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-2026-016569 UB-04 · 2026-10-08 | Scott Cox UHC-67372-25 | 2026-09-25 Emergency room | Meadow Regional Medical Center Emergency Medicine · in network | 99285 | $1,711.00 | $791.05 | Clean approval | — | Approved |
| CLM-2026-016401 CMS-1500 · 2026-10-08 | Danielle Murphy UHC-76083-23 | 2026-09-04 Office | Meadow Cardiovascular Associates Cardiology · in network | 99214 | $293.00 | $141.66 | Clean approval | — | Approved |
| CLM-2026-016361 CMS-1500 · 2026-10-08 | Logan Yang UHC-36471-89 | 2026-09-14 Office | Northgate Dermatology Clinic Dermatology · in network | 99213, 11102 | $433.00 | $208.46 | Clean approval | — | Approved |
| CLM-2026-016188 UB-04 · 2026-10-08 | Angela Perez UHC-15991-36 | 2026-09-24 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 74177 | $2,249.00 | $791.44 | Clean approval | — | Approved |
| CLM-2026-015635 UB-04 · 2026-10-08 | Adam Wong UHC-95552-17 | 2026-09-14 Outpatient hospital | Summit Regional Medical Center Emergency Medicine · in network | 70553 | $3,181.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-015596 CMS-1500 · 2026-10-08 | Teresa Sims UHC-19809-99 | 2026-08-11 Office | Harbor Cardiovascular Associates Cardiology · in network | 99214 | $236.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-015105 CMS-1500 · 2026-10-08 | Keith Garcia UHC-31785-44 | 2026-08-29 Office | Northgate Medical Group Internal Medicine · in network | 99215 | $402.00 | $229.24 | Clean approval | — | Approved |
| CLM-2026-014607 CMS-1500 · 2026-10-08 | Jesse Cole UHC-22366-11 | 2026-09-03 Office | Canyon Counseling Center Behavioral Health · out of network | 90791, 90837 | $635.00 | $245.75 | Clean approval | — | Approved |
| CLM-2026-014351 CMS-1500 · 2026-10-08 | Lori Porter UHC-02218-88 | 2026-08-24 Office | Heritage Primary Care Associates Family Medicine · in network | 36415 | $12.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-014280 CMS-1500 · 2026-10-08 | Ronald Espinoza UHC-88715-46 | 2026-09-10 Independent laboratory | Summit Reference Lab Clinical Laboratory · in network | 80061, 83036, 85025 | $177.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-014226 CMS-1500 · 2026-10-08 | Jessica Hunt UHC-73352-65 | 2026-09-08 Office | Sunrise Digestive Health Center Gastroenterology · in network | 99214 | $273.00 | $94.26 | Clean approval | — | Approved |
| CLM-2026-013830 CMS-1500 · 2026-10-08 | Wayne Castillo UHC-95042-59 | 2026-09-27 Office | Riverside Medical Group Family Medicine · in network | 99214, 36415 | $312.00 | $153.44 | Clean approval | — | Approved |
| CLM-2026-013701 CMS-1500 · 2026-10-08 | Elijah Gray UHC-73436-77 | 2026-08-26 Office | Evergreen Medical Group Family Medicine · in network | 90471, 99213 | $246.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-013189 CMS-1500 · 2026-10-08 | Camila Jensen UHC-66295-51 | 2026-08-27 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086, 83036, 85025 | $171.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-012989 CMS-1500 · 2026-10-08 | Laura Park UHC-74626-53 | 2026-09-17 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90791, 90837 | $551.00 | $266.62 | Clean approval | — | Approved |
| CLM-2026-012365 CMS-1500 · 2026-10-08 | Theresa Morrison UHC-09600-88 | 2026-09-13 Office | Evergreen Dermatology Clinic Dermatology · in network | 99213 | $159.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-012332 UB-04 · 2026-10-08 | Scott Anderson UHC-38641-40 | 2026-08-28 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99285 | $2,020.00 | $961.00 | Clean approval | — | Approved |
