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-2026-013002 UB-04 · 2026-09-24 | Michael Reyes UHC-84549-13 | 2026-09-09 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 43239 | $1,845.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-012628 UB-04 · 2026-09-24 | Gary Fields UHC-65382-80 | 2026-09-03 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378, 88305, 43239 | $3,858.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-011290 CMS-1500 · 2026-09-24 | Sean Alvarado UHC-95582-59 | 2026-08-27 Office | Northgate Primary Care Associates Family Medicine · out of network | 99203, 99395 | $420.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-011221 CMS-1500 · 2026-09-24 | Lori Bradley UHC-54008-33 | 2026-08-18 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $173.00 | $17.85 | Clean approval | — | Approved |
| CLM-2026-010296 CMS-1500 · 2026-09-24 | Robert Jacobs UHC-25481-39 | 2026-08-16 Office | Cornerstone Family Practice Family Medicine · out of network | 99395, 99203 | $451.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-009019 UB-04 · 2026-09-24 | Patrick Foster UHC-07454-34 | 2026-08-29 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99284, 71046, 99285 | $3,495.00 | $1,422.75 | Clean approval | — | Approved |
| CLM-2026-005200 UB-04 · 2026-09-24 | Sara Jimenez no member ID | 2026-08-25 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 74177, 71046 | $1,693.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-004019 UB-04 · 2026-09-24 | Betty Soto UHC-28968-52 | 2026-08-31 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 71046, 96374 | $368.00 | $69.30 | Clean approval | — | Approved |
| CLM-2026-002827 CMS-1500 · 2026-09-24 | Frank Guzman UHC-66444-28 | 2026-09-16 Office | Valley Skin Care Associates Dermatology · out of network | 17110 | $170.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001998 UB-04 · 2026-09-24 | Lori Dixon UHC-20645-16 | 2026-08-29 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99285 | $2,519.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-033103 CMS-1500 · 2026-09-23 | Henry Perkins UHC-17569-05 | 2026-08-20 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 85025 | $70.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-030015 CMS-1500 · 2026-09-23 | Christian Woods UHC-54667-79 | 2026-08-31 Office | Lakeside Medical Group Family Medicine · out of network | 36415, 99214 | $331.00 | $140.40 | Clean approval | — | Approved |
| CLM-2026-029868 CMS-1500 · 2026-09-23 | Adam Young UHC-88914-95 | 2026-07-23 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90837, 90834 | $394.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-027310 CMS-1500 · 2026-09-23 | Zachary Johnson UHC-34766-38 | 2026-08-14 Telehealth | Lakeside Behavioral Health Behavioral Health · out of network | 99214 | $257.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-027092 CMS-1500 · 2026-09-23 | Billy Welch UHC-99018-57 | 2026-09-04 Telehealth | Canyon Counseling Center Behavioral Health · out of network | 99214 | $288.00 | $69.60 | Clean approval | — | Approved |
| CLM-2026-026403 UB-04 · 2026-09-23 | Amy Laron UHC-55275-97 | 2026-09-19 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285, 96374 | $2,822.00 | $1,019.90 | Clean approval | — | Approved |
| CLM-2026-026241 CMS-1500 · 2026-09-23 | Helen Rivera UHC-98891-36 | 2026-09-09 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 93224 | $465.00 | $149.25 | Clean approval | — | Approved |
| CLM-2026-021506 UB-04 · 2026-09-23 | Joshua Gordon UHC-19807-30 | 2026-09-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99284, 99285 | $3,441.00 | $1,198.45 | Clean approval | — | Approved |
| CLM-2026-019861 CMS-1500 · 2026-09-23 | Nicole Guerrero no member ID | 2026-09-06 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $228.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017248 UB-04 · 2026-09-23 | Sandra Patel no member ID | 2026-09-09 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93458, 93306 | $10,495.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-016819 CMS-1500 · 2026-09-23 | Natalie Ramos UHC-03397-06 | 2026-09-11 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 80061 | $58.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-011913 UB-04 · 2026-09-23 | Douglas Morales UHC-93164-60 | 2026-09-20 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 77067 | $288.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-009151 UB-04 · 2026-09-23 | Logan Bradley UHC-10378-53 | 2026-09-01 Outpatient hospital | Desert Reference Lab Clinical Laboratory · out of network | 70553 | $2,380.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-000575 CMS-1500 · 2026-09-23 | Kelly Watson UHC-78347-04 | 2026-09-03 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 80061 | $46.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-000436 UB-04 · 2026-09-23 | Patrick Boyd UHC-93836-29 | 2026-08-10 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93306 | $1,313.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-033969 UB-04 · 2026-09-22 | Charlotte Edwards UHC-97135-95 | 2026-09-19 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $9,204.00 | $2,987.07 | Clean approval | — | Approved |
