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-2026-003147 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-2026-009471 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-2026-013023 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 |
| CLM-2026-015610 CMS-1500 · 2026-09-10 | Diane Snyder UHC-68765-36 | 2026-08-09 Office | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 20610 | $251.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-032668 CMS-1500 · 2026-09-09 | Rachel Smith UHC-82124-92 | 2026-07-26 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99215, 93000 | $366.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029184 CMS-1500 · 2026-09-07 | Maria Hart UHC-81705-80 | 2026-08-06 Office | Evergreen Primary Care Associates Family Medicine · in network | 99214, 99213 | $373.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-006229 CMS-1500 · 2026-09-07 | Sophia Evans UHC-99110-39 | 2026-08-20 Office | Riverside Primary Care Associates Family Medicine · in network | 36415, 99395 | $257.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-022447 CMS-1500 · 2026-09-03 | Gregory Roberts UHC-77088-92 | 2026-07-12 Office | Valley Cardiovascular Associates Cardiology · in network | 99214 | $318.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-016684 CMS-1500 · 2026-09-03 | Jean Vega UHC-31783-01 | 2026-07-26 Office | Riverside Internal Medicine Associates Internal Medicine · in network | 99215 | $286.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-007796 CMS-1500 · 2026-09-01 | Ronald Hanson UHC-39935-64 | 2026-07-09 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 80053 | $44.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-030814 CMS-1500 · 2026-08-30 | Judy Robinson UHC-50698-88 | 2026-07-29 Office | Desert Primary Care Associates Family Medicine · in network | 99213 | $140.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-011223 CMS-1500 · 2026-08-29 | Amanda Schmidt UHC-60957-45 | 2026-07-02 Office | Harbor Primary Care Associates Family Medicine · in network | 99214, 36415 | $320.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-004926 CMS-1500 · 2026-08-26 | Joan Jackson UHC-61315-20 | 2026-07-23 Office | Desert Medical Group Internal Medicine · in network | 93000 | $97.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-025405 CMS-1500 · 2026-08-23 | Eugene Cox UHC-38773-39 | 2026-07-21 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 87086 | $43.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-020805 CMS-1500 · 2026-08-20 | Nancy Fields UHC-70642-29 | 2026-07-16 Office | Northgate Medical Group Family Medicine · in network | 99203 | $231.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-012376 CMS-1500 · 2026-08-19 | Rachel Walker UHC-21212-52 | 2026-07-09 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 83036, 80053 | $117.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-002996 CMS-1500 · 2026-08-19 | Natalie McCoy UHC-26564-74 | 2026-08-04 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110, 97140 | $337.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-009123 CMS-1500 · 2026-08-17 | Russell Andrews UHC-37663-59 | 2026-06-22 Office | Canyon Internal Medicine Associates Internal Medicine · in network | 99215, 93000, 99214 | $643.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-004530 CMS-1500 · 2026-08-17 | Logna King UHC-67632-43 | 2026-06-26 Office | Desert Medical Group Internal Medicine · in network | 93000 | $68.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-021218 CMS-1500 · 2026-08-16 | Lauren Guzman UHC-74677-14 | 2026-07-24 Office | Lakeside Medical Group Internal Medicine · in network | 93000 | $70.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-017900 CMS-1500 · 2026-08-15 | Jessica Grant UHC-60955-53 | 2026-07-30 Office | Unity Primary Care Associates Family Medicine · in network | 99203 | $202.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-030216 CMS-1500 · 2026-08-14 | Charlotte Salazar UHC-57911-24 | 2026-06-20 Office | Canyon Primary Care Associates Family Medicine · in network | 36415, 90471 | $62.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-028808 CMS-1500 · 2026-08-14 | Amanda Hall UHC-90296-30 | 2026-07-24 Office | Harbor Medical Group Internal Medicine · in network | 99214 | $266.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-020038 CMS-1500 · 2026-08-14 | Shirley Soto UHC-96595-31 | 2026-07-25 Telehealth | Evergreen Counseling Center Behavioral Health · in network | 99214 | $238.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-007814 CMS-1500 · 2026-08-14 | Sofia Ramirez UHC-92206-23 | 2026-07-07 Office | Sunrise Medical Group Internal Medicine · in network | 99214 | $204.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-033467 CMS-1500 · 2026-08-13 | William Ray UHC-70885-47 | 2026-07-21 Independent laboratory | Sunrise Clinical Laboratories Clinical Laboratory · in network | 80061, 80053 | $97.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-032011 CMS-1500 · 2026-08-13 | Christine Garrett UHC-76492-95 | 2026-07-04 Office | Canyon Medical Group Internal Medicine · in network | 93000, 99215, 80053 | $440.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-034017 CMS-1500 · 2026-08-12 | Marilyn Barnes UHC-48806-49 | 2026-06-24 Office | Canyon Medical Group Internal Medicine · in network | 93000 | $65.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-016240 CMS-1500 · 2026-08-11 | Jack Robertson UHC-33762-69 | 2026-07-09 Office | Unity Medical Group Family Medicine · in network | 36415, 99203, 99213 | $471.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-034437 CMS-1500 · 2026-08-10 | Elijah Owens UHC-32230-66 | 2026-07-18 Office | Mesa GI Associates Gastroenterology · in network | 99214 | $251.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-030728 CMS-1500 · 2026-08-10 | Priya Montgomery UHC-56767-57 | 2026-07-30 Office | Valley Heart Institute Cardiology · in network | 99214, 93224 | $758.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-032246 CMS-1500 · 2026-08-09 | Carol Cunningham UHC-63509-20 | 2026-07-18 Office | Sunrise Behavioral Health Behavioral Health · in network | 90791 | $367.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-007917 CMS-1500 · 2026-08-09 | Rebecca Campbell UHC-89802-47 | 2026-07-18 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99214, 99215 | $571.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029959 CMS-1500 · 2026-08-07 | Albert Marquez UHC-90690-86 | 2026-06-19 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 80053, 85025 | $148.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029571 CMS-1500 · 2026-08-07 | Nancy Gray UHC-05050-07 | 2026-07-13 Office | Riverside Primary Care Associates Family Medicine · in network | 99395, 99213, 99214 | $825.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-026886 CMS-1500 · 2026-08-07 | Carl Owens UHC-24250-02 | 2026-07-18 Independent laboratory | Meadow Clinical Laboratories Clinical Laboratory · in network | 87086, 80061, 85025 | $156.00 | — | 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.