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
3,664
50 with an AI recommendation
Pended
2,586
awaiting information or identity
Approved
23,942
$6,757,768.45 plan paid
Denied
4,454
with remittance reason codes
Examiner decided
0
167 not attached to an identity
| Claim | Member | Service | Provider | Procedures | Billed | Plan pays | Rules | AI | Status |
|---|---|---|---|---|---|---|---|---|---|
| CLM-2026-033989 CMS-1500 · 2026-10-11 | Diana Phillips UHC-60258-47 | 2026-08-27 Office | Sunrise Medical Group Internal Medicine · out of network | 99214, 93000, 99215 | $715.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-033721 CMS-1500 · 2026-10-11 | Terry Gomez UHC-19314-17 | 2026-09-10 Office | Valley Skin Care Associates Dermatology · out of network | 11403, 11102 | $843.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032985 CMS-1500 · 2026-10-11 | Billy Contreras UHC-74899-95 | 2026-09-22 Office | Cornerstone Family Practice Family Medicine · out of network | 99213, 90471 | $211.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-017261 CMS-1500 · 2026-10-11 | Marilyn Ferguson UHC-33529-32 | 2026-09-21 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061 | $80.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010386 CMS-1500 · 2026-10-11 | Noah Coleman UHC-80842-13 | 2026-09-03 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11403, 99213 | $537.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-006310 CMS-1500 · 2026-10-11 | Santiago Johnston UHC-07734-93 | 2026-09-03 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90837 | $216.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006231 CMS-1500 · 2026-10-11 | Debra Powell UHC-90874-75 | 2026-09-13 Office | Harbor Medical Group Internal Medicine · out of network | 93000, 80053 | $148.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-031974 CMS-1500 · 2026-10-10 | Terry Walker UHC-13254-77 | 2026-09-04 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 83036, 80053 | $98.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-025925 CMS-1500 · 2026-10-10 | Debbie Mendez UHC-11886-57 | 2026-08-31 Office | Unity Primary Care Associates Family Medicine · out of network | 99395, 90471, 99203 | $578.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-025852 UB-04 · 2026-10-10 | Karen Rodriguez UHC-78012-31 | 2026-09-20 Inpatient hospital | Riverside Internal Medicine Associates Internal Medicine · out of network | 99232 | $187.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-014643 UB-04 · 2026-10-10 | Wayne Williamson UHC-45751-58 | 2026-10-06 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553, 76700 | $2,815.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-014578 CMS-1500 · 2026-10-10 | Victoria Knight UHC-33507-96 | 2026-09-27 Office | Sunrise Dermatology Clinic Dermatology · out of network | 99213, 11102, 17110 | $719.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-013376 CMS-1500 · 2026-10-10 | Martha Williamson UHC-86118-06 | 2026-09-20 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 83036, 80053 | $119.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010448 UB-04 · 2026-10-10 | Judy Rose UHC-80661-85 | 2026-09-26 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 43239, 88305, 45378 | $4,718.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009169 CMS-1500 · 2026-10-10 | Omar Harvey UHC-08537-63 | 2026-10-06 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 85025, 80053 | $108.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-008327 CMS-1500 · 2026-10-10 | Deborah Owens UHC-36207-21 | 2026-08-26 Office | Valley Primary Care Associates Family Medicine · out of network | 36415 | $19.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-004597 CMS-1500 · 2026-10-10 | Betty Le UHC-26618-68 | 2026-10-02 Office | Canyon Internal Medicine Associates Internal Medicine · out of network | 93000, 99215 | $384.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-003296 CMS-1500 · 2026-10-10 | Mason Santos UHC-10432-64 | 2026-09-03 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · out of network | 80053 | $89.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001295 CMS-1500 · 2026-10-10 | Russell Morales UHC-05073-10 | 2026-09-12 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $244.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-015276 CMS-1500 · 2026-10-09 | Jerry Price UHC-62204-46 | 2026-08-28 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $278.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-011074 UB-04 · 2026-10-09 | Anna Harvey UHC-53608-54 | 2026-09-15 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378, 43239 | $4,163.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-013189 CMS-1500 · 2026-10-08 | Camila Jensen UHC-66295-51 | 2026-08-27 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086, 83036, 85025 | $171.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010694 CMS-1500 · 2026-10-08 | Mary George UHC-99908-37 | 2026-10-03 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $315.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-002457 CMS-1500 · 2026-10-08 | Jeffrey Clark UHC-45965-92 | 2026-09-01 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 80053 | $84.