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-2026-008699 CMS-1500 · 2026-10-16 | Margaret Gonzales UHC-59119-32 | 2026-10-13 Office | Meadow Family Practice Family Medicine · in network | 36415, 99213 | $202.00 | $114.70 | Clean approval | — | Approved |
| CLM-2026-008671 CMS-1500 · 2026-10-16 | Julie Walsh UHC-41401-24 | 2026-09-13 Office | Meadow Primary Care Associates Family Medicine · in network | 99203, 99213 | $366.00 | $196.92 | Clean approval | — | Approved |
| CLM-2026-008593 UB-04 · 2026-10-16 | Daniel Marshall UHC-78984-90 | 2026-09-03 Outpatient hospital | Valley Cardiovascular Associates Cardiology · in network | 93306 | $1,002.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-008504 UB-04 · 2026-10-16 | Andrew Dean UHC-73405-81 | 2026-09-04 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,115.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-008389 CMS-1500 · 2026-10-16 | Kyle Salazar UHC-42261-80 | 2026-09-07 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 80061 | $65.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008373 CMS-1500 · 2026-10-16 | Jonathan Ortega UHC-09877-57 | 2026-09-02 Office | Sunrise Dermatology Clinic Dermatology · in network | 99213 | $203.00 | $75.86 | Clean approval | — | Approved |
| CLM-2026-008361 UB-04 · 2026-10-16 | Judy Payne UHC-70825-08 | 2026-09-23 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 71046 | $137.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-008054 UB-04 · 2026-10-16 | Terry Cooper no member ID | 2026-09-26 Emergency room | Harbor Regional Medical Center Emergency Medicine · in network | 71046 | $246.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-007243 UB-04 · 2026-10-16 | Jesse Alexander UHC-98335-18 | 2026-10-08 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553, 71046 | $3,684.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006859 UB-04 · 2026-10-16 | Sara Wallace UHC-78913-28 | 2026-09-23 Outpatient hospital | Evergreen GI Associates Gastroenterology · in network | 45378, 43239 | $3,976.00 | $401.38 | Clean approval | — | Approved |
| CLM-2026-006836 UB-04 · 2026-10-16 | Nancy Simpson UHC-55422-71 | 2026-10-14 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 71046 | $176.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-006470 CMS-1500 · 2026-10-16 | Adam Evans UHC-68420-99 | 2026-10-12 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 85025 | $42.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-006396 UB-04 · 2026-10-16 | Jesse Kim UHC-45304-40 | 2026-09-04 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284, 99283 | $1,928.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-006277 CMS-1500 · 2026-10-16 | Santiago Rivera UHC-93168-85 | 2026-09-22 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 99215, 80053 | $405.00 | $226.10 | Clean approval | — | Approved |
| CLM-2026-006148 UB-04 · 2026-10-16 | Scott Mills UHC-95658-73 | 2026-09-27 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 77067, 71046 | $562.00 | $0.00 | 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-2026-005655 CMS-1500 · 2026-10-16 | Jacqueline Brooks UHC-71813-52 | 2026-09-30 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 93000 | $105.00 | $25.10 | 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-2026-005496 CMS-1500 · 2026-10-16 | Sarah Morris UHC-40918-63 | 2026-10-08 Office | Unity Counseling Center Behavioral Health · in network | 90791 | $443.00 | $224.66 | Clean approval | — | Approved |
| CLM-2026-005344 CMS-1500 · 2026-10-16 | Lori Coooper UHC-56472-37 | 2026-09-17 Office | Evergreen Rehabilitation Center Physical Therapy · in network | 97110, 97140, 97014 | $361.00 | $203.82 | Clean approval | — | Approved |
| CLM-2026-005195 CMS-1500 · 2026-10-16 | Mei Howell UHC-44146-28 | 2026-09-16 Office | Northgate Medical Group Internal Medicine · in network | 99215 | $281.00 | $149.22 | Clean approval | — | Approved |
| CLM-2026-004573 CMS-1500 · 2026-10-16 | Lawrence Hayes UHC-29287-75 | 2026-09-05 Office | Unity Physical Therapy Physical Therapy · in network | 97110, 97014 | $338.00 | $169.56 | Clean approval | — | Approved |
| CLM-2026-004493 CMS-1500 · 2026-10-16 | Brandon Bryant UHC-60328-88 | 2026-10-05 Office | Heritage Physical Therapy Physical Therapy · in network | 97110, 97161 | $374.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-004387 CMS-1500 · 2026-10-16 | Bryan Mitchell UHC-04861-43 | 2026-10-01 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 83036, 80061 | $98.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-004385 CMS-1500 · 2026-10-16 | Joan Rivera UHC-22799-76 | 2026-09-08 Office | Pinecrest Medical Group Internal Medicine · in network | 99215 | $347.00 | $175.14 | Clean approval | — | Approved |
