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-2026-032479 UB-04 · 2026-10-17 | Ralph Garza UHC-69417-14 | 2026-09-30 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $203.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-031941 UB-04 · 2026-10-17 | Mark Riley UHC-38683-19 | 2026-10-01 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 96374, 99284 | $1,564.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-029651 CMS-1500 · 2026-10-17 | Rachel Coleman UHC-34040-77 | 2026-09-26 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99215, 80053 | $437.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-028239 UB-04 · 2026-10-17 | Christopher Mendez UHC-78590-93 | 2026-10-01 Outpatient hospital | Meadow Regional Medical Center Emergency Medicine · in network | 70553 | $2,335.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-023184 UB-04 · 2026-10-17 | Joshua Campbell UHC-12728-30 | 2026-09-13 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 74177 | $1,255.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-011706 UB-04 · 2026-10-17 | Tyler Silva UHC-89750-63 | 2026-09-26 Outpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 70553 | $3,523.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-010982 UB-04 · 2026-10-17 | Deborah Ramos UHC-13452-14 | 2026-09-07 Outpatient hospital | Unity Clinical Laboratories Clinical Laboratory · in network | 70553 | $2,722.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-010759 UB-04 · 2026-10-17 | Beth Jimenez UHC-65211-83 | 2026-09-13 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $3,075.00 | — | Left for review NET | — | Needs review |
| CLM-2026-007132 UB-04 · 2026-10-17 | Laura Reyes UHC-58818-28 | 2026-09-20 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284, 99283 | $2,378.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-004044 CMS-1500 · 2026-10-17 | Christian Gonzalez UHC-05076-98 | 2026-08-28 Office | Sunrise Medical Group Family Medicine · in network | 99203, 90471 | $220.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003706 CMS-1500 · 2026-10-17 | Jordan Fowler UHC-84332-87 | 2026-09-15 Office | Mesa Diabetes Center Endocrinology · in network | 83036, 95251, 99215 | $578.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-001809 UB-04 · 2026-10-17 | Timothy Myers UHC-88645-59 | 2026-09-11 Outpatient hospital | Desert Medical Group Internal Medicine · in network | 70553 | $2,478.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-000967 UB-04 · 2026-10-17 | Virginia Roberts UHC-23292-08 | 2026-10-09 Outpatient hospital | Heritage Imaging Center Radiology · in network | 74177 | $1,611.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-034606 CMS-1500 · 2026-10-16 | Evelyn Ramos UHC-70497-07 | 2026-09-25 Office | Evergreen Medical Group Family Medicine · in network | 99395, 99213 | $411.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-033094 UB-04 · 2026-10-16 | Alexander Rose UHC-33854-74 | 2026-10-12 Outpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 70553 | $3,192.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-032994 UB-04 · 2026-10-16 | Betty Stephens UHC-08557-91 | 2026-10-04 Outpatient hospital | Summit Medical Group Internal Medicine · in network | 70553 | $2,557.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-032345 UB-04 · 2026-10-16 | Carol Pierce UHC-80359-24 | 2026-10-11 Outpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 70553 | $2,131.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-029892 CMS-1500 · 2026-10-16 | Sophia Alexander UHC-65817-15 | 2026-09-08 Office | Sunrise Behavioral Health Behavioral Health · in network | 90834, 90837 | $468.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-024336 UB-04 · 2026-10-16 | Sean Payne UHC-34145-90 | 2026-09-15 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99283 | $970.00 | — | Left for review NET | — | Needs review |
| CLM-2026-020953 UB-04 · 2026-10-16 | Perry Arthur UHC-34387-88 | 2026-09-30 Outpatient hospital | Riverside GI Associates Gastroenterology · in network | 43239, 45378 | $4,992.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-020792 UB-04 · 2026-10-16 | Gregory Reid UHC-65879-07 | 2026-10-07 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $46,944.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-019732 UB-04 · 2026-10-16 | Mason Hoffman UHC-12915-20 | 2026-10-05 Outpatient hospital | Riverside Imaging Center Radiology · in network | 70553, 74177 | $4,770.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-017481 CMS-1500 · 2026-10-16 | Jeremy Bishop UHC-33995-12 | 2026-10-04 Office | Northgate Medical Group Family Medicine · in network | 99213, 99214 | $434.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-014114 UB-04 · 2026-10-16 | Joseph Flores UHC-55754-19 | 2026-09-27 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 70553 | $3,583.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-013898 UB-04 · 2026-10-16 | Walter Stewart UHC-24161-31 | 2026-09-01 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 76700 | $381.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008389 CMS-1500 · 2026-10-16 | Kyle Salazar UHC-42261-80 | 2026-09-07 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 80061 | $65.