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-2026-025429 UB-04 · 2026-10-04 | Jordan Wheeler UHC-10993-15 | 2026-08-31 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $214.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-018826 CMS-1500 · 2026-10-04 | Joyce Spencer UHC-22576-11 | 2026-09-20 Office | Evergreen Family Practice Family Medicine · in network | 99395, 99214 | $465.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-010776 UB-04 · 2026-10-04 | Hiroshi Martinez UHC-21659-34 | 2026-09-11 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $51,314.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-006580 CMS-1500 · 2026-10-04 | Douglas Sandoval UHC-17618-84 | 2026-08-25 Office | Summit Family Practice Family Medicine · in network | 36415, 99213, 99203 | $389.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-031463 CMS-1500 · 2026-10-03 | Ann Ryes UHC-80982-32 | 2026-10-01 Office | Heritage Primary Care Associates Family Medicine · in network | 36415 | $23.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-027120 CMS-1500 · 2026-10-03 | Kayla Mitchell UHC-33941-54 | 2026-09-24 Office | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 20610 | $274.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-020342 UB-04 · 2026-10-03 | Marcus Gardner UHC-24243-44 | 2026-09-16 Outpatient hospital | Valley Imaging Center Radiology · in network | 71046, 77067, 74177 | $2,574.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-020112 UB-04 · 2026-10-03 | James Thompson UHC-57559-48 | 2026-09-05 Inpatient hospital | Mesa Internal Medicine Associates Internal Medicine · in network | 99232 | $253.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-018823 CMS-1500 · 2026-10-03 | Omar Hunt UHC-97434-51 | 2026-09-15 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97014 | $180.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-017964 CMS-1500 · 2026-10-03 | Robert Perkins UHC-38217-24 | 2026-08-21 Telehealth | Evergreen Counseling Center Behavioral Health · in network | 99214 | $258.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-012770 CMS-1500 · 2026-10-03 | Harold Hanson UHC-26394-19 | 2026-09-12 Office | Mesa Behavioral Health Behavioral Health · in network | 90791 | $343.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-012324 CMS-1500 · 2026-10-03 | Carolyn Wong UHC-08618-64 | 2026-09-17 Office | Valley Skin Care Associates Dermatology · in network | 99213, 17110 | $421.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-012145 UB-04 · 2026-10-03 | Camila Wang UHC-11506-03 | 2026-08-20 Outpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $9,249.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-009923 CMS-1500 · 2026-10-03 | Michelle King UHC-13873-93 | 2026-09-03 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · in network | 87086, 80061 | $99.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-006425 UB-04 · 2026-10-03 | Robert Perkins UHC-38217-24 | 2026-09-23 Emergency room | Cornerstone Regional Medical Center Emergency Medicine · in network | 96374, 71046 | $365.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-001345 UB-04 · 2026-10-03 | Alan Pierce UHC-35222-28 | 2026-09-15 Outpatient hospital | Valley Imaging Center Radiology · in network | 76700, 77067 | $782.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014443 CMS-1500 · 2026-10-02 | Alexander Reid UHC-77022-69 | 2026-09-21 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97014 | $417.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-029498 CMS-1500 · 2026-10-01 | Wayne Fields UHC-43751-22 | 2026-09-16 Office | Desert Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $466.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-028114 CMS-1500 · 2026-10-01 | Albert Olson UHC-39661-50 | 2026-09-26 Office | Meadow Primary Care Associates Family Medicine · in network | 36415 | $12.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-016205 CMS-1500 · 2026-10-01 | Samuel Castro UHC-99010-79 | 2026-09-11 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 99215 | $360.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-007090 UB-04 · 2026-10-01 | Brenda Turner UHC-44384-04 | 2026-08-20 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458 | $6,974.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-006314 CMS-1500 · 2026-10-01 | Theresa Ferguson UHC-58580-76 | 2026-09-17 Office | Northgate Medical Group Family Medicine · in network | 36415, 99214 | $254.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-003038 CMS-1500 · 2026-10-01 | Randy Wood UHC-10379-19 | 2026-09-15 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99214 | $300.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-034052 UB-04 · 2026-09-30 | Keith Gordon UHC-57784-50 | 2026-09-18 Outpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 29881 | $5,831.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-031780 CMS-1500 · 2026-09-30 | Barbara Vazquez UHC-62480-15 | 2026-09-19 Office | Unity Family Practice Family Medicine · in network | 99214, 90471 | $285.