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-2026-022357 CMS-1500 · 2026-10-11 | Denise Sanders UHC-61727-63 | 2026-09-20 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 99215 | $370.00 | $126.50 | Clean approval | — | Approved |
| CLM-2026-022262 UB-04 · 2026-10-11 | Justin Pena UHC-23865-08 | 2026-10-01 Inpatient hospital | Unity Internal Medicine Associates Internal Medicine · out of network | 99232 | $218.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-021824 CMS-1500 · 2026-10-11 | Lawrence Rice UHC-99232-21 | 2026-08-27 Office | Sunrise Medical Group Family Medicine · in network | 99213, 36415 | $176.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-021474 UB-04 · 2026-10-11 | Gerald Lynch UHC-99823-73 | 2026-09-22 Outpatient hospital | Riverside Imaging Center Radiology · in network | 70553, 76700 | $2,528.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-021207 CMS-1500 · 2026-10-11 | Bobby Evans UHC-75183-23 | 2026-09-07 Office | Riverside Primary Care Associates Family Medicine · in network | 99213, 90471, 99214 | $488.00 | $282.56 | Clean approval | — | Approved |
| CLM-2026-021102 CMS-1500 · 2026-10-11 | Thomaas Johnston no member ID | 2026-10-07 Office | Valley Medical Group Family Medicine · in network | 99213, 90471, 99214 | $454.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-020961 UB-04 · 2026-10-11 | John Hughes UHC-46207-33 | 2026-10-05 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 77067, 70553 | $2,609.00 | $828.34 | Clean approval | — | Approved |
| CLM-2026-020772 UB-04 · 2026-10-11 | Alexander Pena UHC-14599-26 | 2026-09-04 Outpatient hospital | Sunrise Heart Institute Cardiology · in network | 93458, 93015 | $9,536.00 | $3,813.99 | Clean approval | — | Approved |
| CLM-2026-020599 UB-04 · 2026-10-11 | Mariana Green UHC-41515-80 | 2026-09-05 Inpatient hospital | Sunrise Medical Group Internal Medicine · in network | 99232 | $245.00 | $14.89 | Clean approval | — | Approved |
| CLM-2026-020026 CMS-1500 · 2026-10-11 | Sean Gordon UHC-57083-46 | 2026-10-06 Office | Sunrise Digestive Health Center Gastroenterology · out of network | 99214 | $310.00 | $99.50 | Clean approval | — | Approved |
| CLM-2026-019828 CMS-1500 · 2026-10-11 | Ann Chapman UHC-64581-18 | 2026-08-30 Office | Canyon Medical Group Internal Medicine · in network | 99214 | $200.00 | $99.00 | Clean approval | — | Approved |
| CLM-2026-019726 UB-04 · 2026-10-11 | Douglas Ford UHC-73862-03 | 2026-09-18 Outpatient hospital | Sunrise Physical Therapy Physical Therapy · in network | 70553 | $7,038.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-018556 CMS-1500 · 2026-10-11 | Katherine Santiago UHC-57983-34 | 2026-10-09 Office | Harbor Medical Group Family Medicine · in network | 99214 | $275.00 | $130.50 | Clean approval | — | Approved |
| CLM-2026-017325 CMS-1500 · 2026-10-11 | Grace Burton UHC-52024-75 | 2026-09-30 Office | Canyon Medical Group Internal Medicine · in network | 80053, 99214 | $387.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-017261 CMS-1500 · 2026-10-11 | Marilyn Ferguson UHC-33529-32 | 2026-09-21 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061 | $80.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-016853 UB-04 · 2026-10-11 | Donald Chapman UHC-04060-56 | 2026-10-06 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 77067 | $345.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-016637 CMS-1500 · 2026-10-11 | Nicole Cooper UHC-91874-56 | 2026-09-18 Office | Evergreen Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $353.00 | $198.86 | Clean approval | — | Approved |
