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-2026-011558 UB-04 · 2026-09-28 | Jesse Green UHC-20267-72 | 2026-09-04 Outpatient hospital | Lakeside Digestive Health Center Gastroenterology · in network | 43239, 88305 | $2,403.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022507 CMS-1500 · 2026-09-27 | Gabriel Watson UHC-73072-51 | 2026-08-31 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · in network | 83036 | $60.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-005335 CMS-1500 · 2026-09-27 | Santiago Crawford no member ID | 2026-08-17 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 83036, 80053, 85025 | $179.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028860 CMS-1500 · 2026-09-26 | Margaret Ramirez no member ID | 2026-08-09 Office | Heritage Medical Group Internal Medicine · in network | 99215, 99214 | $543.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-027093 CMS-1500 · 2026-09-26 | Billy Welch UHC-99018-57 | 2026-09-04 Telehealth | Canyon Counseling Center Behavioral Health · out of network | 99214 | $288.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-015732 CMS-1500 · 2026-09-25 | Andrea Kennedy UHC-99655-87 | 2026-09-02 Office | Canyon Primary Care Associates Family Medicine · in network | 99213, 99203 | $348.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-006935 CMS-1500 · 2026-09-25 | Juan Powell UHC-99289-88 | 2026-08-25 Office | Mesa Cardiovascular Associates Cardiology · in network | 93224, 99214 | $799.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-005683 CMS-1500 · 2026-09-25 | Robert Ross UHC-39201-16 | 2026-09-12 Office | Summit Cardiovascular Associates Cardiology · in network | 93224 | $379.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-005540 CMS-1500 · 2026-09-25 | Arjun Larson UHC-89929-24 | 2026-08-05 Office | Harbor Medical Group Family Medicine · in network | 36415, 99213 | $194.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-034184 UB-04 · 2026-09-24 | William Weaver UHC-50237-81 | 2026-08-22 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284, 99285, 71046 | $3,997.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014977 CMS-1500 · 2026-09-23 | Olivia Padilla UHC-81861-12 | 2026-08-07 Office | Mesa Behavioral Health Behavioral Health · in network | 90834 | $206.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-005712 CMS-1500 · 2026-09-23 | Adam Vega UHC-59055-13 | 2026-08-06 Independent laboratory | Desert Clinical Laboratories Clinical Laboratory · in network | 80061, 87086, 83036 | $194.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024049 CMS-1500 · 2026-09-22 | Larry Chapman UHC-59123-12 | 2026-09-02 Independent laboratory | Meadow Clinical Laboratories Clinical Laboratory · in network | 85025 | $54.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-001664 UB-04 · 2026-09-22 | Randy Barnes UHC-19730-93 | 2026-09-02 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306 | $1,144.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-033063 CMS-1500 · 2026-09-21 | Mariana Johnson UHC-60276-16 | 2026-08-11 Office | Summit Internal Medicine Associates Internal Medicine · in network | 99214, 99215 | $623.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-009057 CMS-1500 · 2026-09-21 | Richard Hawkins UHC-05462-25 | 2026-08-19 Office | Lakeside Skin Care Associates Dermatology · in network | 17110 | $221.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-004107 CMS-1500 · 2026-09-20 | Juan Kelly UHC-12228-04 | 2026-08-03 Independent laboratory | Northgate Reference Lab Clinical Laboratory · in network | 87086, 83036 | $108.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-002176 CMS-1500 · 2026-09-20 | Jacqueline West UHC-85592-57 | 2026-08-27 Office | Summit Cardiovascular Associates Cardiology · in network | 93224 | $347.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-016399 CMS-1500 · 2026-09-19 | Wei Gomez UHC-05045-78 | 2026-08-23 Office | Desert Medical Group Internal Medicine · in network | 99215 | $381.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-012054 CMS-1500 · 2026-09-19 | Janet Stone UHC-04296-62 | 2026-08-03 Office | Summit Counseling Center Behavioral Health · in network | 90791, 90834 | $556.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-002193 CMS-1500 · 2026-09-19 | Logan Payne UHC-81447-44 | 2026-08-23 Independent laboratory | Sunrise Clinical Laboratories Clinical Laboratory · in network | 87086, 80053 | $111.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-000891 UB-04 · 2026-09-18 | Lauren Valdez UHC-73108-23 | 2026-08-20 Outpatient hospital | Desert Imaging Center Radiology · in network | 70553 | $3,414.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-026630 CMS-1500 · 2026-09-17 | Logan Luna UHC-90592-70 | 2026-08-07 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110, 97140, 97161 | $435.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-026586 CMS-1500 · 2026-09-17 | Larry Gutierrez UHC-44338-82 | 2026-08-11 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 83036 | $71.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-002859 CMS-1500 · 2026-09-17 | Anthony Knight UHC-86954-11 | 2026-08-02 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 80061, 83036 | $131.