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-2026-002360 CMS-1500 · 2026-10-11 | Virginia Smith UHC-62024-73 | 2026-09-22 Office | Summit Family Practice Family Medicine · in network | 99395, 99214 | $533.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-030438 CMS-1500 · 2026-10-10 | Scott Thomas UHC-23637-74 | 2026-09-30 Office | Lakeside Dermatology Clinic Dermatology · in network | 99213, 11403, 17110 | $986.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-029298 CMS-1500 · 2026-10-10 | Frank Thompson UHC-47481-78 | 2026-09-07 Office | Mesa Primary Care Associates Family Medicine · in network | 99214, 36415, 99203 | $440.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-029178 UB-04 · 2026-10-10 | Lucia Soto UHC-71796-85 | 2026-09-15 Outpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 70553, 73721 | $5,854.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-025925 CMS-1500 · 2026-10-10 | Debbie Mendez UHC-11886-57 | 2026-08-31 Office | Unity Primary Care Associates Family Medicine · out of network | 99395, 90471, 99203 | $578.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014518 CMS-1500 · 2026-10-10 | George Fernandez UHC-94231-07 | 2026-09-18 Office | Pinecrest Medical Group Family Medicine · in network | 90471 | $31.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-008327 CMS-1500 · 2026-10-10 | Deborah Owens UHC-36207-21 | 2026-08-26 Office | Valley Primary Care Associates Family Medicine · out of network | 36415 | $19.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-001629 UB-04 · 2026-10-10 | Keith Bell UHC-34516-56 | 2026-08-30 Outpatient hospital | Meadow GI Associates Gastroenterology · in network | 88305 | $270.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-001295 CMS-1500 · 2026-10-10 | Russell Morales UHC-05073-10 | 2026-09-12 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $244.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-032186 CMS-1500 · 2026-10-09 | Andrea Anderson UHC-88955-23 | 2026-09-18 Office | Harbor Medical Group Family Medicine · in network | 99213 | $220.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-023856 CMS-1500 · 2026-10-09 | Diego Wood UHC-94499-61 | 2026-09-11 Office | Meadow Skin Care Associates Dermatology · in network | 17110 | $286.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-016777 CMS-1500 · 2026-10-09 | Jesse Hughes UHC-62926-91 | 2026-09-22 Independent laboratory | Evergreen Clinical Laboratories Clinical Laboratory · in network | 83036, 87086, 85025 | $161.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-016092 UB-04 · 2026-10-09 | Isabella Williams UHC-55456-26 | 2026-09-13 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 71046, 74177 | $2,579.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-016060 CMS-1500 · 2026-10-09 | Oliver Linda UHC-29977-44 | 2026-09-22 Office | Evergreen Medical Group Family Medicine · in network | 99203, 99214 | $460.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-011074 UB-04 · 2026-10-09 | Anna Harvey UHC-53608-54 | 2026-09-15 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378, 43239 | $4,163.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-006226 CMS-1500 · 2026-10-09 | Denise Knight UHC-58065-29 | 2026-09-28 Office | Valley Rehabilitation Center Physical Therapy · in network | 97110, 97014 | $170.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-004701 CMS-1500 · 2026-10-09 | Pamela Santiago UHC-70706-81 | 2026-09-30 Office | Canyon Primary Care Associates Family Medicine · in network | 99395 | $272.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-033093 UB-04 · 2026-10-08 | Jacob Cooper UHC-27394-07 | 2026-09-30 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · in network | 88305 | $311.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-026978 CMS-1500 · 2026-10-08 | Doris Brooks UHC-60379-29 | 2026-09-07 Office | Meadow Heart Institute Cardiology · in network | 99214 | $247.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-012365 CMS-1500 · 2026-10-08 | Theresa Morrison UHC-09600-88 | 2026-09-13 Office | Evergreen Dermatology Clinic Dermatology · in network | 99213 | $159.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-009106 CMS-1500 · 2026-10-08 | Amy Marshall UHC-80245-87 | 2026-09-05 Office | Pinecrest Medical Group Internal Medicine · in network | 93000, 80053 | $124.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-006128 UB-04 · 2026-10-08 | Karen Wong UHC-75927-48 | 2026-08-29 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 71046, 76700 | $692.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-006087 CMS-1500 · 2026-10-08 | Cynthia Flores UHC-94639-58 | 2026-09-08 Office | Mesa Medical Group Family Medicine · in network | 99395, 99213 | $398.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-002457 CMS-1500 · 2026-10-08 | Jeffrey Clark UHC-45965-92 | 2026-09-01 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 80053 | $84.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-034214 CMS-1500 · 2026-10-07 | Grace Phillips UHC-93122-46 | 2026-09-16 Office | Desert Primary Care Associates Family Medicine · in network | 99203, 99214 | $505.