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-2026-031918 CMS-1500 · 2026-10-14 | Gary Armstrong UHC-04189-51 | 2026-09-05 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 85025 | $51.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-026540 CMS-1500 · 2026-10-14 | Samuel Obrien UHC-78534-34 | 2026-08-18 Independent laboratory | Summit Reference Lab Clinical Laboratory · in network | 80061, 85025 | $114.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014338 CMS-1500 · 2026-10-14 | Ralph Cole UHC-07842-57 | 2026-09-22 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140, 97161 | $507.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-030736 CMS-1500 · 2026-10-13 | Ethan Vazquez UHC-36033-31 | 2026-08-25 Independent laboratory | Summit Reference Lab Clinical Laboratory · in network | 80061 | $46.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-030070 CMS-1500 · 2026-10-13 | Pamela Snadoval UHC-52330-59 | 2026-09-14 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99203 | $242.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024891 CMS-1500 · 2026-10-13 | Doris Coleman UHC-38524-53 | 2026-09-08 Office | Desert Medical Group Internal Medicine · in network | 93000 | $92.00 | — | Denied by rule CO18 | — | Denied |
| 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-2026-022834 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-2026-018964 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-2026-016133 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-2026-003740 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-2026-032272 UB-04 · 2026-10-11 | Eugeene Reyes UHC-32191-16 | 2026-08-25 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $7,356.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-021824 CMS-1500 · 2026-10-11 | Lawrence Rice UHC-99232-21 | 2026-08-27 Office | Sunrise Medical Group Family Medicine · in network | 99213, 36415 | $176.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014959 CMS-1500 · 2026-10-11 | Cunningham Omar UHC-84013-63 | 2026-08-13 Office | Riverside Bone and Joint Center Orthopedic Surgery · in network | 99213 | $208.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007811 CMS-1500 · 2026-10-11 | Santiago Gardner UHC-96725-82 | 2026-08-29 Office | Mesa Dermatology Clinic Dermatology · in network | 99213 | $177.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-025789 UB-04 · 2026-10-10 | Sarah Smith no member ID | 2026-09-12 Emergency room | Unity Community Hospital Emergency Medicine · in network | 96374 | $220.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-029531 CMS-1500 · 2026-10-08 | Sophia Fox UHC-96989-32 | 2026-08-26 Office | Evergreen Internal Medicine Associates Internal Medicine · in network | 99215 | $351.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024080 CMS-1500 · 2026-10-08 | Theresa Ferguson UHC-72869-72 | 2026-08-24 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99214 | $204.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-015596 CMS-1500 · 2026-10-08 | Teresa Sims UHC-19809-99 | 2026-08-11 Office | Harbor Cardiovascular Associates Cardiology · in network | 99214 | $236.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-034077 CMS-1500 · 2026-10-07 | Brenda Ortiz UHC-96228-35 | 2026-08-30 Office | Harbor Physical Therapy Physical Therapy · in network | 97110, 97014 | $272.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022089 CMS-1500 · 2026-10-07 | Jacqueline Davis UHC-40454-55 | 2026-08-20 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90837 | $262.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022479 CMS-1500 · 2026-10-05 | Logan Green no member ID | 2026-08-13 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110, 97140 | $329.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-002331 CMS-1500 · 2026-10-05 | James Fernandez UHC-25043-68 | 2026-09-04 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 83036 | $74.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-029957 CMS-1500 · 2026-10-04 | Andrew Garza UHC-05082-55 | 2026-08-30 Office | Mesa Primary Care Associates Family Medicine · in network | 99395, 99203 | $469.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022511 UB-04 · 2026-10-04 | Melissa Anderson UHC-00123-95 | 2026-08-20 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 88305 | $224.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-016413 CMS-1500 · 2026-10-04 | Theresa Hoffman UHC-15893-12 | 2026-08-05 Office | Lakeside Medical Group Family Medicine · out of network | 99203, 36415, 99214 | $451.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024771 CMS-1500 · 2026-10-03 | Jessica Murray UHC-68586-02 | 2026-09-06 Office | Harbor Family Practice Family Medicine · in network | 90471, 99203 | $249.