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-2026-032853 UB-04 · 2026-09-24 | Logan Delgado UHC-87471-01 | 2026-09-01 Emergency room | Lakeside Regional Medical Center Emergency Medicine · in network | 99285, 99283 | $2,630.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-029923 CMS-1500 · 2026-09-24 | Kyle Harrison UHC-34852-96 | 2026-08-25 Office | Desert Primary Care Associates Family Medicine · in network | 36415, 99213 | $175.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-018528 UB-04 · 2026-09-24 | George Jensen UHC-11856-62 | 2026-09-07 Outpatient hospital | Meadow Cardiovascular Associates Cardiology · in network | 93306, 93458 | $6,790.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-012628 UB-04 · 2026-09-24 | Gary Fields UHC-65382-80 | 2026-09-03 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378, 88305, 43239 | $3,858.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-001137 CMS-1500 · 2026-09-24 | George Holmes UHC-85048-47 | 2026-09-01 Office | Pinecrest Medical Group Family Medicine · in network | 99214, 36415, 90471 | $272.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-000045 CMS-1500 · 2026-09-23 | Marcus Wong UHC-03574-75 | 2026-08-20 Office | Harbor Primary Care Associates Family Medicine · in network | 99203, 90471, 99213 | $446.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-028951 UB-04 · 2026-09-20 | Sean Evans UHC-66436-57 | 2026-09-01 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 71046, 70553, 76700 | $3,282.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-003349 CMS-1500 · 2026-09-20 | Kenneth Dunn UHC-30577-22 | 2026-09-08 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 80053, 80061 | $140.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-010920 UB-04 · 2026-09-19 | Olivia Thomas UHC-31622-35 | 2026-08-22 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 70553, 74177 | $4,626.00 | — | Left for review CO50 CO97 | — | Needs review |
| CLM-2026-004438 CMS-1500 · 2026-09-17 | Kimberly Payne UHC-83579-91 | 2026-08-26 Office | Evergreen Medical Group Family Medicine · in network | 36415, 99203 | $246.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-011862 CMS-1500 · 2026-09-16 | Joseph Obrien UHC-03406-45 | 2026-09-14 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $273.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-007573 CMS-1500 · 2026-09-16 | Vincent Armstrong UHC-92198-01 | 2026-09-08 Office | Unity Dermatology Clinic Dermatology · in network | 11403, 11102 | $896.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-029699 CMS-1500 · 2026-09-15 | Zachary Carlson UHC-05862-91 | 2026-08-08 Office | Unity Medical Group Internal Medicine · in network | 93000, 99214 | $341.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-008985 CMS-1500 · 2026-09-15 | David Ford UHC-92766-36 | 2026-08-07 Office | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 20610, 99213 | $508.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023347 UB-04 · 2026-09-14 | Mariana Matthews UHC-24776-39 | 2026-08-04 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 74177, 70553 | $4,626.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-022839 CMS-1500 · 2026-09-14 | Bruce Ray UHC-75568-84 | 2026-08-05 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 85025, 80061 | $73.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-018637 CMS-1500 · 2026-09-13 | Karen Elliott UHC-05863-63 | 2026-08-08 Office | Harbor Primary Care Associates Family Medicine · in network | 36415, 90471 | $53.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-013791 CMS-1500 · 2026-09-13 | Victoria Flores UHC-25370-92 | 2026-08-30 Office | Valley Family Practice Family Medicine · in network | 99203, 99213 | $456.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-010819 UB-04 · 2026-09-13 | Priya Carroll UHC-18639-53 | 2026-09-02 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 45378, 43239 | $3,835.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-008908 CMS-1500 · 2026-09-13 | Raymond Cox UHC-58166-35 | 2026-08-07 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 80053, 83036 | $121.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-021328 CMS-1500 · 2026-09-12 | Karen Foster UHC-09837-69 | 2026-07-30 Office | Unity Dermatology Clinic Dermatology · in network | 11403, 11102 | $781.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-029060 UB-04 · 2026-09-11 | Thomas Matthews UHC-54543-72 | 2026-07-28 Outpatient hospital | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 29881, 73721 | $11,417.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-025626 UB-04 · 2026-09-11 | Fatima Bell UHC-10435-53 | 2026-07-29 Outpatient hospital | Evergreen GI Associates Gastroenterology · in network | 88305, 45378 | $1,825.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023951 CMS-1500 · 2026-09-11 | Valentina Guerrero UHC-71193-02 | 2026-08-28 Office | Lakeside Medical Group Family Medicine · in network | 90471, 99213 | $223.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-015094 CMS-1500 · 2026-09-11 | Evelyn Fisher UHC-52353-84 | 2026-07-29 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $287.