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
3,663
89 with an AI recommendation
Pended
2,587
awaiting information or identity
Approved
23,942
$6,757,768.45 plan paid
Denied
4,454
with remittance reason codes
Examiner decided
1
167 not attached to an identity
| Claim | Member | Service | Provider | Procedures | Billed | Plan pays | Rules | AI | Status |
|---|---|---|---|---|---|---|---|---|---|
| CLM-2026-003099 CMS-1500 · 2026-10-24 | Wayne Garza UHC-17167-67 | 2026-10-15 Office | Evergreen GI Associates Gastroenterology · in network | 99214 | $289.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-027220 UB-04 · 2026-10-23 | Amber Walker UHC-76429-95 | 2026-09-19 Outpatient hospital | Desert Cardiovascular Associates Cardiology · in network | 93015 | $596.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-023083 CMS-1500 · 2026-10-23 | Hiroshi Fowler UHC-09603-43 | 2026-09-12 Office | Heritage Primary Care Associates Family Medicine · in network | 36415, 99203 | $217.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-018199 CMS-1500 · 2026-10-23 | Betty Warren UHC-12406-55 | 2026-08-25 Office | Heritage Primary Care Associates Family Medicine · in network | 99395, 99213 | $528.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-014055 UB-04 · 2026-10-23 | Danielle Gomez UHC-89338-09 | 2026-09-11 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 71046 | $141.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-013960 CMS-1500 · 2026-10-23 | Patrick Sanders UHC-58486-46 | 2026-10-07 Office | Canyon Skin Care Associates Dermatology · in network | 17110, 11403 | $650.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-025363 CMS-1500 · 2026-10-22 | Luis Clark UHC-84938-13 | 2026-09-14 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99214 | $276.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-017716 CMS-1500 · 2026-10-22 | Amber Delgado UHC-52060-85 | 2026-09-24 Independent laboratory | Unity Clinical Laboratories Clinical Laboratory · in network | 80053, 80061 | $147.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007191 CMS-1500 · 2026-10-22 | Ahmed Vega UHC-03347-26 | 2026-08-31 Independent laboratory | Mesa Reference Lab Clinical Laboratory · in network | 85025, 80061 | $89.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-002070 UB-04 · 2026-10-22 | Ana Jackson UHC-71686-49 | 2026-09-23 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $29,621.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-030532 CMS-1500 · 2026-10-21 | Logan James UHC-25785-59 | 2026-09-11 Office | Sunrise Medical Group Internal Medicine · in network | 99214, 99215, 80053 | $760.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029204 UB-04 · 2026-10-21 | Jesse Price UHC-05475-09 | 2026-08-29 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 71046, 99283 | $910.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028764 CMS-1500 · 2026-10-21 | Edward Phillips UHC-73690-84 | 2026-08-21 Office | Lakeside Medical Group Family Medicine · out of network | 90471, 36415 | $58.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028212 CMS-1500 · 2026-10-21 | Virginia Graham UHC-41763-34 | 2026-08-25 Office | Harbor Physical Therapy Physical Therapy · in network | 97110 | $364.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-023357 CMS-1500 · 2026-10-21 | Keith Williamson UHC-70723-03 | 2026-09-09 Office | Desert Rehabilitation Center Physical Therapy · in network | 97110 | $56.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-022570 CMS-1500 · 2026-10-21 | Not attached | 2026-10-04 Office | Mesa Family Practice Family Medicine · in network | 99214, 36415, 90471 | $348.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-007624 UB-04 · 2026-10-21 | James Cox UHC-14257-05 | 2026-09-25 Outpatient hospital | Harbor Diagnostic Imaging Radiology · in network | 71046, 70553 | $2,856.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-031856 CMS-1500 · 2026-10-20 | Carol Fowler UHC-12538-47 | 2026-08-24 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 80053, 93000 | $124.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-030104 CMS-1500 · 2026-10-20 | Brenda Lee UHC-79610-84 | 2026-08-17 Office | Meadow Primary Care Associates Family Medicine · in network | 99395 | $290.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-017158 CMS-1500 · 2026-10-20 | Alice Butler no member ID | 2026-09-20 Telehealth | Evergreen Counseling Center Behavioral Health · in network | 99214 | $233.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014290 CMS-1500 · 2026-10-20 | Amanda Espinoza UHC-65635-71 | 2026-09-17 Office | Evergreen Family Practice Family Medicine · in network | 36415, 99213, 90471 | $189.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007597 CMS-1500 · 2026-10-20 | Emma Mendez UHC-16028-30 | 2026-10-09 Office | Desert Internal Medicine Associates Internal Medicine · in network | 80053 | $85.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-003042 CMS-1500 · 2026-10-20 | Judith Sanchez UHC-37863-85 | 2026-10-02 Office | Riverside Primary Care Associates Family Medicine · in network | 99213, 36415 | $211.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-001654 CMS-1500 · 2026-10-20 | Ana Robinson UHC-45904-17 | 2026-10-02 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99214 | $236.