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-2026-031373 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-2026-030692 UB-04 · 2026-10-03 | Kimberly Howard UHC-44964-12 | 2026-09-22 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99283, 99284 | $1,943.00 | $526.95 | Clean approval | — | Approved |
| 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-2026-025572 UB-04 · 2026-10-03 | Diego Nguyen UHC-76302-57 | 2026-09-08 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99283 | $855.00 | $134.75 | Clean approval | — | Approved |
| 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 |
| CLM-2026-020913 CMS-1500 · 2026-10-03 | Willie Morris UHC-45440-30 | 2026-09-01 Office | Lakeside Medical Group Family Medicine · out of network | 99395, 99214, 36415 | $591.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-020803 CMS-1500 · 2026-10-03 | Kathleen Lee UHC-70217-02 | 2026-08-19 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · out of network | 80061, 85025 | $106.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-019141 UB-04 · 2026-10-03 | Anthony Perkins UHC-29134-84 | 2026-08-31 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $1,005.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-017600 UB-04 · 2026-10-03 | Ryan Wright UHC-72160-97 | 2026-08-26 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 71046 | $156.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-016902 CMS-1500 · 2026-10-03 | Albert Daniels UHC-88907-28 | 2026-09-05 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 93224, 99214 | $637.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-016473 CMS-1500 · 2026-10-03 | Robert Carter UHC-70161-33 | 2026-09-22 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 85025, 87086, 80053 | $157.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-016366 CMS-1500 · 2026-10-03 | Santiago Graham UHC-34126-09 | 2026-09-07 Office | Northgate Primary Care Associates Family Medicine · out of network | 99203, 99395 | $464.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-015467 CMS-1500 · 2026-10-03 | Nathan Wong UHC-21440-42 | 2026-08-27 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 85025 | $42.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-015437 UB-04 · 2026-10-03 | Joshua Harper UHC-85497-41 | 2026-08-19 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 71046, 99283 | $1,059.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-010133 UB-04 · 2026-10-03 | Pamela Harvey no member ID | 2026-09-01 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99284, 99283, 99285 | $3,759.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-008495 CMS-1500 · 2026-10-03 | Jonathan Aguilar UHC-85529-50 | 2026-09-02 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 93224 | $356.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004083 CMS-1500 · 2026-10-03 | Diana Stephens UHC-94285-82 | 2026-08-27 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 83036, 87086 | $69.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-001682 UB-04 · 2026-10-03 | Hannah Valdez UHC-12876-94 | 2026-09-30 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $47,130.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-033293 CMS-1500 · 2026-10-02 | Jose Jensen UHC-42670-96 | 2026-09-15 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086 | $40.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032353 UB-04 · 2026-10-02 | Cheryl Chavez UHC-63288-21 | 2026-08-26 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $1,307.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-030647 CMS-1500 · 2026-10-02 | Billy Bennett UHC-96082-25 | 2026-08-20 Office | Heritage Medical Group Family Medicine · out of network | 99395 | $231.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-026145 CMS-1500 · 2026-10-02 | Mariana Anderson UHC-20476-18 | 2026-08-18 Office | Valley Skin Care Associates Dermatology · out of network | 17110 | $247.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-024001 CMS-1500 · 2026-10-02 | Fatima Perkins UHC-00138-75 | 2026-08-30 Telehealth | Canyon Counseling Center Behavioral Health · out of network | 99214 | $229.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-023989 UB-04 · 2026-10-02 | Kelly Flores UHC-81413-97 | 2026-08-20 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93306 | $1,133.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-022552 CMS-1500 · 2026-10-02 | Not attached | 2026-09-23 Office | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $217.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-020706 CMS-1500 · 2026-10-02 | Abigail Olson UHC-32653-35 | 2026-08-21 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 93224, 99214 | $639.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-018773 CMS-1500 · 2026-10-02 | Sean Miller UHC-14551-01 | 2026-09-28 Office | Sunrise Medical Group Internal Medicine · out of network | 93000, 99215 | $471.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-016772 CMS-1500 · 2026-10-02 | Betty Howell UHC-02016-96 | 2026-09-01 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97140, 97014 | $395.00 | $157.75 | Clean approval | — | Approved |
