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-2026-027629 CMS-1500 · 2026-10-13 | Mason Hansen UHC-96817-98 | 2026-09-18 Office | Canyon Skin Care Associates Dermatology · in network | 11403 | $402.00 | $189.24 | Clean approval | — | Approved |
| CLM-2026-027567 UB-04 · 2026-10-13 | James Wright UHC-88515-11 | 2026-09-14 Outpatient hospital | Pinecrest Cardiovascular Associates Cardiology · in network | 93458, 93306 | $8,092.00 | $2,735.27 | Clean approval | — | Approved |
| CLM-2026-027474 CMS-1500 · 2026-10-13 | Scott Simmons no member ID | 2026-09-12 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 80061, 87086, 83036 | $177.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-027382 CMS-1500 · 2026-10-13 | Christina Payne UHC-71667-70 | 2026-09-16 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99215, 99214, 80053 | $665.00 | $392.30 | Clean approval | — | Approved |
| CLM-2026-027359 CMS-1500 · 2026-10-13 | Yuki Berry UHC-79256-52 | 2026-10-06 Independent laboratory | Northgate Reference Lab Clinical Laboratory · in network | 87086, 85025, 80061, 80053 | $284.00 | $11.70 | Clean approval | — | Approved |
| CLM-2026-027149 CMS-1500 · 2026-10-13 | Michael Carpenter UHC-99707-65 | 2026-10-09 Office | Evergreen Dermatology Clinic Dermatology · in network | 17110, 99213, 11403 | $850.00 | $467.00 | Clean approval | — | Approved |
| CLM-2026-027086 CMS-1500 · 2026-10-13 | Gordon Stephen UHC-82600-06 | 2026-09-23 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 87086, 80061 | $89.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-026524 CMS-1500 · 2026-10-13 | Susan Myers UHC-25021-80 | 2026-09-21 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 85025, 80061 | $93.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-026211 UB-04 · 2026-10-13 | Judy Wells UHC-84471-03 | 2026-10-10 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 70553, 74177 | $5,764.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-026115 CMS-1500 · 2026-10-13 | Fatima Nguyen UHC-77642-95 | 2026-09-23 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 80053 | $89.00 | $15.18 | Clean approval | — | Approved |
| CLM-2026-025708 CMS-1500 · 2026-10-13 | Sofia Lynch UHC-06069-32 | 2026-10-09 Independent laboratory | Northgate Reference Lab Clinical Laboratory · in network | 87086 | $39.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-025627 UB-04 · 2026-10-13 | Bradley Brown UHC-19081-69 | 2026-09-11 Outpatient hospital | Mesa Internal Medicine Associates Internal Medicine · in network | 70553 | $2,619.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-025554 CMS-1500 · 2026-10-13 | Jennyfer Padilla UHC-90521-32 | 2026-09-22 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 80053, 80061 | $101.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-025541 CMS-1500 · 2026-10-13 | Frances Jensen no member ID | 2026-10-03 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 83036 | $74.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-025473 CMS-1500 · 2026-10-13 | Alan Adams UHC-50559-22 | 2026-09-15 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97014 | $202.00 | $95.24 | Clean approval | — | Approved |
| CLM-2026-025302 UB-04 · 2026-10-13 | Helen Singh UHC-90545-25 | 2026-09-09 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 71046, 77067 | $499.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-024891 CMS-1500 · 2026-10-13 | Doris Coleman UHC-38524-53 | 2026-09-08 Office | Desert Medical Group Internal Medicine · in network | 93000 | $92.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024708 UB-04 · 2026-10-13 | Heather Nichols UHC-39281-13 | 2026-08-30 Outpatient hospital | Meadow Imaging Center Radiology · in network | 70553, 76700 | $3,490.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-024563 CMS-1500 · 2026-10-13 | Janice Luna UHC-02636-28 | 2026-09-14 Office | Unity Primary Care Associates Family Medicine · in network | 99213 | $166.00 | $62.92 | Clean approval | — | Approved |
| CLM-2026-024514 UB-04 · 2026-10-13 | Logan Collins UHC-11070-99 | 2026-09-11 Inpatient hospital | Cornerstone Internal Medicine Associates Internal Medicine · in network | 99232 | $224.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023759 CMS-1500 · 2026-10-13 | Dorothy Alexander UHC-81221-87 | 2026-09-14 Office | Pinecrest Family Practice Family Medicine · in network | 36415, 99395, 90471 | $295.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-023704 CMS-1500 · 2026-10-13 | Gordon Stephen UHC-82600-06 | 2026-10-10 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 80053 | $87.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023673 CMS-1500 · 2026-10-13 | Arthur Little UHC-02842-96 | 2026-09-24 Office | Northgate Medical Group Family Medicine · in network | 99213, 99395 | $456.00 | $262.72 | Clean approval | — | Approved |
| CLM-2026-023629 CMS-1500 · 2026-10-13 | Sean Sean UHC-92857-60 | 2026-09-06 Office | Mesa Dermatology Clinic Dermatology · in network | 99213, 17110 | $350.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-023582 CMS-1500 · 2026-10-13 | Vincent Hayes UHC-40423-93 | 2026-09-10 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 99214 | $231.00 | $113.22 | Clean approval | — | Approved |
