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-2026-029203 UB-04 · 2026-10-09 | Jesse Price UHC-05475-09 | 2026-08-29 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 71046, 99283 | $910.00 | $295.65 | Clean approval | — | Approved |
| CLM-2026-028456 CMS-1500 · 2026-10-09 | Dennis Jimenez UHC-68640-21 | 2026-10-06 Office | Sunrise Internal Medicine Associates Internal Medicine · in network | 80053 | $54.00 | $13.48 | Clean approval | — | Approved |
| CLM-2026-028385 CMS-1500 · 2026-10-09 | Christopher Young UHC-27607-79 | 2026-09-12 Office | Meadow Cardiovascular Associates Cardiology · in network | 99214 | $277.00 | $121.74 | Clean approval | — | Approved |
| CLM-2026-028135 UB-04 · 2026-10-09 | Marcus Luna UHC-28607-59 | 2026-09-03 Outpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 29881, 73721 | $9,547.00 | $3,043.49 | Clean approval | — | Approved |
| CLM-2026-027756 CMS-1500 · 2026-10-09 | Elizabeth Knight UHC-29520-95 | 2026-09-28 Office | Mesa Primary Care Associates Family Medicine · in network | 90471, 36415 | $41.00 | $8.06 | Clean approval | — | Approved |
| CLM-2026-027679 UB-04 · 2026-10-09 | Martha Stone UHC-83497-59 | 2026-08-25 Emergency room | Lakeside Regional Medical Center Emergency Medicine · in network | 99284 | $1,698.00 | $783.90 | Clean approval | — | Approved |
| CLM-2026-027144 UB-04 · 2026-10-09 | Carlos Lucas UHC-26021-69 | 2026-09-05 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 73721 | $2,301.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-027104 UB-04 · 2026-10-09 | Denise King UHC-24696-32 | 2026-09-16 Outpatient hospital | Summit Clinical Laboratories Clinical Laboratory · in network | 70553 | $3,396.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-027076 UB-04 · 2026-10-09 | Ashley Richardson UHC-10095-43 | 2026-09-23 Emergency room | Riverside Community Hospital Emergency Medicine · in network | 96374 | $172.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-026784 UB-04 · 2026-10-09 | Doris Brown UHC-03661-81 | 2026-09-01 Outpatient hospital | Mesa Regional Medical Center Emergency Medicine · out of network | 70553 | $2,433.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-026591 UB-04 · 2026-10-09 | Lisa Young UHC-82516-84 | 2026-09-16 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · in network | 99284 | $1,253.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-026266 CMS-1500 · 2026-10-09 | Juan Tran UHC-08444-39 | 2026-10-05 Office | Meadow Primary Care Associates Family Medicine · in network | 36415 | $25.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-025927 CMS-1500 · 2026-10-09 | Betty Boyd UHC-00389-04 | 2026-09-11 Office | Meadow GI Associates Gastroenterology · in network | 99214 | $259.00 | $85.58 | Clean approval | — | Approved |
| CLM-2026-025919 CMS-1500 · 2026-10-09 | Elijah Ray UHC-16733-85 | 2026-08-25 Office | Mesa Primary Care Associates Family Medicine · in network | 36415, 99213, 90471 | $259.00 | $146.32 | Clean approval | — | Approved |
| CLM-2026-025724 CMS-1500 · 2026-10-09 | Walter Moreno UHC-84396-39 | 2026-09-13 Office | Evergreen Cardiovascular Associates Cardiology · in network | 93224 | $396.00 | $205.52 | Clean approval | — | Approved |
| CLM-2026-024890 CMS-1500 · 2026-10-09 | Doris Coleman UHC-38524-53 | 2026-09-08 Office | Desert Medical Group Internal Medicine · in network | 93000 | $92.00 | $27.04 | Clean approval | — | Approved |
| CLM-2026-023937 CMS-1500 · 2026-10-09 | Larry Gibson UHC-74898-55 | 2026-09-26 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 80053, 87086 | $91.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023929 UB-04 · 2026-10-09 | Bobby Romero UHC-25052-40 | 2026-08-27 Inpatient hospital | Heritage Medical Group Internal Medicine · in network | 99232 | $227.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023904 CMS-1500 · 2026-10-09 | Austin Bennett UHC-98289-93 | 2026-09-14 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99215, 99214 | $541.00 | $315.42 | Clean approval | — | Approved |
| CLM-2026-023856 CMS-1500 · 2026-10-09 | Diego Wood UHC-94499-61 | 2026-09-11 Office | Meadow Skin Care Associates Dermatology · in network | 17110 | $286.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-023586 UB-04 · 2026-10-09 | Virginia Boyd UHC-21870-52 | 2026-09-22 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93306 | $1,343.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023001 UB-04 · 2026-10-09 | Deborah Johnston UHC-79873-39 | 2026-09-05 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 74177, 71046, 70553 | $4,913.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-022703 CMS-1500 · 2026-10-09 | Kathryn Lawson UHC-96469-23 | 2026-09-16 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140 | $236.00 | $121.32 | Clean approval | — | Approved |