| CLM-2026-015230 UB-04 · 2026-10-02 | Shirley Harper UHC-21504-79 | 2026-09-19 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283, 96374 | $1,072.00 | $232.40 | Clean approval | — | Approved |
| CLM-2026-014691 CMS-1500 · 2026-10-02 | Sofia Lewis UHC-91831-67 | 2026-08-23 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 83036, 87086 | $116.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009908 CMS-1500 · 2026-10-02 | Yuki Murphy UHC-24467-37 | 2026-09-15 Office | Lakeside Medical Group Family Medicine · out of network | 99203, 99213 | $351.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-008761 CMS-1500 · 2026-10-02 | Anthony Rios UHC-38512-88 | 2026-09-28 Office | Harbor Medical Group Internal Medicine · out of network | 99214, 99215 | $683.00 | $282.35 | Clean approval | — | Approved |
| CLM-2026-007846 CMS-1500 · 2026-10-02 | Patricia Martin UHC-85046-13 | 2026-09-01 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $287.00 | $69.15 | Clean approval | — | Approved |
| CLM-2026-005467 CMS-1500 · 2026-10-02 | Luis Patterson UHC-74727-19 | 2026-09-06 Telehealth | Lakeside Behavioral Health Behavioral Health · out of network | 99214 | $262.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004772 UB-04 · 2026-10-02 | Bryan Ray UHC-15231-85 | 2026-09-28 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,734.00 | $430.30 | Clean approval | — | Approved |
| CLM-2026-004480 CMS-1500 · 2026-10-02 | Gerald Sanders UHC-66151-99 | 2026-08-29 Office | Valley Skin Care Associates Dermatology · out of network | 17110, 11403 | $795.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004310 CMS-1500 · 2026-10-02 | Ashley Carr UHC-40523-42 | 2026-08-25 Office | Harbor Primary Care Associates Family Medicine · out of network | 99213, 99203, 90471 | $423.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-030050 UB-04 · 2026-10-01 | Ruth Jordan UHC-16459-44 | 2026-09-08 Inpatient hospital | Mesa Internal Medicine Associates Internal Medicine · out of network | 99232 | $237.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-029825 UB-04 · 2026-10-01 | Mark Evans UHC-79386-51 | 2026-08-23 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177, 77067, 76700 | $2,577.00 | $293.11 | Clean approval | — | Approved |
| CLM-2026-028098 UB-04 · 2026-10-01 | Willie Garcia UHC-41138-39 | 2026-09-07 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 77067, 76700 | $546.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026359 UB-04 · 2026-10-01 | James Owens UHC-46110-34 | 2026-08-18 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283, 71046 | $1,013.00 | $105.85 | Clean approval | — | Approved |
| CLM-2026-025721 CMS-1500 · 2026-10-01 | Philip Simmons UHC-94170-33 | 2026-09-15 Office | Lakeside Medical Group Family Medicine · out of network | 36415, 99203, 90471 | $286.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-023859 CMS-1500 · 2026-10-01 | Joseph Day UHC-62916-46 | 2026-09-12 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086, 80053 | $88.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-021733 UB-04 · 2026-10-01 | Christopher Chen UHC-07924-36 | 2026-09-09 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283 | $843.00 | $29.35 | Clean approval | — | Approved |
| CLM-2026-015372 CMS-1500 · 2026-10-01 | Yuki Freeman UHC-15344-01 | 2026-08-29 Office | Unity Primary Care Associates Family Medicine · out of network | 99214, 36415 | $329.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-014318 CMS-1500 · 2026-10-01 | Virginia Ross UHC-66259-56 | 2026-09-18 Office | Cornerstone Family Practice Family Medicine · out of network | 36415, 99214, 90471 | $317.00 | $132.30 | Clean approval | — | Approved |
| CLM-2026-012366 UB-04 · 2026-10-01 | Diego Matthews UHC-11271-69 | 2026-09-29 Inpatient hospital | Riverside Internal Medicine Associates Internal Medicine · out of network | 99232 | $217.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011304 UB-04 · 2026-10-01 | Elizabeth Dunn UHC-59946-17 | 2026-09-14 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93015 | $668.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011216 CMS-1500 · 2026-10-01 | Helen Gibosn UHC-11787-25 | 2026-09-08 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053 | $44.00 | — | Pended by rule IDQ | — | 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.