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024774 CMS-1500 · 2026-09-16 | Angela Cole UHC-48801-96 | 2026-08-01 Office | Valley Medical Group Internal Medicine · in network | 93000 | $73.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022902 CMS-1500 · 2026-09-16 | Amy Kennedy UHC-82897-98 | 2026-08-29 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · in network | 80061 | $67.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-021558 CMS-1500 · 2026-09-16 | Don Richardson UHC-97967-62 | 2026-08-11 Office | Harbor Primary Care Associates Family Medicine · out of network | 99203 | $260.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-016743 CMS-1500 · 2026-09-16 | Megan Richardson UHC-70659-16 | 2026-09-07 Office | Northgate Cardiovascular Associates Cardiology · in network | 99214 | $293.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-012638 UB-04 · 2026-09-16 | Brian Burke UHC-98758-75 | 2026-09-07 Outpatient hospital | Riverside Imaging Center Radiology · in network | 76700, 71046, 70553 | $3,433.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022001 CMS-1500 · 2026-09-15 | Alice Armstrong no member ID | 2026-08-02 Office | Sunrise GI Associates Gastroenterology · in network | 99214 | $293.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-006800 CMS-1500 · 2026-09-15 | Melissa Butler UHC-21038-92 | 2026-08-07 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 80061, 80053 | $109.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-005392 CMS-1500 · 2026-09-15 | William Banks UHC-17248-72 | 2026-08-05 Office | Meadow Family Practice Family Medicine · in network | 99213, 99214, 36415 | $426.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-018923 CMS-1500 · 2026-09-14 | Christina Estrada UHC-05394-63 | 2026-07-27 Office | Meadow Medical Group Family Medicine · in network | 99203, 99395 | $516.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-016705 CMS-1500 · 2026-09-14 | Charles Ortiz UHC-92395-20 | 2026-08-27 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $292.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-020694 CMS-1500 · 2026-09-12 | Samuel Fields UHC-70900-77 | 2026-07-22 Office | Desert Medical Group Internal Medicine · in network | 99214, 80053 | $273.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-016873 CMS-1500 · 2026-09-12 | Gary Carr UHC-96382-92 | 2026-08-08 Telehealth | Sunrise Counseling Center Behavioral Health · in network | 99214 | $250.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-001451 UB-04 · 2026-09-12 | Edward Garcia UHC-82255-21 | 2026-08-02 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99284 | $1,740.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-029966 CMS-1500 · 2026-09-11 | Joan Maldonado UHC-93987-64 | 2026-07-24 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 93000 | $83.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-015088 UB-04 · 2026-09-11 | Wei Riley UHC-77186-88 | 2026-07-20 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,304.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-011227 CMS-1500 · 2026-09-11 | Brandon Duncan UHC-13760-68 | 2026-08-08 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 87086, 80061, 85025, 83036 | $212.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-008220 CMS-1500 · 2026-09-11 | Lawrence Kelly UHC-78966-48 | 2026-08-11 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 85025, 83036 | $126.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-034556 CMS-1500 · 2026-09-10 | Willie Medina UHC-66180-38 | 2026-07-11 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 85025 | $43.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-009850 CMS-1500 · 2026-09-10 | Christian Ray UHC-82209-54 | 2026-08-09 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 80053 | $40.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-008887 CMS-1500 · 2026-09-10 | Christopher Perkins UHC-80375-81 | 2026-08-28 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $296.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-001449 CMS-1500 · 2026-09-10 | Amy Myers UHC-78281-86 | 2026-08-29 Office | Valley Skin Care Associates Dermatology · out of network | 11403, 11102 | $705.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-031622 UB-04 · 2026-09-09 | Ana Gibson UHC-12515-95 | 2026-07-31 Outpatient hospital | Valley Heart Institute Cardiology · in network | 93306, 93015 | $1,543.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-023169 UB-04 · 2026-09-09 | Santiago Gonzales UHC-46097-50 | 2026-08-04 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 70553, 74177 | $4,442.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-011896 CMS-1500 · 2026-09-09 | Jack Fowler UHC-96462-49 | 2026-07-17 Office | Meadow Primary Care Associates Family Medicine · in network | 36415 | $18.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024813 CMS-1500 · 2026-09-08 | Eric Schmidt UHC-94650-89 | 2026-08-23 Office | Harbor Physical Therapy Physical Therapy · in network | 97110 | $340.00 | — | Denied by rule CO18 | — | Denied |
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.