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
3,663
89 with an AI recommendation
Pended
2,587
awaiting information or identity
Approved
23,942
$6,757,768.45 plan paid
Denied
4,454
with remittance reason codes
Examiner decided
1
167 not attached to an identity
| Claim | Member | Service | Provider | Procedures | Billed | Plan pays | Rules | AI | Status |
|---|---|---|---|---|---|---|---|---|---|
| CLM-2026-026696 CMS-1500 · 2026-10-18 | Paul Kelley UHC-55115-85 | 2026-10-04 Office | Harbor Physical Therapy Physical Therapy · in network | 97110, 97161 | $449.00 | $248.38 | Clean approval | — | Approved |
| CLM-2026-026691 CMS-1500 · 2026-10-18 | Gabriel Sanders UHC-13138-62 | 2026-09-03 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99214, 93000 | $392.00 | $223.04 | Clean approval | — | Approved |
| CLM-2026-025903 CMS-1500 · 2026-10-18 | Jason Garrett UHC-04664-80 | 2026-09-18 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99215, 80053 | $385.00 | $213.70 | Clean approval | — | Approved |
| CLM-2026-025758 CMS-1500 · 2026-10-18 | Joseph Olson UHC-17116-81 | 2026-09-28 Office | Mesa Behavioral Health Behavioral Health · in network | 90837 | $221.00 | $87.02 | Clean approval | — | Approved |
| CLM-2026-025618 UB-04 · 2026-10-18 | Janet Delgado UHC-86657-86 | 2026-10-13 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 43239, 88305 | $1,736.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-025606 CMS-1500 · 2026-10-18 | Lawrence Watson UHC-48583-08 | 2026-10-04 Office | Desert Cardiovascular Associates Cardiology · in network | 93224, 99214 | $516.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-025088 CMS-1500 · 2026-10-18 | Julie Hart UHC-16029-61 | 2026-09-02 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $310.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024838 UB-04 · 2026-10-18 | Gloria Simpson UHC-36962-36 | 2026-10-01 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 77067, 74177 | $2,662.00 | $865.05 | Clean approval | — | Approved |
| CLM-2026-024711 UB-04 · 2026-10-18 | Kenneth Henry UHC-27427-73 | 2026-09-17 Outpatient hospital | Unity Imaging Center Radiology · out of network | 77067, 71046, 76700 | $982.00 | $39.38 | Clean approval | — | Approved |
| CLM-2026-024653 UB-04 · 2026-10-18 | Keith Jones UHC-95396-91 | 2026-09-17 Outpatient hospital | Valley Imaging Center Radiology · in network | 71046, 74177 | $1,959.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-024368 UB-04 · 2026-10-18 | Omar Holmes UHC-04491-04 | 2026-09-27 Outpatient hospital | Unity Diagnostic Imaging Radiology · in network | 74177, 70553 | $5,077.00 | — | Left for review CO50 CO97 | — | Needs review |
| CLM-2026-024333 UB-04 · 2026-10-18 | Thomas Walker UHC-98355-06 | 2026-09-15 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 45378, 88305 | $2,964.00 | $1,076.06 | Clean approval | — | Approved |
| CLM-2026-024186 CMS-1500 · 2026-10-18 | Joyce Guerrero UHC-29388-20 | 2026-09-15 Independent laboratory | Unity Reference Lab Clinical Laboratory · in network | 85025 | $56.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-024142 CMS-1500 · 2026-10-18 | Helen Hicks UHC-81077-42 | 2026-09-16 Office | Evergreen Medical Group Family Medicine · in network | 99213 | $171.00 | $66.02 | Clean approval | — | Approved |
| CLM-2026-024099 UB-04 · 2026-10-18 | Roger Bennett UHC-51537-03 | 2026-10-11 Outpatient hospital | Evergreen Digestive Health Center Gastroenterology · in network | 70553 | $3,498.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-024097 UB-04 · 2026-10-18 | Christine Wright UHC-27440-91 | 2026-09-15 Outpatient hospital | Heritage Digestive Health Center Gastroenterology · in network | 45378, 88305 | $1,824.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-024000 CMS-1500 · 2026-10-18 | Lawrence George UHC-17614-13 | 2026-10-03 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80061, 83036 | $137.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-023996 UB-04 · 2026-10-18 | Frank Richards UHC-92254-86 | 2026-09-29 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 96374, 71046 | $468.00 | $122.10 | Clean approval | — | Approved |
| CLM-2026-023751 CMS-1500 · 2026-10-18 | Samantha Washington UHC-17963-87 | 2026-09-21 Office | Pinecrest Medical Group Family Medicine · in network | 99203, 99213 | $386.00 | $199.32 | Clean approval | — | Approved |
| CLM-2026-023733 CMS-1500 · 2026-10-18 | Isabella Burton UHC-09055-50 | 2026-09-21 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 93000, 80053, 99214 | $416.00 | $232.92 | Clean approval | — | Approved |
| CLM-2026-023692 CMS-1500 · 2026-10-18 | Sofia Guerrero UHC-42523-31 | 2026-09-06 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 80061, 87086 | $164.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023616 UB-04 · 2026-10-18 | Tyler Carter UHC-34633-94 | 2026-09-11 Outpatient hospital | Canyon Primary Care Associates Family Medicine · in network | 70553 | $3,097.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-023366 UB-04 · 2026-10-18 | Paul Marshall UHC-10623-89 | 2026-09-29 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 93015 | $418.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023208 UB-04 · 2026-10-18 | Austin Li UHC-41620-28 | 2026-09-03 Outpatient hospital | Canyon Regional Medical Center Emergency Medicine · in network | 70553 | $2,294.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-023016 CMS-1500 · 2026-10-18 | Joe Weaver UHC-65868-91 | 2026-09-10 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 85025, 87086, 80053 | $163.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-022851 UB-04 · 2026-10-18 | Pamela Tran UHC-95837-67 | 2026-04-02 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 29881 | $8,489.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-021847 CMS-1500 · 2026-10-18 | Tony Luna UHC-56014-62 | 2026-09-30 Office | Evergreen Family Practice Family Medicine · in network | 99213, 90471, 99395 | $525.00 | $295.50 | Clean approval | — | Approved |
