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-2026-032379 CMS-1500 · 2026-10-08 | Katherine Bell UHC-91757-89 | 2026-10-02 Office | Summit Endocrine Associates Endocrinology · in network | 99214 | $244.00 | $76.28 | Clean approval | — | Approved |
| CLM-2026-032325 CMS-1500 · 2026-10-08 | James Riley no member ID | 2026-09-22 Office | Harbor Physical Therapy Physical Therapy · in network | 97110, 97161 | $536.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-031998 CMS-1500 · 2026-10-08 | Dorothy Herrera UHC-12392-13 | 2026-09-16 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90834 | $191.00 | $45.95 | Clean approval | — | Approved |
| CLM-2026-030480 CMS-1500 · 2026-10-08 | Not attached | 2026-09-01 Office | Valley Cardiovascular Associates Cardiology · in network | 99214 | $220.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-030444 UB-04 · 2026-10-08 | Kenneth Hughes no member ID | 2026-05-06 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 96374, 99285 | $2,613.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-029982 UB-04 · 2026-10-08 | Maria Hansen UHC-86468-12 | 2026-09-13 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283 | $725.00 | — | Left for review NET | — | Needs review |
| CLM-2026-029978 CMS-1500 · 2026-10-08 | Carl Pena UHC-49648-62 | 2026-09-05 Office | Sunrise Internal Medicine Associates Internal Medicine · in network | 93000, 99215 | $504.00 | $287.48 | Clean approval | — | Approved |
| CLM-2026-029717 CMS-1500 · 2026-10-08 | Roger Bishop UHC-15509-76 | 2026-08-31 Office | Lakeside Medical Group Family Medicine · in network | 36415 | $14.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-029566 CMS-1500 · 2026-10-08 | Pauul Willis UHC-36011-62 | 2026-08-24 Office | Unity Counseling Center Behavioral Health · in network | 90791 | $431.00 | $192.22 | Clean approval | — | Approved |
| CLM-2026-029531 CMS-1500 · 2026-10-08 | Sophia Fox UHC-96989-32 | 2026-08-26 Office | Evergreen Internal Medicine Associates Internal Medicine · in network | 99215 | $351.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-029026 UB-04 · 2026-10-08 | Cheryl Guzman UHC-71613-42 | 2026-09-03 Outpatient hospital | Meadow Cardiovascular Associates Cardiology · in network | 93306, 93015 | $1,684.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-028937 UB-04 · 2026-10-08 | Olivia Soto no member ID | 2026-09-21 Outpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,512.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-028472 CMS-1500 · 2026-10-08 | Mary Carroll UHC-52050-46 | 2026-09-02 Office | Meadow Cardiovascular Associates Cardiology · in network | 93224, 99214 | $735.00 | $405.70 | Clean approval | — | Approved |
| CLM-2026-028196 CMS-1500 · 2026-10-08 | Carolyn Dixon UHC-69047-67 | 2026-09-03 Office | Meadow Medical Group Family Medicine · in network | 99213 | $196.00 | $96.52 | Clean approval | — | Approved |
| CLM-2026-028092 CMS-1500 · 2026-10-08 | Mari Webb UHC-08787-13 | 2026-10-01 Office | Valley Skin Care Associates Dermatology · in network | 17110, 99213, 11102 | $721.00 | $387.02 | Clean approval | — | Approved |
| CLM-2026-028070 CMS-1500 · 2026-10-08 | Roy Wright UHC-76478-99 | 2026-09-09 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061, 83036 | $116.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-027815 CMS-1500 · 2026-10-08 | Kathryn Ortega UHC-85581-79 | 2026-09-05 Independent laboratory | Unity Reference Lab Clinical Laboratory · in network | 80061, 85025, 83036 | $199.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-027712 UB-04 · 2026-10-08 | Douglas Smith UHC-05345-58 | 2026-09-27 Outpatient hospital | Heritage Digestive Health Center Gastroenterology · in network | 88305, 43239 | $2,431.00 | $67.16 | Clean approval | — | Approved |
| CLM-2026-027707 UB-04 · 2026-10-08 | Aisha Rojas UHC-94886-33 | 2026-09-21 Outpatient hospital | Riverside GI Associates Gastroenterology · in network | 88305, 45378 | $2,205.00 | $632.61 | Clean approval | — | Approved |
| CLM-2026-027248 CMS-1500 · 2026-10-08 | Edward Wilson UHC-81351-96 | 2026-10-05 Office | Unity Primary Care Associates Family Medicine · out of network | 99213 | $184.00 | $62.80 | Clean approval | — | Approved |
| CLM-2026-026978 CMS-1500 · 2026-10-08 | Doris Brooks UHC-60379-29 | 2026-09-07 Office | Meadow Heart Institute Cardiology · in network | 99214 | $247.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-026952 CMS-1500 · 2026-10-08 | David Wang UHC-66449-08 | 2026-09-11 Office | Canyon Medical Group Internal Medicine · in network | 99214, 80053 | $370.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-026741 CMS-1500 · 2026-10-08 | Omar Green UHC-55015-60 | 2026-09-01 Office | Heritage Primary Care Associates Family Medicine · in network | 36415 | $22.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-025648 UB-04 · 2026-10-08 | Dennis Murphy UHC-72122-15 | 2026-09-28 Outpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 29881 | $8,955.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025579 CMS-1500 · 2026-10-08 | Gregory Hudson UHC-64213-60 | 2026-09-09 Office | Heritage Physical Therapy Physical Therapy · in network | 97110, 97014, 97140 | $284.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-024712 CMS-1500 · 2026-10-08 | Jerry Watkins UHC-20153-72 | 2026-09-07 Office | Sunrise Dermatology Clinic Dermatology · in network | 17110 | $257.00 | $119.34 | Clean approval | — | Approved |
