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-2026-022851 UB-04 · 2026-10-18 | Pamela Tran UHC-95837-67 | 2026-04-02 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 29881 | $8,489.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-017708 CMS-1500 · 2026-10-18 | Noah Rogers UHC-89314-56 | 2026-10-11 Office | Heritage Internal Medicine Associates Internal Medicine · in network | 80053, 93000 | $168.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-017564 CMS-1500 · 2026-10-18 | Henry Espinoza UHC-50850-98 | 2026-05-19 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 93000 | $90.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-017491 CMS-1500 · 2026-10-18 | Joyce Roberts UHC-91571-60 | 2026-10-16 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $180.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-016082 CMS-1500 · 2026-10-18 | Judith Jenkins UHC-83319-71 | 2026-10-09 Office | Unity Medical Group Internal Medicine · in network | 93000 | $76.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014800 UB-04 · 2026-10-18 | Shirley Gordon UHC-16318-59 | 2026-09-24 Outpatient hospital | Unity Digestive Health Center Gastroenterology · in network | 43239 | $2,507.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014600 CMS-1500 · 2026-10-18 | Angela Bailey UHC-80041-28 | 2026-09-05 Office | Summit Endocrine Associates Endocrinology · in network | 99215, 83036 | $355.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-013424 UB-04 · 2026-10-18 | Jordan Thomas UHC-00688-86 | 2026-04-19 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 71046, 99285 | $2,289.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-013042 CMS-1500 · 2026-10-18 | Sara Ortiz UHC-96234-58 | 2026-09-18 Office | Evergreen Internal Medicine Associates Internal Medicine · in network | 80053 | $43.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-012577 UB-04 · 2026-10-18 | Steven Brooks UHC-72425-74 | 2026-09-25 Outpatient hospital | Pinecrest Cardiovascular Associates Cardiology · in network | 93458 | $7,698.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-009947 CMS-1500 · 2026-10-18 | Melissa Tran UHC-46772-18 | 2026-10-08 Office | Canyon Counseling Center Behavioral Health · out of network | 90837 | $194.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-007716 CMS-1500 · 2026-10-18 | Jacqueline Mitchell UHC-85622-08 | 2026-08-23 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99214, 80053 | $350.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007459 CMS-1500 · 2026-10-18 | Priya Nelson UHC-65947-09 | 2026-09-28 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 80061, 87086 | $85.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-006554 UB-04 · 2026-10-18 | Doris Alvarez UHC-77452-71 | 2026-10-12 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 43239, 88305 | $2,152.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004773 UB-04 · 2026-10-18 | Bryan Ray UHC-15231-85 | 2026-09-28 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,734.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-004216 UB-04 · 2026-10-18 | Alexander Reid UHC-77022-69 | 2026-09-16 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 71046, 70553 | $3,057.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-003319 CMS-1500 · 2026-10-18 | Keith Vazquez UHC-01356-46 | 2026-10-06 Office | Unity Dermatology Clinic Dermatology · in network | 99213, 11403 | $760.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-003164 UB-04 · 2026-10-18 | Nancy Wong UHC-74984-66 | 2026-09-13 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 88305, 45378 | $2,851.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-002809 UB-04 · 2026-10-18 | Olivia Armstrong UHC-25797-48 | 2026-05-27 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458, 93015 | $5,527.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-002357 CMS-1500 · 2026-10-18 | Charles Nguyen UHC-11107-77 | 2026-09-12 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 85025, 80061 | $106.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-001208 UB-04 · 2026-10-18 | Alexander Robertson UHC-20832-08 | 2026-09-29 Outpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,651.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-030671 UB-04 · 2026-10-17 | Peter Lane UHC-22452-89 | 2026-09-28 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $35,985.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-026123 CMS-1500 · 2026-10-17 | William Simpson UHC-87572-94 | 2026-10-14 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 93000, 80053 | $135.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-022113 UB-04 · 2026-10-17 | Maria Moore UHC-93684-85 | 2026-10-07 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 76700, 74177 | $1,965.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-019759 CMS-1500 · 2026-10-17 | Sofia Price UHC-91931-96 | 2026-10-11 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 80061, 83036 | $77.