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-2026-006702 UB-04 · 2026-10-14 | Patricia Green UHC-31727-18 | 2026-09-23 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285, 71046, 99283 | $4,165.00 | $2,040.75 | Clean approval | — | Approved |
| CLM-2026-006611 UB-04 · 2026-10-14 | William Harris UHC-03532-97 | 2026-10-07 Outpatient hospital | Meadow GI Associates Gastroenterology · in network | 88305 | $342.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-006344 CMS-1500 · 2026-10-14 | Noah Campbell UHC-25272-68 | 2026-10-06 Office | Sunrise Medical Group Family Medicine · in network | 99395, 99203 | $516.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-005750 UB-04 · 2026-10-14 | Dennis Sims UHC-61431-40 | 2026-09-18 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99284, 99285 | $4,534.00 | $2,243.70 | Clean approval | — | Approved |
| CLM-2026-004988 CMS-1500 · 2026-10-14 | Aisha Lawson UHC-24582-90 | 2026-09-14 Office | Meadow Medical Group Family Medicine · in network | 99203, 99213 | $395.00 | $219.90 | Clean approval | — | Approved |
| CLM-2026-004887 CMS-1500 · 2026-10-14 | Sandra Reyes UHC-36461-68 | 2026-09-24 Office | Valley Skin Care Associates Dermatology · in network | 11403, 11102, 99213 | $804.00 | $438.48 | Clean approval | — | Approved |
| CLM-2026-004768 CMS-1500 · 2026-10-14 | Patricia Wang UHC-99901-23 | 2026-09-04 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 93000 | $73.00 | $2.85 | Clean approval | — | Approved |
| CLM-2026-003642 CMS-1500 · 2026-10-14 | George Miller UHC-23025-90 | 2026-09-02 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 99215, 93000 | $411.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-003422 UB-04 · 2026-10-14 | Pamela Hansen UHC-70145-78 | 2026-09-25 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93015 | $455.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003388 CMS-1500 · 2026-10-14 | Natalie Palmer UHC-30236-51 | 2026-08-31 Office | Meadow Bone and Joint Center Orthopedic Surgery · in network | 20610 | $261.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-003183 UB-04 · 2026-10-14 | Terry Yung UHC-16318-17 | 2026-09-06 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $201.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003163 UB-04 · 2026-10-14 | Nicole Simpson UHC-07493-84 | 2026-10-07 Outpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 29881 | $6,370.00 | $2,462.50 | Clean approval | — | Approved |
| CLM-2026-002756 CMS-1500 · 2026-10-14 | Luis Richardson UHC-29830-20 | 2026-09-23 Office | Summit Endocrine Associates Endocrinology · in network | 83036 | $64.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-002652 CMS-1500 · 2026-10-14 | Elizabeth Fox UHC-85549-30 | 2026-09-13 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 99214, 93000 | $380.00 | $195.60 | Clean approval | — | Approved |
| CLM-2026-002487 CMS-1500 · 2026-10-14 | Keith Cruz UHC-71380-39 | 2026-08-24 Office | Meadow Physical Therapy Physical Therapy · in network | 97110 | $162.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-002239 CMS-1500 · 2026-10-14 | Camila Coleman UHC-30287-02 | 2026-10-10 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $360.00 | $203.20 | Clean approval | — | Approved |
| CLM-2026-002142 CMS-1500 · 2026-10-14 | Ralph Ruiz UHC-42464-05 | 2026-09-09 Office | Lakeside Medical Group Family Medicine · out of network | 99214 | $289.00 | $100.05 | Clean approval | — | Approved |
| CLM-2026-002067 CMS-1500 · 2026-10-14 | Diana Clark UHC-38721-43 | 2026-10-05 Office | Sunrise Internal Medicine Associates Internal Medicine · in network | 99214, 93000 | $324.00 | $175.88 | Clean approval | — | Approved |
| CLM-2026-001968 CMS-1500 · 2026-10-14 | Christina Ramos UHC-50875-92 | 2026-10-09 Office | Riverside Internal Medicine Associates Internal Medicine · in network | 99214 | $263.00 | $123.06 | Clean approval | — | Approved |
| CLM-2026-001282 UB-04 · 2026-10-14 | Julia Castillo no member ID | 2026-10-06 Inpatient hospital | Canyon Medical Group Internal Medicine · in network | 99232 | $182.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-000783 CMS-1500 · 2026-10-14 | Theresa Green UHC-97725-62 | 2026-09-04 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 87086, 83036, 80053 | $173.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-000742 CMS-1500 · 2026-10-14 | Ruth Martin UHC-14182-10 | 2026-09-14 Office | Unity Counseling Center Behavioral Health · in network | 90837, 90791 | $506.00 | $238.72 | Clean approval | — | Approved |
| CLM-2026-000731 CMS-1500 · 2026-10-14 | Harold Bishop UHC-58284-64 | 2026-09-22 Office | Heritage Family Practice Family Medicine · in network | 99213 | $157.00 | $57.34 | Clean approval | — | Approved |
| CLM-2026-000548 CMS-1500 · 2026-10-14 | Stephen Holmes UHC-84368-17 | 2026-10-09 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97014 | $200.00 | $104.00 | Clean approval | — | Approved |
| CLM-2026-000128 CMS-1500 · 2026-10-14 | Adam Simpson UHC-19865-62 | 2026-09-26 Office | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 20610 | $276.00 | $131.12 | Clean approval | — | Approved |
