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-2026-013569 CMS-1500 · 2026-10-12 | Patricia Owens UHC-87048-14 | 2026-09-15 Office | Unity Counseling Center Behavioral Health · in network | 90837, 90791, 90834 | $937.00 | $505.94 | Clean approval | — | Approved |
| CLM-2026-013555 CMS-1500 · 2026-10-12 | Helen Hill UHC-07235-61 | 2026-09-12 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97161 | $399.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-013526 CMS-1500 · 2026-10-12 | Joseph Wheeler UHC-76888-73 | 2026-09-16 Office | Mesa Medical Group Family Medicine · in network | 99203, 99213 | $387.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013499 CMS-1500 · 2026-10-12 | Samuel Tucker no member ID | 2026-08-30 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $187.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-013417 UB-04 · 2026-10-12 | John Cunningham UHC-37758-42 | 2026-08-16 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553 | $2,471.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013391 UB-04 · 2026-10-12 | Nathan Singh UHC-25477-01 | 2026-09-07 Outpatient hospital | Desert Imaging Center Radiology · in network | 77067, 70553 | $2,676.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-013362 CMS-1500 · 2026-10-12 | Ann Long UHC-06317-61 | 2026-10-03 Office | Riverside Medical Group Family Medicine · in network | 36415, 90471, 99214 | $295.00 | $174.22 | Clean approval | — | Approved |
| CLM-2026-013059 CMS-1500 · 2026-10-12 | Luis Schultz UHC-32378-87 | 2026-09-27 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99215, 93000 | $399.00 | $227.38 | Clean approval | — | Approved |
| CLM-2026-012144 UB-04 · 2026-10-12 | Sandra McCoy UHC-43501-97 | 2026-08-30 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 76700 | $328.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011948 CMS-1500 · 2026-10-12 | Jack Hooffman UHC-84193-50 | 2026-09-26 Office | Evergreen GI Associates Gastroenterology · in network | 99214 | $320.00 | $158.40 | Clean approval | — | Approved |
| CLM-2026-011632 CMS-1500 · 2026-10-12 | Carlos Perkins UHC-67445-33 | 2026-09-02 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061, 83036, 87086 | $156.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-011600 CMS-1500 · 2026-10-12 | Cynthia Nichols UHC-36208-79 | 2026-08-29 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 83036 | $71.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011493 CMS-1500 · 2026-10-12 | Samantah Castillo UHC-23757-47 | 2026-09-25 Office | Riverside Family Practice Family Medicine · in network | 99213, 36415 | $161.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-010720 CMS-1500 · 2026-10-12 | Laura Thomas UHC-63477-40 | 2026-09-10 Office | Summit Medical Group Internal Medicine · in network | 99215, 93000, 99214 | $616.00 | $356.92 | Clean approval | — | Approved |
| CLM-2026-010416 CMS-1500 · 2026-10-12 | Katleen Tran no member ID | 2026-10-05 Office | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 99213 | $160.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-010205 CMS-1500 · 2026-10-12 | Carol Garza UHC-96037-74 | 2026-09-29 Office | Unity Medical Group Internal Medicine · in network | 99214 | $250.00 | $135.00 | Clean approval | — | Approved |
| CLM-2026-010199 CMS-1500 · 2026-10-12 | Melissa Hudson UHC-49229-90 | 2026-09-23 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 83036 | $64.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-010142 CMS-1500 · 2026-10-12 | James Hanson UHC-90765-54 | 2026-08-26 Office | Riverside Primary Care Associates Family Medicine · in network | 99203, 36415 | $253.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-010090 UB-04 · 2026-10-12 | Fatima Ford UHC-30941-57 | 2026-09-29 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99283 | $790.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-009549 CMS-1500 · 2026-10-12 | Christine Wallace UHC-56875-41 | 2026-10-03 Office | Lakeside Skin Care Associates Dermatology · in network | 99213 | $162.00 | $50.44 | Clean approval | — | Approved |
| CLM-2026-009116 CMS-1500 · 2026-10-12 | Yuki Sullivan UHC-25113-73 | 2026-09-07 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $491.00 | $264.42 | Clean approval | — | Approved |
| CLM-2026-008527 CMS-1500 · 2026-10-12 | Blily Larson UHC-69765-55 | 2026-09-08 Office | Sunrise Behavioral Health Behavioral Health · in network | 90791 | $327.00 | $127.74 | Clean approval | — | Approved |
| CLM-2026-008523 CMS-1500 · 2026-10-12 | Joshua Williamson UHC-99344-22 | 2026-10-08 Independent laboratory | Unity Clinical Laboratories Clinical Laboratory · in network | 83036 | $42.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-008388 CMS-1500 · 2026-10-12 | Kyle Salazar UHC-42261-80 | 2026-09-07 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 80061 | $65.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-007608 UB-04 · 2026-10-12 | Kimberly Vazquez UHC-88315-80 | 2026-09-10 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $1,119.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-007606 CMS-1500 · 2026-10-12 | David Berry UHC-53040-86 | 2026-09-02 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 85025, 83036, 80061 | $150.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-007578 CMS-1500 · 2026-10-12 | Tyler Cole UHC-88625-13 | 2026-10-05 Office | Desert Medical Group Family Medicine · in network | 99395, 90471 | $319.00 | $172.78 | Clean approval | — | Approved |