| CLM-2026-011716 CMS-1500 · 2026-10-08 | Marcus Collins UHC-00187-28 | 2026-09-10 Office | Meadow Family Practice Family Medicine · in network | 99214 | $259.00 | $130.58 | Clean approval | — | Approved |
| CLM-2026-011694 CMS-1500 · 2026-10-08 | Douglas Harris UHC-03403-79 | 2026-08-29 Office | Meadow Physical Therapy Physical Therapy · in network | 97110, 97140, 97014 | $210.00 | $105.20 | Clean approval | — | Approved |
| CLM-2026-011377 CMS-1500 · 2026-10-08 | Julia Hanson UHC-74657-99 | 2026-09-13 Office | Desert Rehabilitation Center Physical Therapy · in network | 97110, 97014 | $162.00 | $60.44 | Clean approval | — | Approved |
| CLM-2026-011280 CMS-1500 · 2026-10-08 | Teresa Johnson no member ID | 2026-09-05 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 85025, 83036 | $138.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-011129 CMS-1500 · 2026-10-08 | Diana Patterson UHC-03595-51 | 2026-09-19 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99214 | $239.00 | $118.18 | Clean approval | — | Approved |
| CLM-2026-010728 CMS-1500 · 2026-10-08 | Deborah Gilbert UHC-22494-09 | 2026-08-26 Office | Canyon Primary Care Associates Family Medicine · in network | 99214, 99395 | $561.00 | $317.82 | Clean approval | — | Approved |
| CLM-2026-010694 CMS-1500 · 2026-10-08 | Mary George UHC-99908-37 | 2026-10-03 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $315.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010536 CMS-1500 · 2026-10-08 | Philip Williams UHC-13566-04 | 2026-09-03 Office | Cornerstone Diabetes Center Endocrinology · in network | 83036 | $42.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-010129 CMS-1500 · 2026-10-08 | Scott Ward UHC-40403-01 | 2026-09-26 Office | Sunrise Digestive Health Center Gastroenterology · in network | 99214 | $229.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-009735 CMS-1500 · 2026-10-08 | Joe Bishop UHC-58513-77 | 2026-10-06 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97161 | $417.00 | $218.54 | Clean approval | — | Approved |
| CLM-2026-009705 CMS-1500 · 2026-10-08 | Shirley Jensen UHC-92914-52 | 2026-09-13 Office | Lakeside Medical Group Family Medicine · in network | 99213, 99214 | $400.00 | $223.00 | Clean approval | — | Approved |
| CLM-2026-009570 CMS-1500 · 2026-10-08 | Shirley Ferguson UHC-88576-07 | 2026-09-29 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 93000 | $112.00 | $39.44 | Clean approval | — | Approved |
| CLM-2026-009568 UB-04 · 2026-10-08 | Julie Kelly UHC-04129-50 | 2026-10-05 Outpatient hospital | Cornerstone Cardiovascular Associates Cardiology · in network | 93306 | $1,114.00 | $350.34 | Clean approval | — | Approved |
| CLM-2026-009229 UB-04 · 2026-10-08 | Stephen Alexander UHC-53417-56 | 2026-09-20 Emergency room | Riverside Community Hospital Emergency Medicine · in network | 96374, 71046 | $373.00 | $112.75 | Clean approval | — | Approved |
| CLM-2026-009206 UB-04 · 2026-10-08 | Samantha Morris UHC-72872-02 | 2026-10-06 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · in network | 93306, 93458 | $9,899.00 | $2,457.02 | Clean approval | — | Approved |
| CLM-2026-009106 CMS-1500 · 2026-10-08 | Amy Marshall UHC-80245-87 | 2026-09-05 Office | Pinecrest Medical Group Internal Medicine · in network | 93000, 80053 | $124.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-007810 CMS-1500 · 2026-10-08 | Santiago Gardner UHC-96725-82 | 2026-08-29 Office | Mesa Dermatology Clinic Dermatology · in network | 99213 | $177.00 | $69.74 | Clean approval | — | Approved |