| CLM-2026-021441 CMS-1500 · 2026-10-18 | Jeremy Fernandez UHC-50658-84 | 2026-09-19 Office | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 99213 | $205.00 | $67.10 | Clean approval | — | Approved |
| CLM-2026-020927 UB-04 · 2026-10-18 | Lauren Hoffman UHC-16769-64 | 2026-09-11 Outpatient hospital | Evergreen Cardiovascular Associates Cardiology · in network | 93458, 93015 | $5,623.00 | $543.26 | Clean approval | — | Approved |
| CLM-2026-020561 CMS-1500 · 2026-10-18 | John Maldonado UHC-79682-77 | 2026-10-05 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97161 | $403.00 | $219.86 | Clean approval | — | Approved |
| CLM-2026-020330 CMS-1500 · 2026-10-18 | Emma McDonald UHC-14703-77 | 2026-10-04 Office | Pinecrest Family Practice Family Medicine · in network | 99203, 36415, 99214 | $460.00 | $265.20 | Clean approval | — | Approved |
| CLM-2026-019971 UB-04 · 2026-10-18 | Vincent Bell UHC-71011-63 | 2026-09-15 Outpatient hospital | Valley Digestive Health Center Gastroenterology · in network | 88305, 43239 | $2,936.00 | $354.44 | Clean approval | — | Approved |
| CLM-2026-019733 CMS-1500 · 2026-10-18 | Daniel Le no member ID | 2026-09-12 Office | Harbor Medical Group Family Medicine · in network | 99203 | $230.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-019418 CMS-1500 · 2026-10-18 | Lori Jones UHC-48852-57 | 2026-10-02 Office | Riverside Primary Care Associates Family Medicine · in network | 99213, 99395 | $497.00 | $278.14 | Clean approval | — | Approved |
| CLM-2026-019413 CMS-1500 · 2026-10-18 | Samuel Wheeler UHC-26647-40 | 2026-09-21 Office | Evergreen Medical Group Family Medicine · in network | 99214, 90471, 99213 | $462.00 | $266.44 | Clean approval | — | Approved |
| CLM-2026-018696 UB-04 · 2026-10-18 | Kyle Garcia UHC-39892-95 | 2026-09-06 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 88305, 43239, 45378 | $4,748.00 | $1,426.52 | Clean approval | — | Approved |
| CLM-2026-018689 UB-04 · 2026-10-18 | Gabriel Sanders UHC-13138-62 | 2026-09-06 Outpatient hospital | Mesa Internal Medicine Associates Internal Medicine · in network | 70553 | $2,621.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-018460 CMS-1500 · 2026-10-18 | Joyce Carr UHC-88883-33 | 2026-09-29 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 80053, 93000, 99214 | $340.00 | $185.80 | Clean approval | — | Approved |
| CLM-2026-018402 CMS-1500 · 2026-10-18 | Sara Jones UHC-75451-48 | 2026-09-14 Office | Lakeside Medical Group Family Medicine · in network | 99395, 90471, 99214 | $594.00 | $338.28 | Clean approval | — | Approved |
| CLM-2026-018059 UB-04 · 2026-10-18 | Donald Gonzales UHC-12549-84 | 2026-09-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99284, 99283 | $2,310.00 | $789.50 | Clean approval | — | Approved |
| CLM-2026-017708 CMS-1500 · 2026-10-18 | Noah Rogers UHC-89314-56 | 2026-10-11 Office | Heritage Internal Medicine Associates Internal Medicine · in network | 80053, 93000 | $168.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-017673 CMS-1500 · 2026-10-18 | Betty Jones UHC-95087-33 | 2026-09-24 Office | Sunrise Medical Group Family Medicine · in network | 90471, 99203, 99214 | $455.00 | $266.60 | Clean approval | — | Approved |
| CLM-2026-017571 UB-04 · 2026-10-18 | Jeffrey Wagner UHC-02624-89 | 2026-09-16 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 45378, 88305 | $3,102.00 | $1,056.89 | Clean approval | — | Approved |
| CLM-2026-017564 CMS-1500 · 2026-10-18 | Henry Espinoza UHC-50850-98 | 2026-05-19 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 93000 | $90.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-017491 CMS-1500 · 2026-10-18 | Joyce Roberts UHC-91571-60 | 2026-10-16 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $180.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-017328 UB-04 · 2026-10-18 | Jerry Edwards UHC-51204-16 | 2026-09-15 Outpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 70553 | $2,954.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-017139 CMS-1500 · 2026-10-18 | Eirc Foster UHC-97726-64 | 2026-09-09 Office | Meadow Family Practice Family Medicine · in network | 36415, 99214, 99395 | $539.00 | $318.68 | Clean approval | — | Approved |
| CLM-2026-016730 UB-04 · 2026-10-18 | Kathlean Silva UHC-59277-27 | 2026-09-12 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 70553 | $3,592.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-016564 CMS-1500 · 2026-10-18 | Jeremy Harper UHC-46303-79 | 2026-09-11 Office | Harbor Physical Therapy Physical Therapy · in network | 97110 | $320.00 | $168.40 | Clean approval | — | Approved |
| CLM-2026-016547 CMS-1500 · 2026-10-18 | Bobby Campbell UHC-12188-14 | 2026-09-22 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 80053 | $51.00 | $1.62 | 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.