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-2026-006584 CMS-1500 · 2026-09-27 | Brdley Hernandez UHC-53383-59 | 2026-09-15 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 85025, 80061, 87086 | $153.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-005335 CMS-1500 · 2026-09-27 | Santiago Crawford no member ID | 2026-08-17 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 83036, 80053, 85025 | $179.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-004469 CMS-1500 · 2026-09-27 | Noah Bryant UHC-89912-12 | 2026-09-07 Office | Lakeside Medical Group Family Medicine · out of network | 90471 | $28.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-002837 UB-04 · 2026-09-27 | Betsy Perez UHC-65690-96 | 2026-08-17 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 74177 | $1,545.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-002261 CMS-1500 · 2026-09-27 | Steven Carroll UHC-89841-95 | 2026-09-15 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 83036 | $40.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-000718 CMS-1500 · 2026-09-27 | Charlotte Patel UHC-45528-19 | 2026-08-18 Office | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $178.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-000654 CMS-1500 · 2026-09-27 | Deborah Jones UHC-84110-46 | 2026-08-30 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 87086 | $70.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032775 UB-04 · 2026-09-26 | Terry Burns UHC-17911-64 | 2026-08-12 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · out of network | 93015 | $446.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030646 CMS-1500 · 2026-09-26 | Billy Bennett UHC-96082-25 | 2026-08-20 Office | Heritage Medical Group Family Medicine · out of network | 99395 | $231.00 | $83.95 | Clean approval | — | Approved |
| CLM-2026-029962 CMS-1500 · 2026-09-26 | Denise Hayes UHC-92115-37 | 2026-09-19 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 80053, 85025, 83036 | $177.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-028069 CMS-1500 · 2026-09-26 | Roy Wright UHC-76478-99 | 2026-09-09 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061, 83036 | $116.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-027093 CMS-1500 · 2026-09-26 | Billy Welch UHC-99018-57 | 2026-09-04 Telehealth | Canyon Counseling Center Behavioral Health · out of network | 99214 | $288.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024742 CMS-1500 · 2026-09-26 | Carol Lane UHC-55885-02 | 2026-09-13 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97014 | $327.00 | $117.15 | Clean approval | — | Approved |
| CLM-2026-024458 UB-04 · 2026-09-26 | Robert Jacobs UHC-66748-29 | 2026-08-25 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285, 96374 | $2,119.00 | — | Left for review NET | — | Needs review |
| CLM-2026-023460 CMS-1500 · 2026-09-26 | Luis Fernandez UHC-36488-55 | 2026-08-18 Office | Canyon Internal Medicine Associates Internal Medicine · out of network | 99214, 80053 | $314.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-019840 UB-04 · 2026-09-26 | Virginia Fernandez UHC-33328-14 | 2026-08-23 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93306 | $913.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-019564 CMS-1500 · 2026-09-26 | Bruce Jensen UHC-93320-87 | 2026-09-24 Office | Northgate Primary Care Associates Family Medicine · out of network | 90471, 99213 | $209.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-017142 CMS-1500 · 2026-09-26 | Jordan Wheeler UHC-10993-15 | 2026-08-13 Office | Unity Primary Care Associates Family Medicine · out of network | 99214, 99395 | $511.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-015312 CMS-1500 · 2026-09-26 | Hannah Park UHC-14529-43 | 2026-09-06 Office | Canyon Counseling Center Behavioral Health · out of network | 90791, 90834 | $656.00 | $245.20 | Clean approval | — | Approved |
| CLM-2026-014950 UB-04 · 2026-09-26 | Jesse Morrison UHC-56221-72 | 2026-09-13 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 29881, 73721 | $12,709.00 | $4,990.77 | Clean approval | — | Approved |
| CLM-2026-011597 UB-04 · 2026-09-26 | Kayla Williamson UHC-28782-70 | 2026-08-28 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99285, 71046 | $2,042.00 | $568.90 | Clean approval | — | Approved |
| CLM-2026-007865 CMS-1500 · 2026-09-26 | Janet Carroll UHC-53874-23 | 2026-09-23 Office | Northgate Primary Care Associates Family Medicine · out of network | 99395 | $261.00 | $87.45 | Clean approval | — | Approved |
| CLM-2026-006664 CMS-1500 · 2026-09-26 | Rachel Brooks UHC-42063-06 | 2026-08-16 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · out of network | 83036, 85025 | $115.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-005719 CMS-1500 · 2026-09-26 | Craolyn Florees UHC-73681-40 | 2026-09-14 Office | Valley Primary Care Associates Family Medicine · out of network | 99213, 36415 | $231.00 | $63.95 | Clean approval | — | Approved |
| CLM-2026-004094 CMS-1500 · 2026-09-26 | Russell Meyer UHC-54061-64 | 2026-09-08 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97161 | $430.00 | $153.50 | Clean approval | — | Approved |
