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-2026-008060 UB-04 · 2026-10-10 | Judith Gomez UHC-71940-96 | 2026-10-06 Outpatient hospital | Unity Diagnostic Imaging Radiology · in network | 74177 | $1,310.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-007960 UB-04 · 2026-10-10 | Jordan Richards UHC-99630-40 | 2026-09-11 Outpatient hospital | Valley Cardiovascular Associates Cardiology · in network | 93458 | $8,484.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-007837 UB-04 · 2026-10-10 | Samantha Lawrence UHC-39266-73 | 2026-09-16 Outpatient hospital | Unity Diagnostic Imaging Radiology · in network | 77067, 74177 | $1,653.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-007822 CMS-1500 · 2026-10-10 | Kevin Lewis UHC-47662-48 | 2026-09-29 Office | Riverside Primary Care Associates Family Medicine · in network | 99395, 36415, 90471 | $374.00 | $191.88 | Clean approval | — | Approved |
| CLM-2026-007801 CMS-1500 · 2026-10-10 | Margaret Morgan UHC-97317-10 | 2026-10-05 Office | Evergreen Counseling Center Behavioral Health · in network | 90834 | $174.00 | $32.88 | Clean approval | — | Approved |
| CLM-2026-007677 UB-04 · 2026-10-10 | Joseph Porter UHC-81468-86 | 2026-09-02 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 70553 | $2,918.00 | — | Left for review REPL CO50 | — | Needs review |
| CLM-2026-007662 UB-04 · 2026-10-10 | Tyler Lawson UHC-01679-18 | 2026-08-30 Outpatient hospital | Northgate Medical Group Family Medicine · in network | 70553 | $1,980.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-007564 UB-04 · 2026-10-10 | Julie Kelly UHC-04129-50 | 2026-08-31 Inpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 27447 | $43,866.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-007556 CMS-1500 · 2026-10-10 | Judith Gilbert UHC-52805-66 | 2026-08-28 Independent laboratory | Summit Clinical Laboratories Clinical Laboratory · in network | 80061, 83036 | $118.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-007224 UB-04 · 2026-10-10 | Sean Carpenter UHC-27165-58 | 2026-10-04 Emergency room | Meadow Regional Medical Center Emergency Medicine · in network | 99283, 99285 | $3,896.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-006824 CMS-1500 · 2026-10-10 | Betty Morales UHC-75997-35 | 2026-09-30 Office | Desert Diabetes Center Endocrinology · in network | 95251, 99214 | $464.00 | $237.68 | Clean approval | — | Approved |
| CLM-2026-006361 CMS-1500 · 2026-10-10 | Mari Schmidt UHC-33033-18 | 2026-09-01 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 80053, 85025, 83036 | $177.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-005636 CMS-1500 · 2026-10-10 | Cheryl Simmons UHC-92867-01 | 2026-09-12 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97140 | $176.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-005482 UB-04 · 2026-10-10 | Lawrence Andrews UHC-44841-77 | 2026-10-07 Outpatient hospital | Lakeside Digestive Health Center Gastroenterology · in network | 45378 | $2,038.00 | $269.89 | Clean approval | — | Approved |
| CLM-2026-005414 CMS-1500 · 2026-10-10 | Kelly Espinoza UHC-51195-87 | 2026-09-09 Office | Cornerstone Family Practice Family Medicine · out of network | 99203, 99214 | $497.00 | $183.65 | Clean approval | — | Approved |
| CLM-2026-004597 CMS-1500 · 2026-10-10 | Betty Le UHC-26618-68 | 2026-10-02 Office | Canyon Internal Medicine Associates Internal Medicine · out of network | 93000, 99215 | $384.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004415 UB-04 · 2026-10-10 | Judy Rivera UHC-37285-52 | 2026-09-07 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 71046, 74177 | $2,424.00 | $601.06 | Clean approval | — | Approved |
| CLM-2026-004305 UB-04 · 2026-10-10 | Arthur Thompson UHC-87768-94 | 2026-09-21 Outpatient hospital | Desert Cardiovascular Associates Cardiology · in network | 93458, 93015 | $7,786.00 | $3,231.46 | Clean approval | — | Approved |
| CLM-2026-003754 UB-04 · 2026-10-10 | Brian Little UHC-65114-56 | 2026-09-09 Outpatient hospital | Desert Imaging Center Radiology · in network | 77067, 71046 | $560.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003296 CMS-1500 · 2026-10-10 | Mason Santos UHC-10432-64 | 2026-09-03 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · out of network | 80053 | $89.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-003231 CMS-1500 · 2026-10-10 | Michael Nelson UHC-89097-26 | 2026-09-11 Office | Northgate Medical Group Family Medicine · in network | 99395, 99214, 99203 | $748.00 | $423.76 | Clean approval | — | Approved |
| CLM-2026-002900 CMS-1500 · 2026-10-10 | Amannda Graham UHC-29738-16 | 2026-09-22 Office | Heritage Primary Care Associates Family Medicine · in network | 36415, 90471, 99213 | $272.00 | $155.00 | Clean approval | — | Approved |
| CLM-2026-002263 CMS-1500 · 2026-10-10 | Richard Hicks UHC-29945-79 | 2026-10-01 Office | Harbor Primary Care Associates Family Medicine · in network | 99213, 36415 | $224.00 | $98.88 | Clean approval | — | Approved |
| CLM-2026-002122 UB-04 · 2026-10-10 | Jon Oliver UHC-44697-32 | 2026-09-06 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 96374, 71046 | $409.00 | $79.65 | Clean approval | — | Approved |
