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-2026-017825 CMS-1500 · 2026-10-15 | Carol Cook UHC-10883-60 | 2026-09-22 Office | Valley Internal Medicine Associates Internal Medicine · in network | 80053, 93000 | $189.00 | $87.18 | Clean approval | — | Approved |
| CLM-2026-017612 CMS-1500 · 2026-10-15 | Karen Jackson UHC-05379-68 | 2026-10-11 Office | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 20610 | $271.00 | $93.02 | Clean approval | — | Approved |
| CLM-2026-015970 UB-04 · 2026-10-15 | George Kelley UHC-50392-85 | 2026-10-01 Outpatient hospital | Valley Imaging Center Radiology · in network | 70553, 74177 | $4,486.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-015835 UB-04 · 2026-10-15 | Angela Sanders UHC-47771-45 | 2026-09-25 Outpatient hospital | Heritage Primary Care Associates Family Medicine · in network | 70553 | $2,840.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-015772 CMS-1500 · 2026-10-15 | Wayne Roberts UHC-40291-13 | 2026-10-04 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99214 | $270.00 | $137.40 | Clean approval | — | Approved |
| CLM-2026-015737 CMS-1500 · 2026-10-15 | Vicky Lynch UHC-39117-66 | 2026-09-11 Office | Pinecrest Medical Group Internal Medicine · in network | 99215 | $393.00 | $223.66 | Clean approval | — | Approved |
| CLM-2026-015358 CMS-1500 · 2026-10-15 | Jerry Dominguez UHC-34607-27 | 2026-08-31 Office | Unity Primary Care Associates Family Medicine · in network | 90471, 99214, 99395 | $497.00 | $291.40 | Clean approval | — | Approved |
| CLM-2026-014947 CMS-1500 · 2026-10-15 | Stephen Soto UHC-38096-98 | 2026-09-18 Office | Valley Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $461.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014761 UB-04 · 2026-10-15 | Peterson Laura UHC-01699-49 | 2026-09-06 Outpatient hospital | Mesa Clinical Laboratories Clinical Laboratory · in network | 70553 | $3,003.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-014746 CMS-1500 · 2026-10-15 | Becky George UHC-12353-35 | 2026-09-05 Office | Canyon Medical Group Internal Medicine · in network | 99214 | $317.00 | $176.54 | Clean approval | — | Approved |
| CLM-2026-014586 CMS-1500 · 2026-10-15 | Nicholas Carr UHC-93074-69 | 2026-10-11 Office | Desert Medical Group Internal Medicine · in network | 99215, 99214, 93000 | $787.00 | $467.94 | Clean approval | — | Approved |
| CLM-2026-013959 CMS-1500 · 2026-10-15 | Patrick Sanders UHC-58486-46 | 2026-10-07 Office | Canyon Skin Care Associates Dermatology · in network | 17110, 11403 | $650.00 | $353.00 | Clean approval | — | Approved |
| CLM-2026-013282 CMS-1500 · 2026-10-15 | Mason Porter UHC-76399-31 | 2026-09-20 Office | Canyon Cardiovascular Associates Cardiology · in network | 93224, 99214 | $740.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-013268 UB-04 · 2026-10-15 | Bruce Foster UHC-80846-56 | 2026-10-10 Outpatient hospital | Meadow Imaging Center Radiology · in network | 76700 | $615.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-013015 CMS-1500 · 2026-10-15 | Mateo Carroll UHC-49936-66 | 2026-10-02 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99214 | $290.00 | $139.80 | Clean approval | — | Approved |
| CLM-2026-012988 UB-04 · 2026-10-15 | Sanitago Franklin UHC-54865-20 | 2026-09-04 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99284, 71046, 99285 | $4,024.00 | — | Left for review NET | — | Needs review |
| CLM-2026-012741 UB-04 · 2026-10-15 | Raymond Alvarado UHC-63639-31 | 2026-09-12 Outpatient hospital | Pinecrest Primary Care Associates Family Medicine · in network | 70553 | $3,358.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-012708 CMS-1500 · 2026-10-15 | Christina Lynch UHC-75863-44 | 2026-09-14 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 83036, 80061 | $108.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-012574 UB-04 · 2026-10-15 | Juan Graham no member ID | 2026-10-02 Inpatient hospital | Canyon Medical Group Internal Medicine · in network | 99232 | $185.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-012370 CMS-1500 · 2026-10-15 | Olivia Grant UHC-50903-76 | 2026-09-29 Independent laboratory | Pinecrest Clinical Laboratories Clinical Laboratory · in network | 80061, 80053, 83036, 87086 | $269.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011274 CMS-1500 · 2026-10-15 | Nancy Welch UHC-74613-35 | 2026-09-13 Telehealth | Pinecrest Behavioral Health Behavioral Health · in network | 99214 | $279.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010915 CMS-1500 · 2026-10-15 | Ethan Lewis UHC-22221-92 | 2026-09-05 Office | Lakeside Medical Group Internal Medicine · in network | 93000, 80053 | $174.00 | $82.88 | Clean approval | — | Approved |
| CLM-2026-010424 UB-04 · 2026-10-15 | Adm Torres UHC-94361-64 | 2026-10-03 Outpatient hospital | Cornerstone Imaging Center Radiology · in network | 77067, 71046 | $553.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-010213 CMS-1500 · 2026-10-15 | Donna Diaz UHC-14269-08 | 2026-10-04 Office | Meadow Primary Care Associates Family Medicine · in network | 36415, 99213, 99214 | $490.00 | $290.78 | Clean approval | — | Approved |
