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-2026-001871 UB-04 · 2026-10-13 | Vincent Howard UHC-15428-40 | 2026-09-11 Inpatient hospital | Harbor Medical Group Internal Medicine · out of network | 99232 | $181.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-028136 CMS-1500 · 2026-10-12 | Mason Garcia UHC-80156-07 | 2026-05-09 Office | Meadow Heart Institute Cardiology · out of network | 93224 | $438.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-027724 CMS-1500 · 2026-10-12 | Michael Owens UHC-07421-16 | 2026-09-12 Office | Evergreen Dermatology Clinic Dermatology · out of network | 11403 | $641.00 | $228.45 | Clean approval | — | Approved |
| CLM-2026-027083 CMS-1500 · 2026-10-12 | Amanda Santiiago no member ID | 2026-09-29 Office | Unity Primary Care Associates Family Medicine · out of network | 99213 | $176.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-025482 CMS-1500 · 2026-10-12 | Ralph Harper UHC-54586-42 | 2026-10-08 Office | Canyon Counseling Center Behavioral Health · out of network | 90837 | $246.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-024888 UB-04 · 2026-10-12 | Eric Robertson UHC-01745-78 | 2026-08-28 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $31,691.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-013499 CMS-1500 · 2026-10-12 | Samuel Tucker no member ID | 2026-08-30 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $187.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-013417 UB-04 · 2026-10-12 | John Cunningham UHC-37758-42 | 2026-08-16 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553 | $2,471.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-012144 UB-04 · 2026-10-12 | Sandra McCoy UHC-43501-97 | 2026-08-30 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 76700 | $328.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011632 CMS-1500 · 2026-10-12 | Carlos Perkins UHC-67445-33 | 2026-09-02 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061, 83036, 87086 | $156.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010199 CMS-1500 · 2026-10-12 | Melissa Hudson UHC-49229-90 | 2026-09-23 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 83036 | $64.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-007608 UB-04 · 2026-10-12 | Kimberly Vazquez UHC-88315-80 | 2026-09-10 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $1,119.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-007606 CMS-1500 · 2026-10-12 | David Berry UHC-53040-86 | 2026-09-02 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 85025, 83036, 80061 | $150.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-007527 CMS-1500 · 2026-10-12 | Deborah Wang UHC-09134-29 | 2026-10-09 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 99214, 80053 | $364.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001237 CMS-1500 · 2026-10-12 | Karen Anderson UHC-48865-86 | 2026-09-05 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086 | $64.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-034365 UB-04 · 2026-10-11 | Vincent Thomas UHC-37542-71 | 2026-10-09 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177, 77067 | $1,752.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-031356 UB-04 · 2026-10-11 | Barbara Cooper UHC-62320-38 | 2026-09-02 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99284 | $1,392.00 | $476.40 | Clean approval | — | Approved |
| CLM-2026-030867 CMS-1500 · 2026-10-11 | Lawrence Nichols UHC-55829-92 | 2026-09-07 Office | Unity Primary Care Associates Family Medicine · out of network | 99395, 99203, 99214 | $794.00 | $337.30 | Clean approval | — | Approved |
| CLM-2026-024453 UB-04 · 2026-10-11 | Grace Kennedy UHC-94262-16 | 2026-09-28 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $38,659.00 | — | Left for review HIGH | — | Needs review |
| 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-2026-022262 UB-04 · 2026-10-11 | Justin Pena UHC-23865-08 | 2026-10-01 Inpatient hospital | Unity Internal Medicine Associates Internal Medicine · out of network | 99232 | $218.00 | — | Left for review CO16 | — | Needs review |
| 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-2026-017261 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-2026-016853 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-2026-010386 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-2026-003697 CMS-1500 · 2026-10-11 | Carl Clark UHC-07708-62 | 2026-09-07 Office | Canyon Counseling Center Behavioral Health · out of network | 90837, 90791, 90834 | $933.00 | — | Left for review CO16 | — | Needs review |
| 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-2026-032543 UB-04 · 2026-10-10 | Brittany Alvarado UHC-89357-17 | 2026-08-30 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 96374, 99285 | $2,580.00 | — | Left for review NET | — | Needs review |
| 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-2026-030384 UB-04 · 2026-10-10 | Jeffrey Padilla UHC-92939-82 | 2026-09-25 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $37,665.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027261 UB-04 · 2026-10-10 | Brittany Holmes UHC-82722-34 | 2026-10-01 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93015 | $438.00 | — | Pended by rule IDQ | — | Pended |
| 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-2026-025362 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-2026-014643 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-2026-012757 UB-04 · 2026-10-10 | Russell King UHC-80971-11 | 2026-09-16 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99285, 99284 | $4,796.00 | — | Left for review NET | — | Needs review |
| 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-2026-008737 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-2026-008327 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 |
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.