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-2026-009793 UB-04 · 2026-10-01 | Joan Coleman UHC-76680-53 | 2026-08-29 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 71046 | $328.00 | — | Left for review NET | — | Needs review |
| CLM-2026-034031 CMS-1500 · 2026-09-30 | Bradley Guerrero UHC-50760-89 | 2026-09-28 Office | Cornerstone Family Practice Family Medicine · out of network | 99213, 99203 | $394.00 | $147.30 | Clean approval | — | Approved |
| CLM-2026-029170 UB-04 · 2026-09-30 | Edward Howard UHC-57201-34 | 2026-09-25 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 77067 | $304.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-028763 CMS-1500 · 2026-09-30 | Edward Phillips UHC-73690-84 | 2026-08-21 Office | Lakeside Medical Group Family Medicine · out of network | 90471, 36415 | $58.00 | $8.10 | Clean approval | — | Approved |
| CLM-2026-027708 UB-04 · 2026-09-30 | Grace Ross UHC-85981-15 | 2026-09-23 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 43239 | $1,447.00 | $437.71 | Clean approval | — | Approved |
| CLM-2026-026726 UB-04 · 2026-09-30 | Mary Daniels UHC-02753-64 | 2026-08-28 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $7,693.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-024402 UB-04 · 2026-09-30 | Aisha Kelley UHC-59132-34 | 2026-09-13 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93458, 93306 | $9,934.00 | $1,959.75 | Clean approval | — | Approved |
| CLM-2026-023173 CMS-1500 · 2026-09-30 | Sara Hicks UHC-24394-15 | 2026-08-19 Office | Unity Primary Care Associates Family Medicine · out of network | 36415, 99203, 99395 | $491.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-022405 CMS-1500 · 2026-09-30 | Kathleen Soto UHC-10461-05 | 2026-09-12 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 87086 | $106.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-021212 CMS-1500 · 2026-09-30 | Eric Walker UHC-52069-26 | 2026-09-05 Office | Heritage Medical Group Family Medicine · out of network | 99203, 99213 | $424.00 | $170.80 | Clean approval | — | Approved |
| CLM-2026-014772 CMS-1500 · 2026-09-30 | Mary Rivera UHC-91758-33 | 2026-08-19 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 85025, 83036, 80053 | $159.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-014640 CMS-1500 · 2026-09-30 | Alice Singh UHC-74636-77 | 2026-09-18 Office | Cornerstone Family Practice Family Medicine · out of network | 99214 | $284.00 | $87.80 | Clean approval | — | Approved |
| CLM-2026-011175 CMS-1500 · 2026-09-30 | Kathryn Hart UHC-34576-96 | 2026-08-21 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90834, 90791 | $540.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009624 UB-04 · 2026-09-30 | Karen Cook UHC-61680-99 | 2026-09-19 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 77067, 71046 | $472.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-008046 UB-04 · 2026-09-30 | Kimberly Mejia UHC-56315-91 | 2026-08-16 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99284, 99285 | $4,427.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-007995 UB-04 · 2026-09-30 | Sandra Morris UHC-98911-16 | 2026-08-26 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 71046, 99283, 96374 | $981.00 | — | Left for review NET | — | Needs review |
| CLM-2026-007386 CMS-1500 · 2026-09-30 | Eric Cooper UHC-23594-28 | 2026-09-28 Office | Canyon Counseling Center Behavioral Health · out of network | 90834, 90837, 90791 | $745.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-005144 UB-04 · 2026-09-30 | Gary Valdez UHC-70464-74 | 2026-09-02 Outpatient hospital | Canyon Reference Lab Clinical Laboratory · out of network | 70553 | $1,952.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-002011 CMS-1500 · 2026-09-30 | Larry Jones UHC-94064-39 | 2026-09-10 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 85025, 87086 | $103.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-001843 UB-04 · 2026-09-30 | Karen Morrison UHC-03154-63 | 2026-08-22 Outpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,415.00 | $197.88 | Clean approval | — | Approved |
| CLM-2026-000535 UB-04 · 2026-09-30 | Kayla Wong UHC-96362-36 | 2026-08-29 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285 | $2,598.00 | $819.10 | Clean approval | — | Approved |
| CLM-2026-030983 CMS-1500 · 2026-09-29 | Andrea Martinez UHC-02997-04 | 2026-08-16 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $216.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-025562 UB-04 · 2026-09-29 | Carl Sandoval UHC-49946-01 | 2026-08-24 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 96374, 99284 | $1,716.00 | $690.30 | Clean approval | — | Approved |
| CLM-2026-024972 UB-04 · 2026-09-29 | David Brooks UHC-87270-42 | 2026-08-30 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378, 43239 | $3,580.00 | $744.16 | Clean approval | — | Approved |
