 | Kenneth Mitchell UHC-90378-34 | 2026-08-29 Office | Evergreen Medical Group Internal Medicine · out of network | 99215, 80053 | $386.00 | $148.70 | Clean approval | — | Approved |
| CLM-2026-032491 CMS-1500 · 2026-09-02 | Sofia Arnold UHC-41265-38 | 2026-07-31 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 80053, 83036, 80061, 87086 | $180.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026527 CMS-1500 · 2026-09-02 | Abigail Ruiz UHC-10453-32 | 2026-08-22 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90791 | $399.00 | $139.55 | Clean approval | — | Approved |
| CLM-2026-024904 CMS-1500 · 2026-09-02 | Charles Gonzalez UHC-02909-70 | 2026-08-20 Office | Valley Skin Care Associates Dermatology · out of network | 17110 | $276.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-018354 UB-04 · 2026-09-02 | Joyce Rice UHC-64786-05 | 2026-08-24 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99285 | $2,321.00 | $794.45 | Clean approval | — | Approved |
| CLM-2026-016850 CMS-1500 · 2026-09-02 | Abigail Reynolds UHC-56842-65 | 2026-07-22 Office | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 20610, 99213 | $430.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-013523 CMS-1500 · 2026-09-02 | Jan Simpson UHC-60353-59 | 2026-07-31 Office | Northgate Primary Care Associates Family Medicine · out of network | 99213, 99214, 90471 | $451.00 | $172.95 | Clean approval | — | Approved |
| CLM-2026-013452 CMS-1500 · 2026-09-02 | Kathryn Turner UHC-15096-04 | 2026-08-17 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97140 | $275.00 | $83.75 | Clean approval | — | Approved |
| CLM-2026-007754 CMS-1500 · 2026-09-02 | Michelle Schultz UHC-74086-57 | 2026-08-06 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $160.00 | — | Denied by rule CO27 CO204 LIM | — | 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.