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-2026-006361 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-2026-004597 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-2026-002122 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-2026-001295 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-2026-001118 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-2026-026784 UB-04 · 2026-10-09 | Doris Brown UHC-03661-81 | 2026-09-01 Outpatient hospital | Mesa Regional Medical Center Emergency Medicine · out of network | 70553 | $2,433.00 | — | Left for review CO50 | — | Needs review |
| 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-2026-015168 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-2026-013714 UB-04 · 2026-10-09 | Gerald Bowman no member ID | 2026-10-05 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553 | $2,319.00 | — | Pended by rule N30 | — | Pended |
| 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-2026-011074 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-2026-010412 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-2026-005070 UB-04 · 2026-10-09 | Logan Greene UHC-34472-84 | 2026-10-06 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 96374 | $170.00 | — | Left for review NET | — | Needs review |
| 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-2026-029982 UB-04 · 2026-10-08 | Maria Hansen UHC-86468-12 | 2026-09-13 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283 | $725.00 | — | Left for review NET | — | Needs review |
| CLM-2026-028070 CMS-1500 · 2026-10-08 | Roy Wright UHC-76478-99 | 2026-09-09 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061, 83036 | $116.00 | — | Left for review REPL | — | Needs review |
| 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-2026-022319 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-2026-029044 UB-04 · 2026-10-07 | Maira Kim UHC-95297-64 | 2026-08-25 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $2,579.00 | — | Left for review NET | — | Needs review |
| 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-2026-026693 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-2026-024401 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-2026-013746 UB-04 · 2026-10-07 | Joe Dean no member ID | 2026-08-31 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 71046 | $220.00 | — | Pended by rule IDQ N30 | — | Pended |
| 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-2026-012918 UB-04 · 2026-10-07 | Megan Williams UHC-64753-11 | 2026-08-24 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 77067, 71046, 74177 | $2,863.00 | — | Left for review REPL CO50 | — | Needs review |
| 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-2026-007431 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-2026-005660 UB-04 · 2026-10-07 | Ashley Nunez UHC-90338-03 | 2026-10-04 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 88305 | $262.00 | — | Pended by rule IDQ | — | Pended |
| 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 |
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.