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022157 UB-04 · 2026-10-03 | Mary Contreras UHC-87904-93 | 2026-09-05 Outpatient hospital | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $10,210.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-018463 CMS-1500 · 2026-10-03 | Mason Jenkins UHC-44213-31 | 2026-08-23 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 80053, 99215 | $399.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-002526 CMS-1500 · 2026-10-03 | Noah Soto UHC-40906-06 | 2026-08-14 Office | Pinecrest Medical Group Family Medicine · in network | 99214 | $202.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-030647 CMS-1500 · 2026-10-02 | Billy Bennett UHC-96082-25 | 2026-08-20 Office | Heritage Medical Group Family Medicine · out of network | 99395 | $231.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-012642 CMS-1500 · 2026-10-02 | Stephanie Berry UHC-73453-17 | 2026-08-22 Office | Northgate Cardiovascular Associates Cardiology · in network | 99214, 93224 | $691.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-004348 CMS-1500 · 2026-10-02 | Sean Hamilton UHC-23119-97 | 2026-08-17 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 80053, 99215 | $376.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024271 CMS-1500 · 2026-10-01 | Isabella Walsh UHC-12076-16 | 2026-09-14 Office | Northgate Counseling Center Behavioral Health · in network | 90791 | $390.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-023859 CMS-1500 · 2026-10-01 | Joseph Day UHC-62916-46 | 2026-09-12 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086, 80053 | $88.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-023392 CMS-1500 · 2026-10-01 | Donna Renolds UHC-53206-63 | 2026-09-04 Office | Summit Medical Group Internal Medicine · in network | 80053 | $72.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-029709 UB-04 · 2026-09-30 | James Maldonado UHC-48927-65 | 2026-08-19 Outpatient hospital | Meadow Cardiovascular Associates Cardiology · in network | 93015 | $572.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-025383 UB-04 · 2026-09-30 | Abby Nichols UHC-31174-53 | 2026-08-27 Outpatient hospital | Meadow Cardiovascular Associates Cardiology · in network | 93458 | $7,824.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022140 CMS-1500 · 2026-09-30 | Paul White UHC-79899-25 | 2026-09-17 Office | Riverside Primary Care Associates Family Medicine · in network | 99213 | $148.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-021622 UB-04 · 2026-09-30 | Mariana Delgado UHC-65759-31 | 2026-08-03 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 43239 | $1,936.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-020729 UB-04 · 2026-09-30 | Jean Nunez no member ID | 2026-08-22 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99285, 96374, 99283 | $3,666.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-020491 CMS-1500 · 2026-09-30 | Omar Carter UHC-59754-70 | 2026-09-14 Office | Sunrise Medical Group Internal Medicine · in network | 99215 | $327.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-017890 CMS-1500 · 2026-09-30 | Richard Jenkins UHC-62559-30 | 2026-08-18 Office | Sunrise Medical Group Family Medicine · in network | 36415, 99395 | $243.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-013473 UB-04 · 2026-09-30 | Peter Austin UHC-85220-86 | 2026-09-18 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93306 | $1,377.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-032659 CMS-1500 · 2026-09-29 | Ryan Riley UHC-78345-09 | 2026-08-03 Office | Pinecrest Heart Institute Cardiology · in network | 99214, 93224 | $574.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014838 CMS-1500 · 2026-09-29 | Virginia Bennett UHC-85901-18 | 2026-08-19 Telehealth | Sunrise Behavioral Health Behavioral Health · in network | 99214 | $237.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-013770 UB-04 · 2026-09-29 | Cheryl Gibson UHC-20991-85 | 2026-09-08 Inpatient hospital | Mesa Medical Group Internal Medicine · in network | 99232 | $212.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-011839 UB-04 · 2026-09-29 | Amber Wells UHC-80479-97 | 2026-09-13 Inpatient hospital | Heritage Medical Group Internal Medicine · in network | 99232 | $163.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-005147 UB-04 · 2026-09-29 | Frank Gomez UHC-57895-27 | 2026-08-07 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 74177 | $1,520.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022799 UB-04 · 2026-09-28 | Ryan Harvey UHC-08814-34 | 2026-08-21 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 74177, 71046, 77067 | $2,522.00 | — | Denied by rule CO18 | — | Denied |
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.