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
3,664
50 with an AI recommendation
Pended
2,586
awaiting information or identity
Approved
23,942
$6,757,768.45 plan paid
Denied
4,454
with remittance reason codes
Examiner decided
0
167 not attached to an identity
| Claim | Member | Service | Provider | Procedures | Billed | Plan pays | Rules | AI | Status |
|---|---|---|---|---|---|---|---|---|---|
| CLM-2026-000837 UB-04 · 2026-10-12 | Shirley Boyd UHC-95505-65 | 2026-09-08 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · in network | 99283, 96374 | $1,074.00 | $440.70 | Clean approval | — | Approved |
| CLM-2026-000449 CMS-1500 · 2026-10-12 | Austin Pena UHC-44306-49 | 2026-08-31 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $264.00 | $143.68 | Clean approval | — | Approved |
| CLM-2026-034566 CMS-1500 · 2026-10-11 | Natalie Cruz UHC-78014-98 | 2026-09-21 Office | Desert Primary Care Associates Family Medicine · in network | 99203 | $183.00 | $88.46 | Clean approval | — | Approved |
| CLM-2026-034365 UB-04 · 2026-10-11 | Vincent Thomas UHC-37542-71 | 2026-10-09 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177, 77067 | $1,752.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-033989 CMS-1500 · 2026-10-11 | Diana Phillips UHC-60258-47 | 2026-08-27 Office | Sunrise Medical Group Internal Medicine · out of network | 99214, 93000, 99215 | $715.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-033721 CMS-1500 · 2026-10-11 | Terry Gomez UHC-19314-17 | 2026-09-10 Office | Valley Skin Care Associates Dermatology · out of network | 11403, 11102 | $843.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-033714 CMS-1500 · 2026-10-11 | Scott Vazquez UHC-50406-76 | 2026-09-22 Office | Unity Primary Care Associates Family Medicine · in network | 99203, 90471 | $240.00 | $123.80 | Clean approval | — | Approved |
| CLM-2026-033519 CMS-1500 · 2026-10-11 | Martha Powell UHC-78239-03 | 2026-09-19 Office | Meadow Primary Care Associates Family Medicine · in network | 99203, 99395 | $469.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-033352 CMS-1500 · 2026-10-11 | Peterson Jordan UHC-55506-99 | 2026-09-13 Office | Riverside Primary Care Associates Family Medicine · in network | 99214 | $252.00 | $136.24 | Clean approval | — | Approved |
| CLM-2026-033303 CMS-1500 · 2026-10-11 | Lisa Knight UHC-55792-79 | 2026-09-21 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99215 | $387.00 | $199.94 | Clean approval | — | Approved |
| CLM-2026-033242 CMS-1500 · 2026-10-11 | Rachel Coleman UHC-34040-77 | 2026-09-21 Independent laboratory | Meadow Reference Lab Clinical Laboratory · in network | 80053 | $59.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-033226 CMS-1500 · 2026-10-11 | Ruth Weaver UHC-27012-03 | 2026-09-20 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $224.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-032985 CMS-1500 · 2026-10-11 | Billy Contreras UHC-74899-95 | 2026-09-22 Office | Cornerstone Family Practice Family Medicine · out of network | 99213, 90471 | $211.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032669 UB-04 · 2026-10-11 | Henry Hanson no member ID | 2026-09-23 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · in network | 45378 | $2,462.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-032440 CMS-1500 · 2026-10-11 | Robert Garcia UHC-56494-97 | 2026-06-29 Office | Canyon Primary Care Associates Family Medicine · in network | 99213, 99214 | $440.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-032414 UB-04 · 2026-10-11 | Lucia Howell UHC-54508-07 | 2026-09-07 Outpatient hospital | Desert Imaging Center Radiology · in network | 70553 | $3,574.00 | $1,590.88 | Clean approval | — | Approved |
| CLM-2026-032376 CMS-1500 · 2026-10-11 | Wayne Diez UHC-82176-57 | 2026-10-01 Office | Mesa GI Associates Gastroenterology · in network | 99214 | $315.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-032360 UB-04 · 2026-10-11 | Arthur Hall UHC-60721-03 | 2026-09-29 Outpatient hospital | Heritage Imaging Center Radiology · in network | 76700, 71046 | $657.00 | $13.98 | Clean approval | — | Approved |
| CLM-2026-032272 UB-04 · 2026-10-11 | Eugeene Reyes UHC-32191-16 | 2026-08-25 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $7,356.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-032232 CMS-1500 · 2026-10-11 | Sara Carter UHC-19581-65 | 2026-09-07 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99214, 90471 | $290.00 | $159.80 | Clean approval | — | Approved |
| CLM-2026-032110 CMS-1500 · 2026-10-11 | Hiroshi Sims UHC-85479-92 | 2026-09-03 Office | Valley Rehabilitation Center Physical Therapy · in network | 97110, 97161, 97140 | $478.00 | $266.36 | Clean approval | — | Approved |
| CLM-2026-031370 CMS-1500 · 2026-10-11 | Brittany Romero UHC-23742-38 | 2026-09-09 Office | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 20610, 99213 | $440.00 | $197.80 | Clean approval | — | Approved |
| CLM-2026-031356 UB-04 · 2026-10-11 | Barbara Cooper UHC-62320-38 | 2026-09-02 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99284 | $1,392.00 | $476.40 | Clean approval | — | Approved |
| CLM-2026-030867 CMS-1500 · 2026-10-11 | Lawrence Nichols UHC-55829-92 | 2026-09-07 Office | Unity Primary Care Associates Family Medicine · out of network | 99395, 99203, 99214 | $794.00 | $337.30 | Clean approval | — | Approved |