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-028305 UB-04 · 2026-09-30 | Helen Patel UHC-69833-28 | 2026-09-21 Outpatient hospital | Meadow Imaging Center Radiology · in network | 74177 | $1,483.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-027998 CMS-1500 · 2026-09-30 | Nicholas Cunningham UHC-89997-78 | 2026-09-24 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $279.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-003340 CMS-1500 · 2026-09-30 | Not attached | 2026-08-17 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · in network | 85025 | $37.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-002011 CMS-1500 · 2026-09-30 | Larry Jones UHC-94064-39 | 2026-09-10 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 85025, 87086 | $103.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-001788 CMS-1500 · 2026-09-30 | Michelle Kennedy UHC-59953-53 | 2026-08-30 Office | Pinecrest Medical Group Internal Medicine · in network | 99215 | $394.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-031908 CMS-1500 · 2026-09-29 | Isabella Lynch UHC-18597-75 | 2026-09-09 Office | Canyon Primary Care Associates Family Medicine · in network | 99395 | $294.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-031497 CMS-1500 · 2026-09-29 | Daniel Thomas UHC-78647-56 | 2026-09-26 Independent laboratory | Unity Reference Lab Clinical Laboratory · in network | 80061 | $79.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-028799 CMS-1500 · 2026-09-29 | Diana Woods UHC-77073-62 | 2026-08-29 Office | Lakeside Medical Group Family Medicine · in network | 99203, 99213 | $424.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-027186 CMS-1500 · 2026-09-29 | Elizabeth Washington UHC-87962-74 | 2026-08-28 Independent laboratory | Meadow Clinical Laboratories Clinical Laboratory · in network | 87086, 83036 | $126.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-027047 UB-04 · 2026-09-29 | Christian Carter UHC-93847-10 | 2026-09-03 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 71046, 70553 | $2,301.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-008407 CMS-1500 · 2026-09-29 | Diana Cruz UHC-19574-09 | 2026-09-03 Office | Pinecrest Family Practice Family Medicine · in network | 36415 | $25.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-024381 CMS-1500 · 2026-09-28 | Jason Herrera UHC-87054-06 | 2026-09-01 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 93000 | $111.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-007228 CMS-1500 · 2026-09-28 | Sean Alvarado UHC-95582-59 | 2026-09-15 Office | Mesa Family Practice Family Medicine · in network | 90471, 99214, 99203 | $422.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-007134 CMS-1500 · 2026-09-28 | Victoria Rogers UHC-72044-34 | 2026-09-23 Office | Valley Internal Medicine Associates Internal Medicine · in network | 93000, 80053 | $195.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-002353 CMS-1500 · 2026-09-28 | Janice Herrera UHC-91917-46 | 2026-09-07 Office | Meadow Family Practice Family Medicine · in network | 99213 | $209.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-024641 CMS-1500 · 2026-09-27 | Jason Grant UHC-51451-91 | 2026-08-21 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061 | $73.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-007377 CMS-1500 · 2026-09-27 | Christine James UHC-20756-55 | 2026-08-30 Office | Evergreen Medical Group Family Medicine · in network | 99213, 36415 | $187.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-027612 UB-04 · 2026-09-26 | Douglas Cole UHC-11333-58 | 2026-09-08 Emergency room | Meadow Regional Medical Center Emergency Medicine · in network | 99285 | $2,976.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-027053 CMS-1500 · 2026-09-26 | Grace Ray UHC-29887-60 | 2026-08-13 Office | Sunrise Counseling Center Behavioral Health · in network | 90837 | $277.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-024846 CMS-1500 · 2026-09-26 | Vincent Palmer UHC-31592-87 | 2026-09-17 Office | Mesa Family Practice Family Medicine · in network | 99214 | $234.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-023842 UB-04 · 2026-09-26 | Katherine Lucas UHC-29115-96 | 2026-08-23 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99284 | $1,636.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-021084 UB-04 · 2026-09-26 | Judy Burns UHC-13174-98 | 2026-08-13 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $9,739.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-018651 CMS-1500 · 2026-09-26 | Abigail Stephens UHC-27778-62 | 2026-08-17 Office | Harbor Diabetes Center Endocrinology · in network | 99215 | $419.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-017142 CMS-1500 · 2026-09-26 | Jordan Wheeler UHC-10993-15 | 2026-08-13 Office | Unity Primary Care Associates Family Medicine · out of network | 99214, 99395 | $511.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-016323 CMS-1500 · 2026-09-26 | Eugene Campbell UHC-94513-70 | 2026-09-15 Office | Unity Family Practice Family Medicine · in network | 36415 | $24.00 | — | Denied by rule CO27 | — | 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.