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-2026-003301 CMS-1500 · 2026-10-08 | Kyle Richards UHC-09435-37 | 2026-08-29 Office | Meadow Family Practice Family Medicine · in network | 99213, 99395, 99214 | $712.00 | $421.44 | Clean approval | — | Approved |
| CLM-2026-003143 CMS-1500 · 2026-10-08 | Mason Edwards UHC-10902-28 | 2026-09-17 Office | Meadow Medical Group Family Medicine · in network | 99395, 36415, 90471 | $309.00 | $171.58 | Clean approval | — | Approved |
| CLM-2026-002869 UB-04 · 2026-10-08 | Camila Munoz no member ID | 2026-09-30 Outpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 70553 | $2,983.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002485 CMS-1500 · 2026-10-08 | Mark Hoffman UHC-11330-50 | 2026-09-16 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 80061 | $82.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-002457 CMS-1500 · 2026-10-08 | Jeffrey Clark UHC-45965-92 | 2026-09-01 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 80053 | $84.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-002434 CMS-1500 · 2026-10-08 | Kathryn Duncan UHC-43519-95 | 2026-09-26 Office | Meadow Physical Therapy Physical Therapy · in network | 97110, 97161, 97014 | $532.00 | $304.84 | Clean approval | — | Approved |
| CLM-2026-002069 UB-04 · 2026-10-08 | Ana Jackson UHC-71686-49 | 2026-09-23 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $29,621.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-001794 CMS-1500 · 2026-10-08 | Frances Wilson UHC-38544-97 | 2026-10-01 Office | Lakeside Medical Group Family Medicine · out of network | 99395, 99213 | $468.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001583 UB-04 · 2026-10-08 | Ryan Grant UHC-15044-36 | 2026-08-25 Outpatient hospital | Pinecrest Heart Institute Cardiology · in network | 70553, 93015 | $2,227.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-001351 CMS-1500 · 2026-10-08 | Joan Knight UHC-05751-15 | 2026-09-04 Office | Harbor Family Practice Family Medicine · in network | 99214, 90471, 36415 | $337.00 | $178.94 | Clean approval | — | Approved |
| CLM-2026-000581 UB-04 · 2026-10-08 | Camila James UHC-60493-89 | 2026-09-29 Inpatient hospital | Unity Medical Group Internal Medicine · in network | 99232 | $208.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-000571 CMS-1500 · 2026-10-08 | Maria Perry UHC-77478-68 | 2026-09-01 Independent laboratory | Northgate Reference Lab Clinical Laboratory · in network | 80053, 80061, 87086 | $186.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-000458 CMS-1500 · 2026-10-08 | Austin Herrera UHC-82062-87 | 2026-09-10 Independent laboratory | Cornerstone Clinical Laboratories Clinical Laboratory · in network | 80053, 85025 | $133.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-034309 UB-04 · 2026-10-07 | Cheryl Grant UHC-37922-39 | 2026-09-24 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 77067, 76700, 71046 | $972.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-034214 CMS-1500 · 2026-10-07 | Grace Phillips UHC-93122-46 | 2026-09-16 Office | Desert Primary Care Associates Family Medicine · in network | 99203, 99214 | $505.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-034077 CMS-1500 · 2026-10-07 | Brenda Ortiz UHC-96228-35 | 2026-08-30 Office | Harbor Physical Therapy Physical Therapy · in network | 97110, 97014 | $272.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-034039 UB-04 · 2026-10-07 | Tyler Meyer UHC-68314-07 | 2026-10-01 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 70553 | $3,117.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-033080 UB-04 · 2026-10-07 | Jason Gray UHC-15887-53 | 2026-08-21 Outpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 29881, 73721 | $9,059.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-032798 CMS-1500 · 2026-10-07 | Alan Washington UHC-48480-40 | 2026-09-09 Office | Meadow Primary Care Associates Family Medicine · in network | 99213, 99395, 36415 | $413.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-032499 CMS-1500 · 2026-10-07 | Rebecca Howard UHC-89882-71 | 2026-09-04 Office | Sunrise Counseling Center Behavioral Health · in network | 90837, 90834 | $484.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-032055 CMS-1500 · 2026-10-07 | Fatima Coleman UHC-25318-23 | 2026-09-29 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99215 | $280.00 | $143.60 | Clean approval | — | Approved |
| CLM-2026-031605 CMS-1500 · 2026-10-07 | Jerry Garrett UHC-37380-56 | 2026-09-06 Office | Heritage Family Practice Family Medicine · in network | 90471 | $30.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-031503 CMS-1500 · 2026-10-07 | Aaron Evans UHC-51560-75 | 2026-09-06 Office | Canyon Internal Medicine Associates Internal Medicine · in network | 80053, 99215 | $413.00 | $226.06 | Clean approval | — | Approved |
| CLM-2026-031234 UB-04 · 2026-10-07 | Jean Contreras UHC-29251-65 | 2026-08-29 Outpatient hospital | Riverside Community Hospital Emergency Medicine · in network | 70553 | $2,827.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-031132 CMS-1500 · 2026-10-07 | Diana Spencer UHC-15396-79 | 2026-08-30 Office | Riverside Family Practice Family Medicine · in network | 99203, 99214 | $519.00 | $301.78 | Clean approval | — | Approved |
