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-2026-000806 UB-04 · 2026-10-07 | Lori Austin UHC-45897-76 | 2026-09-23 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553, 71046 | $2,712.00 | — | Left for review CO50 | — | Needs review |
| 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-2026-024844 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-2026-021597 UB-04 · 2026-10-06 | Kelly Tucker UHC-00488-72 | 2026-09-07 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283, 99284, 99285 | $4,892.00 | — | Left for review NET | — | Needs review |
| 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-2026-016122 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-2026-014472 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-2026-007086 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-2026-001288 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-2026-028782 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-2026-025490 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-2026-024380 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-2026-023985 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 |
| 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-2026-009704 UB-04 · 2026-10-05 | William Walsh UHC-07070-34 | 2026-08-31 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · out of network | 99232 | $236.00 | — | Left for review CO16 | — | Needs review |
| 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-2026-005618 UB-04 · 2026-10-05 | Emma Harrison UHC-63140-98 | 2026-09-07 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99283 | $737.00 | — | Left for review NET | — | Needs review |
| 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-2026-002465 UB-04 · 2026-10-05 | Patricia Robertson UHC-63151-88 | 2026-09-02 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284, 96374, 99285 | $3,674.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-001270 UB-04 · 2026-10-05 | Brittany Shaw UHC-43130-16 | 2026-08-26 Outpatient hospital | Unity Imaging Center Radiology · out of network | 76700, 77067, 70553 | $3,764.00 | — | Left for review CO50 | — | Needs review |
| 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-2026-030008 UB-04 · 2026-10-04 | Nathan Palmer UHC-78327-09 | 2026-08-25 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285 | $1,925.00 | $616.25 | 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-2026-014273 UB-04 · 2026-10-04 | James Chen UHC-30142-52 | 2026-09-27 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 74177 | $1,634.00 | $194.71 | Clean approval | — | Approved |
| 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-2026-003532 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-2026-000493 UB-04 · 2026-10-04 | Beverly Hughes UHC-84048-28 | 2026-09-28 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93015, 93306 | $1,601.00 | $0.00 | Clean approval | — | Approved |
| 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 |
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.