| CLM-2026-034571 CMS-1500 · 2026-10-13 | Elizabeth Schultz UHC-01992-56 | 2026-09-30 Office | Evergreen Medical Group Internal Medicine · out of network | 80053, 93000, 99215 | $530.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-034284 UB-04 · 2026-10-13 | Mateo Perez UHC-46817-61 | 2026-09-23 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 70553, 76700 | $3,143.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-033804 CMS-1500 · 2026-10-13 | Marilyn Perkins UHC-97616-01 | 2026-09-01 Office | Unity Counseling Center Behavioral Health · in network | 90834 | $211.00 | $80.82 | Clean approval | — | Approved |
| CLM-2026-033347 CMS-1500 · 2026-10-13 | Hannah Nguyen UHC-20168-56 | 2026-10-04 Independent laboratory | Meadow Reference Lab Clinical Laboratory · in network | 80053 | $60.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-032699 CMS-1500 · 2026-10-13 | Mei Hoffman UHC-76616-84 | 2026-09-28 Office | Riverside Primary Care Associates Family Medicine · in network | 99395 | $236.00 | $126.32 | Clean approval | — | Approved |
| CLM-2026-032486 UB-04 · 2026-10-13 | Willie Roberts UHC-15064-57 | 2026-10-03 Outpatient hospital | Valley Imaging Center Radiology · in network | 77067, 71046 | $534.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032073 UB-04 · 2026-10-13 | Danielle Austin UHC-75102-81 | 2026-10-02 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 71046, 70553, 77067 | $3,701.00 | $373.18 | Clean approval | — | Approved |
| CLM-2026-031527 UB-04 · 2026-10-13 | Arjun Anderson UHC-56313-59 | 2026-09-29 Inpatient hospital | Heritage Medical Group Internal Medicine · in network | 99232 | $240.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-031414 CMS-1500 · 2026-10-13 | Nathan Mendoza UHC-94958-64 | 2026-10-08 Independent laboratory | Meadow Clinical Laboratories Clinical Laboratory · in network | 85025, 80061 | $118.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-031334 CMS-1500 · 2026-10-13 | Ahmed Davis UHC-86559-68 | 2026-08-31 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 85025, 80061, 87086 | $160.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030838 CMS-1500 · 2026-10-13 | Brittany Nunez UHC-13686-89 | 2026-09-14 Office | Mesa Family Practice Family Medicine · in network | 99395, 90471 | $382.00 | $196.84 | Clean approval | — | Approved |
| CLM-2026-030823 UB-04 · 2026-10-13 | Justin Ray UHC-04481-51 | 2026-10-07 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 71046 | $124.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030736 CMS-1500 · 2026-10-13 | Ethan Vazquez UHC-36033-31 | 2026-08-25 Independent laboratory | Summit Reference Lab Clinical Laboratory · in network | 80061 | $46.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-030169 CMS-1500 · 2026-10-13 | Marcus Nelson UHC-34131-61 | 2026-09-23 Office | Canyon Cardiovascular Associates Cardiology · in network | 99214 | $259.00 | $85.58 | Clean approval | — | Approved |
| CLM-2026-030070 CMS-1500 · 2026-10-13 | Pamela Snadoval UHC-52330-59 | 2026-09-14 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99203 | $242.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-029742 UB-04 · 2026-10-13 | Gloria Le UHC-07005-78 | 2026-09-03 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 77067 | $296.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-029729 UB-04 · 2026-10-13 | Pamela Wilson UHC-86455-03 | 2026-09-20 Outpatient hospital | Cornerstone Imaging Center Radiology · in network | 71046 | $237.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-029616 CMS-1500 · 2026-10-13 | Anna Scott UHC-14025-28 | 2026-08-26 Office | Meadow Primary Care Associates Family Medicine · in network | 99395, 99214, 99203 | $724.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029501 CMS-1500 · 2026-10-13 | Roger Howard UHC-89900-25 | 2026-09-17 Office | Sunrise Dermatology Clinic Dermatology · in network | 11102, 17110 | $449.00 | $218.38 | Clean approval | — | Approved |
| CLM-2026-029398 UB-04 · 2026-10-13 | William Carpenter no member ID | 2026-09-06 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 71046, 99283 | $1,129.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-028979 CMS-1500 · 2026-10-13 | Eric Butler UHC-18784-76 | 2026-09-27 Office | Northgate Cardiovascular Associates Cardiology · in network | 93224 | $463.00 | $227.06 | Clean approval | — | Approved |
| CLM-2026-028115 CMS-1500 · 2026-10-13 | Sharon Hanson UHC-31736-86 | 2026-09-09 Office | Sunrise Diabetes Center Endocrinology · in network | 95251, 99215 | $578.00 | $308.36 | Clean approval | — | Approved |
| CLM-2026-028031 CMS-1500 · 2026-10-13 | Lucia Gomez UHC-42126-16 | 2026-03-20 Office | Meadow Heart Institute Cardiology · in network | 99214, 93224 | $630.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-028026 UB-04 · 2026-10-13 | Patricia Phillips UHC-42386-79 | 2026-08-30 Inpatient hospital | Unity Medical Group Internal Medicine · in network | 99232 | $188.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-027849 CMS-1500 · 2026-10-13 | Barbara Hanson UHC-41769-76 | 2026-09-01 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99203, 90471, 99213 | $434.00 | $244.08 | 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.