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-2026-006157 CMS-1500 · 2026-10-11 | Natalie Crawford UHC-94219-79 | 2026-09-11 Telehealth | Pinecrest Behavioral Health Behavioral Health · in network | 99214 | $215.00 | $73.30 | Clean approval | — | Approved |
| CLM-2026-005804 CMS-1500 · 2026-10-11 | Evelyn Vargas UHC-61305-53 | 2026-09-10 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97014, 97161 | $508.00 | $294.96 | Clean approval | — | Approved |
| CLM-2026-005668 UB-04 · 2026-10-11 | Diane Mendez UHC-02276-61 | 2026-09-04 Inpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 27447 | $43,670.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-005529 UB-04 · 2026-10-11 | Alexis Price UHC-80433-48 | 2026-09-12 Inpatient hospital | Northgate Medical Group Internal Medicine · in network | 99232 | $163.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-005439 CMS-1500 · 2026-10-11 | Scott Cooper UHC-57705-65 | 2026-09-05 Office | Canyon Internal Medicine Associates Internal Medicine · in network | 80053, 99215 | $476.00 | $265.12 | Clean approval | — | Approved |
| CLM-2026-005233 CMS-1500 · 2026-10-11 | Robert Robinson UHC-71882-37 | 2026-09-14 Office | Heritage Physical Therapy Physical Therapy · in network | 97110, 97140 | $259.00 | $135.58 | Clean approval | — | Approved |
| CLM-2026-004766 UB-04 · 2026-10-11 | Marilyn Berry UHC-72413-38 | 2026-09-09 Outpatient hospital | Riverside GI Associates Gastroenterology · in network | 43239 | $2,236.00 | $245.32 | Clean approval | — | Approved |
| CLM-2026-004018 CMS-1500 · 2026-10-11 | Nancy Wallace UHC-28795-61 | 2026-09-03 Office | Valley Skin Care Associates Dermatology · in network | 99213, 17110, 11403 | $962.00 | $521.44 | Clean approval | — | Approved |
| CLM-2026-003724 CMS-1500 · 2026-10-11 | Kenneth Santos UHC-35521-44 | 2026-09-15 Office | Canyon Cardiovascular Associates Cardiology · in network | 99214 | $222.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-003697 CMS-1500 · 2026-10-11 | Carl Clark UHC-07708-62 | 2026-09-07 Office | Canyon Counseling Center Behavioral Health · out of network | 90837, 90791, 90834 | $933.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-003522 UB-04 · 2026-10-11 | Arthur Gibson UHC-31926-06 | 2026-09-14 Outpatient hospital | Desert Imaging Center Radiology · in network | 70553, 76700 | $2,987.00 | $285.08 | Clean approval | — | Approved |
| CLM-2026-002360 CMS-1500 · 2026-10-11 | Virginia Smith UHC-62024-73 | 2026-09-22 Office | Summit Family Practice Family Medicine · in network | 99395, 99214 | $533.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-002248 CMS-1500 · 2026-10-11 | Betty Rojas UHC-59588-79 | 2026-09-09 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 80053, 99215 | $474.00 | $253.88 | Clean approval | — | Approved |
| CLM-2026-001540 CMS-1500 · 2026-10-11 | Fatima Knight UHC-92327-02 | 2026-08-29 Office | Summit Medical Group Internal Medicine · in network | 80053, 99214, 93000 | $401.00 | $218.62 | Clean approval | — | Approved |
| CLM-2026-001514 CMS-1500 · 2026-10-11 | Hiroshi Harvey UHC-85614-59 | 2026-10-08 Independent laboratory | Summit Reference Lab Clinical Laboratory · in network | 85025, 83036 | $138.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-001234 CMS-1500 · 2026-10-11 | Bobby Wilson UHC-41416-73 | 2026-08-31 Office | Lakeside Medical Group Family Medicine · in network | 99213, 36415, 90471 | $257.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-001204 UB-04 · 2026-10-11 | Debra Hoffman UHC-18077-63 | 2026-09-28 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 77067 | $248.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-000972 UB-04 · 2026-10-11 | Ronald Sanders UHC-31632-29 | 2026-09-28 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 70553, 74177, 76700 | $6,591.00 | $1,469.39 | Clean approval | — | Approved |
| CLM-2026-000944 UB-04 · 2026-10-11 | Lori Roberts UHC-78605-17 | 2026-09-12 Outpatient hospital | Unity Community Hospital Emergency Medicine · in network | 70553 | $3,484.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-000827 UB-04 · 2026-10-11 | Michelle Jimenez UHC-06168-30 | 2026-09-11 Emergency room | Valley Regional Medical Center Emergency Medicine · in network | 99284, 96374 | $1,924.00 | $808.20 | Clean approval | — | Approved |
| CLM-2026-000805 UB-04 · 2026-10-11 | George Day UHC-52847-57 | 2026-09-03 Outpatient hospital | Riverside Imaging Center Radiology · in network | 76700 | $629.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-000594 UB-04 · 2026-10-11 | Aaron Knight UHC-95721-09 | 2026-09-13 Outpatient hospital | Mesa Cardiovascular Associates Cardiology · in network | 93458 | $7,299.00 | $2,017.82 | Clean approval | — | Approved |
| CLM-2026-000249 CMS-1500 · 2026-10-11 | William Garcia UHC-02353-22 | 2026-09-10 Office | Heritage Family Practice Family Medicine · in network | 36415, 99395, 90471 | $402.00 | $235.60 | Clean approval | — | Approved |
| CLM-2026-000109 UB-04 · 2026-10-11 | Brian Bell UHC-05015-78 | 2026-08-30 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285, 96374 | $1,873.00 | $692.85 | Clean approval | — | Approved |
| CLM-2026-034588 UB-04 · 2026-10-10 | Vicky Hamilton UHC-20657-68 | 2026-09-02 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99283, 96374 | $973.00 | $285.15 | Clean approval | — | Approved |