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-032798 CMS-1500 · 2026-10-07 | Alan Washington UHC-48480-40 | 2026-09-09 Office | Meadow Primary Care Associates Family Medicine · in network | 99213, 99395, 36415 | $413.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-032499 CMS-1500 · 2026-10-07 | Rebecca Howard UHC-89882-71 | 2026-09-04 Office | Sunrise Counseling Center Behavioral Health · in network | 90837, 90834 | $484.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-024401 UB-04 · 2026-10-07 | Brandon Boyd UHC-74380-08 | 2026-09-26 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284 | $1,478.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-009890 UB-04 · 2026-10-07 | Albert Olson UHC-39661-50 | 2026-09-16 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $51,724.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-004676 CMS-1500 · 2026-10-07 | Walter Hoffman UHC-83616-67 | 2026-09-30 Office | Valley Primary Care Associates Family Medicine · out of network | 99213, 99203 | $441.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-003976 CMS-1500 · 2026-10-07 | Marilyn Long UHC-18585-05 | 2026-08-29 Office | Desert Primary Care Associates Family Medicine · in network | 99214, 36415 | $237.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-031973 UB-04 · 2026-10-06 | Jean Lawrence UHC-43612-23 | 2026-08-30 Inpatient hospital | Pinecrest Medical Group Internal Medicine · in network | 99232 | $161.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-020678 UB-04 · 2026-10-06 | Grace Vazquez UHC-00903-59 | 2026-09-19 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 77067, 70553 | $2,398.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-019877 CMS-1500 · 2026-10-06 | Cynthia Wheeler UHC-95456-05 | 2026-09-28 Office | Meadow Primary Care Associates Family Medicine · in network | 36415 | $23.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-015755 UB-04 · 2026-10-06 | Larry Hamilton UHC-53343-08 | 2026-09-15 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 88305, 45378 | $2,324.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-012550 CMS-1500 · 2026-10-06 | Karen Woods UHC-39950-19 | 2026-10-04 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 80053 | $61.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-008695 UB-04 · 2026-10-06 | Bobby Santos UHC-83369-97 | 2026-09-16 Emergency room | Harbor Regional Medical Center Emergency Medicine · in network | 71046, 99284 | $1,735.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-000057 CMS-1500 · 2026-10-06 | Dan Carroll UHC-28665-19 | 2026-09-20 Office | Valley Family Practice Family Medicine · in network | 99213, 99214 | $364.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-029909 UB-04 · 2026-10-05 | Logan Bell UHC-88125-05 | 2026-09-11 Outpatient hospital | Valley Reference Lab Clinical Laboratory · in network | 70553 | $3,426.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-024380 UB-04 · 2026-10-05 | Elijah Aguilar UHC-11836-39 | 2026-09-14 Outpatient hospital | Unity Imaging Center Radiology · out of network | 71046, 70553 | $2,673.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-023378 CMS-1500 · 2026-10-05 | George Sullivan UHC-30278-64 | 2026-09-21 Office | Northgate Medical Group Family Medicine · in network | 90471, 99213 | $184.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-021337 UB-04 · 2026-10-05 | Nicole Watkins UHC-16399-53 | 2026-09-23 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 70553 | $2,968.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-016587 CMS-1500 · 2026-10-05 | Henry King UHC-09665-72 | 2026-09-02 Office | Unity Cardiovascular Associates Cardiology · in network | 93224, 99214 | $700.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-015367 CMS-1500 · 2026-10-05 | Logan Bell UHC-88125-05 | 2026-08-23 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · in network | 83036, 80053 | $122.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-007602 UB-04 · 2026-10-05 | William Stevens UHC-98045-07 | 2026-09-05 Outpatient hospital | Desert Internal Medicine Associates Internal Medicine · in network | 70553 | $2,464.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-003045 CMS-1500 · 2026-10-05 | Shirley Brooks UHC-51174-59 | 2026-09-26 Office | Heritage Primary Care Associates Family Medicine · in network | 99213 | $142.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-001089 CMS-1500 · 2026-10-05 | Dorothy Walker UHC-09439-74 | 2026-09-07 Office | Heritage Primary Care Associates Family Medicine · in network | 90471, 99214 | $329.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-030283 CMS-1500 · 2026-10-04 | Ethan Williamson UHC-49331-36 | 2026-09-08 Office | Riverside Cardiovascular Associates Cardiology · in network | 93224 | $257.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-028250 CMS-1500 · 2026-10-04 | Douglas Henderson UHC-07476-51 | 2026-09-01 Office | Heritage Medical Group Family Medicine · out of network | 36415, 99203, 99213 | $409.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-025992 UB-04 · 2026-10-04 | Raymond Banks UHC-72994-01 | 2026-09-29 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 76700, 71046 | $706.00 | — | Denied by rule CO27 | — | 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.