| CLM-2026-030557 CMS-1500 · 2026-10-07 | Samuel Marquez UHC-23159-56 | 2026-09-24 Office | Harbor Primary Care Associates Family Medicine · in network | 99213 | $174.00 | $87.88 | Clean approval | — | Approved |
| CLM-2026-030456 CMS-1500 · 2026-10-07 | Nancy Lane UHC-50508-51 | 2026-09-26 Office | Harbor Medical Group Internal Medicine · in network | 80053 | $82.00 | $10.84 | Clean approval | — | Approved |
| CLM-2026-030289 CMS-1500 · 2026-10-07 | Daniel Freeman UHC-53118-31 | 2026-09-21 Office | Valley Skin Care Associates Dermatology · out of network | 99213, 17110 | $378.00 | $120.10 | Clean approval | — | Approved |
| CLM-2026-029961 CMS-1500 · 2026-10-07 | Zachary Thompson no member ID | 2026-09-02 Office | Sunrise Medical Group Internal Medicine · out of network | 93000 | $98.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-029912 CMS-1500 · 2026-10-07 | Nancy Myers UHC-82208-74 | 2026-08-25 Office | Lakeside Skin Care Associates Dermatology · in network | 17110 | $226.00 | $100.12 | Clean approval | — | Approved |
| CLM-2026-029891 CMS-1500 · 2026-10-07 | Sophia Alexander UHC-65817-15 | 2026-09-08 Office | Sunrise Behavioral Health Behavioral Health · in network | 90834, 90837 | $468.00 | $230.16 | Clean approval | — | Approved |
| CLM-2026-029650 CMS-1500 · 2026-10-07 | Rachel Coleman UHC-34040-77 | 2026-09-26 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99215, 80053 | $437.00 | $240.94 | Clean approval | — | Approved |
| CLM-2026-029649 UB-04 · 2026-10-07 | Gary Wood UHC-33276-59 | 2026-09-30 Emergency room | Cornerstone Regional Medical Center Emergency Medicine · in network | 99283, 71046 | $1,095.00 | $252.25 | Clean approval | — | Approved |
| CLM-2026-029386 CMS-1500 · 2026-10-07 | Pamela Jordan UHC-28186-78 | 2026-09-06 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 87086, 80053 | $114.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-029383 CMS-1500 · 2026-10-07 | Joe Crawford UHC-55441-33 | 2026-09-04 Office | Evergreen Family Practice Family Medicine · in network | 36415 | $21.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-029100 CMS-1500 · 2026-10-07 | Alan Romero UHC-40574-12 | 2026-09-17 Office | Unity Family Practice Family Medicine · in network | 99395, 99214 | $523.00 | $284.26 | Clean approval | — | Approved |
| CLM-2026-029044 UB-04 · 2026-10-07 | Maira Kim UHC-95297-64 | 2026-08-25 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $2,579.00 | — | Left for review NET | — | Needs review |
| CLM-2026-028269 UB-04 · 2026-10-07 | Teresa Coleman UHC-01517-27 | 2026-10-02 Inpatient hospital | Pinecrest Medical Group Internal Medicine · in network | 99232 | $196.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-028211 CMS-1500 · 2026-10-07 | Virginia Graham UHC-41763-34 | 2026-08-25 Office | Harbor Physical Therapy Physical Therapy · in network | 97110 | $364.00 | $185.68 | Clean approval | — | Approved |
| CLM-2026-027664 CMS-1500 · 2026-10-07 | Mari Park UHC-74024-31 | 2026-09-20 Office | Pinecrest Medical Group Family Medicine · in network | 99203, 36415 | $198.00 | $82.76 | Clean approval | — | Approved |
| CLM-2026-027565 CMS-1500 · 2026-10-07 | Beverly Grant UHC-75207-50 | 2026-08-23 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110 | $237.00 | $116.94 | Clean approval | — | Approved |
| CLM-2026-027470 CMS-1500 · 2026-10-07 | Raymond Day UHC-13009-12 | 2026-09-01 Office | Heritage Medical Group Family Medicine · out of network | 90471, 36415 | $58.00 | $10.35 | Clean approval | — | Approved |
| CLM-2026-027205 CMS-1500 · 2026-10-07 | Hiroshi Brooks UHC-65032-33 | 2026-08-27 Office | Unity Family Practice Family Medicine · in network | 99214, 36415 | $323.00 | $175.26 | Clean approval | — | Approved |
| CLM-2026-027178 UB-04 · 2026-10-07 | Ryan Hunter UHC-48235-63 | 2026-09-16 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285, 99284, 96374 | $4,448.00 | $1,851.60 | Clean approval | — | Approved |
| CLM-2026-026732 UB-04 · 2026-10-07 | Lori George UHC-37487-27 | 2026-08-29 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 76700 | $383.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-026693 CMS-1500 · 2026-10-07 | Janet Grant UHC-09003-41 | 2026-10-04 Office | Cornerstone Family Practice Family Medicine · out of network | 99214, 90471 | $266.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026491 UB-04 · 2026-10-07 | Lucia Holmes UHC-11141-74 | 2026-09-11 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 74177 | $1,305.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025220 CMS-1500 · 2026-10-07 | Peter Brooks UHC-56867-96 | 2026-09-12 Office | Cornerstone Diabetes Center Endocrinology · in network | 99214, 95251 | $457.00 | $208.34 | Clean approval | — | Approved |
| CLM-2026-024741 CMS-1500 · 2026-10-07 | Alan Lopez UHC-37303-83 | 2026-08-30 Office | Unity Primary Care Associates Family Medicine · out of network | 90471 | $37.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-024532 CMS-1500 · 2026-10-07 | Richard Brown UHC-07594-55 | 2026-09-10 Office | Desert Cardiovascular Associates Cardiology · in network | 99214 | $278.00 | $97.36 | 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.