| CLM-2026-034363 CMS-1500 · 2026-10-10 | Philip Vasquez UHC-19675-29 | 2026-10-06 Office | Cornerstone Digestive Health Center Gastroenterology · in network | 99214 | $321.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-033991 UB-04 · 2026-10-10 | Amanda Shaw UHC-91321-72 | 2026-09-21 Outpatient hospital | Desert Imaging Center Radiology · in network | 71046, 70553 | $3,071.00 | $949.15 | Clean approval | — | Approved |
| CLM-2026-033346 CMS-1500 · 2026-10-10 | Hannah Nguyen UHC-20168-56 | 2026-10-04 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 80053 | $60.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-033132 CMS-1500 · 2026-10-10 | Henry Wells UHC-34465-23 | 2026-09-21 Office | Lakeside Endocrine Associates Endocrinology · out of network | 95251, 83036, 99215 | $658.00 | $221.10 | Clean approval | — | Approved |
| CLM-2026-032682 UB-04 · 2026-10-10 | Frank Phillips no member ID | 2026-09-22 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 74177 | $1,730.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-032543 UB-04 · 2026-10-10 | Brittany Alvarado UHC-89357-17 | 2026-08-30 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 96374, 99285 | $2,580.00 | — | Left for review NET | — | Needs review |
| CLM-2026-032439 UB-04 · 2026-10-10 | Ralph Burns UHC-63658-24 | 2026-09-30 Outpatient hospital | Lakeside Skin Care Associates Dermatology · in network | 70553 | $2,987.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-031974 CMS-1500 · 2026-10-10 | Terry Walker UHC-13254-77 | 2026-09-04 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 83036, 80053 | $98.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-031878 UB-04 · 2026-10-10 | Brittany Crawford UHC-52699-22 | 2026-08-27 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 71046 | $235.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-031633 CMS-1500 · 2026-10-10 | Aaron Nunez UHC-75381-08 | 2026-08-30 Office | Sunrise GI Associates Gastroenterology · in network | 99214 | $284.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-031011 CMS-1500 · 2026-10-10 | Sanitago Franklin UHC-54865-20 | 2026-09-26 Office | Valley Family Practice Family Medicine · in network | 99395, 99213 | $460.00 | $245.20 | Clean approval | — | Approved |
| CLM-2026-030935 CMS-1500 · 2026-10-10 | Amanda George UHC-69524-04 | 2026-09-26 Office | Sunrise Orthopedic Specialists Orthopedic Surgery · in network | 99213, 20610 | $458.00 | $243.96 | Clean approval | — | Approved |
| CLM-2026-030598 CMS-1500 · 2026-10-10 | Bradley Barnes UHC-82109-20 | 2026-09-18 Office | Mesa Family Practice Family Medicine · in network | 90471, 99395 | $278.00 | $152.36 | Clean approval | — | Approved |
| CLM-2026-030582 CMS-1500 · 2026-10-10 | Jean Phillips UHC-92483-07 | 2026-10-08 Office | Canyon Primary Care Associates Family Medicine · in network | 90471, 99214 | $291.00 | $158.72 | Clean approval | — | Approved |
| CLM-2026-030438 CMS-1500 · 2026-10-10 | Scott Thomas UHC-23637-74 | 2026-09-30 Office | Lakeside Dermatology Clinic Dermatology · in network | 99213, 11403, 17110 | $986.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-030384 UB-04 · 2026-10-10 | Jeffrey Padilla UHC-92939-82 | 2026-09-25 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $37,665.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-030069 CMS-1500 · 2026-10-10 | Pamela Snadoval UHC-52330-59 | 2026-09-14 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99203 | $242.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030052 UB-04 · 2026-10-10 | Bradley Fernandez UHC-37198-75 | 2026-10-05 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $44,057.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-029914 CMS-1500 · 2026-10-10 | Brandon Andrews UHC-68112-03 | 2026-10-04 Office | Sunrise Behavioral Health Behavioral Health · in network | 90834 | $166.00 | $62.92 | Clean approval | — | Approved |
| CLM-2026-029298 CMS-1500 · 2026-10-10 | Frank Thompson UHC-47481-78 | 2026-09-07 Office | Mesa Primary Care Associates Family Medicine · in network | 99214, 36415, 99203 | $440.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-029178 UB-04 · 2026-10-10 | Lucia Soto UHC-71796-85 | 2026-09-15 Outpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 70553, 73721 | $5,854.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-028727 CMS-1500 · 2026-10-10 | Gregory Ward UHC-42600-61 | 2026-08-26 Office | Canyon Primary Care Associates Family Medicine · in network | 99203, 90471 | $282.00 | $149.84 | Clean approval | — | Approved |
| CLM-2026-027314 CMS-1500 · 2026-10-10 | Diana Hunt UHC-91212-74 | 2026-10-08 Office | Mesa Family Practice Family Medicine · in network | 99214, 90471 | $281.00 | $154.22 | Clean approval | — | Approved |
| CLM-2026-027261 UB-04 · 2026-10-10 | Brittany Holmes UHC-82722-34 | 2026-10-01 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93015 | $438.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-026627 UB-04 · 2026-10-10 | Arjun Hughes UHC-32299-75 | 2026-09-15 Outpatient hospital | Meadow Dermatology Clinic Dermatology · in network | 70553 | $1,808.00 | — | 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.