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-2026-030954 CMS-1500 · 2026-10-12 | Catherine Wheeler UHC-48380-89 | 2026-09-12 Office | Harbor Medical Group Internal Medicine · in network | 99215 | $384.00 | $208.08 | Clean approval | — | Approved |
| CLM-2026-030347 CMS-1500 · 2026-10-12 | Deborah Rose UHC-81029-42 | 2026-09-07 Office | Unity Digestive Health Center Gastroenterology · in network | 99214 | $256.00 | $83.72 | Clean approval | — | Approved |
| CLM-2026-029192 CMS-1500 · 2026-10-12 | Natalie Chavez UHC-93945-67 | 2026-09-11 Independent laboratory | Desert Reference Lab Clinical Laboratory · in network | 80053, 80061 | $98.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-029133 CMS-1500 · 2026-10-12 | Joseph Bradley UHC-09212-23 | 2026-09-05 Office | Mesa Medical Group Family Medicine · in network | 99213, 99203 | $331.00 | $185.22 | Clean approval | — | Approved |
| CLM-2026-028968 CMS-1500 · 2026-10-12 | Timoty Rice UHC-18511-80 | 2026-10-09 Office | Mesa Diabetes Center Endocrinology · in network | 83036, 95251, 99214 | $479.00 | $248.00 | Clean approval | — | Approved |
| CLM-2026-028827 UB-04 · 2026-10-12 | Ahmed Harper UHC-66686-95 | 2026-10-09 Outpatient hospital | Heritage Community Hospital Emergency Medicine · in network | 70553 | $2,352.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-028755 UB-04 · 2026-10-12 | Debra Cook UHC-39496-64 | 2026-09-28 Inpatient hospital | Meadow Internal Medicine Associates Internal Medicine · in network | 99232 | $188.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-028625 CMS-1500 · 2026-10-12 | Judith Riley UHC-59294-39 | 2026-09-03 Office | Mesa Dermatology Clinic Dermatology · in network | 99213 | $171.00 | $46.02 | Clean approval | — | Approved |
| CLM-2026-028479 CMS-1500 · 2026-10-12 | Patricia Carpenter UHC-50496-96 | 2026-10-01 Office | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 99213, 20610 | $465.00 | $238.30 | Clean approval | — | Approved |
| CLM-2026-028136 CMS-1500 · 2026-10-12 | Mason Garcia UHC-80156-07 | 2026-05-09 Office | Meadow Heart Institute Cardiology · out of network | 93224 | $438.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-027724 CMS-1500 · 2026-10-12 | Michael Owens UHC-07421-16 | 2026-09-12 Office | Evergreen Dermatology Clinic Dermatology · out of network | 11403 | $641.00 | $228.45 | Clean approval | — | Approved |
| CLM-2026-027407 UB-04 · 2026-10-12 | Amy Medina UHC-94216-16 | 2026-10-07 Outpatient hospital | Unity Cardiovascular Associates Cardiology · in network | 70553, 93458 | $12,439.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-027083 CMS-1500 · 2026-10-12 | Amanda Santiiago no member ID | 2026-09-29 Office | Unity Primary Care Associates Family Medicine · out of network | 99213 | $176.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-026974 CMS-1500 · 2026-10-12 | Mark Valdez UHC-55520-85 | 2026-09-23 Office | Heritage Physical Therapy Physical Therapy · in network | 97110 | $168.00 | $64.16 | Clean approval | — | Approved |
| CLM-2026-026415 CMS-1500 · 2026-10-12 | Frank Alvarez UHC-05360-90 | 2026-09-15 Office | Pinecrest Medical Group Family Medicine · in network | 36415 | $15.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-026233 CMS-1500 · 2026-10-12 | Anna Meyer UHC-14968-48 | 2026-09-29 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 80053, 99214 | $301.00 | $156.62 | Clean approval | — | Approved |
| CLM-2026-025640 CMS-1500 · 2026-10-12 | Denise Cox UHC-00474-84 | 2026-09-04 Office | Riverside Primary Care Associates Family Medicine · in network | 36415 | $23.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-025482 CMS-1500 · 2026-10-12 | Ralph Harper UHC-54586-42 | 2026-10-08 Office | Canyon Counseling Center Behavioral Health · out of network | 90837 | $246.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-025155 CMS-1500 · 2026-10-12 | John Fox UHC-40679-15 | 2026-09-17 Office | Heritage Family Practice Family Medicine · in network | 36415, 99213 | $222.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-024888 UB-04 · 2026-10-12 | Eric Robertson UHC-01745-78 | 2026-08-28 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $31,691.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-024723 CMS-1500 · 2026-10-12 | Bobby Rojas UHC-53291-78 | 2026-09-20 Office | Pinecrest Medical Group Internal Medicine · in network | 93000, 99215 | $485.00 | $270.70 | Clean approval | — | Approved |
| CLM-2026-024560 UB-04 · 2026-10-12 | Hiroshi Schultz UHC-49624-39 | 2026-08-26 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $36,744.00 | — | Left for review REPL HIGH | — | Needs review |
| CLM-2026-023841 CMS-1500 · 2026-10-12 | Kathryn Schmidt UHC-18595-46 | 2026-09-20 Office | Desert Primary Care Associates Family Medicine · in network | 99213 | $199.00 | $83.38 | Clean approval | — | Approved |
| CLM-2026-023835 CMS-1500 · 2026-10-12 | Ashley Pena UHC-93084-46 | 2026-09-09 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 93000, 80053 | $129.00 | $39.98 | Clean approval | — | Approved |
