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
3,664
50 with an AI recommendation
Pended
2,586
awaiting information or identity
Approved
23,942
$6,757,768.45 plan paid
Denied
4,454
with remittance reason codes
Examiner decided
0
167 not attached to an identity
| Claim | Member | Service | Provider | Procedures | Billed | Plan pays | Rules | AI | Status |
|---|---|---|---|---|---|---|---|---|---|
| CLM-2026-028070 CMS-1500 · 2026-10-08 | Roy Wright UHC-76478-99 | 2026-09-09 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061, 83036 | $116.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-022319 CMS-1500 · 2026-10-08 | Jason Ryan UHC-14330-97 | 2026-08-30 Office | Canyon Cardiovascular Associates Cardiology · out of network | 99214 | $259.00 | — | Left for review REPL | — | Needs review |
| 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-2026-012959 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-2026-003147 CMS-1500 · 2026-09-19 | Lisa Porter UHC-43480-38 | 2026-08-21 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 85025, 83036 | $123.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-027327 CMS-1500 · 2026-09-17 | Thomas Morales UHC-74441-71 | 2026-07-28 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11403 | $719.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-025405 CMS-1500 · 2026-08-23 | Eugene Cox UHC-38773-39 | 2026-07-21 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 87086 | $43.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029959 CMS-1500 · 2026-08-07 | Albert Marquez UHC-90690-86 | 2026-06-19 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 80053, 85025 | $148.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-005552 CMS-1500 · 2026-08-05 | Sophia Long UHC-32948-05 | 2026-06-25 Office | Heritage Medical Group Family Medicine · out of network | 99213 | $188.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-005790 CMS-1500 · 2026-08-04 | Susan Greene UHC-10018-12 | 2026-07-20 Office | Unity Internal Medicine Associates Internal Medicine · out of network | 80053 | $87.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-000205 CMS-1500 · 2026-07-31 | Valentina Thomas UHC-90800-20 | 2026-06-13 Office | Meadow Heart Institute Cardiology · out of network | 99214 | $331.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-027174 CMS-1500 · 2026-07-27 | Gloria Guerrero UHC-00519-84 | 2026-06-25 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 80053, 85025 | $106.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-025551 CMS-1500 · 2026-07-20 | Roy Duncan UHC-19828-47 | 2026-07-07 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 87086 | $31.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-002564 CMS-1500 · 2026-07-14 | Sophia Myers UHC-31513-50 | 2026-05-28 Telehealth | Canyon Counseling Center Behavioral Health · out of network | 99214 | $315.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-014155 CMS-1500 · 2026-06-28 | Maria Castro UHC-41645-88 | 2026-06-17 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97161 | $493.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-019793 CMS-1500 · 2026-06-10 | Austin Johnson UHC-23041-70 | 2026-05-18 Office | Lakeside Medical Group Family Medicine · out of network | 90471 | $27.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-022154 CMS-1500 · 2026-05-14 | Theresa Espinoza UHC-67186-14 | 2026-04-19 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 93000, 80053 | $178.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-005451 CMS-1500 · 2026-04-19 | Timothy Wang UHC-63226-44 | 2026-03-03 Office | Heritage Medical Group Family Medicine · out of network | 36415 | $16.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-014027 CMS-1500 · 2026-04-16 | Carlos Daniels UHC-27376-91 | 2026-03-04 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · out of network | 80053, 85025 | $114.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008503 CMS-1500 · 2026-03-30 | Lisa Gilbert UHC-20142-82 | 2026-02-17 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086, 85025 | $69.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-019312 CMS-1500 · 2026-03-27 | Teresa Gonzales UHC-82828-61 | 2026-02-10 Office | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 99213, 20610 | $421.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-001704 CMS-1500 · 2026-03-05 | Joshua Burke UHC-01003-36 | 2026-01-04 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 99214, 80053 | $279.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-018260 CMS-1500 · 2026-03-02 | Debra Jensen UHC-66581-10 | 2026-01-06 Office | Unity Internal Medicine Associates Internal Medicine · out of network | 80053 | $62.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008552 CMS-1500 · 2026-03-01 | Vicky Yang UHC-95449-76 | 2026-02-05 Office | Lakeside Endocrine Associates Endocrinology · out of network | 99214 | $267.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-009707 CMS-1500 · 2026-02-26 | Lawrence Garrett UHC-83755-59 | 2026-01-08 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 85025, 87086 | $111.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-015031 CMS-1500 · 2026-02-15 | Steven Matthews UHC-10194-82 | 2025-12-18 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 80061, 87086, 83036, 85025 | $208.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008338 CMS-1500 · 2026-02-08 | Virginia Jenkins UHC-21056-21 | 2026-01-01 Office | Evergreen Dermatology Clinic Dermatology · out of network | 17110, 11403 | $648.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-022381 CMS-1500 · 2026-02-07 | Stephen Ford UHC-14624-83 | 2025-12-29 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $151.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-028845 CMS-1500 · 2026-01-22 | Stewart Mateo UHC-20020-02 | 2025-12-24 Office | Sunrise Digestive Health Center Gastroenterology · out of network | 99214 | $313.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-033765 CMS-1500 · 2026-01-09 | Adam Roberts UHC-61455-54 | 2025-11-27 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90837 | $262.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-016575 CMS-1500 · 2026-01-07 | Sharon Gomez UHC-34933-75 | 2025-12-16 Office | Canyon Counseling Center Behavioral Health · out of network | 90834 | $140.00 | — | Left for review REPL | — | 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.