| CLM-2026-009695 CMS-1500 · 2026-10-15 | Kayla Richards no member ID | 2026-10-02 Office | Sunrise Cardiovascular Associates Cardiology · in network | 93224 | $350.00 | — | Pended by rule N30 | — | Pended |
| 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-2026-007944 UB-04 · 2026-10-15 | Ryan Walker UHC-79552-94 | 2026-05-28 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283, 71046 | $1,287.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-007521 CMS-1500 · 2026-10-15 | Sofia Wilson UHC-06608-41 | 2026-10-10 Telehealth | Sunrise Behavioral Health Behavioral Health · in network | 99214 | $263.00 | $113.06 | Clean approval | — | Approved |
| CLM-2026-006601 CMS-1500 · 2026-10-15 | Laura Davis UHC-05707-46 | 2026-09-11 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 99214, 80053 | $300.00 | $161.00 | Clean approval | — | Approved |
| CLM-2026-006483 UB-04 · 2026-10-15 | John Cox no member ID | 2026-09-24 Outpatient hospital | Summit Heart Institute Cardiology · in network | 93015 | $583.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-006356 UB-04 · 2026-10-15 | Julie Martinez UHC-50684-90 | 2026-09-28 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99285 | $2,503.00 | $776.35 | Clean approval | — | Approved |
| 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-2026-006237 CMS-1500 · 2026-10-15 | Lauren Snyder UHC-29407-99 | 2026-09-11 Office | Evergreen Primary Care Associates Family Medicine · in network | 90471 | $41.00 | $5.42 | Clean approval | — | Approved |
| CLM-2026-005927 CMS-1500 · 2026-10-15 | Sophia Lawrence UHC-54923-39 | 2026-08-31 Office | Meadow Family Practice Family Medicine · in network | 90471, 99395, 99214 | $666.00 | $385.64 | Clean approval | — | Approved |
| CLM-2026-005798 CMS-1500 · 2026-10-15 | Martha Simmons no member ID | 2026-10-07 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 87086, 83036 | $72.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-005317 UB-04 · 2026-10-15 | Helen Snyder UHC-08676-93 | 2026-10-01 Outpatient hospital | Meadow Imaging Center Radiology · in network | 70553, 76700 | $3,998.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-005000 CMS-1500 · 2026-10-15 | Douglas Alvarado UHC-27382-79 | 2026-09-14 Office | Lakeside Medical Group Family Medicine · in network | 90471 | $32.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-004891 CMS-1500 · 2026-10-15 | Cheryl Carr no member ID | 2026-09-30 Office | Sunrise GI Associates Gastroenterology · in network | 99214 | $267.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-004719 UB-04 · 2026-10-15 | Douglas Harris UHC-15357-52 | 2026-10-07 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $39,961.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-004521 CMS-1500 · 2026-10-15 | Danielle Olson UHC-55505-62 | 2026-10-06 Office | Lakeside Medical Group Family Medicine · in network | 36415, 99213 | $229.00 | $130.82 | Clean approval | — | Approved |
| CLM-2026-004341 UB-04 · 2026-10-15 | Victoria Gray UHC-19111-25 | 2026-09-04 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $826.00 | $298.80 | Clean approval | — | Approved |
| CLM-2026-004162 CMS-1500 · 2026-10-15 | Virginia Wong UHC-96611-25 | 2026-10-12 Office | Evergreen Medical Group Family Medicine · in network | 99203, 99213 | $351.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-004128 CMS-1500 · 2026-10-15 | Ronald Gonzales UHC-77889-07 | 2026-10-05 Office | Unity Cardiovascular Associates Cardiology · in network | 93224 | $262.00 | $87.44 | Clean approval | — | Approved |
| CLM-2026-003876 CMS-1500 · 2026-10-15 | Brian Coleman UHC-17963-76 | 2026-09-20 Office | Harbor Endocrine Associates Endocrinology · in network | 99214, 83036 | $285.00 | $116.70 | Clean approval | — | Approved |
| CLM-2026-003870 CMS-1500 · 2026-10-15 | Mariana Arnold UHC-39533-22 | 2026-09-05 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $236.00 | $106.32 | Clean approval | — | Approved |
| CLM-2026-003712 UB-04 · 2026-10-15 | Kimberly Delgado UHC-27985-96 | 2026-09-21 Outpatient hospital | Sunrise GI Associates Gastroenterology · in network | 45378, 43239 | $4,787.00 | $1,175.59 | Clean approval | — | Approved |
| CLM-2026-003579 UB-04 · 2026-10-15 | Albert Tran no member ID | 2026-09-10 Outpatient hospital | Evergreen GI Associates Gastroenterology · in network | 45378 | $2,026.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-002265 CMS-1500 · 2026-10-15 | Luis Peters UHC-99143-52 | 2026-09-07 Office | Evergreen Primary Care Associates Family Medicine · in network | 90471, 99213 | $205.00 | $103.54 | Clean approval | — | Approved |
| CLM-2026-002146 UB-04 · 2026-10-15 | Kevin Scott UHC-95333-52 | 2026-10-02 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 70553 | $3,296.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-001418 CMS-1500 · 2026-10-15 | Hiroshi Miller UHC-76081-36 | 2026-10-05 Office | Mesa Medical Group Family Medicine · in network | 36415, 99203 | $242.00 | $135.78 | 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.