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-2026-025033 UB-04 · 2026-08-27 | Not attached | 2026-07-26 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99285, 71046 | $2,179.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-032461 UB-04 · 2026-08-26 | Zachary Greene UHC-69793-13 | 2026-08-13 Outpatient hospital | Summit Imaging Center Radiology · in network | 71046 | $148.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-027020 UB-04 · 2026-08-26 | Santiago Reed UHC-53248-15 | 2026-08-16 Outpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 29881, 73721 | $8,284.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-021300 UB-04 · 2026-08-26 | Carol Jordan UHC-04959-09 | 2026-07-20 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 45378 | $1,715.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-013582 CMS-1500 · 2026-08-26 | Logan Hart UHC-52400-48 | 2026-08-16 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97014 | $248.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-012629 UB-04 · 2026-08-23 | Donald Griffin UHC-74616-95 | 2026-07-29 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 45378 | $2,338.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-028178 CMS-1500 · 2026-08-22 | Austin Burton UHC-94455-39 | 2026-07-24 Office | Meadow Physical Therapy Physical Therapy · in network | 97110 | $279.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-006957 CMS-1500 · 2026-08-22 | Not attached | 2026-08-17 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $431.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-000947 CMS-1500 · 2026-08-22 | Teresa Reyes UHC-34995-40 | 2026-08-08 Independent laboratory | Pinecrest Clinical Laboratories Clinical Laboratory · in network | 80053 | $81.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-026409 UB-04 · 2026-08-20 | Samuel Mitchell UHC-84599-11 | 2026-08-04 Emergency room | Meadow Regional Medical Center Emergency Medicine · in network | 71046, 99283, 96374 | $1,381.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-023645 CMS-1500 · 2026-08-20 | Camila Chen UHC-66437-32 | 2026-07-07 Independent laboratory | Unity Clinical Laboratories Clinical Laboratory · in network | 83036 | $63.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-017334 CMS-1500 · 2026-08-20 | Not attached | 2026-07-31 Independent laboratory | Cornerstone Clinical Laboratories Clinical Laboratory · in network | 83036, 80053 | $141.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-007299 CMS-1500 · 2026-08-20 | Brittany Richardson UHC-80551-30 | 2026-08-05 Office | Northgate Medical Group Family Medicine · in network | 99203, 36415 | $263.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-009585 CMS-1500 · 2026-08-19 | Amanda Li UHC-98440-07 | 2026-07-23 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 99214, 99215, 93000 | $774.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-009573 CMS-1500 · 2026-08-19 | Not attached | 2026-08-13 Office | Sunrise Internal Medicine Associates Internal Medicine · in network | 93000, 99215 | $447.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-013732 CMS-1500 · 2026-08-18 | Patrick Sanders UHC-58486-46 | 2026-08-04 Office | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 20610 | $259.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-002422 CMS-1500 · 2026-08-18 | Not attached | 2026-07-28 Office | Lakeside Medical Group Family Medicine · in network | 99203, 99395 | $455.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-022425 CMS-1500 · 2026-08-17 | Billy Cook UHC-50005-94 | 2026-07-06 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97014 | $356.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-011351 CMS-1500 · 2026-08-17 | Carolyn Guzman UHC-42076-73 | 2026-08-13 Office | Evergreen Medical Group Family Medicine · in network | 90471, 99214 | $337.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-005337 UB-04 · 2026-08-17 | Carl Gardner UHC-45737-62 | 2026-08-07 Outpatient hospital | Harbor Diagnostic Imaging Radiology · in network | 76700 | $549.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-030802 UB-04 · 2026-08-16 | Elijah Vega UHC-68333-42 | 2026-07-05 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 45378, 43239 | $3,431.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-018726 CMS-1500 · 2026-08-16 | Mark Reyes UHC-44839-36 | 2026-07-31 Office | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 99213 | $185.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-001120 UB-04 · 2026-08-16 | James Henderson UHC-00613-90 | 2026-07-10 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 43239, 45378, 88305 | $3,675.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-021339 CMS-1500 · 2026-08-14 | Timothy Long UHC-46380-98 | 2026-08-08 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110 | $146.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-020584 CMS-1500 · 2026-08-13 | Benjamin Tran UHC-71519-79 | 2026-07-17 Office | Sunrise Skin Care Associates Dermatology · in network | 11403 | $475.