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-2026-013842 CMS-1500 · 2026-10-13 | Maria Fields UHC-68748-96 | 2026-10-02 Office | Lakeside Skin Care Associates Dermatology · in network | 11102, 99213 | $433.00 | $193.46 | Clean approval | — | Approved |
| CLM-2026-012271 UB-04 · 2026-10-13 | Dylan King UHC-53344-87 | 2026-10-11 Outpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 29881 | $9,263.00 | $3,273.43 | Clean approval | — | Approved |
| CLM-2026-012167 UB-04 · 2026-10-13 | Debra Elliott UHC-29655-41 | 2026-10-04 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 76700, 77067 | $864.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011878 CMS-1500 · 2026-10-13 | Kevin Patel UHC-81454-64 | 2026-09-16 Office | Unity Physical Therapy Physical Therapy · in network | 97110 | $372.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-011641 CMS-1500 · 2026-10-13 | Aisha Bradley UHC-72236-46 | 2026-10-09 Office | Unity Primary Care Associates Family Medicine · in network | 99395, 90471, 99203 | $490.00 | $263.80 | Clean approval | — | Approved |
| CLM-2026-011584 CMS-1500 · 2026-10-13 | Emily Fox UHC-83540-64 | 2026-10-05 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 80061 | $67.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011571 UB-04 · 2026-10-13 | Judy Montgomery UHC-91198-73 | 2026-09-03 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 76700 | $425.00 | $9.58 | Clean approval | — | Approved |
| CLM-2026-011230 CMS-1500 · 2026-10-13 | Debra Coleman UHC-55489-25 | 2026-09-22 Office | Sunrise Dermatology Clinic Dermatology · out of network | 17110, 11403 | $776.00 | $299.20 | Clean approval | — | Approved |
| CLM-2026-010290 CMS-1500 · 2026-10-13 | Mariana Robertson UHC-59750-05 | 2026-09-18 Office | Heritage Physical Therapy Physical Therapy · in network | 97110, 97161 | $485.00 | $275.70 | Clean approval | — | Approved |
| CLM-2026-010121 CMS-1500 · 2026-10-13 | Jonathan Jenkins UHC-60703-67 | 2026-10-07 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 87086, 80061 | $116.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-009296 UB-04 · 2026-10-13 | Jeffrey Silva UHC-06689-67 | 2026-09-05 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $237.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-009232 CMS-1500 · 2026-10-13 | Lauren Alexander UHC-35766-20 | 2026-10-03 Office | Harbor Physical Therapy Physical Therapy · in network | 97110 | $348.00 | $185.76 | Clean approval | — | Approved |
| CLM-2026-009027 UB-04 · 2026-10-13 | Jacob Fields UHC-76092-02 | 2026-09-02 Outpatient hospital | Unity Imaging Center Radiology · out of network | 71046, 77067, 76700 | $928.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-008197 CMS-1500 · 2026-10-13 | Yuki Ward UHC-49692-58 | 2026-09-30 Office | Heritage Primary Care Associates Family Medicine · in network | 99203 | $254.00 | $127.48 | Clean approval | — | Approved |
| CLM-2026-007063 CMS-1500 · 2026-10-13 | Gerald Jimenez UHC-02738-67 | 2026-09-12 Office | Unity Primary Care Associates Family Medicine · out of network | 99203, 36415, 99213 | $443.00 | $174.35 | Clean approval | — | Approved |
| CLM-2026-006515 UB-04 · 2026-10-13 | Doris Simmons UHC-64986-08 | 2026-09-06 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 71046, 76700 | $805.00 | $86.48 | Clean approval | — | Approved |
| CLM-2026-005689 CMS-1500 · 2026-10-13 | Samuel Lynch UHC-18157-27 | 2026-09-02 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 80053 | $68.00 | $2.16 | Clean approval | — | Approved |
| CLM-2026-005210 CMS-1500 · 2026-10-13 | Jeremy Reed UHC-59517-34 | 2026-09-16 Office | Mesa Family Practice Family Medicine · in network | 99214, 99213 | $432.00 | $227.84 | Clean approval | — | Approved |
| CLM-2026-005037 CMS-1500 · 2026-10-13 | Joe Harvey UHC-44826-03 | 2026-09-10 Independent laboratory | Meadow Clinical Laboratories Clinical Laboratory · in network | 87086, 83036, 85025 | $158.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-004445 CMS-1500 · 2026-10-13 | Barbara Weber UHC-24739-99 | 2026-09-11 Office | Unity Digestive Health Center Gastroenterology · in network | 99214 | $306.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003983 CMS-1500 · 2026-10-13 | Frank Williamson UHC-38568-32 | 2026-09-19 Office | Meadow Medical Group Family Medicine · in network | 36415 | $17.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003890 CMS-1500 · 2026-10-13 | Alexis Fox UHC-32649-36 | 2026-09-27 Independent laboratory | Riverside Clinical Laboratories Clinical Laboratory · in network | 80061 | $38.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003421 CMS-1500 · 2026-10-13 | Daine Foster UHC-82396-81 | 2026-10-09 Office | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 99213 | $150.00 | $33.00 | Clean approval | — | Approved |
| CLM-2026-002971 CMS-1500 · 2026-10-13 | Charles Jackson UHC-14808-33 | 2026-09-28 Office | Lakeside Skin Care Associates Dermatology · in network | 17110 | $259.00 | $110.58 | Clean approval | — | Approved |
