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-2026-033652 CMS-1500 · 2026-10-18 | Tyler Moore UHC-71756-75 | 2026-09-03 Office | Evergreen Dermatology Clinic Dermatology · out of network | 11403, 99213 | $902.00 | — | Left for review CO97 | — | Needs review |
| 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-2026-016700 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-2026-012628 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-2026-022839 CMS-1500 · 2026-09-14 | Bruce Ray UHC-75568-84 | 2026-08-05 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 85025, 80061 | $73.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-008908 CMS-1500 · 2026-09-13 | Raymond Cox UHC-58166-35 | 2026-08-07 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 80053, 83036 | $121.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-019965 UB-04 · 2026-09-04 | Hannah Rose UHC-38319-19 | 2026-08-09 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283, 99285 | $2,618.00 | — | Left for review NET CO97 | — | Needs review |
| CLM-2026-034434 CMS-1500 · 2026-09-01 | Maria Patterson UHC-97217-21 | 2026-08-07 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 87086, 85025 | $66.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-019087 UB-04 · 2026-09-01 | Laura Rivera UHC-17261-47 | 2026-07-20 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046, 99283 | $1,279.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-009477 CMS-1500 · 2026-08-30 | Ashley Perry UHC-75552-09 | 2026-08-16 Office | Unity Primary Care Associates Family Medicine · out of network | 99203, 99213 | $421.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023696 CMS-1500 · 2026-08-26 | Danielle Pierce UHC-91432-68 | 2026-08-24 Office | Lakeside Medical Group Family Medicine · out of network | 90471, 99213 | $187.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-004417 CMS-1500 · 2026-08-26 | Philip Johnston UHC-61230-27 | 2026-08-15 Office | Harbor Medical Group Internal Medicine · out of network | 99215, 99214 | $551.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-000629 CMS-1500 · 2026-08-23 | Lauren Gutierrez UHC-72049-97 | 2026-08-15 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 85025, 83036, 80053 | $178.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-029527 UB-04 · 2026-08-19 | Joan Silva UHC-84623-38 | 2026-07-29 Outpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 73721, 29881 | $11,251.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-025150 CMS-1500 · 2026-08-15 | Laura Dunn UHC-73734-03 | 2026-07-16 Office | Northgate Primary Care Associates Family Medicine · out of network | 99203, 99213 | $454.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-034207 UB-04 · 2026-08-10 | Frank Daniels UHC-02600-13 | 2026-08-02 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447, 29881 | $39,675.00 | — | Left for review CO97 HIGH | — | Needs review |
| CLM-2026-008683 CMS-1500 · 2026-08-06 | Isabella Ramirez UHC-93692-17 | 2026-06-28 Office | Northgate Primary Care Associates Family Medicine · out of network | 99213, 90471 | $227.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-012768 CMS-1500 · 2026-07-16 | Christian Weber UHC-95154-03 | 2026-07-09 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97014, 97140 | $402.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-008110 CMS-1500 · 2026-07-07 | Janice Burton UHC-20074-87 | 2026-06-12 Office | Unity Primary Care Associates Family Medicine · out of network | 36415, 99214 | $312.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-026422 CMS-1500 · 2026-07-04 | Carlos Gibson UHC-74409-30 | 2026-06-06 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 85025 | $81.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-025812 CMS-1500 · 2026-06-26 | Sean Garrett UHC-63417-50 | 2026-05-15 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97161 | $590.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-032611 UB-04 · 2026-06-24 | Emily Kennedy UHC-15065-84 | 2026-06-12 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046, 99283 | $857.00 | — | Left for review NET CO97 | — | Needs review |
| CLM-2026-015697 UB-04 · 2026-06-24 | Mark Johnston UHC-67775-91 | 2026-05-20 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99284, 96374, 71046 | $2,146.00 | — | Left for review NET CO97 | — | Needs review |
| CLM-2026-006212 CMS-1500 · 2026-06-22 | William Tran UHC-33437-18 | 2026-05-08 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97140 | $171.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-013843 UB-04 · 2026-06-12 | Abigail Perkins UHC-99873-07 | 2026-05-28 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99284, 71046 | $1,602.00 | — | Left for review NET CO97 | — | Needs review |
| CLM-2026-007660 CMS-1500 · 2026-06-10 | Mark Olson UHC-48831-04 | 2026-05-09 Office | Northgate Primary Care Associates Family Medicine · out of network | 99214, 36415 | $247.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-032977 UB-04 · 2026-06-05 | Scott Clark UHC-35459-02 | 2026-04-23 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 99285, 99283 | $3,039.00 | — | Left for review NET CO97 | — | Needs review |