| CLM-2026-023399 CMS-1500 · 2026-10-13 | Jack Black UHC-42214-28 | 2026-09-19 Office | Meadow Primary Care Associates Family Medicine · in network | 99214, 90471 | $352.00 | $198.24 | Clean approval | — | Approved |
| CLM-2026-023293 UB-04 · 2026-10-13 | Arthur Myers UHC-40907-37 | 2026-09-20 Emergency room | Desert Regional Medical Center Emergency Medicine · in network | 99284 | $1,464.00 | $455.20 | Clean approval | — | Approved |
| CLM-2026-023222 UB-04 · 2026-10-13 | Joshua Walsh UHC-33244-92 | 2026-10-11 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93306, 93015 | $2,038.00 | $453.33 | Clean approval | — | Approved |
| CLM-2026-023082 CMS-1500 · 2026-10-13 | Hiroshi Fowler UHC-09603-43 | 2026-09-12 Office | Heritage Primary Care Associates Family Medicine · in network | 36415, 99203 | $217.00 | $124.62 | Clean approval | — | Approved |
| CLM-2026-022761 CMS-1500 · 2026-10-13 | Amy Dominguez UHC-21901-22 | 2026-08-31 Office | Riverside Medical Group Family Medicine · in network | 99214, 90471, 99395 | $539.00 | $314.18 | Clean approval | — | Approved |
| CLM-2026-022668 CMS-1500 · 2026-10-13 | Jonathan Edwards UHC-24676-54 | 2026-09-15 Office | Meadow Skin Care Associates Dermatology · in network | 99213 | $204.00 | $51.48 | Clean approval | — | Approved |
| CLM-2026-022066 CMS-1500 · 2026-10-13 | Nathan Martin UHC-79747-51 | 2026-08-30 Office | Canyon Cardiovascular Associates Cardiology · in network | 93224 | $450.00 | $219.00 | Clean approval | — | Approved |
| CLM-2026-020583 UB-04 · 2026-10-13 | Tyler Yang UHC-30040-50 | 2026-09-24 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $48,569.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-020521 CMS-1500 · 2026-10-13 | Amy Ferguson UHC-39422-02 | 2026-09-26 Office | Northgate Counseling Center Behavioral Health · in network | 90834 | $164.00 | $61.68 | Clean approval | — | Approved |
| CLM-2026-020453 UB-04 · 2026-10-13 | Jeremy Hanson UHC-08296-83 | 2026-09-17 Outpatient hospital | Summit Heart Institute Cardiology · in network | 93306 | $1,543.00 | $450.13 | Clean approval | — | Approved |
| CLM-2026-019896 UB-04 · 2026-10-13 | Vincent Howard UHC-15428-40 | 2026-10-09 Inpatient hospital | Heritage Internal Medicine Associates Internal Medicine · in network | 99232 | $182.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-019721 UB-04 · 2026-10-13 | Susan Snyder UHC-74817-71 | 2026-09-13 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283 | $745.00 | — | Left for review NET | — | Needs review |
| CLM-2026-019118 UB-04 · 2026-10-13 | Drew Carroll UHC-88757-58 | 2026-09-25 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · in network | 93306 | $1,294.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-019014 UB-04 · 2026-10-13 | Brian Contreras UHC-26664-65 | 2026-10-07 Emergency room | Desert Regional Medical Center Emergency Medicine · in network | 99284 | $1,305.00 | $367.75 | Clean approval | — | Approved |
| CLM-2026-018491 UB-04 · 2026-10-13 | Peter McCoy UHC-64916-39 | 2026-09-24 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 76700, 70553 | $2,621.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-018080 CMS-1500 · 2026-10-13 | Ronald Mejia UHC-84706-98 | 2026-09-04 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99214, 80053 | $332.00 | $165.84 | Clean approval | — | Approved |
| CLM-2026-017821 CMS-1500 · 2026-10-13 | Bruce Sanchez UHC-55488-72 | 2026-09-06 Office | Mesa Diabetes Center Endocrinology · in network | 83036, 99215 | $449.00 | $238.38 | Clean approval | — | Approved |
| CLM-2026-016326 CMS-1500 · 2026-10-13 | Hiroshi Gonzalez UHC-77778-93 | 2026-09-01 Office | Desert Medical Group Family Medicine · in network | 99213, 36415, 90471 | $264.00 | $138.68 | Clean approval | — | Approved |
| CLM-2026-016194 UB-04 · 2026-10-13 | Carolyn Log UHC-35911-04 | 2026-10-02 Outpatient hospital | Lakeside Digestive Health Center Gastroenterology · in network | 43239, 88305, 45378 | $4,874.00 | $1,712.57 | Clean approval | — | Approved |
| CLM-2026-015769 UB-04 · 2026-10-13 | Eugene Bell UHC-07032-53 | 2026-09-21 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · in network | 96374 | $180.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-015630 UB-04 · 2026-10-13 | Mary Ward UHC-17625-99 | 2026-09-11 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 70553, 71046 | $2,217.00 | $745.14 | Clean approval | — | Approved |
| CLM-2026-015251 CMS-1500 · 2026-10-13 | Don Silva UHC-12940-18 | 2026-10-08 Office | Mesa Medical Group Family Medicine · in network | 99395 | $302.00 | $157.24 | Clean approval | — | Approved |
| CLM-2026-014933 CMS-1500 · 2026-10-13 | Daniel Robertson UHC-23818-80 | 2026-09-02 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140 | $224.00 | $118.88 | Clean approval | — | Approved |
| CLM-2026-014075 CMS-1500 · 2026-10-13 | Anthony Morales UHC-83692-92 | 2026-09-22 Office | Desert Medical Group Family Medicine · in network | 99203, 36415 | $202.00 | $100.24 | Clean approval | — | Approved |
| CLM-2026-014041 CMS-1500 · 2026-10-13 | Camila Sanchez UHC-10395-56 | 2026-08-29 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 80053, 93000, 99215 | $526.00 | $306.12 | 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.