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-2026-008130 CMS-1500 · 2026-09-25 | Not attached | 2026-09-15 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97014 | $379.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-019327 CMS-1500 · 2026-09-24 | Nicholas Le UHC-49251-67 | 2026-09-21 Office | Unity Counseling Center Behavioral Health · in network | 90791 | $378.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-028059 CMS-1500 · 2026-09-23 | Alexander Evans UHC-74290-44 | 2026-08-14 Office | Meadow Primary Care Associates Family Medicine · in network | 99213, 99203, 99214 | $586.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-025947 CMS-1500 · 2026-09-23 | Danielle White UHC-49036-24 | 2026-08-19 Office | Heritage Family Practice Family Medicine · in network | 99203 | $242.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-019291 UB-04 · 2026-09-23 | Nicole Carlson UHC-64211-07 | 2026-08-19 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93015, 93306 | $1,739.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-012268 CMS-1500 · 2026-09-23 | Lawrence Nichhols UHC-93718-40 | 2026-09-06 Office | Northgate Heart Institute Cardiology · in network | 93224, 99214 | $589.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-011279 CMS-1500 · 2026-09-23 | Sharon Reynolds UHC-55069-69 | 2026-08-25 Office | Riverside Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $323.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-010836 UB-04 · 2026-09-23 | Gary Kelly UHC-44852-79 | 2026-08-30 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · in network | 43239 | $2,296.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-013429 CMS-1500 · 2026-09-22 | Not attached | 2026-09-04 Office | Desert Heart Institute Cardiology · in network | 93224 | $275.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-005361 UB-04 · 2026-09-22 | Not attached | 2026-09-19 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285 | $3,094.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-029002 UB-04 · 2026-09-21 | Not attached | 2026-08-31 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,744.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-026636 CMS-1500 · 2026-09-21 | Amanda Chapman UHC-94916-77 | 2026-08-24 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140 | $247.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-014466 CMS-1500 · 2026-09-19 | Not attached | 2026-08-30 Office | Evergreen Medical Group Family Medicine · in network | 36415, 99395 | $290.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-026574 CMS-1500 · 2026-09-16 | Alexis Washington UHC-12260-84 | 2026-09-03 Office | Sunrise Skin Care Associates Dermatology · in network | 17110 | $195.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-008606 UB-04 · 2026-09-16 | Jonathan Hughes UHC-60893-02 | 2026-08-18 Outpatient hospital | Harbor Digestive Health Center Gastroenterology · in network | 45378 | $1,984.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-030209 UB-04 · 2026-09-15 | Diana McDonald UHC-97280-61 | 2026-08-06 Outpatient hospital | Valley Imaging Center Radiology · in network | 74177 | $1,278.00 | — | Left for review CO50 CO16 | — | Needs review |
| CLM-2026-015581 CMS-1500 · 2026-09-14 | Janet Lopez UHC-53522-23 | 2026-08-04 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 80061, 83036 | $105.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-013540 UB-04 · 2026-09-14 | Denise Hamilton UHC-25159-90 | 2026-08-23 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285, 71046 | $2,107.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-033913 UB-04 · 2026-09-12 | Saa Harper UHC-71898-36 | 2026-09-04 Inpatient hospital | Mesa Medical Group Internal Medicine · in network | 99232 | $230.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-033483 CMS-1500 · 2026-09-12 | Amanda Santos UHC-87211-30 | 2026-08-12 Office | Meadow Heart Institute Cardiology · out of network | 99214, 93224 | $679.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-025635 UB-04 · 2026-09-12 | Alex Munoz UHC-78751-46 | 2026-08-14 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $42,944.00 | — | Left for review CO16 HIGH | — | Needs review |
| CLM-2026-001497 CMS-1500 · 2026-09-12 | Gary King UHC-19513-90 | 2026-08-18 Independent laboratory | Summit Clinical Laboratories Clinical Laboratory · in network | 83036, 87086 | $123.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-023697 CMS-1500 · 2026-09-11 | David Gibson UHC-69693-06 | 2026-08-02 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 83036, 80053 | $125.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-023310 CMS-1500 · 2026-09-11 | Joyce Johnson UHC-57438-80 | 2026-08-07 Office | Summit Internal Medicine Associates Internal Medicine · in network | 99215 | $398.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-032964 CMS-1500 · 2026-09-10 | Anna Dixon UHC-96020-28 | 2026-08-16 Office | Sunrise Medical Group Family Medicine · in network | 90471, 36415, 99214 | $328.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-029710 UB-04 · 2026-09-10 | Isabella Bell UHC-68295-82 | 2026-08-06 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · out of network | 99232 | $200.