| CLM-2026-029736 UB-04 · 2026-09-22 | David Moreno UHC-71942-05 | 2026-09-01 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93458 | $8,820.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-027930 CMS-1500 · 2026-09-22 | Janet Henderson UHC-29228-29 | 2026-09-03 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 99214 | $216.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026238 CMS-1500 · 2026-09-22 | Elijah Lynch UHC-37755-50 | 2026-08-08 Office | Harbor Medical Group Internal Medicine · out of network | 99214 | $290.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026138 CMS-1500 · 2026-09-22 | Stephen Montgomery UHC-57923-64 | 2026-08-12 Office | Evergreen Dermatology Clinic Dermatology · out of network | 99213 | $171.00 | $36.95 | Clean approval | — | Approved |
| CLM-2026-022545 UB-04 · 2026-09-22 | Alan Lane UHC-36065-99 | 2026-09-05 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285, 96374 | $2,474.00 | $963.30 | Clean approval | — | Approved |
| CLM-2026-021774 CMS-1500 · 2026-09-22 | Billy Fisher UHC-98030-27 | 2026-08-18 Office | Evergreen Medical Group Internal Medicine · out of network | 99215 | $316.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-018658 CMS-1500 · 2026-09-22 | Virginia Marrtin UHC-82287-41 | 2026-09-07 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 87086 | $145.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-018312 CMS-1500 · 2026-09-22 | Larry Lynch UHC-37451-74 | 2026-08-08 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 99214, 80053 | $328.00 | $117.60 | Clean approval | — | Approved |
| CLM-2026-018153 CMS-1500 · 2026-09-22 | Mariana Hansen no member ID | 2026-09-04 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97140, 97161 | $576.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-015217 CMS-1500 · 2026-09-22 | Wei Mejia UHC-25353-07 | 2026-09-08 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $303.00 | $61.35 | Clean approval | — | Approved |
| CLM-2026-013416 UB-04 · 2026-09-22 | John Cunningham UHC-37758-42 | 2026-08-16 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553 | $2,471.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-012959 CMS-1500 · 2026-09-22 | Joan Edwards UHC-88614-34 | 2026-09-02 Office | Harbor Medical Group Internal Medicine · out of network | 99215, 99214, 93000 | $651.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008541 CMS-1500 · 2026-09-22 | Lawrence Ramirez UHC-95611-07 | 2026-08-06 Office | Harbor Medical Group Internal Medicine · out of network | 80053, 99215 | $429.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-006983 UB-04 · 2026-09-22 | Carl Hill UHC-13848-92 | 2026-09-20 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $9,739.00 | $1,418.37 | Clean approval | — | Approved |
| CLM-2026-006305 UB-04 · 2026-09-22 | Mary Hansen UHC-80131-43 | 2026-09-05 Outpatient hospital | Unity Imaging Center Radiology · out of network | 77067, 76700 | $766.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-005361 UB-04 · 2026-09-22 | Not attached | 2026-09-19 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285 | $3,094.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-005334 CMS-1500 · 2026-09-22 | Santiago Crawford no member ID | 2026-08-17 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 83036, 80053, 85025 | $179.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-004352 UB-04 · 2026-09-22 | Albert Castro UHC-91693-71 | 2026-09-05 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93458, 93306 | $7,867.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-029002 UB-04 · 2026-09-21 | Not attached | 2026-08-31 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,744.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-028414 CMS-1500 · 2026-09-21 | Edward Spencer UHC-51742-53 | 2026-08-21 Office | Evergreen Dermatology Clinic Dermatology · out of network | 11102, 99213, 11403 | $932.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-028362 CMS-1500 · 2026-09-21 | Judy Hawkins UHC-29542-31 | 2026-08-14 Office | Canyon Counseling Center Behavioral Health · out of network | 90834 | $166.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-028120 CMS-1500 · 2026-09-21 | Debra Warren UHC-72923-64 | 2026-09-11 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 87086 | $121.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-027787 CMS-1500 · 2026-09-21 | Jonathan Hunt UHC-20299-86 | 2026-09-01 Office | Canyon Counseling Center Behavioral Health · out of network | 90834, 90791 | $599.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-022465 UB-04 · 2026-09-21 | Lauren Sandoval UHC-88391-59 | 2026-09-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046 | $230.00 | — | Denied by rule CO27 | — | 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.