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-2026-012120 CMS-1500 · 2026-10-09 | Abigail Aguilar UHC-54533-25 | 2026-09-01 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 80053, 80061 | $153.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011681 CMS-1500 · 2026-10-09 | Randy Bishop UHC-81792-57 | 2026-08-09 Independent laboratory | Desert Clinical Laboratories Clinical Laboratory · in network | 83036, 85025, 87086 | $140.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-011624 CMS-1500 · 2026-10-09 | Camila Olson UHC-51240-43 | 2026-08-26 Office | Heritage Medical Group Family Medicine · out of network | 99395 | $302.00 | $110.90 | Clean approval | — | Approved |
| CLM-2026-011426 CMS-1500 · 2026-10-09 | Jean Ramos UHC-39705-70 | 2026-09-11 Office | Evergreen Cardiovascular Associates Cardiology · in network | 93224 | $402.00 | $209.24 | Clean approval | — | Approved |
| CLM-2026-011318 CMS-1500 · 2026-10-09 | Lawrence Russell UHC-94134-10 | 2026-09-26 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99395, 90471 | $313.00 | $154.06 | Clean approval | — | Approved |
| CLM-2026-011074 UB-04 · 2026-10-09 | Anna Harvey UHC-53608-54 | 2026-09-15 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378, 43239 | $4,163.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-011009 CMS-1500 · 2026-10-09 | Austin Berry UHC-63286-32 | 2026-10-02 Office | Meadow Primary Care Associates Family Medicine · in network | 99214 | $264.00 | $123.68 | Clean approval | — | Approved |
| CLM-2026-010471 CMS-1500 · 2026-10-09 | Sophia Fox UHC-96989-32 | 2026-09-25 Office | Canyon Cardiovascular Associates Cardiology · in network | 99214 | $231.00 | $68.22 | Clean approval | — | Approved |
| CLM-2026-010412 CMS-1500 · 2026-10-09 | Carlos Scott UHC-31563-59 | 2026-09-02 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 80061 | $45.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-010036 CMS-1500 · 2026-10-09 | Nancy Sandoval UHC-95939-67 | 2026-09-12 Office | Mesa Medical Group Internal Medicine · in network | 93000 | $68.00 | $12.16 | Clean approval | — | Approved |
| CLM-2026-010020 CMS-1500 · 2026-10-09 | Theresa Carter UHC-04988-64 | 2026-09-22 Office | Pinecrest Medical Group Internal Medicine · in network | 80053 | $69.00 | $12.78 | Clean approval | — | Approved |
| CLM-2026-009820 UB-04 · 2026-10-09 | Walter Weber UHC-22039-25 | 2026-03-31 Outpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,142.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-009690 UB-04 · 2026-10-09 | Laura Ramirez UHC-52343-50 | 2026-08-31 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $237.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-009001 UB-04 · 2026-10-09 | George Morrison UHC-79627-09 | 2026-10-07 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458 | $9,071.00 | $3,748.09 | Clean approval | — | Approved |
| CLM-2026-008783 UB-04 · 2026-10-09 | Nancy Reyes UHC-22688-17 | 2026-09-15 Outpatient hospital | Meadow Imaging Center Radiology · in network | 71046 | $151.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-008497 CMS-1500 · 2026-10-09 | Angela Lopez UHC-47375-08 | 2026-09-21 Office | Canyon Skin Care Associates Dermatology · in network | 11403 | $482.00 | $258.84 | Clean approval | — | Approved |
| CLM-2026-008300 UB-04 · 2026-10-09 | Nicole Gonzalez UHC-37073-66 | 2026-09-10 Outpatient hospital | Lakeside Skin Care Associates Dermatology · in network | 70553 | $1,932.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-007623 UB-04 · 2026-10-09 | James Cox UHC-14257-05 | 2026-09-25 Outpatient hospital | Harbor Diagnostic Imaging Radiology · in network | 71046, 70553 | $2,856.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-007571 CMS-1500 · 2026-10-09 | Joan Phillips UHC-75598-35 | 2026-09-13 Office | Evergreen Medical Group Family Medicine · in network | 99203 | $193.00 | $99.66 | Clean approval | — | Approved |
| CLM-2026-007492 UB-04 · 2026-10-09 | Maria Snyder UHC-84820-97 | 2026-09-01 Outpatient hospital | Harbor Imaging Center Radiology · in network | 74177 | $2,458.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-007411 CMS-1500 · 2026-10-09 | Sandra White UHC-13421-40 | 2026-09-13 Office | Evergreen Medical Group Internal Medicine · out of network | 80053 | $61.00 | $2.45 | Clean approval | — | Approved |
| CLM-2026-007035 UB-04 · 2026-10-09 | Victoria Herrera UHC-13803-78 | 2026-09-16 Outpatient hospital | Riverside Imaging Center Radiology · in network | 70553 | $2,225.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-006852 CMS-1500 · 2026-10-09 | Theresa Torres UHC-55258-87 | 2026-09-22 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $405.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-006821 CMS-1500 · 2026-10-09 | Billy Herrera UHC-97480-71 | 2026-09-21 Office | Desert Diabetes Center Endocrinology · in network | 83036, 99214 | $287.00 | $148.80 | Clean approval | — | Approved |