| CLM-2026-006672 UB-04 · 2026-10-08 | Marilyn Hunt UHC-87899-87 | 2026-09-18 Outpatient hospital | Heritage Imaging Center Radiology · in network | 70553, 71046, 76700 | $2,718.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-006319 UB-04 · 2026-10-08 | Carl Santos UHC-14190-34 | 2026-09-16 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 74177 | $1,776.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-006256 CMS-1500 · 2026-10-08 | Zachary Harris UHC-04428-62 | 2026-09-26 Office | Northgate Heart Institute Cardiology · in network | 93224 | $479.00 | $246.98 | Clean approval | — | Approved |
| CLM-2026-006244 UB-04 · 2026-10-08 | Paul Hughes UHC-04092-93 | 2026-09-30 Emergency room | Canyon Regional Medical Center Emergency Medicine · in network | 71046, 96374 | $433.00 | $95.70 | Clean approval | — | Approved |
| CLM-2026-006128 UB-04 · 2026-10-08 | Karen Wong UHC-75927-48 | 2026-08-29 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 71046, 76700 | $692.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-006087 CMS-1500 · 2026-10-08 | Cynthia Flores UHC-94639-58 | 2026-09-08 Office | Mesa Medical Group Family Medicine · in network | 99395, 99213 | $398.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-006058 CMS-1500 · 2026-10-08 | Timothy Reynolds UHC-76724-37 | 2026-03-19 Office | Meadow Medical Group Family Medicine · in network | 99395, 36415 | $329.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-005967 CMS-1500 · 2026-10-08 | Denise Young UHC-62842-53 | 2026-09-03 Office | Sunrise Physical Therapy Physical Therapy · in network | 97110 | $182.00 | $92.84 | Clean approval | — | Approved |
| CLM-2026-005566 UB-04 · 2026-10-08 | Ashley Owens UHC-03541-20 | 2026-10-02 Outpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $10,560.00 | $4,275.73 | Clean approval | — | Approved |
| CLM-2026-004692 CMS-1500 · 2026-10-08 | Dorothy Hill UHC-52013-53 | 2026-09-22 Office | Evergreen Family Practice Family Medicine · in network | 90471, 99203 | $298.00 | $160.58 | Clean approval | — | Approved |
| CLM-2026-004499 CMS-1500 · 2026-10-08 | Lawrence Clark UHC-09797-27 | 2026-09-27 Office | Sunrise Internal Medicine Associates Internal Medicine · in network | 99214 | $279.00 | $142.98 | Clean approval | — | Approved |
| CLM-2026-004329 CMS-1500 · 2026-10-08 | Carolyn Sullivan UHC-93054-21 | 2026-09-07 Office | Sunrise Behavioral Health Behavioral Health · in network | 90834 | $225.00 | $99.50 | Clean approval | — | Approved |
| CLM-2026-004256 UB-04 · 2026-10-08 | John Torres UHC-31945-76 | 2026-09-30 Emergency room | Unity Community Hospital Emergency Medicine · in network | 71046, 99283 | $1,265.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-003557 UB-04 · 2026-10-08 | Chris Meyer UHC-40579-79 | 2026-09-07 Emergency room | Sunrise Community Hospital Emergency Medicine · in network | 99283, 96374 | $1,255.00 | $440.25 | Clean approval | — | Approved |
| CLM-2026-003468 CMS-1500 · 2026-10-08 | Russell Jacobs UHC-03633-88 | 2026-10-04 Office | Meadow Primary Care Associates Family Medicine · in network | 99395, 99203 | $431.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-003456 CMS-1500 · 2026-10-08 | Michael Holmes UHC-66752-04 | 2026-09-05 Office | Riverside Family Practice Family Medicine · in network | 90471 | $43.00 | $6.66 | 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.