| CLM-2026-002901 CMS-1500 · 2026-09-26 | Frank Richards UHC-87366-39 | 2026-08-27 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97014 | $238.00 | — | Denied by rule CO27 LIM | — | Denied |
| CLM-2026-002715 CMS-1500 · 2026-09-26 | Sarah Bowman UHC-65972-52 | 2026-09-16 Office | Lakeside Medical Group Family Medicine · out of network | 36415, 99214 | $314.00 | $135.00 | Clean approval | — | Approved |
| CLM-2026-000066 UB-04 · 2026-09-26 | Roy Marquez UHC-81106-25 | 2026-08-23 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 70553, 93458 | $11,792.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-034276 UB-04 · 2026-09-25 | Hannah Howell UHC-24927-91 | 2026-08-31 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99283, 71046 | $984.00 | $117.00 | Clean approval | — | Approved |
| CLM-2026-027763 UB-04 · 2026-09-25 | Olivia Padilla no member ID | 2026-09-08 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283 | $862.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-022331 CMS-1500 · 2026-09-25 | Diane Mendez UHC-02276-61 | 2026-09-21 Telehealth | Lakeside Behavioral Health Behavioral Health · out of network | 99214 | $289.00 | $90.05 | Clean approval | — | Approved |
| CLM-2026-015391 CMS-1500 · 2026-09-25 | Jordan Willis UHC-82878-88 | 2026-08-12 Office | Canyon Counseling Center Behavioral Health · out of network | 90834 | $154.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-014452 CMS-1500 · 2026-09-25 | Jeremy Elliott UHC-55568-28 | 2026-09-03 Office | Lakeside Medical Group Family Medicine · out of network | 90471, 99213 | $189.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-013670 CMS-1500 · 2026-09-25 | Betty Pena UHC-94994-59 | 2026-09-02 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 80053, 80061 | $119.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-013312 UB-04 · 2026-09-25 | Hiroshi Meyer UHC-79807-84 | 2026-09-09 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553 | $3,101.00 | $865.27 | Clean approval | — | Approved |
| CLM-2026-011308 CMS-1500 · 2026-09-25 | Arjun Lucas UHC-83630-69 | 2026-09-04 Office | Sunrise Medical Group Internal Medicine · out of network | 80053, 99214 | $260.00 | $97.00 | Clean approval | — | Approved |
| CLM-2026-010515 CMS-1500 · 2026-09-25 | Anna Carpenter no member ID | 2026-09-23 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 93000 | $85.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-010462 UB-04 · 2026-09-25 | Larry Dean UHC-23098-85 | 2026-09-04 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $2,323.00 | $695.35 | Clean approval | — | Approved |
| CLM-2026-003886 CMS-1500 · 2026-09-25 | Harold Patterson UHC-04603-36 | 2026-09-06 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 93000 | $74.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-031607 CMS-1500 · 2026-09-24 | Wayne Castro UHC-05335-91 | 2026-09-21 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90834, 90791 | $527.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-030811 CMS-1500 · 2026-09-24 | Rebecca Gardner UHC-93513-53 | 2026-08-20 Office | Heritage Medical Group Family Medicine · out of network | 99203 | $184.00 | $52.80 | Clean approval | — | Approved |
| CLM-2026-030479 UB-04 · 2026-09-24 | Katherine Simmons UHC-12054-24 | 2026-08-18 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881, 73721 | $7,904.00 | $2,222.21 | Clean approval | — | Approved |
| CLM-2026-028431 CMS-1500 · 2026-09-24 | Fatima Soto UHC-71122-66 | 2026-09-02 Office | Harbor Medical Group Internal Medicine · out of network | 80053, 99215 | $482.00 | $189.00 | Clean approval | — | Approved |
| CLM-2026-028140 CMS-1500 · 2026-09-24 | Jose Schultz UHC-51372-92 | 2026-08-28 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · out of network | 80061, 85025 | $112.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-026809 CMS-1500 · 2026-09-24 | Maria Warren UHC-52031-57 | 2026-08-15 Office | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 99213 | $176.00 | $19.20 | Clean approval | — | Approved |
| CLM-2026-026406 UB-04 · 2026-09-24 | Joshua White UHC-26246-17 | 2026-08-19 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $8,877.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-023585 UB-04 · 2026-09-24 | Janice Washington UHC-80769-32 | 2026-08-11 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · out of network | 93015 | $454.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-022318 CMS-1500 · 2026-09-24 | Jason Ryan UHC-14330-97 | 2026-08-30 Office | Canyon Cardiovascular Associates Cardiology · out of network | 99214 | $259.00 | $41.55 | Clean approval | — | Approved |
| CLM-2026-018713 UB-04 · 2026-09-24 | Charlotte Burns UHC-74235-33 | 2026-08-12 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553 | $3,021.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-017794 UB-04 · 2026-09-24 | Bryan Ferguson UHC-51134-40 | 2026-09-01 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283 | $1,049.00 | $122.05 | Clean approval | — | Approved |
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.