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-006396 UB-04 · 2026-10-16 | Jesse Kim UHC-45304-40 | 2026-09-04 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284, 99283 | $1,928.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-034301 CMS-1500 · 2026-10-15 | Alan Maldonado UHC-40405-98 | 2026-08-16 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90834, 90837, 90791 | $757.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-030326 UB-04 · 2026-10-15 | Mateo Carlson UHC-62488-93 | 2026-10-06 Outpatient hospital | Meadow Physical Therapy Physical Therapy · in network | 70553 | $8,862.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-029862 UB-04 · 2026-10-15 | Anna Morris UHC-60990-54 | 2026-09-05 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $51,290.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-029535 UB-04 · 2026-10-15 | Jordan Gardner UHC-58120-60 | 2026-10-07 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 74177 | $2,355.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-029162 UB-04 · 2026-10-15 | Albert Sanders UHC-40942-62 | 2026-09-08 Outpatient hospital | Riverside Family Practice Family Medicine · in network | 70553 | $2,255.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-027833 UB-04 · 2026-10-15 | Juan Medina UHC-12396-73 | 2026-10-06 Inpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 27447 | $32,984.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-026316 CMS-1500 · 2026-10-15 | Patrick Jordan UHC-27638-29 | 2026-10-06 Office | Evergreen Medical Group Family Medicine · in network | 99213, 99395 | $467.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-023855 UB-04 · 2026-10-15 | Dennis Perez UHC-14032-93 | 2026-09-24 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306, 93458 | $10,569.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-022529 UB-04 · 2026-10-15 | Jesse Baker UHC-05897-89 | 2026-10-05 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 70553, 71046 | $2,150.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-020313 UB-04 · 2026-10-15 | Samuel West UHC-29799-48 | 2026-10-10 Outpatient hospital | Meadow Primary Care Associates Family Medicine · in network | 70553 | $2,486.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-019192 UB-04 · 2026-10-15 | Gloria Vargas UHC-65899-86 | 2026-09-13 Outpatient hospital | Mesa Cardiovascular Associates Cardiology · in network | 93458, 93306 | $6,391.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-018275 UB-04 · 2026-10-15 | Billy Le UHC-22687-90 | 2026-09-28 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285, 99284, 99283 | $5,093.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-015970 UB-04 · 2026-10-15 | George Kelley UHC-50392-85 | 2026-10-01 Outpatient hospital | Valley Imaging Center Radiology · in network | 70553, 74177 | $4,486.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-015835 UB-04 · 2026-10-15 | Angela Sanders UHC-47771-45 | 2026-09-25 Outpatient hospital | Heritage Primary Care Associates Family Medicine · in network | 70553 | $2,840.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-014761 UB-04 · 2026-10-15 | Peterson Laura UHC-01699-49 | 2026-09-06 Outpatient hospital | Mesa Clinical Laboratories Clinical Laboratory · in network | 70553 | $3,003.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-013282 CMS-1500 · 2026-10-15 | Mason Porter UHC-76399-31 | 2026-09-20 Office | Canyon Cardiovascular Associates Cardiology · in network | 93224, 99214 | $740.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-012988 UB-04 · 2026-10-15 | Sanitago Franklin UHC-54865-20 | 2026-09-04 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99284, 71046, 99285 | $4,024.00 | — | Left for review NET | — | Needs review |
| CLM-2026-012741 UB-04 · 2026-10-15 | Raymond Alvarado UHC-63639-31 | 2026-09-12 Outpatient hospital | Pinecrest Primary Care Associates Family Medicine · in network | 70553 | $3,358.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-004162 CMS-1500 · 2026-10-15 | Virginia Wong UHC-96611-25 | 2026-10-12 Office | Evergreen Medical Group Family Medicine · in network | 99203, 99213 | $351.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-001220 CMS-1500 · 2026-10-15 | Gloria Martin UHC-38570-43 | 2026-08-31 Office | Evergreen Family Practice Family Medicine · in network | 99395 | $324.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-032122 CMS-1500 · 2026-10-14 | Charles Williams UHC-34565-98 | 2026-08-26 Independent laboratory | Meadow Reference Lab Clinical Laboratory · in network | 83036, 80061 | $135.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-030597 UB-04 · 2026-10-14 | Lori Santos UHC-54330-79 | 2026-09-17 Outpatient hospital | Mesa Dermatology Clinic Dermatology · in network | 70553 | $3,151.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-029740 UB-04 · 2026-10-14 | Bruce Garza UHC-63823-65 | 2026-09-12 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 74177, 71046 | $2,218.00 | — | Left for review CO50 | — | 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.