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-2026-023692 CMS-1500 · 2026-10-18 | Sofia Guerrero UHC-42523-31 | 2026-09-06 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 80061, 87086 | $164.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-015981 CMS-1500 · 2026-10-18 | Harold Rios UHC-13868-34 | 2026-09-23 Office | Lakeside Endocrine Associates Endocrinology · out of network | 95251 | $183.00 | $22.35 | Clean approval | — | Approved |
| CLM-2026-008013 CMS-1500 · 2026-10-18 | Jason Hunt UHC-16244-46 | 2026-09-23 Office | Northgate Primary Care Associates Family Medicine · out of network | 90471, 99214 | $314.00 | $125.55 | Clean approval | — | Approved |
| CLM-2026-000481 CMS-1500 · 2026-10-18 | Matthew Carpenter UHC-33751-82 | 2026-09-18 Office | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 99213 | $237.00 | $56.65 | Clean approval | — | Approved |
| CLM-2026-033256 CMS-1500 · 2026-10-17 | Scott Ward UHC-40403-01 | 2026-10-01 Office | Unity Primary Care Associates Family Medicine · out of network | 99214, 99213, 90471 | $453.00 | $173.85 | Clean approval | — | Approved |
| CLM-2026-032076 CMS-1500 · 2026-10-17 | Charles Griffin UHC-79368-12 | 2026-09-02 Office | Evergreen Medical Group Internal Medicine · out of network | 99215 | $334.00 | $130.30 | Clean approval | — | Approved |
| CLM-2026-018432 CMS-1500 · 2026-10-17 | Kathryn Watson UHC-16945-29 | 2026-09-11 Office | Unity Internal Medicine Associates Internal Medicine · out of network | 93000 | $80.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-002543 CMS-1500 · 2026-10-17 | Jonathan Wang UHC-79770-03 | 2026-10-04 Office | Harbor Medical Group Internal Medicine · out of network | 99215, 93000 | $428.00 | $162.60 | Clean approval | — | Approved |
| CLM-2026-002084 CMS-1500 · 2026-10-17 | Benjamin Ross UHC-35042-30 | 2026-10-09 Office | Canyon Cardiovascular Associates Cardiology · out of network | 99214 | $246.00 | $70.70 | Clean approval | — | Approved |
| CLM-2026-031241 CMS-1500 · 2026-10-16 | Joshua Payne UHC-40350-50 | 2026-09-23 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053 | $45.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-017534 CMS-1500 · 2026-10-16 | Logan Turner UHC-66944-79 | 2026-10-04 Office | Canyon Internal Medicine Associates Internal Medicine · out of network | 99214 | $206.00 | $72.70 | Clean approval | — | Approved |
| CLM-2026-005780 CMS-1500 · 2026-10-16 | Jerry Banks UHC-69891-94 | 2026-09-03 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 93000 | $84.00 | $17.80 | Clean approval | — | Approved |
| CLM-2026-005502 CMS-1500 · 2026-10-16 | Fatima Fisher UHC-13643-76 | 2026-09-25 Office | Harbor Primary Care Associates Family Medicine · out of network | 36415, 99203, 99214 | $457.00 | $196.65 | Clean approval | — | Approved |
| CLM-2026-002674 CMS-1500 · 2026-10-16 | Jean Day UHC-32810-59 | 2026-10-10 Office | Evergreen Dermatology Clinic Dermatology · out of network | 11102, 99213 | $500.00 | $175.00 | Clean approval | — | Approved |
| CLM-2026-034618 CMS-1500 · 2026-10-15 | Patricia Li UHC-70875-63 | 2026-09-08 Office | Lakeside Medical Group Family Medicine · out of network | 99395 | $226.00 | $76.70 | Clean approval | — | Approved |
| CLM-2026-032823 CMS-1500 · 2026-10-15 | Nathan Montgomery UHC-06179-36 | 2026-10-08 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061 | $72.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-026825 CMS-1500 · 2026-10-15 | Virginia Harvey UHC-14058-43 | 2026-09-03 Office | Valley Primary Care Associates Family Medicine · out of network | 90471, 99213, 99214 | $517.00 | $216.45 | Clean approval | — | Approved |
