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-2026-000147 CMS-1500 · 2026-09-22 | Camila Rios UHC-12493-59 | 2026-03-18 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 93000, 99215 | $371.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-033531 UB-04 · 2026-09-21 | Carol Henry UHC-64577-07 | 2026-05-27 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 77067, 74177, 71046 | $3,177.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-026244 UB-04 · 2026-09-20 | Jackie Diaz UHC-15009-91 | 2026-03-11 Outpatient hospital | Desert Heart Institute Cardiology · in network | 93458 | $5,581.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-021737 CMS-1500 · 2026-09-20 | Bruce Reynolds UHC-33418-96 | 2026-06-13 Office | Evergreen Family Practice Family Medicine · in network | 90471 | $25.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-016107 CMS-1500 · 2026-09-20 | Ronald Reid UHC-15374-37 | 2026-05-15 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 80053 | $76.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-000583 UB-04 · 2026-09-20 | Bruce Martinez UHC-23802-99 | 2026-02-23 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 43239, 88305 | $2,709.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-006029 CMS-1500 · 2026-09-19 | Luis Dominguez UHC-85052-29 | 2026-04-29 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $341.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-005718 CMS-1500 · 2026-09-18 | Judy Schmidt UHC-15358-33 | 2026-02-16 Office | Meadow Heart Institute Cardiology · in network | 93224 | $423.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-034583 UB-04 · 2026-09-17 | Donald Mejia UHC-18967-39 | 2026-02-24 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046, 99285 | $2,180.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-003184 UB-04 · 2026-09-17 | Scott Gibson UHC-52419-70 | 2026-06-14 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99284 | $1,493.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-032496 UB-04 · 2026-09-16 | Sofia Ramirez UHC-92206-23 | 2026-03-02 Outpatient hospital | Unity Diagnostic Imaging Radiology · in network | 77067, 74177 | $2,034.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-021523 CMS-1500 · 2026-09-16 | Richard Boyd UHC-94105-73 | 2026-04-01 Office | Riverside Digestive Health Center Gastroenterology · in network | 99214 | $321.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-027577 UB-04 · 2026-09-15 | Angela Johnston UHC-84082-76 | 2026-04-07 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $48,024.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-032892 CMS-1500 · 2026-09-14 | Jacob Turner UHC-72094-54 | 2026-04-20 Office | Sunrise Behavioral Health Behavioral Health · in network | 90837, 90791 | $543.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-032553 UB-04 · 2026-09-13 | Kelly Herrera UHC-57765-55 | 2026-06-06 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 71046 | $136.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-004291 CMS-1500 · 2026-09-13 | Michael Chapman UHC-78960-31 | 2026-02-16 Office | Heritage Family Practice Family Medicine · in network | 99213, 99214 | $499.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-021722 UB-04 · 2026-09-11 | Donad Ruiz UHC-28641-21 | 2026-02-05 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 76700, 77067, 70553 | $4,251.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-032533 CMS-1500 · 2026-09-10 | Carl Chapman UHC-14869-57 | 2026-02-17 Office | Valley Heart Institute Cardiology · in network | 99214, 93224 | $573.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-031464 CMS-1500 · 2026-09-10 | Michael McDonald UHC-87977-24 | 2026-02-04 Office | Mesa Dermatology Clinic Dermatology · in network | 11403 | $650.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-020448 UB-04 · 2026-09-10 | Amanda Fox UHC-00623-39 | 2026-05-04 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721, 29881 | $8,998.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-012232 CMS-1500 · 2026-09-10 | Stephanie Bell UHC-76947-21 | 2026-02-20 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97140 | $453.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-008685 UB-04 · 2026-09-10 | Randy Sims UHC-91736-60 | 2026-02-25 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458 | $5,465.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-021812 CMS-1500 · 2026-09-09 | Vicky Wilson UHC-22620-08 | 2026-05-25 Independent laboratory | Pinecrest Reference Lab Clinical Laboratory · in network | 87086, 85025 | $76.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-003187 UB-04 · 2026-09-08 | Emily Thompson UHC-60492-22 | 2026-04-25 Outpatient hospital | Riverside GI Associates Gastroenterology · in network | 88305 | $317.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-034605 CMS-1500 · 2026-09-06 | Omar Contreras UHC-81935-53 | 2026-05-20 Telehealth | Sunrise Behavioral Health Behavioral Health · in network | 99214 | $221.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-028592 CMS-1500 · 2026-09-06 | Daniel Oliver UHC-94684-51 | 2026-06-01 Office | Mesa Dermatology Clinic Dermatology · in network | 99213, 11102 | $397.