| CLM-2026-011143 CMS-1500 · 2026-06-02 | Harold Rojas UHC-16881-88 | 2026-05-12 Office | Canyon Cardiovascular Associates Cardiology · out of network | 99214, 93224 | $711.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-027466 CMS-1500 · 2026-06-01 | Timothy Oliver UHC-62177-92 | 2026-05-08 Office | Northgate Primary Care Associates Family Medicine · out of network | 99395, 99213 | $492.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-030492 UB-04 · 2026-05-27 | Sarah Fernandez UHC-46404-59 | 2026-04-30 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721, 29881 | $10,470.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-022774 CMS-1500 · 2026-05-19 | Sarah Fuller UHC-79653-16 | 2026-05-04 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 83036, 80061 | $121.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-009689 UB-04 · 2026-05-17 | Julia Estrada UHC-94226-56 | 2026-04-27 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 96374, 99283, 99285 | $3,620.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-017830 CMS-1500 · 2026-05-11 | Anna Rice UHC-08508-68 | 2026-04-26 Office | Valley Primary Care Associates Family Medicine · out of network | 99213, 99214 | $417.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-032733 CMS-1500 · 2026-05-04 | Keith Price UHC-07851-61 | 2026-03-29 Office | Harbor Medical Group Internal Medicine · out of network | 99214, 99215 | $625.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-003018 CMS-1500 · 2026-05-03 | Alexander Ray UHC-31410-22 | 2026-03-20 Office | Harbor Medical Group Internal Medicine · out of network | 99215, 80053 | $430.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-018340 UB-04 · 2026-04-28 | Pamela Matthews UHC-37090-99 | 2026-04-26 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 76700, 70553 | $2,422.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-029952 UB-04 · 2026-04-24 | Nathan Powell UHC-58381-41 | 2026-03-15 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284, 99283 | $2,655.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-016034 UB-04 · 2026-04-24 | Joshua Simmons UHC-19558-30 | 2026-04-15 Inpatient hospital | Mesa Internal Medicine Associates Internal Medicine · out of network | 99232, 99215 | $625.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-020163 CMS-1500 · 2026-04-22 | Sara Cooer UHC-45515-34 | 2026-04-14 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 99215, 93000 | $481.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-008232 CMS-1500 · 2026-04-22 | Emily White UHC-52127-72 | 2026-04-07 Office | Canyon Cardiovascular Associates Cardiology · out of network | 99214, 93224 | $642.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-029712 CMS-1500 · 2026-04-20 | William Patterson UHC-70673-52 | 2026-03-30 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 83036, 80053 | $161.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-015108 UB-04 · 2026-04-20 | Dylan Green UHC-27229-30 | 2026-03-11 Inpatient hospital | Harbor Medical Group Internal Medicine · out of network | 99232, 99215 | $626.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-033344 CMS-1500 · 2026-04-19 | Edward Brooks UHC-00554-30 | 2026-04-03 Office | Canyon Heart Institute Cardiology · out of network | 99214, 93224 | $722.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-031042 CMS-1500 · 2026-04-08 | Jonathan Dunn UHC-80735-98 | 2026-03-09 Office | Heritage Medical Group Family Medicine · out of network | 90471, 99213 | $213.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-011753 UB-04 · 2026-04-01 | Jason Cox UHC-09193-61 | 2026-02-17 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 27447, 29881 | $40,665.00 | — | Left for review CO97 HIGH | — | Needs review |
| CLM-2026-010115 UB-04 · 2026-03-26 | Ahmed Harrison UHC-65862-40 | 2026-03-20 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 29881, 73721 | $12,099.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-001403 CMS-1500 · 2026-03-25 | Christine Valdez UHC-97505-59 | 2026-03-17 Office | Canyon Counseling Center Behavioral Health · out of network | 90837, 90834 | $411.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-024633 UB-04 · 2026-03-21 | Jacqueline Le UHC-21325-08 | 2026-03-06 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99285, 99283, 99284 | $5,025.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-022349 UB-04 · 2026-03-21 | Lauren Wagner UHC-76656-69 | 2026-02-04 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447, 29881 | $50,948.00 | — | Left for review CO97 HIGH | — | Needs review |
| CLM-2026-011282 UB-04 · 2026-03-21 | Cynthia George UHC-88626-78 | 2026-02-04 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · out of network | 99232, 99215 | $573.00 | — | Left for review CO97 | — | Needs review |
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.