| CLM-2026-022115 CMS-1500 · 2026-10-15 | Mateo Coleman UHC-67652-54 | 2026-09-07 Office | Evergreen Medical Group Internal Medicine · out of network | 93000, 99215 | $499.00 | $199.55 | Clean approval | — | Approved |
| CLM-2026-031543 CMS-1500 · 2026-10-14 | Nancy Fields UHC-70642-29 | 2026-09-28 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $285.00 | $108.25 | Clean approval | — | Approved |
| CLM-2026-018941 CMS-1500 · 2026-10-14 | Donald Fernandez UHC-09849-83 | 2026-09-28 Office | Valley Skin Care Associates Dermatology · out of network | 99213 | $189.00 | $25.05 | Clean approval | — | Approved |
| CLM-2026-017882 CMS-1500 · 2026-10-14 | Betty Daniels UHC-73612-80 | 2026-09-15 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90834 | $217.00 | $47.65 | Clean approval | — | Approved |
| CLM-2026-004768 CMS-1500 · 2026-10-14 | Patricia Wang UHC-99901-23 | 2026-09-04 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 93000 | $73.00 | $2.85 | Clean approval | — | Approved |
| CLM-2026-002142 CMS-1500 · 2026-10-14 | Ralph Ruiz UHC-42464-05 | 2026-09-09 Office | Lakeside Medical Group Family Medicine · out of network | 99214 | $289.00 | $100.05 | Clean approval | — | Approved |
| CLM-2026-031334 CMS-1500 · 2026-10-13 | Ahmed Davis UHC-86559-68 | 2026-08-31 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 85025, 80061, 87086 | $160.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-026524 CMS-1500 · 2026-10-13 | Susan Myers UHC-25021-80 | 2026-09-21 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 85025, 80061 | $93.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011230 CMS-1500 · 2026-10-13 | Debra Coleman UHC-55489-25 | 2026-09-22 Office | Sunrise Dermatology Clinic Dermatology · out of network | 17110, 11403 | $776.00 | $299.20 | Clean approval | — | Approved |
| CLM-2026-007063 CMS-1500 · 2026-10-13 | Gerald Jimenez UHC-02738-67 | 2026-09-12 Office | Unity Primary Care Associates Family Medicine · out of network | 99203, 36415, 99213 | $443.00 | $174.35 | Clean approval | — | Approved |
| CLM-2026-027724 CMS-1500 · 2026-10-12 | Michael Owens UHC-07421-16 | 2026-09-12 Office | Evergreen Dermatology Clinic Dermatology · out of network | 11403 | $641.00 | $228.45 | Clean approval | — | Approved |
| CLM-2026-007606 CMS-1500 · 2026-10-12 | David Berry UHC-53040-86 | 2026-09-02 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 85025, 83036, 80061 | $150.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030867 CMS-1500 · 2026-10-11 | Lawrence Nichols UHC-55829-92 | 2026-09-07 Office | Unity Primary Care Associates Family Medicine · out of network | 99395, 99203, 99214 | $794.00 | $337.30 | Clean approval | — | Approved |
| CLM-2026-022357 CMS-1500 · 2026-10-11 | Denise Sanders UHC-61727-63 | 2026-09-20 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 99215 | $370.00 | $126.50 | Clean approval | — | Approved |
| CLM-2026-020026 CMS-1500 · 2026-10-11 | Sean Gordon UHC-57083-46 | 2026-10-06 Office | Sunrise Digestive Health Center Gastroenterology · out of network | 99214 | $310.00 | $99.50 | Clean approval | — | Approved |
| CLM-2026-033132 CMS-1500 · 2026-10-10 | Henry Wells UHC-34465-23 | 2026-09-21 Office | Lakeside Endocrine Associates Endocrinology · out of network | 95251, 83036, 99215 | $658.00 | $221.10 | Clean approval | — | Approved |