| CLM-2026-002605 CMS-1500 · 2026-10-13 | Bradley Oliver UHC-67161-27 | 2026-09-19 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 99215 | $391.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-002044 CMS-1500 · 2026-10-13 | Lucia Harrison UHC-97007-42 | 2026-09-02 Office | Evergreen Dermatology Clinic Dermatology · in network | 17110, 99213 | $411.00 | $204.82 | Clean approval | — | Approved |
| CLM-2026-001871 UB-04 · 2026-10-13 | Vincent Howard UHC-15428-40 | 2026-09-11 Inpatient hospital | Harbor Medical Group Internal Medicine · out of network | 99232 | $181.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001195 CMS-1500 · 2026-10-13 | Ray Peters UHC-72190-33 | 2026-09-10 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 80053, 93000 | $172.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-000703 CMS-1500 · 2026-10-13 | Elizabeth Bishop UHC-78286-67 | 2026-10-06 Office | Sunrise Counseling Center Behavioral Health · in network | 90791 | $326.00 | $162.12 | Clean approval | — | Approved |
| CLM-2026-000447 UB-04 · 2026-10-13 | Austin Robinson UHC-83901-95 | 2026-09-07 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458 | $5,014.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-000134 UB-04 · 2026-10-13 | Arjun Lawrence UHC-29118-42 | 2026-09-28 Inpatient hospital | Pinecrest Medical Group Internal Medicine · in network | 99232 | $208.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-034484 CMS-1500 · 2026-10-12 | Michael Mills UHC-19184-04 | 2026-09-14 Office | Evergreen Medical Group Family Medicine · in network | 90471, 99203 | $270.00 | $145.70 | Clean approval | — | Approved |
| CLM-2026-034479 CMS-1500 · 2026-10-12 | Raymond Mason UHC-02558-95 | 2026-09-04 Office | Evergreen Family Practice Family Medicine · in network | 36415, 99214 | $276.00 | $158.72 | Clean approval | — | Approved |
| CLM-2026-034164 CMS-1500 · 2026-10-12 | Robert Chen UHC-20989-04 | 2026-09-09 Telehealth | Sunrise Behavioral Health Behavioral Health · in network | 99214 | $292.00 | $141.04 | Clean approval | — | Approved |
| CLM-2026-034155 CMS-1500 · 2026-10-12 | Laura Aguilar UHC-46548-44 | 2026-09-24 Office | Desert Medical Group Internal Medicine · in network | 80053, 99214 | $386.00 | $214.32 | Clean approval | — | Approved |
| CLM-2026-034035 CMS-1500 · 2026-10-12 | Sofia Ward UHC-55808-79 | 2026-09-28 Office | Evergreen Medical Group Family Medicine · in network | 99214, 90471 | $339.00 | $180.18 | Clean approval | — | Approved |
| CLM-2026-033414 UB-04 · 2026-10-12 | Megan Gomez UHC-39159-92 | 2026-09-10 Outpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,906.00 | $4,037.15 | Clean approval | — | Approved |
| CLM-2026-032825 UB-04 · 2026-10-12 | Aisha Cole UHC-86878-50 | 2026-09-07 Emergency room | Valley Regional Medical Center Emergency Medicine · in network | 99283 | $1,083.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-032696 CMS-1500 · 2026-10-12 | Henry Ross UHC-22131-74 | 2026-09-12 Office | Lakeside Medical Group Family Medicine · in network | 99214, 90471 | $363.00 | $205.06 | Clean approval | — | Approved |
| CLM-2026-032694 UB-04 · 2026-10-12 | Karen Johnston UHC-95810-35 | 2026-09-17 Emergency room | Harbor Regional Medical Center Emergency Medicine · in network | 71046 | $240.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032320 CMS-1500 · 2026-10-12 | Benjamin Contreras UHC-74433-78 | 2026-10-07 Office | Sunrise Behavioral Health Behavioral Health · in network | 90791, 90834 | $547.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-032097 UB-04 · 2026-10-12 | Alexander Kennedy UHC-46150-15 | 2026-10-05 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $8,972.00 | $2,076.65 | Clean approval | — | Approved |
| CLM-2026-032024 CMS-1500 · 2026-10-12 | Charles Ford UHC-61827-20 | 2026-09-06 Office | Meadow Primary Care Associates Family Medicine · in network | 36415, 99214 | $280.00 | $160.58 | Clean approval | — | Approved |
| CLM-2026-031970 CMS-1500 · 2026-10-12 | Matthews Lori UHC-03231-10 | 2026-09-10 Office | Meadow Primary Care Associates Family Medicine · in network | 99213, 99395, 36415 | $463.00 | $247.06 | Clean approval | — | Approved |
| CLM-2026-031767 CMS-1500 · 2026-10-12 | Lawrence Young UHC-86523-36 | 2026-09-23 Office | Pinecrest Medical Group Family Medicine · in network | 99395, 99213 | $502.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-031697 UB-04 · 2026-10-12 | Alice Baker UHC-01066-48 | 2026-09-30 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99283, 99284 | $2,412.00 | $984.50 | Clean approval | — | Approved |
| CLM-2026-031551 UB-04 · 2026-10-12 | Sarah Fuller UHC-44743-03 | 2026-09-30 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 43239, 88305 | $2,835.00 | $598.75 | Clean approval | — | Approved |
| CLM-2026-031455 CMS-1500 · 2026-10-12 | Aisha Knight UHC-67772-21 | 2026-09-19 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 99214, 93000 | $363.00 | $205.06 | Clean approval | — | Approved |
| CLM-2026-031122 CMS-1500 · 2026-10-12 | Janice Rose UHC-67004-45 | 2026-09-17 Office | Riverside Primary Care Associates Family Medicine · in network | 99395, 99214, 36415 | $575.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-031017 CMS-1500 · 2026-10-12 | Kathleen Castro UHC-48032-78 | 2026-09-17 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 80053 | $70.00 | $3.40 | 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.