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-2026-025482 CMS-1500 · 2026-10-12 | Ralph Harper UHC-54586-42 | 2026-10-08 Office | Canyon Counseling Center Behavioral Health · out of network | 90837 | $246.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-003697 CMS-1500 · 2026-10-11 | Carl Clark UHC-07708-62 | 2026-09-07 Office | Canyon Counseling Center Behavioral Health · out of network | 90837, 90791, 90834 | $933.00 | — | Left for review CO16 | — | Needs review |
| 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-2026-018859 CMS-1500 · 2026-10-04 | Susan Greene UHC-60400-11 | 2026-09-15 Office | Heritage Medical Group Family Medicine · out of network | 36415 | $22.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-016366 CMS-1500 · 2026-10-03 | Santiago Graham UHC-34126-09 | 2026-09-07 Office | Northgate Primary Care Associates Family Medicine · out of network | 99203, 99395 | $464.00 | — | Left for review DUP | — | 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-2026-025721 CMS-1500 · 2026-10-01 | Philip Simmons UHC-94170-33 | 2026-09-15 Office | Lakeside Medical Group Family Medicine · out of network | 36415, 99203, 90471 | $286.00 | — | Left for review CO16 | — | 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-2026-018658 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-2026-022839 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-2026-033483 CMS-1500 · 2026-09-12 | Amanda Santos UHC-87211-30 | 2026-08-12 Office | Meadow Heart Institute Cardiology · out of network | 99214, 93224 | $679.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-013078 CMS-1500 · 2026-09-10 | Roy Wilson UHC-47553-11 | 2026-09-01 Office | Sunrise Dermatology Clinic Dermatology · out of network | 99213 | $206.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-010253 CMS-1500 · 2026-09-10 | Amy Vasquez UHC-05827-31 | 2026-08-15 Office | Lakeside Medical Group Family Medicine · out of network | 99203 | $229.00 | — | Left for review DUP | — | 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-2026-009477 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-2026-025405 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-2026-000629 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-2026-029731 CMS-1500 · 2026-08-16 | Brian Diaz UHC-83306-67 | 2026-06-28 Office | Harbor Medical Group Internal Medicine · out of network | 99215 | $388.00 | — | Left for review DUP | — | 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-2026-017177 CMS-1500 · 2026-08-15 | Elijah Shaw UHC-28566-72 | 2026-07-24 Office | Northgate Primary Care Associates Family Medicine · out of network | 36415, 99213 | $218.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-012460 CMS-1500 · 2026-08-08 | Lucia Rios UHC-92720-51 | 2026-07-26 Office | Valley Skin Care Associates Dermatology · out of network | 11102, 17110 | $520.00 | — | Left for review CO16 | — | 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-2026-008683 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-2026-005552 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-2026-029686 CMS-1500 · 2026-07-25 | Gary Greene UHC-81078-05 | 2026-07-12 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 80061 | $144.00 | — | Left for review CO16 | — | 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-2026-024903 CMS-1500 · 2026-07-20 | Bradley Jones UHC-59050-84 | 2026-07-01 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 83036, 80053 | $133.00 | — | Left for review CO16 | — | 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-2026-012391 CMS-1500 · 2026-07-16 | Bobby Powell UHC-35845-09 | 2026-05-25 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214, 93224 | $660.00 | — | Left for review DUP | — | 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-2026-008110 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-2026-024084 CMS-1500 · 2026-07-05 | Maria Armstrong UHC-22895-17 | 2026-06-15 Office | Unity Primary Care Associates Family Medicine · out of network | 90471, 36415, 99203 | $254.00 | — | Left for review CO16 | — | 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-2026-022986 CMS-1500 · 2026-06-28 | Kayla Reid UHC-98078-99 | 2026-05-17 Office | Unity Internal Medicine Associates Internal Medicine · out of network | 99214, 93000 | $265.00 | — | Left for review CO16 | — | 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-2026-025812 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-2026-018429 CMS-1500 · 2026-06-23 | Julie Simmons UHC-60087-69 | 2026-06-01 Office | Heritage Medical Group Family Medicine · out of network | 36415 | $14.00 | — | Left for review CO16 | — | 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 |
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.