| CLM-2026-030825 CMS-1500 · 2026-10-11 | Janet Hawkins UHC-01906-34 | 2026-09-25 Office | Evergreen Medical Group Family Medicine · in network | 99214 | $211.00 | $110.82 | Clean approval | — | Approved |
| CLM-2026-030521 CMS-1500 · 2026-10-11 | Scott Vazquez UHC-50406-76 | 2026-09-07 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 87086, 80053 | $96.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030204 CMS-1500 · 2026-10-11 | Gabriel Vazquez UHC-21481-63 | 2026-09-08 Office | Evergreen Rehabilitation Center Physical Therapy · in network | 97110 | $248.00 | $133.76 | Clean approval | — | Approved |
| CLM-2026-030136 CMS-1500 · 2026-10-11 | Madison Lawson UHC-63078-75 | 2026-08-27 Office | Sunrise Family Practice Family Medicine · in network | 99214, 99395 | $586.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-028596 CMS-1500 · 2026-10-11 | Vicky Lynch UHC-39117-66 | 2026-09-08 Office | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 20610 | $251.00 | $80.62 | Clean approval | — | Approved |
| CLM-2026-028562 UB-04 · 2026-10-11 | Douglas Kim UHC-49616-13 | 2026-09-29 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285 | $1,664.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-028533 CMS-1500 · 2026-10-11 | Juan Bradley UHC-92505-70 | 2026-10-05 Office | Meadow Dermatology Clinic Dermatology · in network | 11403, 17110 | $757.00 | $409.34 | Clean approval | — | Approved |
| CLM-2026-027338 UB-04 · 2026-10-11 | Lawrence Lane UHC-33802-81 | 2026-09-25 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 70553 | $3,502.00 | $1,233.62 | Clean approval | — | Approved |
| CLM-2026-027111 CMS-1500 · 2026-10-11 | Natalie Fernandez UHC-04526-89 | 2026-07-01 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $228.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-027101 UB-04 · 2026-10-11 | Virginia Bradley UHC-13669-86 | 2026-09-07 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99285 | $1,959.00 | $927.45 | Clean approval | — | Approved |
| CLM-2026-027068 CMS-1500 · 2026-10-11 | Ronald Dominguez UHC-96584-75 | 2026-09-08 Office | Unity Counseling Center Behavioral Health · in network | 90791 | $427.00 | $189.74 | Clean approval | — | Approved |
| CLM-2026-026856 UB-04 · 2026-10-11 | Megan Pena UHC-82997-21 | 2026-09-12 Outpatient hospital | Desert Imaging Center Radiology · in network | 70553 | $1,943.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-026559 CMS-1500 · 2026-10-11 | Alan Sanchez UHC-35719-69 | 2026-09-17 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 85025 | $51.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-026433 CMS-1500 · 2026-10-11 | Joseph Garcia UHC-81822-24 | 2026-09-09 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97161 | $446.00 | $236.52 | Clean approval | — | Approved |
| CLM-2026-026050 CMS-1500 · 2026-10-11 | Beverly Schultz UHC-83728-87 | 2026-09-03 Office | Heritage Family Practice Family Medicine · in network | 36415, 99203 | $240.00 | $137.02 | Clean approval | — | Approved |
| CLM-2026-025502 CMS-1500 · 2026-10-11 | Samantha Welch UHC-81164-04 | 2026-10-02 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97014 | $308.00 | $165.96 | Clean approval | — | Approved |
| CLM-2026-025452 UB-04 · 2026-10-11 | Jacqueline Bennett UHC-63718-39 | 2026-09-25 Outpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 70553 | $3,279.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-025047 CMS-1500 · 2026-10-11 | Deborah Meyer UHC-43843-48 | 2026-10-07 Office | Harbor Medical Group Family Medicine · in network | 99203, 90471 | $242.00 | $125.04 | Clean approval | — | Approved |
| CLM-2026-024853 CMS-1500 · 2026-10-11 | Stephen Carter UHC-47675-96 | 2026-09-01 Office | Unity Medical Group Internal Medicine · in network | 99215 | $336.00 | $183.32 | Clean approval | — | Approved |
| CLM-2026-024453 UB-04 · 2026-10-11 | Grace Kennedy UHC-94262-16 | 2026-09-28 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $38,659.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-024112 UB-04 · 2026-10-11 | Daniel Thomas UHC-78647-56 | 2026-09-09 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 74177, 77067 | $2,456.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-023677 UB-04 · 2026-10-11 | Priya James UHC-14750-42 | 2026-08-28 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 88305 | $331.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023527 CMS-1500 · 2026-10-11 | Raymond Lawrence UHC-59874-28 | 2026-09-05 Office | Heritage Primary Care Associates Family Medicine · in network | 99214 | $220.00 | $111.40 | Clean approval | — | Approved |
| CLM-2026-023358 UB-04 · 2026-10-11 | Dorothy Austin UHC-48631-14 | 2026-10-04 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · in network | 99285, 71046 | $2,601.00 | $1,080.55 | Clean approval | — | Approved |
| CLM-2026-023112 CMS-1500 · 2026-10-11 | Melissa Tran UHC-46772-18 | 2026-09-22 Office | Heritage Primary Care Associates Family Medicine · in network | 99395, 99213 | $443.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-022853 CMS-1500 · 2026-10-11 | Sara Aguilar UHC-97394-26 | 2026-10-08 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · in network | 83036, 80053 | $134.00 | $0.00 | Clean approval | — | Approved |
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.