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-022134 CMS-1500 · 2026-09-06 | Hiroshi Espinoza UHC-80972-01 | 2026-04-23 Office | Canyon Medical Group Internal Medicine · in network | 93000, 99214 | $318.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-021185 CMS-1500 · 2026-09-06 | Olivia Burke UHC-83224-48 | 2026-05-09 Office | Sunrise Internal Medicine Associates Internal Medicine · in network | 80053, 93000 | $150.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-018945 UB-04 · 2026-09-06 | Megan Maqruez UHC-86538-02 | 2026-03-24 Outpatient hospital | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 73721, 29881 | $8,361.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-031766 CMS-1500 · 2026-09-05 | Brittany Schmidt UHC-24552-67 | 2026-06-01 Independent laboratory | Desert Clinical Laboratories Clinical Laboratory · in network | 83036 | $55.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-018327 UB-04 · 2026-09-05 | Betty Scott UHC-50628-36 | 2026-02-23 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 74177, 76700, 77067 | $2,298.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-010461 CMS-1500 · 2026-09-03 | Wei Castillo UHC-42128-21 | 2026-03-08 Office | Lakeside Medical Group Internal Medicine · in network | 99215 | $393.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-008930 CMS-1500 · 2026-09-02 | Cmaila Jimenez UHC-71123-92 | 2026-01-25 Office | Unity Cardiovascular Associates Cardiology · in network | 99214 | $256.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-029932 UB-04 · 2026-09-01 | Mateo Obrien UHC-64674-51 | 2026-04-25 Outpatient hospital | Riverside Imaging Center Radiology · in network | 76700, 71046, 74177 | $2,240.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-025703 CMS-1500 · 2026-09-01 | Lawrence Ortega UHC-39292-35 | 2026-03-14 Office | Harbor Medical Group Internal Medicine · in network | 93000, 99215 | $428.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-016203 CMS-1500 · 2026-09-01 | Beverly Hughes UHC-84048-28 | 2026-04-11 Independent laboratory | Summit Clinical Laboratories Clinical Laboratory · in network | 83036, 80061, 85025 | $135.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-003892 UB-04 · 2026-09-01 | Nick Walsh no member ID | 2026-05-07 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 74177, 70553 | $4,988.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-026596 CMS-1500 · 2026-08-31 | Douglas Garza UHC-82645-48 | 2026-01-30 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 80053 | $84.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-003159 UB-04 · 2026-08-31 | Austin Cunningham UHC-71262-56 | 2026-02-16 Emergency room | Riverside Community Hospital Emergency Medicine · in network | 96374, 99283, 71046 | $1,444.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-000510 CMS-1500 · 2026-08-31 | Isabella Carter UHC-24455-27 | 2026-05-07 Office | Canyon Cardiovascular Associates Cardiology · in network | 99214 | $316.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-034036 UB-04 · 2026-08-29 | Andrea Whhite UHC-79988-26 | 2026-04-22 Inpatient hospital | Harbor Medical Group Internal Medicine · out of network | 99232 | $219.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-010472 UB-04 · 2026-08-29 | Grace Mdeina UHC-02912-01 | 2026-03-29 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $8,795.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-019128 UB-04 · 2026-08-28 | Grace Burton UHC-52024-75 | 2026-02-11 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99285 | $2,544.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-030900 CMS-1500 · 2026-08-26 | Frances West UHC-96840-78 | 2026-02-15 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110, 97014, 97140 | $241.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-009386 UB-04 · 2026-08-26 | Alexis Diaz no member ID | 2026-04-22 Emergency room | Meadow Regional Medical Center Emergency Medicine · in network | 71046 | $224.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-008262 UB-04 · 2026-08-26 | Samantha Graham UHC-69287-28 | 2026-04-15 Outpatient hospital | Evergreen Cardiovascular Associates Cardiology · in network | 93015 | $485.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-022954 UB-04 · 2026-08-25 | Linda Obrien UHC-52970-96 | 2026-05-06 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 45378, 43239 | $5,211.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-020054 UB-04 · 2026-08-25 | Willie Vega UHC-62858-70 | 2026-02-05 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285 | $2,809.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-012204 CMS-1500 · 2026-08-25 | Santiago Romero UHC-67527-13 | 2026-01-21 Independent laboratory | Evergreen Reference Lab Clinical Laboratory · in network | 83036 | $61.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-001374 CMS-1500 · 2026-08-25 | Cerlos Ford no member ID | 2026-02-25 Independent laboratory | Sunrise Clinical Laboratories Clinical Laboratory · in network | 83036, 85025 | $120.00 | — | Denied by rule CO29 | — | 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.