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-2026-031375 CMS-1500 · 2026-10-15 | Kathryn Morris UHC-54409-02 | 2026-09-19 Office | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 20610 | $261.00 | $111.82 | Clean approval | — | Approved |
| CLM-2026-031035 CMS-1500 · 2026-10-15 | Jesse Santos UHC-21978-49 | 2026-10-07 Office | Desert Primary Care Associates Family Medicine · in network | 99203 | $256.00 | $128.72 | Clean approval | — | Approved |
| CLM-2026-030914 CMS-1500 · 2026-10-15 | Timothy Simmons UHC-23080-10 | 2026-09-12 Office | Mesa Family Practice Family Medicine · in network | 99203, 99213 | $386.00 | $214.32 | Clean approval | — | Approved |
| CLM-2026-030326 UB-04 · 2026-10-15 | Mateo Carlson UHC-62488-93 | 2026-10-06 Outpatient hospital | Meadow Physical Therapy Physical Therapy · in network | 70553 | $8,862.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-030080 CMS-1500 · 2026-10-15 | Rebecca Carlson UHC-32126-56 | 2026-04-23 Office | Meadow Primary Care Associates Family Medicine · in network | 99395 | $285.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-029991 CMS-1500 · 2026-10-15 | Nancy Welch UHC-74613-35 | 2026-09-20 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97014, 97161 | $545.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-029862 UB-04 · 2026-10-15 | Anna Morris UHC-60990-54 | 2026-09-05 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $51,290.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-029535 UB-04 · 2026-10-15 | Jordan Gardner UHC-58120-60 | 2026-10-07 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 74177 | $2,355.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-029162 UB-04 · 2026-10-15 | Albert Sanders UHC-40942-62 | 2026-09-08 Outpatient hospital | Riverside Family Practice Family Medicine · in network | 70553 | $2,255.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-028969 CMS-1500 · 2026-10-15 | Janet Turner UHC-84100-90 | 2026-10-02 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 80053, 99214 | $322.00 | $169.64 | Clean approval | — | Approved |
| CLM-2026-028765 CMS-1500 · 2026-10-15 | Joseph Wheeler UHC-76888-73 | 2026-09-19 Office | Harbor Physical Therapy Physical Therapy · in network | 97110 | $240.00 | $123.80 | Clean approval | — | Approved |
| CLM-2026-028299 CMS-1500 · 2026-10-15 | Bruce Nunez UHC-48675-61 | 2026-09-17 Office | Mesa Family Practice Family Medicine · in network | 36415, 99203, 90471 | $269.00 | $159.34 | Clean approval | — | Approved |
| CLM-2026-028287 UB-04 · 2026-10-15 | Jesse Lewis UHC-25390-99 | 2026-10-12 Outpatient hospital | Evergreen GI Associates Gastroenterology · in network | 88305, 45378 | $3,143.00 | $626.97 | Clean approval | — | Approved |
| CLM-2026-027833 UB-04 · 2026-10-15 | Juan Medina UHC-12396-73 | 2026-10-06 Inpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 27447 | $32,984.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027777 UB-04 · 2026-10-15 | Jean Phillips UHC-92483-07 | 2026-09-30 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 70553, 71046, 74177 | $4,811.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-027769 UB-04 · 2026-10-15 | Philip Willis UHC-00426-62 | 2026-09-06 Inpatient hospital | Harbor Medical Group Internal Medicine · in network | 99232 | $207.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-027714 CMS-1500 · 2026-10-15 | Brenda Mitchell UHC-31490-89 | 2026-09-09 Telehealth | Evergreen Counseling Center Behavioral Health · in network | 99214 | $307.00 | $140.34 | Clean approval | — | Approved |
| CLM-2026-027414 UB-04 · 2026-10-15 | Gregory Hunt UHC-84710-60 | 2026-09-23 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $6,359.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-027343 UB-04 · 2026-10-15 | Carolyn Gutierrez UHC-61047-79 | 2026-10-08 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 96374 | $142.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-027091 CMS-1500 · 2026-10-15 | Arthur Hernandez UHC-81248-74 | 2026-09-13 Office | Sunrise Behavioral Health Behavioral Health · in network | 90791 | $314.00 | $144.68 | 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-2026-026316 CMS-1500 · 2026-10-15 | Patrick Jordan UHC-27638-29 | 2026-10-06 Office | Evergreen Medical Group Family Medicine · in network | 99213, 99395 | $467.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-025880 CMS-1500 · 2026-10-15 | Peter Valdez UHC-67988-31 | 2026-10-08 Telehealth | Sunrise Counseling Center Behavioral Health · in network | 99214 | $205.00 | $67.10 | Clean approval | — | Approved |
| CLM-2026-025650 UB-04 · 2026-10-15 | Rachel Lopez UHC-43524-49 | 2026-10-02 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $35,527.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-025622 UB-04 · 2026-10-15 | George Tucker UHC-44073-63 | 2026-09-28 Outpatient hospital | Mesa Cardiovascular Associates Cardiology · in network | 93015 | $612.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-025402 CMS-1500 · 2026-10-15 | Philip Grant UHC-64888-16 | 2026-10-03 Office | Mesa Medical Group Family Medicine · in network | 99213 | $173.00 | $77.26 | Clean approval | — | Approved |