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-017662 CMS-1500 · 2026-10-17 | Maria Cruz UHC-56006-43 | 2026-09-04 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 80053, 93000 | $174.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-017192 CMS-1500 · 2026-10-17 | Kenneth Morgan UHC-50444-71 | 2026-09-28 Office | Cornerstone Diabetes Center Endocrinology · in network | 99215 | $406.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-015188 UB-04 · 2026-10-17 | Jacqueline Willis UHC-69078-97 | 2026-09-29 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 76700, 74177 | $2,395.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014664 CMS-1500 · 2026-10-17 | Jacqueline Willis UHC-69078-97 | 2026-09-08 Office | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 99213 | $222.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014444 UB-04 · 2026-10-17 | Helen Park UHC-24378-23 | 2026-09-18 Outpatient hospital | Harbor Medical Group Internal Medicine · out of network | 70553 | $2,002.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-011023 CMS-1500 · 2026-10-17 | Nancy Hansen UHC-45838-06 | 2026-09-30 Office | Harbor Primary Care Associates Family Medicine · out of network | 99213 | $140.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009729 CMS-1500 · 2026-10-17 | Vincent Hanson UHC-95245-95 | 2026-09-21 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140 | $233.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-009421 CMS-1500 · 2026-10-17 | Abigail Carr UHC-85206-38 | 2026-09-13 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $287.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-005997 CMS-1500 · 2026-10-17 | Christine Cooper UHC-90180-01 | 2026-10-10 Office | Sunrise Digestive Health Center Gastroenterology · out of network | 99214 | $324.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004662 UB-04 · 2026-10-17 | Juan Franklin UHC-92188-10 | 2026-09-05 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306, 93015 | $1,817.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-033040 CMS-1500 · 2026-10-16 | Edward Delgado UHC-98565-10 | 2026-10-04 Office | Canyon Medical Group Internal Medicine · in network | 99215, 80053, 99214 | $736.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-031371 CMS-1500 · 2026-10-16 | Ann Berry UHC-79552-37 | 2026-10-14 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 80061, 85025 | $95.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-030553 UB-04 · 2026-10-16 | Valentina Olson UHC-29563-18 | 2026-09-11 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $1,458.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-029947 CMS-1500 · 2026-10-16 | Alan Gomez UHC-96329-04 | 2026-08-15 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90837, 90791 | $700.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-029645 UB-04 · 2026-10-16 | Marilyn Wallace UHC-97767-95 | 2026-09-01 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 70553, 77067, 74177 | $4,854.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-027730 CMS-1500 · 2026-10-16 | Luis Wilson UHC-54875-60 | 2026-09-30 Office | Evergreen Medical Group Family Medicine · in network | 99203 | $236.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-026762 CMS-1500 · 2026-10-16 | Timothy Soto UHC-93230-87 | 2026-09-20 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 20610, 99213 | $469.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026161 CMS-1500 · 2026-10-16 | Carol Owens UHC-59852-07 | 2026-05-21 Office | Harbor Endocrine Associates Endocrinology · in network | 95251, 99214 | $439.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-024279 UB-04 · 2026-10-16 | William Webb UHC-11907-97 | 2026-09-08 Outpatient hospital | Sunrise Community Hospital Emergency Medicine · out of network | 70553 | $1,854.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-021952 CMS-1500 · 2026-10-16 | Anthony Fields UHC-31856-02 | 2026-10-10 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99215, 93000 | $395.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-020181 CMS-1500 · 2026-10-16 | Heather Perez UHC-55402-81 | 2026-10-02 Office | Unity Digestive Health Center Gastroenterology · in network | 99214 | $313.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-019881 CMS-1500 · 2026-10-16 | Amanda Olson UHC-71463-79 | 2026-08-15 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $483.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-017831 UB-04 · 2026-10-16 | Gabriel Payne no member ID | 2026-09-23 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 74177, 71046 | $2,565.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-015281 CMS-1500 · 2026-10-16 | Jonathan Lawson UHC-79224-89 | 2026-07-05 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $118.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-013868 CMS-1500 · 2026-10-16 | Heather Perez UHC-55402-81 | 2026-09-04 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 83036, 80061 | $119.00 | — | Denied by rule CO27 | — | 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.