| CLM-2026-007527 CMS-1500 · 2026-10-12 | Deborah Wang UHC-09134-29 | 2026-10-09 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 99214, 80053 | $364.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-007469 UB-04 · 2026-10-12 | Carl Hunt UHC-78785-52 | 2026-09-19 Outpatient hospital | Desert Primary Care Associates Family Medicine · in network | 70553 | $2,235.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-007454 CMS-1500 · 2026-10-12 | Jonathan Carlson UHC-25366-78 | 2026-09-25 Office | Heritage Family Practice Family Medicine · in network | 99213 | $157.00 | $57.34 | Clean approval | — | Approved |
| CLM-2026-006360 UB-04 · 2026-10-12 | Joe Matthews UHC-80322-37 | 2026-09-12 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93015, 93306 | $1,627.00 | $500.14 | Clean approval | — | Approved |
| CLM-2026-006340 CMS-1500 · 2026-10-12 | Kenneth Perkins UHC-16787-95 | 2026-10-05 Office | Evergreen Counseling Center Behavioral Health · in network | 90791 | $329.00 | $143.98 | Clean approval | — | Approved |
| CLM-2026-005924 CMS-1500 · 2026-10-12 | Heather Lopez UHC-55811-29 | 2026-09-04 Office | Sunrise Diabetes Center Endocrinology · in network | 99215 | $296.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-005725 CMS-1500 · 2026-10-12 | Joyce Reid UHC-05392-10 | 2026-08-30 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · in network | 83036, 80053 | $108.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-004844 CMS-1500 · 2026-10-12 | Sean Chapman UHC-35561-40 | 2026-10-09 Office | Canyon Primary Care Associates Family Medicine · in network | 99395, 99214, 36415 | $587.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-004556 CMS-1500 · 2026-10-12 | Donald Patel UHC-14764-41 | 2026-09-10 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 87086, 85025 | $105.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-004317 CMS-1500 · 2026-10-12 | Keith Schultz UHC-59799-84 | 2026-08-29 Office | Heritage Internal Medicine Associates Internal Medicine · in network | 99214 | $308.00 | $150.96 | Clean approval | — | Approved |
| CLM-2026-004288 CMS-1500 · 2026-10-12 | Pamela Russell UHC-06760-29 | 2026-09-29 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 80061, 87086 | $137.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003740 CMS-1500 · 2026-10-12 | Arjun Ward UHC-59588-89 | 2026-09-25 Office | Heritage Medical Group Internal Medicine · in network | 99215 | $299.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-003566 CMS-1500 · 2026-10-12 | Mark Gomez UHC-29262-82 | 2026-06-26 Office | Valley Internal Medicine Associates Internal Medicine · in network | 99215 | $420.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-003438 CMS-1500 · 2026-10-12 | Olivia Stephens UHC-83378-94 | 2026-10-03 Office | Desert Primary Care Associates Family Medicine · in network | 99203, 99214 | $462.00 | $261.44 | Clean approval | — | Approved |
| CLM-2026-003041 CMS-1500 · 2026-10-12 | Judith Sanchez UHC-37863-85 | 2026-10-02 Office | Riverside Primary Care Associates Family Medicine · in network | 99213, 36415 | $211.00 | $110.82 | Clean approval | — | Approved |
| CLM-2026-002835 UB-04 · 2026-10-12 | Lawrence Owens UHC-66059-99 | 2026-09-02 Outpatient hospital | Riverside Cardiovascular Associates Cardiology · in network | 93458, 93306 | $8,796.00 | $1,159.22 | Clean approval | — | Approved |
| CLM-2026-002317 CMS-1500 · 2026-10-12 | Henry Espinoza UHC-08632-94 | 2026-09-21 Office | Valley Medical Group Internal Medicine · in network | 99214, 80053, 93000 | $354.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-002235 CMS-1500 · 2026-10-12 | Sean Olson UHC-92464-20 | 2026-09-30 Independent laboratory | Harbor Reference Lab Clinical Laboratory · in network | 80053, 85025 | $141.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-001970 CMS-1500 · 2026-10-12 | Jacob Jimenez no member ID | 2026-10-04 Office | Desert Medical Group Internal Medicine · in network | 93000 | $95.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-001507 CMS-1500 · 2026-10-12 | Doris King UHC-76651-46 | 2026-10-07 Office | Evergreen Primary Care Associates Family Medicine · in network | 36415, 90471 | $57.00 | $19.84 | Clean approval | — | Approved |
| CLM-2026-001237 CMS-1500 · 2026-10-12 | Karen Anderson UHC-48865-86 | 2026-09-05 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086 | $64.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001196 UB-04 · 2026-10-12 | Adam Harper UHC-83331-37 | 2026-09-25 Outpatient hospital | Cornerstone Cardiovascular Associates Cardiology · in network | 93015 | $436.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-000883 CMS-1500 · 2026-10-12 | Kayla Wheeler UHC-62250-44 | 2026-09-08 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 85025 | $48.00 | $0.00 | 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.