| CLM-2026-025255 CMS-1500 · 2026-10-15 | Bobby Thomas no member ID | 2026-09-27 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90837 | $295.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-025026 UB-04 · 2026-10-15 | Edward Dunn UHC-58248-42 | 2026-10-01 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 88305, 45378 | $2,697.00 | $686.45 | Clean approval | — | Approved |
| CLM-2026-024533 CMS-1500 · 2026-10-15 | Amanda Simmons no member ID | 2026-10-12 Office | Summit Family Practice Family Medicine · in network | 36415, 99395, 99213 | $472.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024517 CMS-1500 · 2026-10-15 | Samuel Watson UHC-80292-19 | 2026-10-09 Office | Mesa Family Practice Family Medicine · in network | 99213, 99214, 99395 | $724.00 | $423.88 | Clean approval | — | Approved |
| CLM-2026-023855 UB-04 · 2026-10-15 | Dennis Perez UHC-14032-93 | 2026-09-24 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306, 93458 | $10,569.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023663 CMS-1500 · 2026-10-15 | Bruce Phillips UHC-32256-98 | 2026-09-12 Office | Pinecrest Medical Group Family Medicine · in network | 36415 | $24.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-022529 UB-04 · 2026-10-15 | Jesse Baker UHC-05897-89 | 2026-10-05 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 70553, 71046 | $2,150.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-022279 CMS-1500 · 2026-10-15 | Olivia Hart UHC-78547-45 | 2026-09-06 Office | Canyon Primary Care Associates Family Medicine · in network | 99203 | $199.00 | $103.38 | Clean approval | — | Approved |
| CLM-2026-022220 CMS-1500 · 2026-10-15 | Henry Mitchell UHC-74665-73 | 2026-09-02 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 85025, 87086 | $94.00 | $0.00 | 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-2026-021401 CMS-1500 · 2026-10-15 | Judy Gordon UHC-42217-51 | 2026-09-21 Office | Sunrise Dermatology Clinic Dermatology · in network | 17110, 11403 | $789.00 | $429.18 | Clean approval | — | Approved |
| CLM-2026-021166 CMS-1500 · 2026-10-15 | Russell Rojas UHC-09549-19 | 2026-10-12 Independent laboratory | Sunrise Clinical Laboratories Clinical Laboratory · in network | 80053 | $90.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-021042 CMS-1500 · 2026-10-15 | Natalie Wallace UHC-21792-24 | 2026-09-26 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 99214, 93000 | $333.00 | $166.46 | Clean approval | — | Approved |
| CLM-2026-020313 UB-04 · 2026-10-15 | Samuel West UHC-29799-48 | 2026-10-10 Outpatient hospital | Meadow Primary Care Associates Family Medicine · in network | 70553 | $2,486.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-020297 CMS-1500 · 2026-10-15 | Elizabeth Walker UHC-96628-55 | 2026-10-06 Office | Heritage Primary Care Associates Family Medicine · in network | 99213 | $189.00 | $92.18 | Clean approval | — | Approved |
| CLM-2026-019962 UB-04 · 2026-10-15 | Elijah Brooks UHC-25287-21 | 2026-10-03 Outpatient hospital | Pinecrest Cardiovascular Associates Cardiology · in network | 93015, 93306 | $1,422.00 | $304.42 | Clean approval | — | Approved |
| CLM-2026-019603 CMS-1500 · 2026-10-15 | Lori Nunez UHC-64875-75 | 2026-08-31 Office | Heritage Physical Therapy Physical Therapy · in network | 97110, 97140 | $310.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-019476 CMS-1500 · 2026-10-15 | Sean Phillips UHC-68068-92 | 2026-09-12 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97161 | $503.00 | $281.86 | Clean approval | — | Approved |
| CLM-2026-019192 UB-04 · 2026-10-15 | Gloria Vargas UHC-65899-86 | 2026-09-13 Outpatient hospital | Mesa Cardiovascular Associates Cardiology · in network | 93458, 93306 | $6,391.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-018854 UB-04 · 2026-10-15 | Gloria Yang UHC-77975-62 | 2026-10-07 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 93458, 93306 | $10,394.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-018758 CMS-1500 · 2026-10-15 | Logan Jensen UHC-93744-90 | 2026-10-02 Office | Desert Rehabilitation Center Physical Therapy · in network | 97110, 97161, 97014 | $457.00 | $258.34 | Clean approval | — | Approved |
| CLM-2026-018741 CMS-1500 · 2026-10-15 | Valentina Patterson UHC-12015-82 | 2026-10-12 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 87086 | $40.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-018704 CMS-1500 · 2026-10-15 | Emily Lucas UHC-12704-17 | 2026-10-07 Office | Heritage Primary Care Associates Family Medicine · in network | 99213 | $201.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-018275 UB-04 · 2026-10-15 | Billy Le UHC-22687-90 | 2026-09-28 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285, 99284, 99283 | $5,093.00 | — | 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.