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-2026-022357 CMS-1500 · 2026-10-11 | Denise Sanders UHC-61727-63 | 2026-09-20 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 99215 | $370.00 | $126.50 | Clean approval | — | Approved |
| CLM-2026-020026 CMS-1500 · 2026-10-11 | Sean Gordon UHC-57083-46 | 2026-10-06 Office | Sunrise Digestive Health Center Gastroenterology · out of network | 99214 | $310.00 | $99.50 | Clean approval | — | Approved |
| CLM-2026-016853 UB-04 · 2026-10-11 | Donald Chapman UHC-04060-56 | 2026-10-06 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 77067 | $345.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-000109 UB-04 · 2026-10-11 | Brian Bell UHC-05015-78 | 2026-08-30 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285, 96374 | $1,873.00 | $692.85 | Clean approval | — | Approved |
| CLM-2026-033132 CMS-1500 · 2026-10-10 | Henry Wells UHC-34465-23 | 2026-09-21 Office | Lakeside Endocrine Associates Endocrinology · out of network | 95251, 83036, 99215 | $658.00 | $221.10 | Clean approval | — | Approved |
| CLM-2026-025362 CMS-1500 · 2026-10-10 | Luis Clark UHC-84938-13 | 2026-09-14 Office | Unity Internal Medicine Associates Internal Medicine · out of network | 99214 | $276.00 | $99.20 | Clean approval | — | Approved |
| CLM-2026-023956 CMS-1500 · 2026-10-10 | Isabella Herrera UHC-50875-68 | 2026-09-11 Office | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $272.00 | $82.40 | Clean approval | — | Approved |
| CLM-2026-017901 CMS-1500 · 2026-10-10 | Elizabeth Hanson UHC-09556-36 | 2026-09-14 Office | Valley Primary Care Associates Family Medicine · out of network | 99203, 99214 | $438.00 | $172.10 | Clean approval | — | Approved |
| CLM-2026-008737 UB-04 · 2026-10-10 | Camila Coleman UHC-30287-02 | 2026-09-01 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93015, 93458 | $9,840.00 | $3,371.37 | Clean approval | — | Approved |
| CLM-2026-006361 CMS-1500 · 2026-10-10 | Mari Schmidt UHC-33033-18 | 2026-09-01 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 80053, 85025, 83036 | $177.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-005414 CMS-1500 · 2026-10-10 | Kelly Espinoza UHC-51195-87 | 2026-09-09 Office | Cornerstone Family Practice Family Medicine · out of network | 99203, 99214 | $497.00 | $183.65 | Clean approval | — | Approved |
| CLM-2026-002122 UB-04 · 2026-10-10 | Jon Oliver UHC-44697-32 | 2026-09-06 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 96374, 71046 | $409.00 | $79.65 | Clean approval | — | Approved |
| CLM-2026-001118 UB-04 · 2026-10-10 | Vazquez Mei UHC-53731-44 | 2026-08-27 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 96374 | $203.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-033895 UB-04 · 2026-10-09 | Joan Phillips UHC-75598-35 | 2026-09-14 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $1,754.00 | $439.30 | Clean approval | — | Approved |
| CLM-2026-033296 CMS-1500 · 2026-10-09 | Dorothy Hicks UHC-74134-54 | 2026-09-28 Office | Unity Primary Care Associates Family Medicine · out of network | 36415 | $14.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-029203 UB-04 · 2026-10-09 | Jesse Price UHC-05475-09 | 2026-08-29 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 71046, 99283 | $910.00 | $295.65 | Clean approval | — | Approved |
| CLM-2026-015168 CMS-1500 · 2026-10-09 | Natalie Guzman UHC-13685-46 | 2026-09-11 Office | Meadow Heart Institute Cardiology · out of network | 99214, 93224 | $698.00 | $264.10 | Clean approval | — | Approved |
| CLM-2026-013054 UB-04 · 2026-10-09 | Charles Lynch UHC-82241-22 | 2026-09-30 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93015 | $517.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011624 CMS-1500 · 2026-10-09 | Camila Olson UHC-51240-43 | 2026-08-26 Office | Heritage Medical Group Family Medicine · out of network | 99395 | $302.00 | $110.90 | Clean approval | — | Approved |
| CLM-2026-010412 CMS-1500 · 2026-10-09 | Carlos Scott UHC-31563-59 | 2026-09-02 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 80061 | $45.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-007411 CMS-1500 · 2026-10-09 | Sandra White UHC-13421-40 | 2026-09-13 Office | Evergreen Medical Group Internal Medicine · out of network | 80053 | $61.00 | $2.45 | Clean approval | — | Approved |
| CLM-2026-031998 CMS-1500 · 2026-10-08 | Dorothy Herrera UHC-12392-13 | 2026-09-16 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90834 | $191.00 | $45.95 | Clean approval | — | Approved |
| CLM-2026-027248 CMS-1500 · 2026-10-08 | Edward Wilson UHC-81351-96 | 2026-10-05 Office | Unity Primary Care Associates Family Medicine · out of network | 99213 | $184.00 | $62.80 | Clean approval | — | Approved |
| CLM-2026-020598 CMS-1500 · 2026-10-08 | Dylan Dean UHC-33903-05 | 2026-09-28 Office | Sunrise Digestive Health Center Gastroenterology · out of network | 99214 | $245.00 | $35.25 | Clean approval | — | Approved |
| CLM-2026-018088 CMS-1500 · 2026-10-08 | Zachary Greene UHC-69793-13 | 2026-09-25 Office | Sunrise Dermatology Clinic Dermatology · out of network | 99213, 11102 | $453.00 | $143.85 | Clean approval | — | Approved |
