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-2026-026157 CMS-1500 · 2026-10-10 | Stephanie Vargas no member ID | 2026-09-06 Office | Desert Primary Care Associates Family Medicine · in network | 99395, 99214 | $519.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-025925 CMS-1500 · 2026-10-10 | Debbie Mendez UHC-11886-57 | 2026-08-31 Office | Unity Primary Care Associates Family Medicine · out of network | 99395, 90471, 99203 | $578.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-025852 UB-04 · 2026-10-10 | Karen Rodriguez UHC-78012-31 | 2026-09-20 Inpatient hospital | Riverside Internal Medicine Associates Internal Medicine · out of network | 99232 | $187.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-025789 UB-04 · 2026-10-10 | Sarah Smith no member ID | 2026-09-12 Emergency room | Unity Community Hospital Emergency Medicine · in network | 96374 | $220.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-025522 CMS-1500 · 2026-10-10 | Dylan Arnold UHC-34868-16 | 2026-09-11 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $272.00 | $148.64 | Clean approval | — | Approved |
| CLM-2026-025362 CMS-1500 · 2026-10-10 | Luis Clark UHC-84938-13 | 2026-09-14 Office | Unity Internal Medicine Associates Internal Medicine · out of network | 99214 | $276.00 | $99.20 | Clean approval | — | Approved |
| CLM-2026-024699 UB-04 · 2026-10-10 | Mary Wlilis UHC-39266-51 | 2026-10-05 Outpatient hospital | Summit Imaging Center Radiology · in network | 76700, 77067 | $764.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-024225 UB-04 · 2026-10-10 | Robert Webb UHC-71570-03 | 2026-10-02 Outpatient hospital | Pinecrest GI Associates Gastroenterology · in network | 45378 | $2,400.00 | $687.24 | Clean approval | — | Approved |
| CLM-2026-023956 CMS-1500 · 2026-10-10 | Isabella Herrera UHC-50875-68 | 2026-09-11 Office | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $272.00 | $82.40 | Clean approval | — | Approved |
| CLM-2026-023701 CMS-1500 · 2026-10-10 | Sarah Banks UHC-19530-96 | 2026-09-22 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 80053, 85025 | $121.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-022387 CMS-1500 · 2026-10-10 | Kelly Espinoza UHC-51195-87 | 2026-10-02 Office | Desert Rehabilitation Center Physical Therapy · in network | 97110, 97140, 97161 | $545.00 | $297.90 | Clean approval | — | Approved |
| CLM-2026-022251 CMS-1500 · 2026-10-10 | Samantha Ward UHC-59135-15 | 2026-09-16 Office | Heritage Primary Care Associates Family Medicine · in network | 99395, 90471 | $258.00 | $139.96 | Clean approval | — | Approved |
| CLM-2026-021958 CMS-1500 · 2026-10-10 | Dylan Rivera UHC-21374-40 | 2026-10-04 Independent laboratory | Evergreen Reference Lab Clinical Laboratory · in network | 87086, 83036 | $69.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-020712 UB-04 · 2026-10-10 | Maria Nunez UHC-05838-12 | 2026-09-20 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 76700, 71046, 70553 | $4,041.00 | $1,207.61 | Clean approval | — | Approved |
| CLM-2026-019729 CMS-1500 · 2026-10-10 | Abigail Montgomery UHC-74702-59 | 2026-09-13 Office | Riverside Family Practice Family Medicine · in network | 99213, 99214 | $422.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-018622 CMS-1500 · 2026-10-10 | Madison Hall UHC-47979-10 | 2026-09-11 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 83036, 80061, 80053 | $157.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-017901 CMS-1500 · 2026-10-10 | Elizabeth Hanson UHC-09556-36 | 2026-09-14 Office | Valley Primary Care Associates Family Medicine · out of network | 99203, 99214 | $438.00 | $172.10 | Clean approval | — | Approved |
| CLM-2026-017157 CMS-1500 · 2026-10-10 | Alice Butler no member ID | 2026-09-20 Telehealth | Evergreen Counseling Center Behavioral Health · in network | 99214 | $233.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-016643 UB-04 · 2026-10-10 | Brian Peterson UHC-97293-31 | 2026-09-18 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99285, 99283 | $2,389.00 | $963.95 | Clean approval | — | Approved |
| CLM-2026-016632 UB-04 · 2026-10-10 | Jason Phillips UHC-16875-64 | 2026-08-29 Outpatient hospital | Valley Digestive Health Center Gastroenterology · in network | 45378, 43239 | $3,438.00 | $856.44 | Clean approval | — | Approved |
| CLM-2026-016539 CMS-1500 · 2026-10-10 | Benjamin Hunt UHC-46402-70 | 2026-09-16 Office | Pinecrest Medical Group Family Medicine · in network | 99214 | $267.00 | $125.54 | Clean approval | — | Approved |
| CLM-2026-015046 CMS-1500 · 2026-10-10 | Joyce Wong UHC-83210-22 | 2026-09-10 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 83036, 85025 | $101.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-014643 UB-04 · 2026-10-10 | Wayne Williamson UHC-45751-58 | 2026-10-06 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553, 76700 | $2,815.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-014578 CMS-1500 · 2026-10-10 | Victoria Knight UHC-33507-96 | 2026-09-27 Office | Sunrise Dermatology Clinic Dermatology · out of network | 99213, 11102, 17110 | $719.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-014518 CMS-1500 · 2026-10-10 | George Fernandez UHC-94231-07 | 2026-09-18 Office | Pinecrest Medical Group Family Medicine · in network | 90471 | $31.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014289 CMS-1500 · 2026-10-10 | Amanda Espinoza UHC-65635-71 | 2026-09-17 Office | Evergreen Family Practice Family Medicine · in network | 36415, 99213, 90471 | $189.00 | $107.26 | Clean approval | — | Approved |
