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-2026-024338 CMS-1500 · 2026-10-14 | Noah Allen UHC-20780-46 | 2026-09-12 Office | Desert Internal Medicine Associates Internal Medicine · in network | 93000 | $80.00 | $29.60 | Clean approval | — | Approved |
| CLM-2026-024158 CMS-1500 · 2026-10-14 | Catherine James UHC-83902-40 | 2026-09-20 Office | Mesa Bone and Joint Center Orthopedic Surgery · in network | 99213 | $230.00 | $92.60 | Clean approval | — | Approved |
| CLM-2026-023532 UB-04 · 2026-10-14 | Andrew Hicks UHC-20492-19 | 2026-03-30 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 70553, 71046 | $2,750.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-022820 CMS-1500 · 2026-10-14 | Dorothy Vega UHC-62516-28 | 2026-09-29 Office | Unity Primary Care Associates Family Medicine · in network | 99213 | $173.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-022753 UB-04 · 2026-10-14 | Jonathan Mason UHC-16686-90 | 2026-08-31 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 76700 | $496.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-022688 CMS-1500 · 2026-10-14 | Gerald Willis UHC-23329-03 | 2026-09-27 Office | Mesa Diabetes Center Endocrinology · in network | 95251, 99215 | $563.00 | $309.06 | Clean approval | — | Approved |
| CLM-2026-022630 CMS-1500 · 2026-10-14 | Julie Garrett UHC-79164-92 | 2026-10-03 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · in network | 80053, 83036, 80061 | $224.00 | $0.00 | Clean approval | — | Approved |
| 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-2026-022211 CMS-1500 · 2026-10-14 | Steve Scott no member ID | 2026-09-05 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140 | $379.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-021995 UB-04 · 2026-10-14 | Logan Wang UHC-37033-56 | 2026-09-27 Outpatient hospital | Meadow Primary Care Associates Family Medicine · in network | 70553 | $1,963.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-021919 UB-04 · 2026-10-14 | Joseph Daniels UHC-26322-25 | 2026-09-12 Inpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 27447 | $44,672.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-020920 CMS-1500 · 2026-10-14 | Elijah Sims UHC-66269-95 | 2026-10-07 Office | Canyon Primary Care Associates Family Medicine · in network | 99213 | $207.00 | $88.34 | Clean approval | — | Approved |
| CLM-2026-020898 CMS-1500 · 2026-10-14 | Andrea Carroll UHC-45950-02 | 2026-10-02 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90791, 90837 | $557.00 | $270.34 | Clean approval | — | Approved |
| CLM-2026-020879 CMS-1500 · 2026-10-14 | John Wood UHC-22176-71 | 2026-09-15 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $166.00 | $82.92 | Clean approval | — | Approved |
| CLM-2026-020836 CMS-1500 · 2026-10-14 | Matthew Day UHC-65445-38 | 2026-09-11 Office | Desert Medical Group Internal Medicine · in network | 99214, 99215 | $568.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-020485 CMS-1500 · 2026-10-14 | Tyler Maldonado UHC-19189-76 | 2026-09-08 Independent laboratory | Pinecrest Reference Lab Clinical Laboratory · in network | 87086 | $36.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-019972 CMS-1500 · 2026-10-14 | Roger Davis UHC-30457-09 | 2026-09-08 Office | Evergreen Cardiovascular Associates Cardiology · in network | 93224 | $380.00 | $175.60 | Clean approval | — | Approved |
| 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-2026-018733 UB-04 · 2026-10-14 | Susan Larson UHC-58072-95 | 2026-09-19 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $207.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-018519 UB-04 · 2026-10-14 | Steven Gilbert UHC-22739-27 | 2026-09-25 Emergency room | Riverside Community Hospital Emergency Medicine · in network | 96374 | $203.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-017989 CMS-1500 · 2026-10-14 | Lucia Yang UHC-92465-76 | 2026-09-18 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99214 | $285.00 | $156.70 | 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-2026-017878 CMS-1500 · 2026-10-14 | Carl Schmidt UHC-97348-98 | 2026-10-04 Office | Meadow Medical Group Internal Medicine · in network | 99215, 80053 | $366.00 | $206.92 | Clean approval | — | Approved |
| CLM-2026-017165 CMS-1500 · 2026-10-14 | Kimberly Armstrong UHC-28465-51 | 2026-09-16 Office | Sunrise Digestive Health Center Gastroenterology · in network | 99214 | $227.00 | $90.74 | Clean approval | — | Approved |
| CLM-2026-016714 CMS-1500 · 2026-10-14 | Matthew Day UHC-65445-38 | 2026-09-16 Office | Canyon Primary Care Associates Family Medicine · in network | 99203, 99395, 36415 | $452.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-016603 CMS-1500 · 2026-10-14 | Jeffrey Hall UHC-39370-03 | 2026-09-02 Office | Evergreen Primary Care Associates Family Medicine · in network | 36415 | $18.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-016524 UB-04 · 2026-10-14 | Jordan Willis UHC-82878-88 | 2026-09-30 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 43239, 88305 | $2,561.00 | $939.30 | Clean approval | — | Approved |
