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-2026-024336 UB-04 · 2026-10-16 | Sean Payne UHC-34145-90 | 2026-09-15 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99283 | $970.00 | — | Left for review NET | — | Needs review |
| CLM-2026-024279 UB-04 · 2026-10-16 | William Webb UHC-11907-97 | 2026-09-08 Outpatient hospital | Sunrise Community Hospital Emergency Medicine · out of network | 70553 | $1,854.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-017534 CMS-1500 · 2026-10-16 | Logan Turner UHC-66944-79 | 2026-10-04 Office | Canyon Internal Medicine Associates Internal Medicine · out of network | 99214 | $206.00 | $72.70 | Clean approval | — | Approved |
| CLM-2026-015281 CMS-1500 · 2026-10-16 | Jonathan Lawson UHC-79224-89 | 2026-07-05 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $118.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-014992 UB-04 · 2026-10-16 | Patricia Hayes UHC-59679-50 | 2026-10-03 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99285, 96374, 99284 | $4,868.00 | $1,840.60 | Clean approval | — | Approved |
| CLM-2026-011852 CMS-1500 · 2026-10-16 | Heather Carpenter UHC-81594-70 | 2026-09-23 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80053, 85025 | $106.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009760 CMS-1500 · 2026-10-16 | Jose Vega UHC-35189-94 | 2026-09-12 Office | Canyon Counseling Center Behavioral Health · out of network | 90791 | $315.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-007243 UB-04 · 2026-10-16 | Jesse Alexander UHC-98335-18 | 2026-10-08 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553, 71046 | $3,684.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-005780 CMS-1500 · 2026-10-16 | Jerry Banks UHC-69891-94 | 2026-09-03 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 93000 | $84.00 | $17.80 | Clean approval | — | Approved |
| CLM-2026-005502 CMS-1500 · 2026-10-16 | Fatima Fisher UHC-13643-76 | 2026-09-25 Office | Harbor Primary Care Associates Family Medicine · out of network | 36415, 99203, 99214 | $457.00 | $196.65 | Clean approval | — | Approved |
| CLM-2026-002674 CMS-1500 · 2026-10-16 | Jean Day UHC-32810-59 | 2026-10-10 Office | Evergreen Dermatology Clinic Dermatology · out of network | 11102, 99213 | $500.00 | $175.00 | Clean approval | — | Approved |
| CLM-2026-034618 CMS-1500 · 2026-10-15 | Patricia Li UHC-70875-63 | 2026-09-08 Office | Lakeside Medical Group Family Medicine · out of network | 99395 | $226.00 | $76.70 | Clean approval | — | Approved |
| CLM-2026-034327 UB-04 · 2026-10-15 | Mary Baker UHC-41912-65 | 2026-09-02 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 71046 | $157.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032823 CMS-1500 · 2026-10-15 | Nathan Montgomery UHC-06179-36 | 2026-10-08 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061 | $72.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-031999 CMS-1500 · 2026-10-15 | Dorothy Herrera UHC-12392-13 | 2026-09-16 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90834 | $191.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-026825 CMS-1500 · 2026-10-15 | Virginia Harvey UHC-14058-43 | 2026-09-03 Office | Valley Primary Care Associates Family Medicine · out of network | 90471, 99213, 99214 | $517.00 | $216.45 | Clean approval | — | Approved |
| CLM-2026-025650 UB-04 · 2026-10-15 | Rachel Lopez UHC-43524-49 | 2026-10-02 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $35,527.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-022115 CMS-1500 · 2026-10-15 | Mateo Coleman UHC-67652-54 | 2026-09-07 Office | Evergreen Medical Group Internal Medicine · out of network | 93000, 99215 | $499.00 | $199.55 | Clean approval | — | Approved |
| CLM-2026-012988 UB-04 · 2026-10-15 | Sanitago Franklin UHC-54865-20 | 2026-09-04 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99284, 71046, 99285 | $4,024.00 | — | Left for review NET | — | Needs review |
| CLM-2026-009682 CMS-1500 · 2026-10-15 | Sandra Jackson UHC-78773-38 | 2026-10-09 Office | Valley Skin Care Associates Dermatology · out of network | 17110, 99213 | $480.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-007944 UB-04 · 2026-10-15 | Ryan Walker UHC-79552-94 | 2026-05-28 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283, 71046 | $1,287.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-006356 UB-04 · 2026-10-15 | Julie Martinez UHC-50684-90 | 2026-09-28 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99285 | $2,503.00 | $776.35 | Clean approval | — | Approved |
| CLM-2026-006258 CMS-1500 · 2026-10-15 | Jerry Jensen UHC-63050-35 | 2026-09-03 Office | Harbor Medical Group Internal Medicine · out of network | 99214, 80053 | $257.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004719 UB-04 · 2026-10-15 | Douglas Harris UHC-15357-52 | 2026-10-07 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $39,961.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-004341 UB-04 · 2026-10-15 | Victoria Gray UHC-19111-25 | 2026-09-04 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $826.00 | $298.80 | Clean approval | — | Approved |