| CLM-2026-002107 CMS-1500 · 2026-10-10 | Mei Thompson UHC-34224-49 | 2026-10-06 Office | Mesa Behavioral Health Behavioral Health · in network | 90837 | $271.00 | $108.02 | Clean approval | — | Approved |
| CLM-2026-002072 CMS-1500 · 2026-10-10 | Billy Jacobs UHC-33970-88 | 2026-04-22 Office | Harbor Primary Care Associates Family Medicine · in network | 99395, 99213 | $444.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-001830 CMS-1500 · 2026-10-10 | Natalie Singh UHC-94046-18 | 2026-09-12 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97161, 97014 | $470.00 | $266.40 | Clean approval | — | Approved |
| CLM-2026-001762 UB-04 · 2026-10-10 | Jackie Nelson UHC-14047-09 | 2026-10-07 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284, 99285, 96374 | $4,716.00 | $2,443.80 | Clean approval | — | Approved |
| CLM-2026-001629 UB-04 · 2026-10-10 | Keith Bell UHC-34516-56 | 2026-08-30 Outpatient hospital | Meadow GI Associates Gastroenterology · in network | 88305 | $270.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-001512 CMS-1500 · 2026-10-10 | Gregory Price UHC-11694-58 | 2026-09-14 Independent laboratory | Sunrise Clinical Laboratories Clinical Laboratory · in network | 87086, 80061, 83036 | $185.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-001295 CMS-1500 · 2026-10-10 | Russell Morales UHC-05073-10 | 2026-09-12 Office | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $244.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-001118 UB-04 · 2026-10-10 | Vazquez Mei UHC-53731-44 | 2026-08-27 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 96374 | $203.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-034553 UB-04 · 2026-10-09 | Mason Williams no member ID | 2026-09-04 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 70553 | $2,139.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-034381 CMS-1500 · 2026-10-09 | Amy Lane UHC-24923-31 | 2026-09-24 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99215 | $312.00 | $168.44 | Clean approval | — | Approved |
| CLM-2026-033895 UB-04 · 2026-10-09 | Joan Phillips UHC-75598-35 | 2026-09-14 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $1,754.00 | $439.30 | Clean approval | — | Approved |
| CLM-2026-033780 CMS-1500 · 2026-10-09 | Helen Lee UHC-14813-54 | 2026-09-03 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 85025 | $58.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-033296 CMS-1500 · 2026-10-09 | Dorothy Hicks UHC-74134-54 | 2026-09-28 Office | Unity Primary Care Associates Family Medicine · out of network | 36415 | $14.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032934 CMS-1500 · 2026-10-09 | Bradley Carlson UHC-48617-01 | 2026-09-29 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 80053, 87086, 80061, 83036 | $272.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-032288 UB-04 · 2026-10-09 | Robert Chen UHC-20989-04 | 2026-09-09 Emergency room | Meadow Regional Medical Center Emergency Medicine · in network | 99283, 71046 | $919.00 | $255.45 | Clean approval | — | Approved |
| CLM-2026-032190 CMS-1500 · 2026-10-09 | Cynthia Sandoval UHC-40936-82 | 2026-10-01 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 80053 | $45.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032186 CMS-1500 · 2026-10-09 | Andrea Anderson UHC-88955-23 | 2026-09-18 Office | Harbor Medical Group Family Medicine · in network | 99213 | $220.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-031185 UB-04 · 2026-10-09 | Logan Rodriguez UHC-67574-82 | 2026-09-09 Emergency room | Unity Community Hospital Emergency Medicine · in network | 71046, 96374, 99284 | $1,381.00 | $672.10 | Clean approval | — | Approved |
| CLM-2026-031181 CMS-1500 · 2026-10-09 | Karen Stewart UHC-89576-14 | 2026-09-29 Office | Summit Medical Group Internal Medicine · in network | 99214 | $309.00 | $151.58 | Clean approval | — | Approved |
| CLM-2026-030866 UB-04 · 2026-10-09 | Mari Park UHC-74024-31 | 2026-08-25 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 74177 | $1,301.00 | — | Left for review REPL CO50 | — | Needs review |
| CLM-2026-030848 UB-04 · 2026-10-09 | David Contreras UHC-93508-57 | 2026-09-19 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 74177 | $1,926.00 | $92.98 | Clean approval | — | Approved |
| CLM-2026-030684 CMS-1500 · 2026-10-09 | Jonathan Harris UHC-49757-35 | 2026-09-01 Office | Unity Counseling Center Behavioral Health · in network | 90834, 90791 | $591.00 | $316.42 | Clean approval | — | Approved |
| CLM-2026-030531 CMS-1500 · 2026-10-09 | Logan James UHC-25785-59 | 2026-09-11 Office | Sunrise Medical Group Internal Medicine · in network | 99214, 99215, 80053 | $760.00 | $451.20 | Clean approval | — | Approved |
| CLM-2026-030511 CMS-1500 · 2026-10-09 | Sharon Bennett UHC-03245-02 | 2026-08-26 Office | Harbor Primary Care Associates Family Medicine · in network | 99214 | $226.00 | $115.12 | Clean approval | — | Approved |
| CLM-2026-029551 CMS-1500 · 2026-10-09 | Peter Mendoza UHC-10519-63 | 2026-08-27 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 80053, 99214 | $305.00 | $164.30 | Clean approval | — | Approved |
| CLM-2026-029523 CMS-1500 · 2026-10-09 | Julie Fernandez no member ID | 2026-09-27 Office | Mesa Diabetes Center Endocrinology · in network | 83036 | $48.00 | — | Pended by rule IDQ N30 | — | Pended |
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.