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-2026-001220 CMS-1500 · 2026-10-15 | Gloria Martin UHC-38570-43 | 2026-08-31 Office | Evergreen Family Practice Family Medicine · in network | 99395 | $324.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-001185 UB-04 · 2026-10-15 | Wei Washington UHC-27182-89 | 2026-09-17 Outpatient hospital | Meadow Imaging Center Radiology · in network | 70553, 76700 | $3,938.00 | — | Pended by rule IDQ | — | Pended |
| 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-2026-000946 CMS-1500 · 2026-10-15 | Matthew Jones UHC-41159-40 | 2026-09-13 Office | Unity Medical Group Internal Medicine · in network | 93000 | $113.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000582 UB-04 · 2026-10-15 | Arjun Santos UHC-17803-51 | 2026-09-03 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378 | $1,676.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-000486 CMS-1500 · 2026-10-15 | Jason Hunt UHC-16244-46 | 2026-09-22 Independent laboratory | Pinecrest Clinical Laboratories Clinical Laboratory · in network | 83036 | $71.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-034579 CMS-1500 · 2026-10-14 | Keith Vazquez UHC-01356-46 | 2026-09-09 Office | Lakeside Medical Group Family Medicine · in network | 99395, 99213 | $508.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-034140 UB-04 · 2026-10-14 | Donald Fernandez UHC-09849-83 | 2026-09-03 Outpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 73721 | $2,345.00 | $299.48 | Clean approval | — | Approved |
| CLM-2026-034073 CMS-1500 · 2026-10-14 | Dennnis Estrada UHC-28133-57 | 2026-10-10 Office | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 20610 | $232.00 | $68.84 | Clean approval | — | Approved |
| CLM-2026-034029 UB-04 · 2026-10-14 | Ryan Li UHC-59343-89 | 2026-06-24 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 88305 | $352.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-033610 CMS-1500 · 2026-10-14 | Sofa Weaver UHC-57114-29 | 2026-10-02 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97161 | $459.00 | $259.58 | Clean approval | — | Approved |
| CLM-2026-033362 CMS-1500 · 2026-10-14 | Jean Burns UHC-41583-14 | 2026-09-26 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 80053, 99214 | $348.00 | $185.76 | Clean approval | — | Approved |
| CLM-2026-033243 UB-04 · 2026-10-14 | Joan Hoffman UHC-38218-33 | 2026-09-18 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284, 99283, 96374 | $2,659.00 | $846.55 | Clean approval | — | Approved |
| CLM-2026-032952 CMS-1500 · 2026-10-14 | Carlos Payne UHC-13103-96 | 2026-09-02 Office | Canyon Primary Care Associates Family Medicine · in network | 99214, 99395 | $566.00 | $330.92 | Clean approval | — | Approved |
| CLM-2026-032893 CMS-1500 · 2026-10-14 | Shirley George UHC-25946-28 | 2026-09-28 Office | Sunrise Behavioral Health Behavioral Health · in network | 90834 | $152.00 | $54.24 | Clean approval | — | Approved |
| CLM-2026-032306 CMS-1500 · 2026-10-14 | Christina Larson UHC-33882-58 | 2026-09-29 Office | Valley Heart Institute Cardiology · in network | 99214 | $234.00 | $95.08 | Clean approval | — | Approved |
| CLM-2026-032152 UB-04 · 2026-10-14 | Jason Alexander UHC-25888-14 | 2026-09-18 Outpatient hospital | Harbor Digestive Health Center Gastroenterology · in network | 88305, 43239 | $1,807.00 | $656.52 | Clean approval | — | Approved |
| CLM-2026-032122 CMS-1500 · 2026-10-14 | Charles Williams UHC-34565-98 | 2026-08-26 Independent laboratory | Meadow Reference Lab Clinical Laboratory · in network | 83036, 80061 | $135.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-032109 CMS-1500 · 2026-10-14 | Donald Silva UHC-01229-52 | 2026-10-11 Office | Mesa Diabetes Center Endocrinology · in network | 83036, 99214 | $307.00 | $150.34 | Clean approval | — | Approved |
| CLM-2026-031918 CMS-1500 · 2026-10-14 | Gary Armstrong UHC-04189-51 | 2026-09-05 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 85025 | $51.00 | — | Denied by rule CO18 | — | 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-2026-031052 UB-04 · 2026-10-14 | Nathan Campbell UHC-33373-43 | 2026-10-04 Outpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,994.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030597 UB-04 · 2026-10-14 | Lori Santos UHC-54330-79 | 2026-09-17 Outpatient hospital | Mesa Dermatology Clinic Dermatology · in network | 70553 | $3,151.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-030339 CMS-1500 · 2026-10-14 | Jeremy Jacobs UHC-82894-81 | 2026-09-21 Office | Meadow Family Practice Family Medicine · in network | 99395, 36415 | $313.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-030055 CMS-1500 · 2026-10-14 | Andrew Hoffman UHC-49164-75 | 2026-09-10 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 80053 | $88.00 | $29.56 | Clean approval | — | Approved |