| CLM-2026-013825 CMS-1500 · 2026-10-10 | Jason Phillips UHC-16875-64 | 2026-09-18 Office | Evergreen Internal Medicine Associates Internal Medicine · in network | 99214, 93000, 99215 | $646.00 | $370.52 | Clean approval | — | Approved |
| CLM-2026-013724 CMS-1500 · 2026-10-10 | Edward Porter UHC-26683-20 | 2026-08-26 Office | Heritage Family Practice Family Medicine · in network | 36415, 99395, 99213 | $410.00 | $241.18 | Clean approval | — | Approved |
| CLM-2026-013376 CMS-1500 · 2026-10-10 | Martha Williamson UHC-86118-06 | 2026-09-20 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 83036, 80053 | $119.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-013327 CMS-1500 · 2026-10-10 | Emma Garrett UHC-15927-63 | 2026-08-30 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 93000 | $68.00 | $12.16 | Clean approval | — | Approved |
| CLM-2026-013225 CMS-1500 · 2026-10-10 | Rebecca Lewis UHC-04909-22 | 2026-09-05 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90791, 90837 | $511.00 | $266.82 | Clean approval | — | Approved |
| CLM-2026-013207 UB-04 · 2026-10-10 | Bruce Watson UHC-58660-37 | 2026-09-03 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $5,892.00 | $1,976.64 | Clean approval | — | Approved |
| CLM-2026-012964 CMS-1500 · 2026-10-10 | Julia Rose no member ID | 2026-08-27 Office | Evergreen Medical Group Family Medicine · in network | 36415, 99395 | $362.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-012757 UB-04 · 2026-10-10 | Russell King UHC-80971-11 | 2026-09-16 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99285, 99284 | $4,796.00 | — | Left for review NET | — | Needs review |
| CLM-2026-012752 UB-04 · 2026-10-10 | Robert Lewis UHC-37733-01 | 2026-09-26 Emergency room | Sunrise Community Hospital Emergency Medicine · in network | 99284 | $1,279.00 | $453.45 | Clean approval | — | Approved |
| CLM-2026-012406 CMS-1500 · 2026-10-10 | Bradley Barnes UHC-82109-20 | 2026-09-05 Office | Harbor Primary Care Associates Family Medicine · in network | 36415, 99214 | $312.00 | $183.52 | Clean approval | — | Approved |
| CLM-2026-012132 CMS-1500 · 2026-10-10 | Betsy Perez UHC-65690-96 | 2026-09-13 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 80053 | $79.00 | $18.98 | Clean approval | — | Approved |
| CLM-2026-012068 CMS-1500 · 2026-10-10 | Robert Wang UHC-24041-45 | 2026-09-11 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $152.00 | $54.24 | Clean approval | — | Approved |
| CLM-2026-010826 UB-04 · 2026-10-10 | Evelyn Wilson UHC-19839-19 | 2026-09-02 Outpatient hospital | Valley Imaging Center Radiology · in network | 70553, 71046 | $2,389.00 | — | Left for review CO50 CO16 | — | Needs review |
| CLM-2026-010626 CMS-1500 · 2026-10-10 | Kyle Oliver UHC-64045-01 | 2026-09-07 Office | Lakeside Skin Care Associates Dermatology · in network | 99213 | $179.00 | $60.98 | Clean approval | — | Approved |
| CLM-2026-010448 UB-04 · 2026-10-10 | Judy Rose UHC-80661-85 | 2026-09-26 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 43239, 88305, 45378 | $4,718.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010052 CMS-1500 · 2026-10-10 | Katherine Richardson UHC-45309-24 | 2026-09-24 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 99214, 93000 | $307.00 | $170.34 | Clean approval | — | Approved |
| CLM-2026-009402 UB-04 · 2026-10-10 | Walter Rice UHC-37561-39 | 2026-09-09 Emergency room | Meadow Regional Medical Center Emergency Medicine · in network | 99283 | $866.00 | $126.30 | Clean approval | — | Approved |
| CLM-2026-009356 UB-04 · 2026-10-10 | Roy Daniels UHC-47531-25 | 2026-08-31 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285, 99284, 71046 | $3,617.00 | $1,839.35 | Clean approval | — | Approved |
| CLM-2026-009198 CMS-1500 · 2026-10-10 | Patrick Parker UHC-14708-32 | 2026-09-08 Independent laboratory | Sunrise Clinical Laboratories Clinical Laboratory · in network | 83036, 80061, 80053 | $170.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-009169 CMS-1500 · 2026-10-10 | Omar Harvey UHC-08537-63 | 2026-10-06 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 85025, 80053 | $108.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009026 CMS-1500 · 2026-10-10 | Samantha Jenkins UHC-20745-11 | 2026-09-02 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 99215 | $346.00 | $189.52 | Clean approval | — | Approved |
| CLM-2026-008762 CMS-1500 · 2026-10-10 | Timothy Hunt UHC-84563-77 | 2026-09-23 Office | Valley Internal Medicine Associates Internal Medicine · in network | 80053 | $87.00 | $28.94 | Clean approval | — | Approved |
| CLM-2026-008737 UB-04 · 2026-10-10 | Camila Coleman UHC-30287-02 | 2026-09-01 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93015, 93458 | $9,840.00 | $3,371.37 | Clean approval | — | Approved |
| CLM-2026-008327 CMS-1500 · 2026-10-10 | Deborah Owens UHC-36207-21 | 2026-08-26 Office | Valley Primary Care Associates Family Medicine · out of network | 36415 | $19.00 | — | 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.