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-001794 CMS-1500 · 2026-10-08 | Frances Wilson UHC-38544-97 | 2026-10-01 Office | Lakeside Medical Group Family Medicine · out of network | 99395, 99213 | $468.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026693 CMS-1500 · 2026-10-07 | Janet Grant UHC-09003-41 | 2026-10-04 Office | Cornerstone Family Practice Family Medicine · out of network | 99214, 90471 | $266.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-024401 UB-04 · 2026-10-07 | Brandon Boyd UHC-74380-08 | 2026-09-26 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284 | $1,478.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-009890 UB-04 · 2026-10-07 | Albert Olson UHC-39661-50 | 2026-09-16 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $51,724.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-004676 CMS-1500 · 2026-10-07 | Walter Hoffman UHC-83616-67 | 2026-09-30 Office | Valley Primary Care Associates Family Medicine · out of network | 99213, 99203 | $441.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-024844 UB-04 · 2026-10-06 | Teresa Reid UHC-23512-04 | 2026-08-22 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $42,542.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-016122 UB-04 · 2026-10-06 | Hansen Christopher no member ID | 2026-09-16 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553 | $3,219.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-007086 UB-04 · 2026-10-06 | Shirley Vasquez UHC-30097-39 | 2026-09-25 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553 | $3,371.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-028782 CMS-1500 · 2026-10-05 | Judith Cunningham UHC-73518-90 | 2026-08-30 Office | Lakeside Medical Group Family Medicine · out of network | 99395, 99214, 99213 | $743.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-024380 UB-04 · 2026-10-05 | Elijah Aguilar UHC-11836-39 | 2026-09-14 Outpatient hospital | Unity Imaging Center Radiology · out of network | 71046, 70553 | $2,673.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-016622 CMS-1500 · 2026-10-05 | Christopher Ruiz UHC-69936-01 | 2026-09-15 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086, 83036, 80053 | $160.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-008072 CMS-1500 · 2026-10-05 | Peter Wong UHC-98692-59 | 2026-10-03 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 83036, 80061, 87086 | $157.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004443 CMS-1500 · 2026-10-05 | Diana Ramos UHC-98291-09 | 2026-09-15 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $296.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-028250 CMS-1500 · 2026-10-04 | Douglas Henderson UHC-07476-51 | 2026-09-01 Office | Heritage Medical Group Family Medicine · out of network | 36415, 99203, 99213 | $409.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-025172 CMS-1500 · 2026-10-04 | Brandon Valdez UHC-15383-35 | 2026-09-01 Office | Canyon Counseling Center Behavioral Health · out of network | 90837, 90791 | $646.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-016625 CMS-1500 · 2026-10-04 | Bobby Banks UHC-25181-58 | 2026-09-05 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $284.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-016413 CMS-1500 · 2026-10-04 | Theresa Hoffman UHC-15893-12 | 2026-08-05 Office | Lakeside Medical Group Family Medicine · out of network | 99203, 36415, 99214 | $451.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014644 CMS-1500 · 2026-10-04 | Diego Knight UHC-87115-85 | 2026-08-24 Office | Canyon Internal Medicine Associates Internal Medicine · out of network | 99214 | $221.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010776 UB-04 · 2026-10-04 | Hiroshi Martinez UHC-21659-34 | 2026-09-11 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $51,314.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-004893 UB-04 · 2026-10-04 | Vincent Smith UHC-60680-60 | 2026-09-10 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 74177, 70553 | $4,225.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001385 CMS-1500 · 2026-10-04 | Kimberly Armstrong UHC-44215-61 | 2026-09-19 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90834, 90837, 90791 | $922.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032492 CMS-1500 · 2026-10-03 | Kayla Dixon UHC-70561-56 | 2026-09-23 Office | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 99213, 20610 | $435.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-031373 CMS-1500 · 2026-10-03 | Samuel Guerrero UHC-70261-24 | 2026-09-30 Office | Canyon Internal Medicine Associates Internal Medicine · out of network | 80053 | $73.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-031116 CMS-1500 · 2026-10-03 | Zachary Schultz UHC-17530-09 | 2026-09-13 Office | Unity Primary Care Associates Family Medicine · out of network | 99395 | $325.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-027294 UB-04 · 2026-10-03 | Jenifer Edwards UHC-36162-50 | 2026-09-01 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 77067 | $395.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-023993 CMS-1500 · 2026-10-03 | Jose Owens UHC-07892-04 | 2026-09-01 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 85025, 87086 | $78.00 | — | Denied by rule CO204 | — | 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.