| CLM-2026-022653 CMS-1500 · 2026-10-09 | Alexis Bennett UHC-65598-14 | 2026-09-24 Independent laboratory | Mesa Reference Lab Clinical Laboratory · in network | 80053 | $84.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-022569 CMS-1500 · 2026-10-09 | Not attached | 2026-10-04 Office | Riverside Medical Group Family Medicine · in network | 99214, 36415, 90471 | $348.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-022094 CMS-1500 · 2026-10-09 | Kathryn Gonzalez UHC-91606-76 | 2026-06-28 Office | Harbor Medical Group Family Medicine · in network | 99214, 99213, 99203 | $570.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-021631 CMS-1500 · 2026-10-09 | Theresa Munoz UHC-11208-80 | 2026-09-07 Office | Pinecrest Family Practice Family Medicine · in network | 99203 | $192.00 | $94.04 | Clean approval | — | Approved |
| CLM-2026-021562 CMS-1500 · 2026-10-09 | Stephanie Gilbert UHC-50252-24 | 2026-09-07 Office | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 99213 | $212.00 | $91.44 | Clean approval | — | Approved |
| CLM-2026-020443 CMS-1500 · 2026-10-09 | Thomas Santos UHC-66106-28 | 2026-10-05 Office | Meadow Primary Care Associates Family Medicine · in network | 99214 | $310.00 | $152.20 | Clean approval | — | Approved |
| CLM-2026-020085 UB-04 · 2026-10-09 | Catherine Hart UHC-18151-19 | 2026-09-01 Outpatient hospital | Sunrise Family Practice Family Medicine · in network | 70553 | $2,291.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-019639 CMS-1500 · 2026-10-09 | Samuel Russell UHC-79322-77 | 2026-09-07 Office | Sunrise Dermatology Clinic Dermatology · in network | 11403 | $696.00 | $371.52 | Clean approval | — | Approved |
| CLM-2026-019620 CMS-1500 · 2026-10-09 | Sophia White UHC-42195-58 | 2026-05-15 Independent laboratory | Valley Reference Lab Clinical Laboratory · in network | 87086, 83036 | $128.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-019554 CMS-1500 · 2026-10-09 | Henry Palmer UHC-86219-27 | 2026-10-06 Independent laboratory | Harbor Reference Lab Clinical Laboratory · in network | 85025 | $43.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-017566 UB-04 · 2026-10-09 | Gabriel Shew no member ID | 2026-09-28 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 43239 | $1,993.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-017366 CMS-1500 · 2026-10-09 | John Sims UHC-98485-42 | 2026-08-28 Office | Mesa Family Practice Family Medicine · in network | 36415, 90471 | $55.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-017172 UB-04 · 2026-10-09 | Lucia Welch UHC-74680-11 | 2026-09-20 Outpatient hospital | Lakeside Digestive Health Center Gastroenterology · in network | 45378 | $1,748.00 | $630.49 | Clean approval | — | Approved |
| CLM-2026-017156 CMS-1500 · 2026-10-09 | Steven Rios UHC-51797-42 | 2026-06-28 Office | Lakeside Dermatology Clinic Dermatology · in network | 11102, 99213, 17110 | $666.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-016777 CMS-1500 · 2026-10-09 | Jesse Hughes UHC-62926-91 | 2026-09-22 Independent laboratory | Evergreen Clinical Laboratories Clinical Laboratory · in network | 83036, 87086, 85025 | $161.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-016092 UB-04 · 2026-10-09 | Isabella Williams UHC-55456-26 | 2026-09-13 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 71046, 74177 | $2,579.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-016060 CMS-1500 · 2026-10-09 | Oliver Linda UHC-29977-44 | 2026-09-22 Office | Evergreen Medical Group Family Medicine · in network | 99203, 99214 | $460.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-016048 UB-04 · 2026-10-09 | Peter Phillips UHC-99427-19 | 2026-08-22 Outpatient hospital | Meadow GI Associates Gastroenterology · in network | 43239 | $2,082.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-015982 CMS-1500 · 2026-10-09 | Doris Armstrong UHC-89619-29 | 2026-09-30 Office | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 99213, 20610 | $401.00 | $198.62 | Clean approval | — | Approved |
| CLM-2026-015276 CMS-1500 · 2026-10-09 | Jerry Price UHC-62204-46 | 2026-08-28 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $278.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-015168 CMS-1500 · 2026-10-09 | Natalie Guzman UHC-13685-46 | 2026-09-11 Office | Meadow Heart Institute Cardiology · out of network | 99214, 93224 | $698.00 | $264.10 | Clean approval | — | Approved |
| CLM-2026-014482 CMS-1500 · 2026-10-09 | Ralph Nichols UHC-69144-34 | 2026-09-20 Office | Mesa Family Practice Family Medicine · in network | 99214 | $308.00 | $170.96 | Clean approval | — | Approved |
| CLM-2026-013714 UB-04 · 2026-10-09 | Gerald Bowman no member ID | 2026-10-05 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553 | $2,319.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013071 CMS-1500 · 2026-10-09 | Ashley Cox UHC-39698-83 | 2026-08-28 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97161, 97140 | $632.00 | $361.84 | Clean approval | — | Approved |
| CLM-2026-013054 UB-04 · 2026-10-09 | Charles Lynch UHC-82241-22 | 2026-09-30 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93015 | $517.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-012779 UB-04 · 2026-10-09 | Kenneth Fisher UHC-65531-04 | 2026-09-21 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $174.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-012602 CMS-1500 · 2026-10-09 | Lawrence Weaver UHC-26133-98 | 2026-10-02 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 80053 | $61.00 | $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.