| CLM-2026-016813 CMS-1500 · 2026-10-08 | Joseph Cunningham UHC-10594-91 | 2026-09-19 Office | Lakeside Medical Group Family Medicine · out of network | 99395, 36415 | $321.00 | $104.45 | Clean approval | — | Approved |
| CLM-2026-014607 CMS-1500 · 2026-10-08 | Jesse Cole UHC-22366-11 | 2026-09-03 Office | Canyon Counseling Center Behavioral Health · out of network | 90791, 90837 | $635.00 | $245.75 | Clean approval | — | Approved |
| CLM-2026-030289 CMS-1500 · 2026-10-07 | Daniel Freeman UHC-53118-31 | 2026-09-21 Office | Valley Skin Care Associates Dermatology · out of network | 99213, 17110 | $378.00 | $120.10 | Clean approval | — | Approved |
| CLM-2026-027470 CMS-1500 · 2026-10-07 | Raymond Day UHC-13009-12 | 2026-09-01 Office | Heritage Medical Group Family Medicine · out of network | 90471, 36415 | $58.00 | $10.35 | Clean approval | — | Approved |
| CLM-2026-027178 UB-04 · 2026-10-07 | Ryan Hunter UHC-48235-63 | 2026-09-16 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285, 99284, 96374 | $4,448.00 | $1,851.60 | Clean approval | — | Approved |
| CLM-2026-024741 CMS-1500 · 2026-10-07 | Alan Lopez UHC-37303-83 | 2026-08-30 Office | Unity Primary Care Associates Family Medicine · out of network | 90471 | $37.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-013727 UB-04 · 2026-10-07 | Amanda Guerrero UHC-02982-66 | 2026-10-05 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306, 93015 | $1,529.00 | $507.06 | Clean approval | — | Approved |
| CLM-2026-013030 CMS-1500 · 2026-10-07 | Sophia Alexander UHC-65817-15 | 2026-09-06 Office | Valley Primary Care Associates Family Medicine · out of network | 99214, 99395 | $604.00 | $246.80 | Clean approval | — | Approved |
| CLM-2026-007431 UB-04 · 2026-10-07 | Sean Varrgas UHC-30722-64 | 2026-09-15 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285, 71046 | $3,333.00 | $1,349.85 | Clean approval | — | Approved |
| CLM-2026-029317 CMS-1500 · 2026-10-06 | Victoria Ramirez UHC-01322-01 | 2026-09-03 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 80053, 85025 | $140.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-028748 CMS-1500 · 2026-10-06 | William Oliver UHC-98569-65 | 2026-08-24 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 80053 | $90.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-020626 CMS-1500 · 2026-10-06 | Anthony Weber UHC-65934-35 | 2026-09-25 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 80053, 87086, 83036 | $201.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-019813 UB-04 · 2026-10-06 | Heather Gardner UHC-30555-67 | 2026-09-23 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700 | $634.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-014472 CMS-1500 · 2026-10-06 | Paul Schmidt UHC-33818-80 | 2026-09-03 Office | Unity Primary Care Associates Family Medicine · out of network | 90471, 99213, 99214 | $480.00 | $201.15 | Clean approval | — | Approved |
| CLM-2026-012939 UB-04 · 2026-10-06 | Nicole Rice UHC-22461-47 | 2026-10-04 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 70553, 74177 | $5,115.00 | $700.26 | Clean approval | — | Approved |
| CLM-2026-011284 CMS-1500 · 2026-10-06 | John Wood UHC-54344-81 | 2026-08-25 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97140, 97161 | $408.00 | $163.60 | Clean approval | — | Approved |
| CLM-2026-001288 CMS-1500 · 2026-10-06 | Jacqueline James UHC-45653-48 | 2026-09-12 Office | Northgate Primary Care Associates Family Medicine · out of network | 99214, 36415 | $316.00 | $102.20 | Clean approval | — | Approved |
| CLM-2026-000941 UB-04 · 2026-10-06 | Mason Ramirez UHC-04462-47 | 2026-09-15 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046 | $226.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-031352 CMS-1500 · 2026-10-05 | Victoria Ramirez UHC-01322-01 | 2026-09-10 Office | Sunrise Digestive Health Center Gastroenterology · out of network | 99214 | $265.00 | $59.25 | Clean approval | — | Approved |
| CLM-2026-030845 CMS-1500 · 2026-10-05 | Jessica Marquez UHC-32813-59 | 2026-09-11 Office | Evergreen Medical Group Internal Medicine · out of network | 80053 | $89.00 | $0.05 | Clean approval | — | Approved |
| CLM-2026-028024 CMS-1500 · 2026-10-05 | Marilyn Barnes UHC-46631-14 | 2026-09-10 Office | Harbor Primary Care Associates Family Medicine · out of network | 99213, 90471 | $224.00 | $80.80 | Clean approval | — | Approved |
| CLM-2026-025490 UB-04 · 2026-10-05 | Susan Garrett UHC-86282-68 | 2026-08-30 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 71046 | $211.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023985 CMS-1500 · 2026-10-05 | Rachel Ray UHC-80386-84 | 2026-09-16 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 80061, 85025, 80053 | $184.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-021820 CMS-1500 · 2026-10-05 | Evelyn Moore UHC-51694-74 | 2026-09-26 Office | Evergreen Dermatology Clinic Dermatology · out of network | 11102, 11403 | $591.00 | $215.95 | Clean approval | — | Approved |
| CLM-2026-020243 UB-04 · 2026-10-05 | George Torres UHC-42020-09 | 2026-08-29 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283, 96374 | $1,046.00 | $120.70 | 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.