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-2026-024577 UB-04 · 2026-10-03 | Mei Carter UHC-88572-18 | 2026-09-10 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306 | $1,449.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-017600 UB-04 · 2026-10-03 | Ryan Wright UHC-72160-97 | 2026-08-26 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 71046 | $156.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-015437 UB-04 · 2026-10-03 | Joshua Harper UHC-85497-41 | 2026-08-19 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 71046, 99283 | $1,059.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-010035 UB-04 · 2026-10-03 | Kathy Watkins UHC-19886-37 | 2026-08-13 Outpatient hospital | Valley Imaging Center Radiology · in network | 70553, 71046, 74177 | $4,440.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-031871 CMS-1500 · 2026-10-01 | Carol Ruiz UHC-33407-76 | 2026-09-22 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110 | $80.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-028440 UB-04 · 2026-10-01 | Ahmed Cooper UHC-91936-31 | 2026-08-19 Outpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 73721 | $1,196.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-014251 CMS-1500 · 2026-09-30 | Joseph Cole UHC-31831-74 | 2026-09-04 Office | Heritage GI Associates Gastroenterology · in network | 99214 | $328.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-026720 UB-04 · 2026-09-29 | Dylan Taylor UHC-33407-72 | 2026-08-18 Outpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,949.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008876 CMS-1500 · 2026-09-29 | Isabella Murphy UHC-81397-53 | 2026-08-04 Office | Evergreen Family Practice Family Medicine · in network | 99203, 36415 | $259.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-021068 CMS-1500 · 2026-09-28 | Edward Watkins UHC-04151-64 | 2026-08-19 Office | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 99213 | $240.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-006451 UB-04 · 2026-09-28 | Nathan Tran UHC-26240-33 | 2026-09-19 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378 | $2,766.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029356 CMS-1500 · 2026-09-27 | Nancy Rios UHC-06953-52 | 2026-08-20 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 80053, 83036 | $122.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029077 UB-04 · 2026-09-27 | Hiroshi Webb UHC-42260-19 | 2026-08-28 Outpatient hospital | Desert Imaging Center Radiology · in network | 77067 | $256.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-024994 UB-04 · 2026-09-27 | Noah Dixon UHC-37800-54 | 2026-08-28 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 93458 | $9,040.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-002579 UB-04 · 2026-09-27 | Jordan Ellis UHC-92342-99 | 2026-08-27 Emergency room | Harbor Regional Medical Center Emergency Medicine · in network | 96374, 99283 | $1,106.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-022521 CMS-1500 · 2026-09-25 | Sofia Mitchell UHC-25956-67 | 2026-08-26 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99395, 99213 | $515.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-019566 CMS-1500 · 2026-09-25 | Sophia Hill UHC-72031-89 | 2026-09-02 Office | Northgate Counseling Center Behavioral Health · in network | 90791 | $460.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-030822 UB-04 · 2026-09-24 | Stephanie Ruiz UHC-02243-45 | 2026-08-06 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 43239, 88305, 45378 | $4,244.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-019488 CMS-1500 · 2026-09-24 | Kelly Evans UHC-73587-33 | 2026-08-13 Office | Heritage Family Practice Family Medicine · in network | 36415, 99213 | $163.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-014197 CMS-1500 · 2026-09-24 | Judy Jimenez UHC-32177-75 | 2026-08-20 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 85025, 80053 | $116.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-028175 UB-04 · 2026-09-23 | Ahmed Hicks UHC-09142-06 | 2026-08-10 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99284, 99285 | $3,474.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-024434 CMS-1500 · 2026-09-22 | Donna Ward UHC-89367-54 | 2026-08-30 Office | Sunrise Orthopedic Specialists Orthopedic Surgery · in network | 99213 | $181.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-018658 CMS-1500 · 2026-09-22 | Virginia Marrtin UHC-82287-41 | 2026-09-07 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 87086 | $145.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-012959 CMS-1500 · 2026-09-22 | Joan Edwards UHC-88614-34 | 2026-09-02 Office | Harbor Medical Group Internal Medicine · out of network | 99215, 99214, 93000 | $651.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008541 CMS-1500 · 2026-09-22 | Lawrence Ramirez UHC-95611-07 | 2026-08-06 Office | Harbor Medical Group Internal Medicine · out of network | 80053, 99215 | $429.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-023940 UB-04 · 2026-09-21 | Linda Nelson UHC-41466-73 | 2026-08-13 Inpatient hospital | Desert Internal Medicine Associates Internal Medicine · in network | 99232 | $175.