| CLM-2026-018286 CMS-1500 · 2026-09-29 | Camila Santos UHC-31286-37 | 2026-09-05 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061, 83036, 85025 | $125.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-017599 UB-04 · 2026-09-29 | Ryan Wright UHC-72160-97 | 2026-08-26 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 71046 | $156.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-016700 CMS-1500 · 2026-09-29 | Lori Allen UHC-82292-56 | 2026-09-20 Office | Northgate Primary Care Associates Family Medicine · out of network | 99203, 99213 | $386.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-014906 UB-04 · 2026-09-29 | Jeremy Snyder UHC-72167-18 | 2026-08-17 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283 | $1,009.00 | $204.05 | Clean approval | — | Approved |
| CLM-2026-013102 UB-04 · 2026-09-29 | Linda Wagner UHC-79792-87 | 2026-09-12 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284, 99283 | $1,857.00 | $585.65 | Clean approval | — | Approved |
| CLM-2026-012917 UB-04 · 2026-09-29 | 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 CO50 | — | Needs review |
| CLM-2026-012536 UB-04 · 2026-09-29 | Debra Le UHC-19184-97 | 2026-09-20 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 96374, 71046 | $477.00 | $110.70 | Clean approval | — | Approved |
| CLM-2026-006207 CMS-1500 · 2026-09-29 | Andrew McCoy UHC-41409-07 | 2026-09-15 Office | Valley Primary Care Associates Family Medicine · out of network | 99203 | $186.00 | $53.70 | Clean approval | — | Approved |
| CLM-2026-029358 CMS-1500 · 2026-09-28 | William Hansen UHC-24086-77 | 2026-09-08 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 87086, 80053, 80061 | $172.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-028535 CMS-1500 · 2026-09-28 | Nathan Peters UHC-70952-79 | 2026-08-20 Office | Harbor Medical Group Internal Medicine · out of network | 99215 | $402.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-021928 CMS-1500 · 2026-09-28 | Olivia Franklin UHC-67158-45 | 2026-09-17 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061, 85025, 87086 | $163.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-020053 CMS-1500 · 2026-09-28 | Hannah Phillips UHC-66468-91 | 2026-09-20 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 83036, 87086, 80053 | $146.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-018924 CMS-1500 · 2026-09-28 | Gerald Campbell no member ID | 2026-08-25 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 83036 | $67.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-010118 CMS-1500 · 2026-09-28 | Maria Dominguez UHC-32345-88 | 2026-09-21 Office | Canyon Counseling Center Behavioral Health · out of network | 90791 | $323.00 | $105.35 | Clean approval | — | Approved |
| CLM-2026-006531 UB-04 · 2026-09-28 | Dinae Garrett UHC-57834-07 | 2026-08-08 Outpatient hospital | Unity Imaging Center Radiology · out of network | 76700, 77067 | $757.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006451 UB-04 · 2026-09-28 | Nathan Tran UHC-26240-33 | 2026-09-19 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378 | $2,766.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003919 UB-04 · 2026-09-28 | Richard Chapman UHC-28200-70 | 2026-08-17 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93458, 93015 | $5,559.00 | $55.77 | Clean approval | — | Approved |
| CLM-2026-000715 UB-04 · 2026-09-28 | Bruce Porter UHC-38921-20 | 2026-02-20 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $902.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-000450 CMS-1500 · 2026-09-28 | Brittany Estrada UHC-82467-80 | 2026-09-02 Office | Canyon Counseling Center Behavioral Health · out of network | 90837 | $294.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-031046 CMS-1500 · 2026-09-27 | Dennis Cole UHC-96366-62 | 2026-08-24 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 80053 | $50.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-028830 UB-04 · 2026-09-27 | Dennis Morgan UHC-75155-83 | 2026-09-12 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93306, 93458 | $6,412.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-024641 CMS-1500 · 2026-09-27 | Jason Grant UHC-51451-91 | 2026-08-21 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061 | $73.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-023858 CMS-1500 · 2026-09-27 | Joseph Day UHC-62916-46 | 2026-09-12 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086, 80053 | $88.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023288 CMS-1500 · 2026-09-27 | Becky Moore UHC-69725-87 | 2026-08-29 Office | Unity Internal Medicine Associates Internal Medicine · out of network | 99215 | $304.00 | $96.80 | Clean approval | — | Approved |
| CLM-2026-011150 UB-04 · 2026-09-27 | Judith Castillo UHC-17837-26 | 2026-09-02 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · out of network | 99232 | $175.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006657 CMS-1500 · 2026-09-27 | Natalie Bennett UHC-71271-45 | 2026-09-21 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 87086 | $115.00 | — | 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.