| CLM-2026-025362 CMS-1500 · 2026-10-10 | Luis Clark UHC-84938-13 | 2026-09-14 Office | Unity Internal Medicine Associates Internal Medicine · out of network | 99214 | $276.00 | $99.20 | Clean approval | — | Approved |
| CLM-2026-023956 CMS-1500 · 2026-10-10 | Isabella Herrera UHC-50875-68 | 2026-09-11 Office | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $272.00 | $82.40 | Clean approval | — | Approved |
| CLM-2026-017901 CMS-1500 · 2026-10-10 | Elizabeth Hanson UHC-09556-36 | 2026-09-14 Office | Valley Primary Care Associates Family Medicine · out of network | 99203, 99214 | $438.00 | $172.10 | Clean approval | — | Approved |
| CLM-2026-006361 CMS-1500 · 2026-10-10 | Mari Schmidt UHC-33033-18 | 2026-09-01 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 80053, 85025, 83036 | $177.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-005414 CMS-1500 · 2026-10-10 | Kelly Espinoza UHC-51195-87 | 2026-09-09 Office | Cornerstone Family Practice Family Medicine · out of network | 99203, 99214 | $497.00 | $183.65 | Clean approval | — | Approved |
| CLM-2026-033296 CMS-1500 · 2026-10-09 | Dorothy Hicks UHC-74134-54 | 2026-09-28 Office | Unity Primary Care Associates Family Medicine · out of network | 36415 | $14.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-015168 CMS-1500 · 2026-10-09 | Natalie Guzman UHC-13685-46 | 2026-09-11 Office | Meadow Heart Institute Cardiology · out of network | 99214, 93224 | $698.00 | $264.10 | Clean approval | — | Approved |
| CLM-2026-011624 CMS-1500 · 2026-10-09 | Camila Olson UHC-51240-43 | 2026-08-26 Office | Heritage Medical Group Family Medicine · out of network | 99395 | $302.00 | $110.90 | Clean approval | — | Approved |
| CLM-2026-010412 CMS-1500 · 2026-10-09 | Carlos Scott UHC-31563-59 | 2026-09-02 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 80061 | $45.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-007411 CMS-1500 · 2026-10-09 | Sandra White UHC-13421-40 | 2026-09-13 Office | Evergreen Medical Group Internal Medicine · out of network | 80053 | $61.00 | $2.45 | Clean approval | — | Approved |
| CLM-2026-031998 CMS-1500 · 2026-10-08 | Dorothy Herrera UHC-12392-13 | 2026-09-16 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90834 | $191.00 | $45.95 | Clean approval | — | Approved |
| CLM-2026-027248 CMS-1500 · 2026-10-08 | Edward Wilson UHC-81351-96 | 2026-10-05 Office | Unity Primary Care Associates Family Medicine · out of network | 99213 | $184.00 | $62.80 | Clean approval | — | Approved |
| CLM-2026-020598 CMS-1500 · 2026-10-08 | Dylan Dean UHC-33903-05 | 2026-09-28 Office | Sunrise Digestive Health Center Gastroenterology · out of network | 99214 | $245.00 | $35.25 | Clean approval | — | Approved |
| CLM-2026-018088 CMS-1500 · 2026-10-08 | Zachary Greene UHC-69793-13 | 2026-09-25 Office | Sunrise Dermatology Clinic Dermatology · out of network | 99213, 11102 | $453.00 | $143.85 | Clean approval | — | Approved |
| CLM-2026-016813 CMS-1500 · 2026-10-08 | Joseph Cunningham UHC-10594-91 | 2026-09-19 Office | Lakeside Medical Group Family Medicine · out of network | 99395, 36415 | $321.00 | $104.45 | Clean approval | — | Approved |
| CLM-2026-014607 CMS-1500 · 2026-10-08 | Jesse Cole UHC-22366-11 | 2026-09-03 Office | Canyon Counseling Center Behavioral Health · out of network | 90791, 90837 | $635.00 | $245.75 | Clean approval | — | Approved |
| CLM-2026-030289 CMS-1500 · 2026-10-07 | Daniel Freeman UHC-53118-31 | 2026-09-21 Office | Valley Skin Care Associates Dermatology · out of network | 99213, 17110 | $378.00 | $120.10 | 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.