| CLM-2026-014962 CMS-1500 · 2026-10-11 | Christine Henry UHC-14353-96 | 2026-09-04 Independent laboratory | Evergreen Clinical Laboratories Clinical Laboratory · in network | 80061 | $77.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-014959 CMS-1500 · 2026-10-11 | Cunningham Omar UHC-84013-63 | 2026-08-13 Office | Riverside Bone and Joint Center Orthopedic Surgery · in network | 99213 | $208.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014726 UB-04 · 2026-10-11 | Teresa Lawrence UHC-32126-41 | 2026-10-05 Outpatient hospital | Sunrise GI Associates Gastroenterology · in network | 43239 | $1,598.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-014265 CMS-1500 · 2026-10-11 | Deborah Carlson UHC-44867-77 | 2026-09-18 Independent laboratory | Desert Clinical Laboratories Clinical Laboratory · in network | 83036 | $44.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-013951 UB-04 · 2026-10-11 | Olivia Alvarado UHC-69185-07 | 2026-09-18 Emergency room | Harbor Regional Medical Center Emergency Medicine · in network | 99283, 96374, 99285 | $3,619.00 | $1,840.45 | Clean approval | — | Approved |
| CLM-2026-013919 CMS-1500 · 2026-10-11 | Denise Young UHC-62842-53 | 2026-09-24 Office | Desert Medical Group Internal Medicine · in network | 99215 | $341.00 | $191.42 | Clean approval | — | Approved |
| CLM-2026-013659 CMS-1500 · 2026-10-11 | Eric Coleman UHC-65472-35 | 2026-10-06 Office | Heritage Physical Therapy Physical Therapy · in network | 97110 | $180.00 | $81.60 | Clean approval | — | Approved |
| CLM-2026-013255 CMS-1500 · 2026-10-11 | Victoria Salazar UHC-74312-49 | 2026-09-29 Office | Lakeside Medical Group Internal Medicine · in network | 99215, 99214 | $623.00 | $346.26 | Clean approval | — | Approved |
| CLM-2026-013133 CMS-1500 · 2026-10-11 | Olivia Gonzales UHC-00411-18 | 2026-08-27 Office | Valley Medical Group Internal Medicine · in network | 80053 | $63.00 | $19.06 | Clean approval | — | Approved |
| CLM-2026-013079 CMS-1500 · 2026-10-11 | Tyler Parker UHC-77633-66 | 2026-10-02 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 80053, 99215, 93000 | $409.00 | $228.58 | Clean approval | — | Approved |
| CLM-2026-012329 UB-04 · 2026-10-11 | Wayne Santiago UHC-95759-83 | 2026-09-20 Outpatient hospital | Heritage Family Practice Family Medicine · in network | 70553 | $2,586.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-011835 UB-04 · 2026-10-11 | Matthew Gilbert UHC-74569-95 | 2026-09-27 Outpatient hospital | Valley Heart Institute Cardiology · in network | 93458, 93306 | $9,180.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-011578 CMS-1500 · 2026-10-11 | Helen Bailey UHC-99440-30 | 2026-09-17 Office | Evergreen Family Practice Family Medicine · in network | 36415, 99203 | $241.00 | $135.16 | Clean approval | — | Approved |
| CLM-2026-011434 CMS-1500 · 2026-10-11 | Jacob Rojas UHC-35325-16 | 2026-10-08 Office | Desert Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $323.00 | $170.26 | Clean approval | — | Approved |
| CLM-2026-011423 CMS-1500 · 2026-10-11 | Roy Butler UHC-83875-27 | 2026-09-25 Office | Summit Cardiovascular Associates Cardiology · in network | 99214, 93224 | $747.00 | $403.14 | Clean approval | — | Approved |
| CLM-2026-011153 CMS-1500 · 2026-10-11 | Kathleen Wright UHC-81490-13 | 2026-08-31 Office | Unity Medical Group Internal Medicine · in network | 99214, 99215 | $595.00 | $328.90 | Clean approval | — | Approved |