| CLM-2026-001025 CMS-1500 · 2026-10-15 | Harold Patterson UHC-04603-36 | 2026-09-17 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $337.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-000582 UB-04 · 2026-10-15 | Arjun Santos UHC-17803-51 | 2026-09-03 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378 | $1,676.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-033243 UB-04 · 2026-10-14 | Joan Hoffman UHC-38218-33 | 2026-09-18 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284, 99283, 96374 | $2,659.00 | $846.55 | Clean approval | — | Approved |
| CLM-2026-031543 CMS-1500 · 2026-10-14 | Nancy Fields UHC-70642-29 | 2026-09-28 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $285.00 | $108.25 | Clean approval | — | Approved |
| CLM-2026-028107 CMS-1500 · 2026-10-14 | Dylan Parker UHC-07807-62 | 2026-09-28 Office | Canyon Counseling Center Behavioral Health · out of network | 90834, 90791 | $627.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026672 UB-04 · 2026-10-14 | Betty Butler UHC-72899-24 | 2026-08-24 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $51,185.00 | — | Left for review DUP HIGH | — | Needs review |
| CLM-2026-024818 UB-04 · 2026-10-14 | Aisha Nguyen UHC-89751-57 | 2026-09-10 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700 | $396.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-022432 CMS-1500 · 2026-10-14 | Steven Gilbert UHC-22739-27 | 2026-09-06 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90791, 90834 | $439.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-018941 CMS-1500 · 2026-10-14 | Donald Fernandez UHC-09849-83 | 2026-09-28 Office | Valley Skin Care Associates Dermatology · out of network | 99213 | $189.00 | $25.05 | Clean approval | — | Approved |
| CLM-2026-017882 CMS-1500 · 2026-10-14 | Betty Daniels UHC-73612-80 | 2026-09-15 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90834 | $217.00 | $47.65 | Clean approval | — | Approved |
| CLM-2026-013940 UB-04 · 2026-10-14 | Sarah Gomez no member ID | 2026-10-06 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700, 71046, 74177 | $2,353.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-011058 UB-04 · 2026-10-14 | Justin Palmer UHC-44225-20 | 2026-09-13 Inpatient hospital | Mesa Internal Medicine Associates Internal Medicine · out of network | 99232 | $234.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-004768 CMS-1500 · 2026-10-14 | Patricia Wang UHC-99901-23 | 2026-09-04 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 93000 | $73.00 | $2.85 | Clean approval | — | Approved |
| CLM-2026-002142 CMS-1500 · 2026-10-14 | Ralph Ruiz UHC-42464-05 | 2026-09-09 Office | Lakeside Medical Group Family Medicine · out of network | 99214 | $289.00 | $100.05 | Clean approval | — | Approved |
| CLM-2026-034571 CMS-1500 · 2026-10-13 | Elizabeth Schultz UHC-01992-56 | 2026-09-30 Office | Evergreen Medical Group Internal Medicine · out of network | 80053, 93000, 99215 | $530.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-034284 UB-04 · 2026-10-13 | Mateo Perez UHC-46817-61 | 2026-09-23 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 70553, 76700 | $3,143.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-031334 CMS-1500 · 2026-10-13 | Ahmed Davis UHC-86559-68 | 2026-08-31 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 85025, 80061, 87086 | $160.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-027474 CMS-1500 · 2026-10-13 | Scott Simmons no member ID | 2026-09-12 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 80061, 87086, 83036 | $177.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-026524 CMS-1500 · 2026-10-13 | Susan Myers UHC-25021-80 | 2026-09-21 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 85025, 80061 | $93.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-025302 UB-04 · 2026-10-13 | Helen Singh UHC-90545-25 | 2026-09-09 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 71046, 77067 | $499.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-023222 UB-04 · 2026-10-13 | Joshua Walsh UHC-33244-92 | 2026-10-11 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93306, 93015 | $2,038.00 | $453.33 | Clean approval | — | Approved |
| CLM-2026-019721 UB-04 · 2026-10-13 | Susan Snyder UHC-74817-71 | 2026-09-13 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283 | $745.00 | — | Left for review NET | — | Needs review |
| CLM-2026-011230 CMS-1500 · 2026-10-13 | Debra Coleman UHC-55489-25 | 2026-09-22 Office | Sunrise Dermatology Clinic Dermatology · out of network | 17110, 11403 | $776.00 | $299.20 | Clean approval | — | Approved |
| CLM-2026-009027 UB-04 · 2026-10-13 | Jacob Fields UHC-76092-02 | 2026-09-02 Outpatient hospital | Unity Imaging Center Radiology · out of network | 71046, 77067, 76700 | $928.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-007063 CMS-1500 · 2026-10-13 | Gerald Jimenez UHC-02738-67 | 2026-09-12 Office | Unity Primary Care Associates Family Medicine · out of network | 99203, 36415, 99213 | $443.00 | $174.35 | 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.