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-2026-020880 CMS-1500 · 2026-10-30 | John Wood UHC-22176-71 | 2026-09-15 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $166.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010612 CMS-1500 · 2026-10-26 | Not attached | 2026-09-05 Office | Canyon Counseling Center Behavioral Health · out of network | 90791 | $375.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-028764 CMS-1500 · 2026-10-21 | Edward Phillips UHC-73690-84 | 2026-08-21 Office | Lakeside Medical Group Family Medicine · out of network | 90471, 36415 | $58.00 | — | Denied by rule CO18 | — | Denied |
| 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-2026-032967 CMS-1500 · 2026-10-18 | Amber Howell UHC-88592-44 | 2026-09-18 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11403, 17110 | $956.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032335 CMS-1500 · 2026-10-18 | James Delgado UHC-83159-99 | 2026-09-29 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $186.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-027767 CMS-1500 · 2026-10-18 | Larson Gary no member ID | 2026-09-24 Office | Lakeside Medical Group Family Medicine · out of network | 90471, 36415 | $52.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024000 CMS-1500 · 2026-10-18 | Lawrence George UHC-17614-13 | 2026-10-03 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80061, 83036 | $137.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-009947 CMS-1500 · 2026-10-18 | Melissa Tran UHC-46772-18 | 2026-10-08 Office | Canyon Counseling Center Behavioral Health · out of network | 90837 | $194.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-026123 CMS-1500 · 2026-10-17 | William Simpson UHC-87572-94 | 2026-10-14 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 93000, 80053 | $135.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-019759 CMS-1500 · 2026-10-17 | Sofia Price UHC-91931-96 | 2026-10-11 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 80061, 83036 | $77.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-018925 CMS-1500 · 2026-10-17 | Gerald Campbell no member ID | 2026-08-25 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 83036 | $67.00 | — | Pended by rule N30 | — | Pended |
| 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-2026-011023 CMS-1500 · 2026-10-17 | Nancy Hansen UHC-45838-06 | 2026-09-30 Office | Harbor Primary Care Associates Family Medicine · out of network | 99213 | $140.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009421 CMS-1500 · 2026-10-17 | Abigail Carr UHC-85206-38 | 2026-09-13 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $287.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-005997 CMS-1500 · 2026-10-17 | Christine Cooper UHC-90180-01 | 2026-10-10 Office | Sunrise Digestive Health Center Gastroenterology · out of network | 99214 | $324.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-031371 CMS-1500 · 2026-10-16 | Ann Berry UHC-79552-37 | 2026-10-14 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 80061, 85025 | $95.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-026762 CMS-1500 · 2026-10-16 | Timothy Soto UHC-93230-87 | 2026-09-20 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 20610, 99213 | $469.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-015281 CMS-1500 · 2026-10-16 | Jonathan Lawson UHC-79224-89 | 2026-07-05 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $118.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-011852 CMS-1500 · 2026-10-16 | Heather Carpenter UHC-81594-70 | 2026-09-23 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80053, 85025 | $106.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009760 CMS-1500 · 2026-10-16 | Jose Vega UHC-35189-94 | 2026-09-12 Office | Canyon Counseling Center Behavioral Health · out of network | 90791 | $315.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-031999 CMS-1500 · 2026-10-15 | Dorothy Herrera UHC-12392-13 | 2026-09-16 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90834 | $191.00 | — | Denied by rule CO18 | — | Denied |
| 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-2026-009682 CMS-1500 · 2026-10-15 | Sandra Jackson UHC-78773-38 | 2026-10-09 Office | Valley Skin Care Associates Dermatology · out of network | 17110, 99213 | $480.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006258 CMS-1500 · 2026-10-15 | Jerry Jensen UHC-63050-35 | 2026-09-03 Office | Harbor Medical Group Internal Medicine · out of network | 99214, 80053 | $257.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001025 CMS-1500 · 2026-10-15 | Harold Patterson UHC-04603-36 | 2026-09-17 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $337.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-028107 CMS-1500 · 2026-10-14 | Dylan Parker UHC-07807-62 | 2026-09-28 Office | Canyon Counseling Center Behavioral Health · out of network | 90834, 90791 | $627.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-022432 CMS-1500 · 2026-10-14 | Steven Gilbert UHC-22739-27 | 2026-09-06 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90791, 90834 | $439.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-034571 CMS-1500 · 2026-10-13 | Elizabeth Schultz UHC-01992-56 | 2026-09-30 Office | Evergreen Medical Group Internal Medicine · out of network | 80053, 93000, 99215 | $530.00 | — | Denied by rule CO204 | — | 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.