| CLM-2026-011102 CMS-1500 · 2026-10-11 | Eric Lewis UHC-91782-76 | 2026-09-03 Office | Sunrise Medical Group Family Medicine · in network | 99395, 99214 | $446.00 | $236.52 | Clean approval | — | Approved |
| CLM-2026-010661 CMS-1500 · 2026-10-11 | Adam Freeman UHC-15081-88 | 2026-10-04 Office | Meadow Medical Group Family Medicine · in network | 99214, 36415 | $227.00 | $120.74 | Clean approval | — | Approved |
| CLM-2026-010648 CMS-1500 · 2026-10-11 | Judy Gilbert UHC-05548-84 | 2026-09-28 Independent laboratory | Evergreen Clinical Laboratories Clinical Laboratory · in network | 83036, 87086 | $116.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-010386 CMS-1500 · 2026-10-11 | Noah Coleman UHC-80842-13 | 2026-09-03 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11403, 99213 | $537.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-010009 CMS-1500 · 2026-10-11 | Jacob Carpenter UHC-24720-46 | 2026-09-10 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $272.00 | $143.64 | Clean approval | — | Approved |
| CLM-2026-010004 UB-04 · 2026-10-11 | Diego Valdez UHC-00431-81 | 2026-09-06 Outpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 29881 | $8,636.00 | $3,285.74 | Clean approval | — | Approved |
| CLM-2026-009701 UB-04 · 2026-10-11 | Thomas Butler UHC-27322-96 | 2026-08-27 Outpatient hospital | Riverside GI Associates Gastroenterology · in network | 45378 | $1,436.00 | $228.62 | Clean approval | — | Approved |
| CLM-2026-009420 CMS-1500 · 2026-10-11 | Sharon Guzman UHC-16998-40 | 2026-09-18 Office | Harbor Family Practice Family Medicine · in network | 99395, 99214, 99203 | $758.00 | $429.96 | Clean approval | — | Approved |
| CLM-2026-009336 CMS-1500 · 2026-10-11 | Nancy Rojas UHC-90304-33 | 2026-09-16 Office | Pinecrest Medical Group Internal Medicine · in network | 99215 | $382.00 | $211.84 | Clean approval | — | Approved |
| CLM-2026-008757 CMS-1500 · 2026-10-11 | Ashley Walsh UHC-77677-08 | 2026-09-04 Independent laboratory | Sunrise Clinical Laboratories Clinical Laboratory · in network | 80061, 87086 | $96.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-008538 CMS-1500 · 2026-10-11 | Mark Washington UHC-53180-18 | 2026-09-22 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97014 | $242.00 | $130.04 | Clean approval | — | Approved |
| CLM-2026-008267 CMS-1500 · 2026-10-11 | Noah Riley UHC-02806-19 | 2026-08-28 Office | Pinecrest Primary Care Associates Family Medicine · in network | 90471, 99203 | $244.00 | $135.78 | Clean approval | — | Approved |
| CLM-2026-007811 CMS-1500 · 2026-10-11 | Santiago Gardner UHC-96725-82 | 2026-08-29 Office | Mesa Dermatology Clinic Dermatology · in network | 99213 | $177.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-006386 CMS-1500 · 2026-10-11 | Zachary Marshall UHC-03354-04 | 2026-09-27 Office | Evergreen Counseling Center Behavioral Health · in network | 90791, 90837 | $603.00 | $313.86 | Clean approval | — | Approved |
| CLM-2026-006310 CMS-1500 · 2026-10-11 | Santiago Johnston UHC-07734-93 | 2026-09-03 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90837 | $216.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006288 UB-04 · 2026-10-11 | Cheryl Carr UHC-85484-89 | 2026-09-23 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 70553, 74177 | $4,007.00 | $1,691.22 | Clean approval | — | Approved |
| CLM-2026-006231 CMS-1500 · 2026-10-11 | Debra Powell UHC-90874-75 | 2026-09-13 Office | Harbor Medical Group Internal Medicine · out of network | 93000, 80053 | $148.00 | — | Denied by rule CO204 | — | 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.