| CLM-2026-016030 UB-04 · 2026-10-14 | Timothy Phillips UHC-10844-40 | 2026-08-31 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 74177 | $1,779.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-015995 UB-04 · 2026-10-14 | Hiroshi Greene UHC-44535-99 | 2026-09-24 Outpatient hospital | Meadow Cardiovascular Associates Cardiology · in network | 93458 | $8,717.00 | $4,195.68 | Clean approval | — | Approved |
| CLM-2026-014338 CMS-1500 · 2026-10-14 | Ralph Cole UHC-07842-57 | 2026-09-22 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140, 97161 | $507.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-013942 CMS-1500 · 2026-10-14 | Andrew Hicks UHC-20492-19 | 2026-09-22 Office | Unity Family Practice Family Medicine · in network | 36415, 99203 | $222.00 | $124.00 | Clean approval | — | Approved |
| CLM-2026-013940 UB-04 · 2026-10-14 | Sarah Gomez no member ID | 2026-10-06 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700, 71046, 74177 | $2,353.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013905 CMS-1500 · 2026-10-14 | Natalie Spencer UHC-74798-50 | 2026-09-16 Office | Evergreen Family Practice Family Medicine · in network | 99203, 99395, 99213 | $694.00 | $400.28 | Clean approval | — | Approved |
| CLM-2026-012717 CMS-1500 · 2026-10-14 | Anddrew Berry UHC-83026-24 | 2026-09-10 Office | Unity Family Practice Family Medicine · in network | 99214, 36415, 99395 | $530.00 | $308.60 | Clean approval | — | Approved |
| CLM-2026-012386 CMS-1500 · 2026-10-14 | Albert Flores UHC-31435-25 | 2026-09-26 Office | Sunrise Cardiovascular Associates Cardiology · in network | 99214 | $329.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-012216 CMS-1500 · 2026-10-14 | Lucia Riley UHC-82001-62 | 2026-10-11 Office | Heritage Internal Medicine Associates Internal Medicine · in network | 80053 | $50.00 | $11.00 | Clean approval | — | Approved |
| CLM-2026-011191 CMS-1500 · 2026-10-14 | Christopher Cooper UHC-06864-83 | 2026-10-09 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 99214, 99215 | $537.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-011058 UB-04 · 2026-10-14 | Justin Palmer UHC-44225-20 | 2026-09-13 Inpatient hospital | Mesa Internal Medicine Associates Internal Medicine · out of network | 99232 | $234.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011031 UB-04 · 2026-10-14 | Omar Hunt UHC-97434-51 | 2026-10-03 Outpatient hospital | Heritage Imaging Center Radiology · in network | 76700, 70553 | $3,006.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-010733 CMS-1500 · 2026-10-14 | Gerald Ruiz UHC-14467-45 | 2026-10-07 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $232.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-010426 CMS-1500 · 2026-10-14 | Joan Lane UHC-13637-61 | 2026-09-25 Independent laboratory | Cornerstone Clinical Laboratories Clinical Laboratory · in network | 80061 | $60.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-009653 UB-04 · 2026-10-14 | Kimberly Hernandez UHC-62431-46 | 2026-09-08 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 43239 | $2,413.00 | $495.87 | Clean approval | — | Approved |
| CLM-2026-009553 CMS-1500 · 2026-10-14 | Barbara Park UHC-16638-84 | 2026-09-08 Office | Lakeside Medical Group Family Medicine · in network | 99203, 36415 | $204.00 | $106.48 | Clean approval | — | Approved |
| CLM-2026-009457 CMS-1500 · 2026-10-14 | Kimberly Ferguson UHC-50163-50 | 2026-09-12 Office | Evergreen Family Practice Family Medicine · in network | 99214 | $240.00 | $123.80 | Clean approval | — | Approved |
| CLM-2026-008874 CMS-1500 · 2026-10-14 | Walter Ward UHC-00600-28 | 2026-09-01 Office | Mesa Family Practice Family Medicine · in network | 99214, 90471 | $280.00 | $153.60 | Clean approval | — | Approved |
| CLM-2026-008696 UB-04 · 2026-10-14 | Joan Duncan UHC-84887-28 | 2026-10-02 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 77067 | $373.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-008692 UB-04 · 2026-10-14 | Omar McCoy UHC-42002-69 | 2026-09-21 Outpatient hospital | Harbor Imaging Center Radiology · in network | 70553, 76700, 77067 | $3,572.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-007596 CMS-1500 · 2026-10-14 | Emma Mendez UHC-16028-30 | 2026-10-09 Office | Desert Internal Medicine Associates Internal Medicine · in network | 80053 | $85.00 | $32.70 | Clean approval | — | Approved |
| CLM-2026-007350 CMS-1500 · 2026-10-14 | Brandon Pena UHC-11986-61 | 2026-10-09 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99203, 99214 | $527.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-007036 UB-04 · 2026-10-14 | Victoria Herrera UHC-13803-78 | 2026-09-16 Outpatient hospital | Riverside Imaging Center Radiology · in network | 70553 | $2,225.00 | — | Left for review DUP | — | 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.