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-020702 CMS-1500 · 2026-09-21 | Brian Ford UHC-83014-83 | 2026-09-15 Office | Meadow Family Practice Family Medicine · in network | 36415 | $24.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-012497 UB-04 · 2026-09-21 | Omar Arnold UHC-09544-10 | 2026-08-14 Outpatient hospital | Desert Imaging Center Radiology · in network | 74177, 77067 | $2,256.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-007281 CMS-1500 · 2026-09-20 | Virginia Hughes UHC-52299-91 | 2026-08-15 Office | Evergreen Rehabilitation Center Physical Therapy · in network | 97110 | $82.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-006403 CMS-1500 · 2026-09-20 | Doris Ryan UHC-04166-33 | 2026-08-02 Office | Mesa Primary Care Associates Family Medicine · in network | 99214 | $223.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003147 CMS-1500 · 2026-09-19 | Lisa Porter UHC-43480-38 | 2026-08-21 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 85025, 83036 | $123.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-031675 CMS-1500 · 2026-09-18 | Larry Morrison UHC-07583-42 | 2026-08-02 Office | Harbor Medical Group Family Medicine · in network | 90471, 99395 | $260.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-010744 CMS-1500 · 2026-09-18 | Ana Carr UHC-99021-58 | 2026-07-27 Office | Heritage GI Associates Gastroenterology · in network | 99214 | $275.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-004544 CMS-1500 · 2026-09-18 | Ethan Kennedy UHC-60111-50 | 2026-08-06 Office | Meadow Dermatology Clinic Dermatology · in network | 11403, 11102 | $833.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003332 CMS-1500 · 2026-09-18 | Katherine Palmer UHC-33792-42 | 2026-08-26 Office | Meadow Medical Group Internal Medicine · in network | 99215 | $384.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-034342 CMS-1500 · 2026-09-17 | Nicholas Salazar UHC-48323-60 | 2026-07-26 Independent laboratory | Northgate Reference Lab Clinical Laboratory · in network | 80053, 87086 | $135.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-027327 CMS-1500 · 2026-09-17 | Thomas Morales UHC-74441-71 | 2026-07-28 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11403 | $719.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-009052 CMS-1500 · 2026-09-17 | Dylan Reid UHC-31001-11 | 2026-08-18 Office | Riverside Primary Care Associates Family Medicine · in network | 99213, 99395, 99214 | $772.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003803 CMS-1500 · 2026-09-17 | Helen Nguyen UHC-32465-91 | 2026-08-13 Office | Northgate Medical Group Family Medicine · in network | 99213 | $142.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003467 CMS-1500 · 2026-09-17 | Mateo Perez UHC-46817-61 | 2026-08-07 Office | Evergreen Internal Medicine Associates Internal Medicine · in network | 99214 | $271.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-017345 CMS-1500 · 2026-09-15 | Hiroshi Wood UHC-74279-34 | 2026-07-20 Office | Harbor Endocrine Associates Endocrinology · in network | 83036, 99214 | $338.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-017134 CMS-1500 · 2026-09-15 | Dorothy Mejia UHC-42359-64 | 2026-07-24 Independent laboratory | Sunrise Clinical Laboratories Clinical Laboratory · in network | 87086 | $64.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003621 UB-04 · 2026-09-15 | Arthur Alexander UHC-11557-51 | 2026-08-01 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · in network | 99283, 96374 | $1,081.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-011920 UB-04 · 2026-09-13 | Sara Cox UHC-33317-40 | 2026-08-23 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 76700 | $2,603.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-009471 CMS-1500 · 2026-09-13 | Linda Lucas UHC-20791-83 | 2026-08-13 Office | Heritage Family Practice Family Medicine · in network | 36415, 90471, 99395 | $326.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-023418 UB-04 · 2026-09-12 | Brenda Garrett UHC-01984-24 | 2026-07-18 Outpatient hospital | Summit Imaging Center Radiology · in network | 70553 | $3,449.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-013023 CMS-1500 · 2026-09-12 | Nancy Hunt UHC-19169-81 | 2026-07-31 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 80061, 87086 | $128.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-017785 CMS-1500 · 2026-09-11 | Nancy Munoz UHC-50527-20 | 2026-08-23 Office | Pinecrest Medical Group Internal Medicine · in network | 80053 | $56.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008912 CMS-1500 · 2026-09-11 | Beverly Taylor UHC-10404-50 | 2026-07-17 Office | Evergreen Family Practice Family Medicine · in network | 99214, 99395 | $494.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-023485 CMS-1500 · 2026-09-10 | Teresa Crawford UHC-27980-16 | 2026-08-07 Office | Unity Counseling Center Behavioral Health · in network | 90791 | $401.00 | — | Left for review REPL | — | 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.