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-031649 CMS-1500 · 2026-10-19 | Jonathan Marquez UHC-57626-40 | 2026-10-03 Office | Valley Skin Care Associates Dermatology · in network | 17110 | $215.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-020910 CMS-1500 · 2026-10-19 | James Rodriguez UHC-66449-14 | 2026-09-18 Office | Evergreen Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $444.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-019167 CMS-1500 · 2026-10-19 | Emily Martin UHC-23423-50 | 2026-08-30 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 80061, 83036, 85025 | $145.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-000819 CMS-1500 · 2026-10-19 | Carol Fowler UHC-12538-47 | 2026-09-26 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 99215 | $344.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-034142 CMS-1500 · 2026-10-18 | Wayne Ward UHC-86507-79 | 2026-09-17 Office | Meadow Medical Group Family Medicine · in network | 36415, 99203, 99214 | $452.00 | $272.80 | Clean approval | — | Approved |
| CLM-2026-033652 CMS-1500 · 2026-10-18 | Tyler Moore UHC-71756-75 | 2026-09-03 Office | Evergreen Dermatology Clinic Dermatology · out of network | 11403, 99213 | $902.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-033650 UB-04 · 2026-10-18 | Anna Knight UHC-17139-80 | 2026-09-06 Outpatient hospital | Northgate Cardiovascular Associates Cardiology · in network | 93015 | $448.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-033340 CMS-1500 · 2026-10-18 | Donald Stewart UHC-62097-19 | 2026-09-05 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 85025 | $40.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032967 CMS-1500 · 2026-10-18 | Amber Howell UHC-88592-44 | 2026-09-18 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11403, 17110 | $956.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032473 CMS-1500 · 2026-10-18 | Arjun Cruz UHC-63818-91 | 2026-09-03 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140 | $401.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-032335 CMS-1500 · 2026-10-18 | James Delgado UHC-83159-99 | 2026-09-29 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $186.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-031983 CMS-1500 · 2026-10-18 | Valentina Mejia UHC-96174-01 | 2026-09-17 Office | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 20610 | $276.00 | $96.12 | Clean approval | — | Approved |
| CLM-2026-031883 UB-04 · 2026-10-18 | Gary Rodriguez UHC-65603-12 | 2026-09-08 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $36,915.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-031368 CMS-1500 · 2026-10-18 | Donald Griffin UHC-74616-95 | 2026-10-16 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $240.00 | $128.80 | Clean approval | — | Approved |
| CLM-2026-030928 CMS-1500 · 2026-10-18 | Alexis Long UHC-64773-95 | 2026-10-10 Office | Unity Physical Therapy Physical Therapy · in network | 97110, 97014, 97161 | $540.00 | $309.80 | Clean approval | — | Approved |
| CLM-2026-030554 CMS-1500 · 2026-10-18 | Mateo Castro UHC-93344-27 | 2026-09-20 Independent laboratory | Unity Clinical Laboratories Clinical Laboratory · in network | 80053 | $52.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030299 CMS-1500 · 2026-10-18 | Frances Reed UHC-43006-53 | 2026-10-14 Office | Cornerstone Cardiovascular Associates Cardiology · in network | 99214 | $272.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-029993 CMS-1500 · 2026-10-18 | Lori Duncan UHC-77386-40 | 2026-10-01 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99215, 80053 | $377.00 | $213.74 | Clean approval | — | Approved |
| CLM-2026-029255 CMS-1500 · 2026-10-18 | Matthew Carpenter UHC-33751-82 | 2026-10-14 Office | Desert Medical Group Internal Medicine · in network | 93000 | $113.00 | $30.06 | Clean approval | — | Approved |
| CLM-2026-029120 UB-04 · 2026-10-18 | Ethan Stephens UHC-27099-22 | 2026-09-06 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $239.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-028761 UB-04 · 2026-10-18 | Laura Gonzales UHC-58273-59 | 2026-10-16 Outpatient hospital | Harbor Cardiovascular Associates Cardiology · in network | 93015, 93458 | $10,065.00 | $2,580.79 | Clean approval | — | Approved |
| CLM-2026-028512 UB-04 · 2026-10-18 | Steven Wheeler UHC-11820-74 | 2026-09-27 Inpatient hospital | Canyon Medical Group Internal Medicine · in network | 99232 | $251.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-027767 CMS-1500 · 2026-10-18 | Larson Gary no member ID | 2026-09-24 Office | Lakeside Medical Group Family Medicine · out of network | 90471, 36415 | $52.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-027511 CMS-1500 · 2026-10-18 | Kimberly George UHC-06108-11 | 2026-09-09 Independent laboratory | Unity Clinical Laboratories Clinical Laboratory · in network | 83036, 87086, 80053 | $194.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-026930 UB-04 · 2026-10-18 | Cynthia Silva UHC-94337-87 | 2026-10-09 Emergency room | Summit Community Hospital Emergency Medicine · in network | 71046 | $148.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-026808 CMS-1500 · 2026-10-18 | Megan Davis UHC-00007-16 | 2026-10-12 Office | Northgate Cardiovascular Associates Cardiology · in network | 99214 | $309.00 | $151.58 | 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 REPL490
- 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.