| CLM-2026-029740 UB-04 · 2026-10-14 | Bruce Garza UHC-63823-65 | 2026-09-12 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 74177, 71046 | $2,218.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-029540 UB-04 · 2026-10-14 | Mary Munz UHC-13183-92 | 2026-10-10 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 43239, 45378 | $4,347.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-029150 CMS-1500 · 2026-10-14 | Amanda Campbell UHC-80536-94 | 2026-08-30 Independent laboratory | Cornerstone Clinical Laboratories Clinical Laboratory · in network | 85025, 87086, 80053 | $133.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-029119 CMS-1500 · 2026-10-14 | Brenda Lopez UHC-93886-29 | 2026-09-09 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 99214, 93000, 80053 | $382.00 | $196.84 | Clean approval | — | Approved |
| CLM-2026-028752 UB-04 · 2026-10-14 | Sandra Powell UHC-02733-47 | 2026-09-14 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99283, 71046 | $1,010.00 | $205.50 | Clean approval | — | Approved |
| CLM-2026-028498 CMS-1500 · 2026-10-14 | Frances Jenkins UHC-08557-87 | 2026-10-04 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110 | $282.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-028254 UB-04 · 2026-10-14 | Judy Spencer UHC-59212-16 | 2026-09-23 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,184.00 | $313.58 | Clean approval | — | Approved |
| CLM-2026-028154 CMS-1500 · 2026-10-14 | Julie Pena UHC-64751-19 | 2026-10-08 Office | Canyon Medical Group Internal Medicine · in network | 99215 | $336.00 | $178.32 | 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-2026-028083 UB-04 · 2026-10-14 | Julia McCoy UHC-83978-41 | 2026-10-05 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $28,852.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027995 CMS-1500 · 2026-10-14 | Dennis Brown UHC-22981-87 | 2026-09-02 Office | Northgate Cardiovascular Associates Cardiology · in network | 99214 | $290.00 | $119.80 | Clean approval | — | Approved |
| CLM-2026-027936 CMS-1500 · 2026-10-14 | Andrew Lawis UHC-15384-70 | 2026-09-05 Office | Evergreen Internal Medicine Associates Internal Medicine · in network | 99214, 99215 | $701.00 | $409.62 | Clean approval | — | Approved |
| CLM-2026-027911 UB-04 · 2026-10-14 | Laura Weaver UHC-83781-90 | 2026-09-01 Outpatient hospital | Valley Imaging Center Radiology · in network | 70553, 77067 | $3,656.00 | $1,411.03 | Clean approval | — | Approved |
| CLM-2026-027649 UB-04 · 2026-10-14 | Janice Parker UHC-98137-03 | 2026-10-03 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · in network | 93458, 93015 | $6,541.00 | $2,289.72 | Clean approval | — | Approved |
| CLM-2026-027164 CMS-1500 · 2026-10-14 | Joyce Cole no member ID | 2026-09-20 Office | Harbor Physical Therapy Physical Therapy · in network | 97110 | $236.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-026672 UB-04 · 2026-10-14 | Betty Butler UHC-72899-24 | 2026-08-24 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $51,185.00 | — | Left for review DUP HIGH | — | Needs review |
| CLM-2026-026540 CMS-1500 · 2026-10-14 | Samuel Obrien UHC-78534-34 | 2026-08-18 Independent laboratory | Summit Reference Lab Clinical Laboratory · in network | 80061, 85025 | $114.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-026501 CMS-1500 · 2026-10-14 | Stephanie Henry UHC-38840-31 | 2026-10-05 Office | Harbor Family Practice Family Medicine · in network | 99213, 99395 | $489.00 | $283.18 | Clean approval | — | Approved |
| CLM-2026-026234 UB-04 · 2026-10-14 | Victoria Richards UHC-93067-18 | 2026-09-04 Outpatient hospital | Cornerstone Imaging Center Radiology · in network | 77067, 74177, 71046 | $2,873.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-025937 CMS-1500 · 2026-10-14 | Timothy Roberts UHC-57913-02 | 2026-10-04 Office | Mesa Bone and Joint Center Orthopedic Surgery · in network | 20610 | $292.00 | $131.04 | Clean approval | — | Approved |
| CLM-2026-025233 UB-04 · 2026-10-14 | Steven Carroll UHC-89841-95 | 2026-09-20 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 88305 | $310.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-025174 UB-04 · 2026-10-14 | Katherine Stevens UHC-93932-26 | 2026-09-21 Outpatient hospital | Harbor Family Practice Family Medicine · in network | 70553 | $2,391.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-024940 UB-04 · 2026-10-14 | Jesse Wallace UHC-53717-54 | 2026-09-09 Emergency room | Sunrise Community Hospital Emergency Medicine · in network | 99284 | $1,089.00 | $348.95 | Clean approval | — | Approved |
| CLM-2026-024818 UB-04 · 2026-10-14 | Aisha Nguyen UHC-89751-57 | 2026-09-10 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700 | $396.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-024480 CMS-1500 · 2026-10-14 | Robert Nichols UHC-85627-10 | 2026-09-05 Office | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 20610, 99213 | $425.00 | $203.50 | 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.