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-000628 CMS-1500 · 2026-08-12 | Jose Harvey UHC-69584-36 | 2026-08-07 Office | Evergreen Medical Group Family Medicine · in network | 99203, 99213 | $410.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-021966 CMS-1500 · 2026-08-11 | Raymond Snyder UHC-68621-79 | 2026-07-20 Office | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 20610 | $237.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-004860 CMS-1500 · 2026-08-09 | Matthew Hanson UHC-50046-10 | 2026-07-24 Office | Unity Counseling Center Behavioral Health · in network | 90834 | $182.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-000866 UB-04 · 2026-08-09 | Not attached | 2026-07-25 Outpatient hospital | Riverside Imaging Center Radiology · in network | 76700 | $611.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-015797 CMS-1500 · 2026-08-08 | Stephen Ross UHC-82658-64 | 2026-07-07 Office | Summit Endocrine Associates Endocrinology · in network | 99215 | $354.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-012460 CMS-1500 · 2026-08-08 | Lucia Rios UHC-92720-51 | 2026-07-26 Office | Valley Skin Care Associates Dermatology · out of network | 11102, 17110 | $520.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-007722 CMS-1500 · 2026-08-08 | Stephen Brown UHC-37752-51 | 2026-07-07 Independent laboratory | Unity Clinical Laboratories Clinical Laboratory · in network | 83036, 85025 | $81.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-032394 CMS-1500 · 2026-08-07 | Not attached | 2026-07-09 Office | Pinecrest Medical Group Family Medicine · in network | 36415 | $24.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-024475 UB-04 · 2026-08-07 | Mason Rios UHC-58394-45 | 2026-06-30 Inpatient hospital | Lakeside Medical Group Internal Medicine · in network | 99232 | $215.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-021178 UB-04 · 2026-08-06 | Not attached | 2026-07-26 Outpatient hospital | Desert Imaging Center Radiology · in network | 71046 | $200.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-011700 UB-04 · 2026-08-06 | Zachary Greene UHC-69793-13 | 2026-07-25 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283 | $746.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-003305 UB-04 · 2026-08-06 | Not attached | 2026-07-10 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283 | $917.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-000539 UB-04 · 2026-08-06 | Not attached | 2026-06-27 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · in network | 93306, 93015 | $1,820.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-034071 UB-04 · 2026-08-05 | Mei Nguyen UHC-95381-17 | 2026-07-27 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 96374, 99284 | $1,648.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-025674 CMS-1500 · 2026-08-05 | Mara Reynolds UHC-36945-54 | 2026-06-23 Office | Mesa Family Practice Family Medicine · in network | 99213, 36415 | $233.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-014004 CMS-1500 · 2026-08-05 | Kayla Kelley UHC-25348-74 | 2026-07-11 Office | Unity Medical Group Internal Medicine · in network | 93000 | $107.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-032174 CMS-1500 · 2026-08-04 | Harold Mejia UHC-63645-91 | 2026-07-19 Office | Northgate Medical Group Family Medicine · in network | 90471 | $39.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-022468 UB-04 · 2026-08-04 | Not attached | 2026-07-15 Outpatient hospital | Summit Imaging Center Radiology · in network | 77067, 70553 | $2,817.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-022299 CMS-1500 · 2026-08-04 | Olivia Gonzales UHC-00411-18 | 2026-06-30 Office | Sunrise Dermatology Clinic Dermatology · in network | 99213 | $217.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-011241 UB-04 · 2026-08-02 | Carl Rian UHC-07924-72 | 2026-07-15 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 70553, 71046, 74177 | $4,376.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-021633 UB-04 · 2026-07-31 | Not attached | 2026-06-18 Inpatient hospital | Heritage Internal Medicine Associates Internal Medicine · in network | 99232 | $216.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-018781 CMS-1500 · 2026-07-31 | Janice Henry UHC-34207-15 | 2026-07-07 Office | Mesa Family Practice Family Medicine · in network | 99213, 99395 | $549.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-016525 CMS-1500 · 2026-07-31 | Jacqueline Padilla UHC-58059-62 | 2026-07-10 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 83036 | $47.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-010637 UB-04 · 2026-07-31 | Linda Torres UHC-32071-63 | 2026-07-01 Inpatient hospital | Sunrise Internal Medicine Associates Internal Medicine · in network | 99232 | $260.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-001760 CMS-1500 · 2026-07-31 | Not attached | 2026-07-17 Office | Mesa Family Practice Family Medicine · in network | 36415 | $25.00 | — | Pended by rule CO16 | — | Pended |
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.