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-2026-015188 UB-04 · 2026-10-17 | Jacqueline Willis UHC-69078-97 | 2026-09-29 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 76700, 74177 | $2,395.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-010199 CMS-1500 · 2026-10-12 | Melissa Hudson UHC-49229-90 | 2026-09-23 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 83036 | $64.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-010386 CMS-1500 · 2026-10-11 | Noah Coleman UHC-80842-13 | 2026-09-03 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11403, 99213 | $537.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-025925 CMS-1500 · 2026-10-10 | Debbie Mendez UHC-11886-57 | 2026-08-31 Office | Unity Primary Care Associates Family Medicine · out of network | 99395, 90471, 99203 | $578.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-008327 CMS-1500 · 2026-10-10 | Deborah Owens UHC-36207-21 | 2026-08-26 Office | Valley Primary Care Associates Family Medicine · out of network | 36415 | $19.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-001295 CMS-1500 · 2026-10-10 | Russell Morales UHC-05073-10 | 2026-09-12 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $244.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-011074 UB-04 · 2026-10-09 | Anna Harvey UHC-53608-54 | 2026-09-15 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378, 43239 | $4,163.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-002457 CMS-1500 · 2026-10-08 | Jeffrey Clark UHC-45965-92 | 2026-09-01 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 80053 | $84.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-024401 UB-04 · 2026-10-07 | Brandon Boyd UHC-74380-08 | 2026-09-26 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284 | $1,478.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-009890 UB-04 · 2026-10-07 | Albert Olson UHC-39661-50 | 2026-09-16 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $51,724.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-004676 CMS-1500 · 2026-10-07 | Walter Hoffman UHC-83616-67 | 2026-09-30 Office | Valley Primary Care Associates Family Medicine · out of network | 99213, 99203 | $441.00 | — | Denied by rule CO27 CO204 | — | Denied |
| 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-2026-028250 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-2026-010776 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-2026-002011 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-2026-024641 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-2026-017142 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-2026-002901 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-2026-014452 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-2026-011290 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-2026-010296 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-2026-001998 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-2026-022465 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 |
| CLM-2026-005350 CMS-1500 · 2026-09-19 | Vincent Palmer UHC-31592-87 | 2026-08-05 Office | Lakeside Medical Group Family Medicine · out of network | 90471, 99395, 99203 | $482.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014340 UB-04 · 2026-09-18 | Marcus Alexander UHC-89293-82 | 2026-08-13 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 71046 | $174.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-008834 UB-04 · 2026-09-17 | Terry Le UHC-29632-13 | 2026-08-29 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378 | $1,643.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-015672 UB-04 · 2026-09-15 | Debra Collins UHC-86010-85 | 2026-08-28 Inpatient hospital | Sunrise Medical Group Internal Medicine · out of network | 99232 | $235.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-024973 CMS-1500 · 2026-09-14 | Angela Greene UHC-77777-60 | 2026-08-10 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $190.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-023330 CMS-1500 · 2026-09-11 | Joyce Bryant UHC-62977-32 | 2026-08-18 Office | Evergreen Medical Group Internal Medicine · out of network | 80053, 99214 | $291.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-020365 CMS-1500 · 2026-09-09 | Ana Banks UHC-34703-52 | 2026-08-27 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 83036, 80061 | $89.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-016024 CMS-1500 · 2026-09-07 | Christine Barnes UHC-70917-32 | 2026-09-01 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $276.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-028605 CMS-1500 · 2026-09-06 | Gabriel Padilla UHC-42797-52 | 2026-08-29 Office | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 99213 | $194.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-015960 UB-04 · 2026-09-05 | Susan Ward UHC-82540-45 | 2026-08-28 Inpatient hospital | Unity Internal Medicine Associates Internal Medicine · out of network | 99232 | $188.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-001897 UB-04 · 2026-09-05 | Janice Sto UHC-96551-62 | 2026-08-14 Inpatient hospital | Harbor Medical Group Internal Medicine · out of network | 99232, 99215 | $507.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-033875 UB-04 · 2026-09-04 | Ann Alexandre UHC-97453-82 | 2026-08-28 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $6,961.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-010565 CMS-1500 · 2026-09-04 | Brandon Watson UHC-65481-98 | 2026-07-29 Office | Lakeside Medical Group Family Medicine · out of network | 99395 | $226.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-007754 CMS-1500 · 2026-09-02 | Michelle Schultz UHC-74086-57 | 2026-08-06 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $160.00 | — | Denied by rule CO27 CO204 LIM | — | Denied |
| CLM-2026-025297 UB-04 · 2026-08-31 | Russell Morales UHC-05073-10 | 2026-08-11 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378 | $1,524.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014401 CMS-1500 · 2026-08-30 | Betty Sandoval UHC-13305-47 | 2026-08-20 Office | Heritage Medical Group Family Medicine · out of network | 99203 | $194.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-010217 UB-04 · 2026-08-29 | Susan Boyd UHC-70334-03 | 2026-07-20 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378 | $2,460.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-007953 CMS-1500 · 2026-08-28 | Carol Brooks UHC-66153-39 | 2026-07-28 Office | Canyon Cardiovascular Associates Cardiology · out of network | 99214 | $323.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-030657 CMS-1500 · 2026-08-27 | Ana Bell UHC-07204-04 | 2026-07-19 Office | Unity Primary Care Associates Family Medicine · out of network | 90471 | $38.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-026620 CMS-1500 · 2026-08-27 | Matthew Valdez UHC-71925-83 | 2026-08-04 Office | Heritage Medical Group Family Medicine · out of network | 99203, 99213, 36415 | $363.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-011880 CMS-1500 · 2026-08-27 | Thomas Espinoza UHC-00130-55 | 2026-07-24 Telehealth | Lakeside Behavioral Health Behavioral Health · out of network | 99214 | $275.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-007973 CMS-1500 · 2026-08-27 | Joyce Morrison UHC-80236-49 | 2026-08-08 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 85025 | $129.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-029254 CMS-1500 · 2026-08-25 | Arthur Kelley UHC-28863-81 | 2026-08-09 Office | Evergreen Medical Group Internal Medicine · out of network | 99215 | $328.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-007828 CMS-1500 · 2026-08-24 | Gerald Meyer UHC-45403-71 | 2026-08-21 Office | Lakeside Medical Group Family Medicine · out of network | 99395, 99214 | $559.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-033692 CMS-1500 · 2026-08-22 | Isabella Watkins UHC-63631-99 | 2026-07-25 Office | Lakeside Medical Group Family Medicine · out of network | 99213 | $191.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-019974 CMS-1500 · 2026-08-21 | Anna Bowman UHC-89187-82 | 2026-08-10 Office | Lakeside Endocrine Associates Endocrinology · out of network | 99214, 99215 | $619.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-028515 CMS-1500 · 2026-08-20 | Lauren Moreno UHC-40660-98 | 2026-07-18 Office | Cornerstone Family Practice Family Medicine · out of network | 99214 | $293.00 | — | 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.