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-013078 CMS-1500 · 2026-09-10 | Roy Wilson UHC-47553-11 | 2026-09-01 Office | Sunrise Dermatology Clinic Dermatology · out of network | 99213 | $206.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-029001 UB-04 · 2026-09-09 | Not attached | 2026-08-31 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,744.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-028883 UB-04 · 2026-09-08 | Edward Powell UHC-15445-60 | 2026-08-17 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · in network | 99284 | $1,045.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-025592 CMS-1500 · 2026-09-07 | Not attached | 2026-08-22 Office | Pinecrest Medical Group Family Medicine · in network | 99213, 99203 | $402.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-023619 CMS-1500 · 2026-09-07 | Peter Guzman UHC-91833-33 | 2026-08-25 Office | Unity Primary Care Associates Family Medicine · in network | 36415, 99213, 90471 | $216.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-016834 CMS-1500 · 2026-09-07 | Teresa Fisher UHC-20504-81 | 2026-08-11 Independent laboratory | Evergreen Reference Lab Clinical Laboratory · in network | 80061, 83036, 80053, 85025 | $244.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-025355 UB-04 · 2026-09-05 | Jonathan Reynolds UHC-90138-55 | 2026-08-04 Emergency room | Desert Regional Medical Center Emergency Medicine · in network | 96374, 99285 | $2,511.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-013787 CMS-1500 · 2026-09-04 | Eric Ross UHC-65059-83 | 2026-08-27 Independent laboratory | Unity Reference Lab Clinical Laboratory · in network | 85025 | $42.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-010692 UB-04 · 2026-09-04 | Donna Schmidt UHC-88832-04 | 2026-08-30 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $38,434.00 | — | Left for review CO16 HIGH | — | Needs review |
| CLM-2026-004370 UB-04 · 2026-09-03 | Robert Nichols UHC-85970-41 | 2026-07-31 Outpatient hospital | Meadow Cardiovascular Associates Cardiology · in network | 93458, 93306 | $7,548.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-022325 CMS-1500 · 2026-09-02 | Tyler Rice UHC-71226-29 | 2026-08-21 Office | Sunrise Internal Medicine Associates Internal Medicine · in network | 99214, 99215 | $609.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-022108 CMS-1500 · 2026-09-02 | Not attached | 2026-08-08 Office | Desert Internal Medicine Associates Internal Medicine · in network | 93000 | $91.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-002101 UB-04 · 2026-09-02 | Sandra Owens UHC-89246-62 | 2026-08-23 Outpatient hospital | Desert Imaging Center Radiology · in network | 76700, 71046 | $630.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-017762 CMS-1500 · 2026-09-01 | Not attached | 2026-07-27 Office | Valley Medical Group Internal Medicine · in network | 99214 | $261.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-006522 UB-04 · 2026-09-01 | Lawrence Harvey UHC-80234-32 | 2026-08-04 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 70553, 71046 | $2,580.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-017933 UB-04 · 2026-08-31 | Richard Kelley UHC-11767-95 | 2026-07-25 Emergency room | Sunrise Community Hospital Emergency Medicine · in network | 71046, 99285, 99283 | $4,017.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-003514 UB-04 · 2026-08-31 | Anthony Walsh UHC-21787-35 | 2026-07-23 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · in network | 99284, 71046 | $1,577.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-018428 CMS-1500 · 2026-08-30 | Jessica Cunningham UHC-94194-72 | 2026-08-25 Office | Meadow Internal Medicine Associates Internal Medicine · in network | 99214, 93000, 99215 | $702.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-025974 CMS-1500 · 2026-08-29 | Abby Vazquez UHC-43328-08 | 2026-07-21 Office | Meadow Primary Care Associates Family Medicine · in network | 99213 | $144.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-024682 UB-04 · 2026-08-29 | Not attached | 2026-07-31 Outpatient hospital | Lakeside Medical Group Internal Medicine · in network | 70553 | $2,959.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-000961 CMS-1500 · 2026-08-29 | Janet Henderson UHC-29228-29 | 2026-08-12 Office | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 99213 | $167.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-015443 CMS-1500 · 2026-08-28 | Robert Tucker UHC-80868-20 | 2026-08-07 Independent laboratory | Desert Reference Lab Clinical Laboratory · in network | 87086 | $70.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-005265 UB-04 · 2026-08-28 | Not attached | 2026-08-25 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 71046 | $225.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-034498 CMS-1500 · 2026-08-27 | Heatther Silva UHC-15559-59 | 2026-08-08 Office | Lakeside Medical Group Family Medicine · in network | 90471, 99203 | $284.00 | — | Left for review CO16 | — | 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.