| CLM-2026-003618 CMS-1500 · 2026-10-16 | Anna Long UHC-85185-56 | 2026-09-16 Office | Meadow Family Practice Family Medicine · in network | 99395 | $270.00 | $142.40 | Clean approval | — | Approved |
| CLM-2026-003399 UB-04 · 2026-10-16 | Philip Willis UHC-00426-62 | 2026-09-09 Outpatient hospital | Desert Imaging Center Radiology · in network | 71046, 76700 | $472.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003168 UB-04 · 2026-10-16 | Denise Mills UHC-44700-43 | 2026-09-29 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 71046, 96374 | $465.00 | $142.45 | Clean approval | — | Approved |
| CLM-2026-002991 CMS-1500 · 2026-10-16 | Denise Johnston UHC-20279-55 | 2026-09-11 Office | Lakeside Medical Group Internal Medicine · in network | 93000 | $90.00 | $30.80 | 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-2026-002555 CMS-1500 · 2026-10-16 | Rachel Allen UHC-61641-27 | 2026-09-05 Office | Sunrise Dermatology Clinic Dermatology · in network | 11102 | $266.00 | $124.92 | Clean approval | — | Approved |
| CLM-2026-002377 CMS-1500 · 2026-10-16 | Sandra Scott UHC-00116-94 | 2026-10-03 Office | Canyon Medical Group Internal Medicine · in network | 93000, 99214 | $273.00 | $149.26 | Clean approval | — | Approved |
| CLM-2026-002334 CMS-1500 · 2026-10-16 | Juan Banks no member ID | 2026-06-19 Office | Harbor Diabetes Center Endocrinology · in network | 99214, 95251 | $350.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-001738 CMS-1500 · 2026-10-16 | Susan Burns no member ID | 2026-09-16 Office | Sunrise Diabetes Center Endocrinology · in network | 83036, 99214 | $337.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-001711 UB-04 · 2026-10-16 | Kimberly Bell UHC-86763-22 | 2026-10-06 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 70553 | $3,278.00 | $472.54 | Clean approval | — | Approved |
| CLM-2026-001215 CMS-1500 · 2026-10-16 | Madison Jenkins UHC-28890-43 | 2026-09-11 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 83036 | $76.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-000169 CMS-1500 · 2026-10-16 | Ahmed Wright UHC-78812-39 | 2026-09-27 Office | Evergreen Primary Care Associates Family Medicine · in network | 99213, 99214 | $426.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000082 CMS-1500 · 2026-10-16 | Bradley Hughes UHC-90029-18 | 2026-09-26 Office | Meadow Cardiovascular Associates Cardiology · in network | 93224 | $350.00 | $142.00 | 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-2026-034546 CMS-1500 · 2026-10-15 | Valentina Jacobs UHC-49399-41 | 2026-10-02 Office | Harbor Family Practice Family Medicine · in network | 90471, 99213 | $241.00 | $129.42 | Clean approval | — | Approved |
| CLM-2026-034475 CMS-1500 · 2026-10-15 | Kevin Hicks UHC-63040-61 | 2026-10-12 Office | Mesa Dermatology Clinic Dermatology · in network | 11102, 17110 | $510.00 | $266.20 | Clean approval | — | Approved |
| CLM-2026-034327 UB-04 · 2026-10-15 | Mary Baker UHC-41912-65 | 2026-09-02 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 71046 | $157.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-034301 CMS-1500 · 2026-10-15 | Alan Maldonado UHC-40405-98 | 2026-08-16 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90834, 90837, 90791 | $757.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-033360 CMS-1500 · 2026-10-15 | Donna Perez UHC-15786-23 | 2026-10-09 Office | Meadow GI Associates Gastroenterology · in network | 99214 | $323.00 | $140.26 | Clean approval | — | Approved |
| CLM-2026-033302 UB-04 · 2026-10-15 | Elizabeth Edwards UHC-73277-83 | 2026-09-01 Outpatient hospital | Pinecrest Cardiovascular Associates Cardiology · in network | 93458 | $8,888.00 | $2,940.33 | 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-2026-032329 CMS-1500 · 2026-10-15 | Gary Burns UHC-46900-65 | 2026-10-03 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 83036, 87086, 85025 | $147.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032266 CMS-1500 · 2026-10-15 | Andrea Delgado UHC-69502-60 | 2026-09-26 Office | Mesa Dermatology Clinic Dermatology · in network | 17110 | $169.00 | $54.78 | 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-2026-031620 UB-04 · 2026-10-15 | Gabriel Ward UHC-91327-36 | 2026-09-01 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 88305 | $245.00 | $0.00 | 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.