| CLM-2026-024198 CMS-1500 · 2026-10-08 | Betty Gomez UHC-79259-25 | 2026-10-05 Independent laboratory | Evergreen Clinical Laboratories Clinical Laboratory · in network | 80053, 85025 | $106.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-024080 CMS-1500 · 2026-10-08 | Theresa Ferguson UHC-72869-72 | 2026-08-24 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99214 | $204.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-023944 CMS-1500 · 2026-10-08 | Janet Sullivan UHC-57981-28 | 2026-10-05 Office | Desert Cardiovascular Associates Cardiology · in network | 99214 | $296.00 | $123.52 | Clean approval | — | Approved |
| CLM-2026-023569 CMS-1500 · 2026-10-08 | Judy Ruiz UHC-17475-99 | 2026-09-21 Office | Summit Family Practice Family Medicine · in network | 90471 | $44.00 | $7.28 | Clean approval | — | Approved |
| CLM-2026-023437 CMS-1500 · 2026-10-08 | Nicole Carr UHC-85502-91 | 2026-09-04 Office | Unity Medical Group Internal Medicine · in network | 99215 | $349.00 | $191.38 | Clean approval | — | Approved |
| CLM-2026-023346 CMS-1500 · 2026-10-08 | Dennis Spencer UHC-64143-17 | 2026-09-29 Office | Harbor Physical Therapy Physical Therapy · in network | 97110, 97161 | $305.00 | $169.10 | Clean approval | — | Approved |
| CLM-2026-022319 CMS-1500 · 2026-10-08 | Jason Ryan UHC-14330-97 | 2026-08-30 Office | Canyon Cardiovascular Associates Cardiology · out of network | 99214 | $259.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-022178 UB-04 · 2026-10-08 | Raymond Rodriguez UHC-81501-18 | 2026-09-23 Emergency room | Canyon Regional Medical Center Emergency Medicine · in network | 99284 | $1,667.00 | $766.85 | Clean approval | — | Approved |
| CLM-2026-021362 CMS-1500 · 2026-10-08 | Christian Castillo UHC-97898-44 | 2026-03-19 Office | Mesa Family Practice Family Medicine · in network | 99203, 99395 | $560.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-021242 CMS-1500 · 2026-10-08 | Christine Duncan UHC-74318-39 | 2026-09-15 Office | Desert Rehabilitation Center Physical Therapy · in network | 97110 | $260.00 | $136.20 | Clean approval | — | Approved |
| CLM-2026-021121 CMS-1500 · 2026-10-08 | Mason Carter UHC-49290-17 | 2026-09-29 Independent laboratory | Summit Clinical Laboratories Clinical Laboratory · in network | 80053, 83036 | $92.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-020598 CMS-1500 · 2026-10-08 | Dylan Dean UHC-33903-05 | 2026-09-28 Office | Sunrise Digestive Health Center Gastroenterology · out of network | 99214 | $245.00 | $35.25 | Clean approval | — | Approved |
| CLM-2026-020304 CMS-1500 · 2026-10-08 | Vincent Morgan UHC-89453-55 | 2026-10-06 Office | Sunrise Medical Group Family Medicine · in network | 90471 | $40.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-020066 CMS-1500 · 2026-10-08 | Maria Harper UHC-72350-71 | 2026-09-30 Office | Evergreen Internal Medicine Associates Internal Medicine · in network | 99214, 80053 | $283.00 | $155.46 | Clean approval | — | Approved |
| CLM-2026-019587 CMS-1500 · 2026-10-08 | Banks Banks UHC-47686-95 | 2026-09-28 Independent laboratory | Pinecrest Reference Lab Clinical Laboratory · in network | 85025, 83036, 80061, 80053 | $211.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-019474 UB-04 · 2026-10-08 | Bobby Fisher UHC-87911-25 | 2026-08-29 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $197.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-019387 UB-04 · 2026-10-08 | Jeffrey Chen UHC-36893-66 | 2026-09-29 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 71046, 74177 | $2,406.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-019380 CMS-1500 · 2026-10-08 | Jesse Moreno UHC-10876-97 | 2026-09-07 Office | Canyon Primary Care Associates Family Medicine · in network | 90471, 99395 | $325.00 | $179.18 | Clean approval | — | Approved |
| CLM-2026-019215 UB-04 · 2026-10-08 | Bryan Ortiz UHC-46023-57 | 2026-09-10 Outpatient hospital | Meadow Imaging Center Radiology · in network | 77067 | $390.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-018088 CMS-1500 · 2026-10-08 | Zachary Greene UHC-69793-13 | 2026-09-25 Office | Sunrise Dermatology Clinic Dermatology · out of network | 99213, 11102 | $453.00 | $143.85 | Clean approval | — | Approved |
| CLM-2026-018043 CMS-1500 · 2026-10-08 | Bruce Cole UHC-76142-82 | 2026-09-18 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $280.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-017824 CMS-1500 · 2026-10-08 | Laura Park UHC-74626-53 | 2026-09-26 Office | Sunrise Dermatology Clinic Dermatology · in network | 99213 | $196.00 | $46.52 | Clean approval | — | Approved |
| CLM-2026-016973 CMS-1500 · 2026-10-08 | Deborah Cooper UHC-66987-74 | 2026-09-05 Office | Pinecrest Medical Group Family Medicine · in network | 99203 | $183.00 | $83.46 | Clean approval | — | Approved |
| CLM-2026-016813 CMS-1500 · 2026-10-08 | Joseph Cunningham UHC-10594-91 | 2026-09-19 Office | Lakeside Medical Group Family Medicine · out of network | 99395, 36415 | $321.00 | $104.45 | 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.