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-2026-022319 CMS-1500 · 2026-10-08 | Jason Ryan UHC-14330-97 | 2026-08-30 Office | Canyon Cardiovascular Associates Cardiology · out of network | 99214 | $259.00 | — | Left for review REPL | — | Needs review |
| 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-2026-013189 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-2026-011280 CMS-1500 · 2026-10-08 | Teresa Johnson no member ID | 2026-09-05 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 85025, 83036 | $138.00 | — | Pended by rule IDQ N30 | — | Pended |
| 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-2026-030289 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-2026-029961 CMS-1500 · 2026-10-07 | Zachary Thompson no member ID | 2026-09-02 Office | Sunrise Medical Group Internal Medicine · out of network | 93000 | $98.00 | — | Pended by rule N30 | — | Pended |
| 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-2026-026693 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-2026-024741 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-2026-013030 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-2026-004676 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-2026-029317 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-2026-014472 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-2026-011284 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-2026-031352 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-2026-028782 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-2026-028024 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-2026-023985 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-2026-016622 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-2026-009989 CMS-1500 · 2026-10-05 | Brittany Jensen UHC-37798-78 | 2026-08-26 Office | Sunrise Dermatology Clinic Dermatology · out of network | 17110 | $164.00 | $0.00 | Clean approval | — | Approved |
| 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-2026-005978 CMS-1500 · 2026-10-05 | Brenda Gonzalez UHC-48692-65 | 2026-09-06 Office | Canyon Counseling Center Behavioral Health · out of network | 90837, 90834 | $472.00 | $162.40 | Clean approval | — | Approved |
| CLM-2026-004512 CMS-1500 · 2026-10-05 | Wei Willis UHC-15137-52 | 2026-08-23 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 85025 | $30.00 | $0.00 | Clean approval | — | Approved |
| 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-2026-030251 CMS-1500 · 2026-10-04 | Brenda Johnston UHC-43932-61 | 2026-09-12 Office | Valley Primary Care Associates Family Medicine · out of network | 99395, 99213 | $403.00 | $161.35 | Clean approval | — | Approved |
| 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-2026-023449 CMS-1500 · 2026-10-04 | Ethan Jackson UHC-62313-89 | 2026-09-04 Office | Unity Primary Care Associates Family Medicine · out of network | 36415, 99213 | $201.00 | $81.45 | Clean approval | — | Approved |
| CLM-2026-018859 CMS-1500 · 2026-10-04 | Susan Greene UHC-60400-11 | 2026-09-15 Office | Heritage Medical Group Family Medicine · out of network | 36415 | $22.00 | — | Left for review DUP | — | Needs review |
| 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-2026-003532 CMS-1500 · 2026-10-04 | Mei Weber UHC-36230-97 | 2026-08-22 Office | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $199.00 | $14.55 | Clean approval | — | Approved |
| 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-2026-031968 CMS-1500 · 2026-10-03 | Hart Sofia no member ID | 2026-09-20 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · out of network | 87086, 80061 | $144.00 | — | Pended by rule N30 | — | Pended |
| 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-2026-023993 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.