| CLM-2026-006552 UB-04 · 2026-10-09 | Abigail Phillips UHC-38548-43 | 2026-10-01 Outpatient hospital | Canyon Medical Group Internal Medicine · in network | 70553 | $2,943.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-006247 CMS-1500 · 2026-10-09 | Matthew Ryan no member ID | 2026-10-07 Office | Meadow Primary Care Associates Family Medicine · in network | 90471, 99395 | $358.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-006226 CMS-1500 · 2026-10-09 | Denise Knight UHC-58065-29 | 2026-09-28 Office | Valley Rehabilitation Center Physical Therapy · in network | 97110, 97014 | $170.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-006069 UB-04 · 2026-10-09 | Gerald Fisher UHC-28348-73 | 2026-09-09 Emergency room | Unity Community Hospital Emergency Medicine · in network | 71046, 99283 | $1,307.00 | $576.95 | Clean approval | — | Approved |
| CLM-2026-006044 CMS-1500 · 2026-10-09 | Anthony Chen UHC-39314-93 | 2026-09-24 Office | Canyon Primary Care Associates Family Medicine · in network | 36415, 90471 | $60.00 | $23.56 | Clean approval | — | Approved |
| CLM-2026-005807 CMS-1500 · 2026-10-09 | Hiroshi Cook UHC-54565-77 | 2026-09-13 Office | Mesa Medical Group Family Medicine · in network | 99213, 36415 | $213.00 | $92.06 | Clean approval | — | Approved |
| CLM-2026-005446 CMS-1500 · 2026-10-09 | Sean Moore UHC-28439-67 | 2026-09-26 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99214 | $309.00 | $166.58 | Clean approval | — | Approved |
| CLM-2026-005070 UB-04 · 2026-10-09 | Logan Greene UHC-34472-84 | 2026-10-06 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 96374 | $170.00 | — | Left for review NET | — | Needs review |
| CLM-2026-004701 CMS-1500 · 2026-10-09 | Pamela Santiago UHC-70706-81 | 2026-09-30 Office | Canyon Primary Care Associates Family Medicine · in network | 99395 | $272.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-004384 UB-04 · 2026-10-09 | Gregory Mendez UHC-93422-08 | 2026-08-30 Outpatient hospital | Cornerstone Cardiovascular Associates Cardiology · in network | 93306 | $961.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003309 UB-04 · 2026-10-09 | Fatima Coleman UHC-25318-23 | 2026-09-28 Outpatient hospital | Sunrise Heart Institute Cardiology · in network | 93015 | $467.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-002968 CMS-1500 · 2026-10-09 | Anna Meyer UHC-27108-48 | 2026-09-22 Office | Valley Medical Group Internal Medicine · in network | 93000, 99215 | $363.00 | $195.06 | Clean approval | — | Approved |
| CLM-2026-002904 CMS-1500 · 2026-10-09 | Wei Miller UHC-77831-87 | 2026-10-04 Office | Evergreen Primary Care Associates Family Medicine · in network | 99395 | $228.00 | $101.36 | Clean approval | — | Approved |
| CLM-2026-002673 UB-04 · 2026-10-09 | Omar Castro UHC-27170-07 | 2026-09-24 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $40,011.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-001761 UB-04 · 2026-10-09 | Albert Wells UHC-36051-25 | 2026-09-14 Outpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,397.00 | $498.59 | Clean approval | — | Approved |
| CLM-2026-001653 CMS-1500 · 2026-10-09 | Ana Robinson UHC-45904-17 | 2026-10-02 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99214 | $236.00 | $121.32 | Clean approval | — | Approved |
| CLM-2026-001306 UB-04 · 2026-10-09 | Larry Willis UHC-23228-90 | 2026-09-04 Outpatient hospital | Desert Cardiovascular Associates Cardiology · in network | 93306 | $1,517.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-001269 CMS-1500 · 2026-10-09 | Carol Franklin UHC-98866-30 | 2026-09-24 Office | Canyon Skin Care Associates Dermatology · in network | 17110, 99213 | $367.00 | $177.54 | Clean approval | — | Approved |
| CLM-2026-000842 CMS-1500 · 2026-10-09 | Joe Graham UHC-51875-48 | 2026-09-20 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 83036 | $69.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000342 CMS-1500 · 2026-10-09 | Jennifer Carr no member ID | 2026-09-23 Office | Mesa Behavioral Health Behavioral Health · in network | 90834, 90791 | $550.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-000033 UB-04 · 2026-10-09 | Lynda Greene no member ID | 2026-10-01 Outpatient hospital | Riverside Imaging Center Radiology · in network | 76700 | $485.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-033978 CMS-1500 · 2026-10-08 | Jordan Ferguson UHC-94994-63 | 2026-09-07 Office | Desert Primary Care Associates Family Medicine · in network | 99395, 99214 | $608.00 | $351.96 | Clean approval | — | Approved |
| CLM-2026-033964 CMS-1500 · 2026-10-08 | Brittany Jenkins UHC-52134-96 | 2026-09-12 Independent laboratory | Northgate Reference Lab Clinical Laboratory · in network | 80061, 87086, 80053 | $167.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-033372 CMS-1500 · 2026-10-08 | Kyle Romero UHC-90669-86 | 2026-09-04 Office | Sunrise Cardiovascular Associates Cardiology · in network | 93224 | $371.00 | $170.02 | Clean approval | — | Approved |
| CLM-2026-033093 UB-04 · 2026-10-08 | Jacob Cooper UHC-27394-07 | 2026-09-30 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · in network | 88305 | $311.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-032849 CMS-1500 · 2026-10-08 | Kimberly Moreno UHC-01332-33 | 2026-09-10 Office | Evergreen Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $387.00 | — | Denied by rule LIM | — | 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.