| CLM-2026-023742 UB-04 · 2026-10-12 | Adam Vega UHC-59055-13 | 2026-09-16 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 96374, 99285 | $2,954.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023739 CMS-1500 · 2026-10-12 | Christina Walsh UHC-65890-94 | 2026-09-02 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 87086, 83036 | $125.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023356 CMS-1500 · 2026-10-12 | Keith Williamson UHC-70723-03 | 2026-09-09 Office | Desert Rehabilitation Center Physical Therapy · in network | 97110 | $224.00 | $98.88 | Clean approval | — | Approved |
| CLM-2026-023150 CMS-1500 · 2026-10-12 | Ana Barnes UHC-78790-02 | 2026-08-28 Independent laboratory | Meadow Clinical Laboratories Clinical Laboratory · in network | 85025, 80061, 87086 | $122.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023098 CMS-1500 · 2026-10-12 | Deborah Harper UHC-63588-98 | 2026-09-01 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99214, 99395, 99203 | $809.00 | $476.58 | Clean approval | — | Approved |
| CLM-2026-022834 CMS-1500 · 2026-10-12 | Charlotte Ortiz UHC-52389-49 | 2026-09-27 Office | Mesa Medical Group Internal Medicine · in network | 99214 | $272.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-021954 UB-04 · 2026-10-12 | Justin Gordon UHC-77734-83 | 2026-09-06 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 76700, 77067 | $914.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-020843 CMS-1500 · 2026-10-12 | James Delgado UHC-33344-70 | 2026-09-24 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97014 | $359.00 | $197.58 | Clean approval | — | Approved |
| CLM-2026-020302 UB-04 · 2026-10-12 | Nicholas Jackson UHC-39004-12 | 2026-09-18 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,871.00 | $592.19 | Clean approval | — | Approved |
| CLM-2026-020169 UB-04 · 2026-10-12 | Theresa Green UHC-90230-78 | 2026-09-06 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458 | $6,176.00 | $2,526.96 | Clean approval | — | Approved |
| CLM-2026-019775 UB-04 · 2026-10-12 | Cheryl Munoz UHC-33442-68 | 2026-10-08 Outpatient hospital | Unity Cardiovascular Associates Cardiology · in network | 93306 | $1,096.00 | $319.37 | Clean approval | — | Approved |
| CLM-2026-019544 UB-04 · 2026-10-12 | Daina Ran no member ID | 2026-10-03 Outpatient hospital | Evergreen Reference Lab Clinical Laboratory · in network | 70553 | $1,956.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-019303 UB-04 · 2026-10-12 | Diego Nguyen UHC-76302-57 | 2026-09-24 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99285, 99283 | $3,808.00 | $1,844.40 | Clean approval | — | Approved |
| CLM-2026-019061 CMS-1500 · 2026-10-12 | Santiago McDonald UHC-25511-74 | 2026-10-02 Office | Meadow Family Practice Family Medicine · in network | 99213, 99214 | $470.00 | $251.40 | Clean approval | — | Approved |
| CLM-2026-018964 UB-04 · 2026-10-12 | Charles Burton UHC-47128-17 | 2026-09-07 Outpatient hospital | Riverside Imaging Center Radiology · in network | 77067 | $342.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-018820 UB-04 · 2026-10-12 | Alexander Marshall UHC-93972-26 | 2026-09-25 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99284 | $1,742.00 | $708.10 | Clean approval | — | Approved |
| CLM-2026-017763 CMS-1500 · 2026-10-12 | Bryan Ortiz UHC-46023-57 | 2026-09-14 Office | Heritage Primary Care Associates Family Medicine · in network | 99203, 99395 | $463.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-017685 UB-04 · 2026-10-12 | Steven Turner UHC-95158-61 | 2026-09-03 Outpatient hospital | Meadow Clinical Laboratories Clinical Laboratory · in network | 70553 | $2,890.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-016999 CMS-1500 · 2026-10-12 | Joyce Moreno UHC-70742-07 | 2026-10-09 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110, 97140, 97161 | $508.00 | $294.96 | Clean approval | — | Approved |
| CLM-2026-016427 CMS-1500 · 2026-10-12 | Abigail Aguilar UHC-54533-25 | 2026-09-02 Independent laboratory | Desert Reference Lab Clinical Laboratory · in network | 87086, 80061 | $127.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-016133 UB-04 · 2026-10-12 | Richard Clark UHC-54936-57 | 2026-09-05 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99285 | $2,496.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014798 CMS-1500 · 2026-10-12 | Adam Green UHC-08215-14 | 2026-10-09 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 99214 | $201.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-014584 CMS-1500 · 2026-10-12 | Gutierrez Helen UHC-58583-12 | 2026-09-03 Office | Harbor Endocrine Associates Endocrinology · in network | 99215, 99214, 95251 | $886.00 | $509.32 | Clean approval | — | Approved |
| CLM-2026-014413 CMS-1500 · 2026-10-12 | Billy Elliott UHC-93838-09 | 2026-09-28 Independent laboratory | Unity Clinical Laboratories Clinical Laboratory · in network | 87086 | $61.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-014261 UB-04 · 2026-10-12 | Mark Hudson UHC-88797-59 | 2026-09-20 Emergency room | Cornerstone Regional Medical Center Emergency Medicine · in network | 99284 | $1,340.00 | $387.00 | Clean approval | — | Approved |
| CLM-2026-013966 UB-04 · 2026-10-12 | Lauren Spencer UHC-15892-51 | 2026-08-28 Outpatient hospital | Cornerstone Cardiovascular Associates Cardiology · in network | 93458, 93306 | $9,038.00 | — | Left for review CO97 | — | 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.