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-011344 CMS-1500 · 2026-09-11 | Christine Harvey UHC-40603-08 | 2026-08-23 Office | Harbor Physical Therapy Physical Therapy · in network | 97110, 97161, 97014 | $483.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-028713 CMS-1500 · 2026-09-10 | Lori Hawkins UHC-55156-14 | 2026-07-31 Office | Heritage Digestive Health Center Gastroenterology · in network | 99214, 43239 | $2,848.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-007154 CMS-1500 · 2026-09-10 | Chris Ferguson UHC-41567-67 | 2026-08-31 Office | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 20610, 99213 | $530.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-030639 CMS-1500 · 2026-09-09 | Jonathan Marquez UHC-57626-40 | 2026-08-04 Independent laboratory | Desert Reference Lab Clinical Laboratory · in network | 87086, 85025, 80061 | $166.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-026724 CMS-1500 · 2026-09-09 | Heather Estrada UHC-14837-83 | 2026-08-28 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 80061, 83036, 85025 | $187.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-009745 UB-04 · 2026-09-08 | Lauren Peters UHC-23575-28 | 2026-07-25 Emergency room | Cornerstone Regional Medical Center Emergency Medicine · in network | 96374, 71046 | $433.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-000838 CMS-1500 · 2026-09-08 | Sean Reynolds UHC-33152-78 | 2026-08-21 Office | Heritage Medical Group Internal Medicine · in network | 99215, 99214 | $562.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-026884 UB-04 · 2026-09-06 | Hannah Andrews UHC-15893-43 | 2026-08-20 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284, 99285 | $3,561.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-016905 UB-04 · 2026-09-05 | Donald Adams UHC-26650-54 | 2026-08-21 Emergency room | Sunrise Community Hospital Emergency Medicine · in network | 99283, 99284 | $2,350.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-019965 UB-04 · 2026-09-04 | Hannah Rose UHC-38319-19 | 2026-08-09 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283, 99285 | $2,618.00 | — | Left for review NET CO97 | — | Needs review |
| CLM-2026-010166 UB-04 · 2026-09-04 | Juan Kim UHC-49008-92 | 2026-07-23 Outpatient hospital | Lakeside Heart Institute Cardiology · in network | 93306, 93458 | $7,884.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-031823 UB-04 · 2026-09-03 | Margaret Chavez UHC-92419-11 | 2026-08-13 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 71046, 70553 | $2,256.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-019701 CMS-1500 · 2026-09-03 | Ruth Harper UHC-27779-17 | 2026-08-08 Office | Summit Counseling Center Behavioral Health · in network | 90834, 90791, 90837 | $790.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-005333 CMS-1500 · 2026-09-03 | Luis Larson UHC-85158-48 | 2026-07-22 Office | Mesa Family Practice Family Medicine · in network | 99214, 99213 | $469.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-028778 CMS-1500 · 2026-09-02 | Ana King UHC-25436-16 | 2026-07-26 Office | Mesa Medical Group Internal Medicine · in network | 99215, 99214 | $613.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-001341 CMS-1500 · 2026-09-02 | Brandon Rivera UHC-19255-33 | 2026-08-20 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97140 | $368.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-034434 CMS-1500 · 2026-09-01 | Maria Patterson UHC-97217-21 | 2026-08-07 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 87086, 85025 | $66.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-027999 CMS-1500 · 2026-09-01 | Mason Ramirez UHC-58089-01 | 2026-08-10 Office | Sunrise Behavioral Health Behavioral Health · in network | 90837, 90834, 90791 | $775.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-019087 UB-04 · 2026-09-01 | Laura Rivera UHC-17261-47 | 2026-07-20 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046, 99283 | $1,279.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-012403 UB-04 · 2026-08-31 | Jonathan Davis UHC-33869-68 | 2026-08-18 Emergency room | Meadow Regional Medical Center Emergency Medicine · in network | 99283, 99284 | $2,328.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-018917 UB-04 · 2026-08-30 | Nathan Carpenter UHC-03837-93 | 2026-08-25 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 73721, 29881 | $12,666.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-009477 CMS-1500 · 2026-08-30 | Ashley Perry UHC-75552-09 | 2026-08-16 Office | Unity Primary Care Associates Family Medicine · out of network | 99203, 99213 | $421.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-005532 CMS-1500 · 2026-08-30 | Douglas Nunez UHC-04096-41 | 2026-08-05 Office | Valley Heart Institute Cardiology · in network | 99214, 93224 | $694.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-015384 CMS-1500 · 2026-08-29 | Cheryl Crawford UHC-10278-83 | 2026-08-14 Office | Canyon Primary Care Associates Family Medicine · in network | 90471, 99213 | $226.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-011764 CMS-1500 · 2026-08-29 | Michael Alvarado UHC-14405-57 | 2026-08-16 Office | Riverside Primary Care Associates Family Medicine · in network | 99203, 99213 | $379.00 | — | Left for review CO97 | — | 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.