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-2026-013745 UB-04 · 2026-10-16 | Billy Reid UHC-17079-68 | 2026-09-19 Outpatient hospital | Heritage Imaging Center Radiology · in network | 77067, 70553 | $2,364.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-011852 CMS-1500 · 2026-10-16 | Heather Carpenter UHC-81594-70 | 2026-09-23 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80053, 85025 | $106.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-011470 CMS-1500 · 2026-10-16 | Valentina Coleman UHC-82461-63 | 2026-07-09 Office | Riverside Internal Medicine Associates Internal Medicine · in network | 80053 | $54.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-009760 CMS-1500 · 2026-10-16 | Jose Vega UHC-35189-94 | 2026-09-12 Office | Canyon Counseling Center Behavioral Health · out of network | 90791 | $315.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-008361 UB-04 · 2026-10-16 | Judy Payne UHC-70825-08 | 2026-09-23 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 71046 | $137.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007243 UB-04 · 2026-10-16 | Jesse Alexander UHC-98335-18 | 2026-10-08 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553, 71046 | $3,684.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004493 CMS-1500 · 2026-10-16 | Brandon Bryant UHC-60328-88 | 2026-10-05 Office | Heritage Physical Therapy Physical Therapy · in network | 97110, 97161 | $374.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-002334 CMS-1500 · 2026-10-16 | Juan Banks no member ID | 2026-06-19 Office | Harbor Diabetes Center Endocrinology · in network | 99214, 95251 | $350.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-001215 CMS-1500 · 2026-10-16 | Madison Jenkins UHC-28890-43 | 2026-09-11 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 83036 | $76.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-031999 CMS-1500 · 2026-10-15 | Dorothy Herrera UHC-12392-13 | 2026-09-16 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90834 | $191.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-030080 CMS-1500 · 2026-10-15 | Rebecca Carlson UHC-32126-56 | 2026-04-23 Office | Meadow Primary Care Associates Family Medicine · in network | 99395 | $285.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-027414 UB-04 · 2026-10-15 | Gregory Hunt UHC-84710-60 | 2026-09-23 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $6,359.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-025650 UB-04 · 2026-10-15 | Rachel Lopez UHC-43524-49 | 2026-10-02 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $35,527.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-019603 CMS-1500 · 2026-10-15 | Lori Nunez UHC-64875-75 | 2026-08-31 Office | Heritage Physical Therapy Physical Therapy · in network | 97110, 97140 | $310.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-018854 UB-04 · 2026-10-15 | Gloria Yang UHC-77975-62 | 2026-10-07 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 93458, 93306 | $10,394.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-018704 CMS-1500 · 2026-10-15 | Emily Lucas UHC-12704-17 | 2026-10-07 Office | Heritage Primary Care Associates Family Medicine · in network | 99213 | $201.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014947 CMS-1500 · 2026-10-15 | Stephen Soto UHC-38096-98 | 2026-09-18 Office | Valley Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $461.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-009682 CMS-1500 · 2026-10-15 | Sandra Jackson UHC-78773-38 | 2026-10-09 Office | Valley Skin Care Associates Dermatology · out of network | 17110, 99213 | $480.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-007944 UB-04 · 2026-10-15 | Ryan Walker UHC-79552-94 | 2026-05-28 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283, 71046 | $1,287.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-006258 CMS-1500 · 2026-10-15 | Jerry Jensen UHC-63050-35 | 2026-09-03 Office | Harbor Medical Group Internal Medicine · out of network | 99214, 80053 | $257.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004719 UB-04 · 2026-10-15 | Douglas Harris UHC-15357-52 | 2026-10-07 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $39,961.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-003579 UB-04 · 2026-10-15 | Albert Tran no member ID | 2026-09-10 Outpatient hospital | Evergreen GI Associates Gastroenterology · in network | 45378 | $2,026.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-001025 CMS-1500 · 2026-10-15 | Harold Patterson UHC-04603-36 | 2026-09-17 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $337.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-000582 UB-04 · 2026-10-15 | Arjun Santos UHC-17803-51 | 2026-09-03 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378 | $1,676.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-034579 CMS-1500 · 2026-10-14 | Keith Vazquez UHC-01356-46 | 2026-09-09 Office | Lakeside Medical Group Family Medicine · in network | 99395, 99213 | $508.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-034029 UB-04 · 2026-10-14 | Ryan Li UHC-59343-89 | 2026-06-24 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 88305 | $352.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-031918 CMS-1500 · 2026-10-14 | Gary Armstrong UHC-04189-51 | 2026-09-05 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 85025 | $51.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-030339 CMS-1500 · 2026-10-14 | Jeremy Jacobs UHC-82894-81 | 2026-09-21 Office | Meadow Family Practice Family Medicine · in network | 99395, 36415 | $313.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-029540 UB-04 · 2026-10-14 | Mary Munz UHC-13183-92 | 2026-10-10 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 43239, 45378 | $4,347.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-028498 CMS-1500 · 2026-10-14 | Frances Jenkins UHC-08557-87 | 2026-10-04 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110 | $282.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-028107 CMS-1500 · 2026-10-14 | Dylan Parker UHC-07807-62 | 2026-09-28 Office | Canyon Counseling Center Behavioral Health · out of network | 90834, 90791 | $627.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026540 CMS-1500 · 2026-10-14 | Samuel Obrien UHC-78534-34 | 2026-08-18 Independent laboratory | Summit Reference Lab Clinical Laboratory · in network | 80061, 85025 | $114.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-026234 UB-04 · 2026-10-14 | Victoria Richards UHC-93067-18 | 2026-09-04 Outpatient hospital | Cornerstone Imaging Center Radiology · in network | 77067, 74177, 71046 | $2,873.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-024818 UB-04 · 2026-10-14 | Aisha Nguyen UHC-89751-57 | 2026-09-10 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700 | $396.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-023532 UB-04 · 2026-10-14 | Andrew Hicks UHC-20492-19 | 2026-03-30 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 70553, 71046 | $2,750.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-022432 CMS-1500 · 2026-10-14 | Steven Gilbert UHC-22739-27 | 2026-09-06 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90791, 90834 | $439.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-020836 CMS-1500 · 2026-10-14 | Matthew Day UHC-65445-38 | 2026-09-11 Office | Desert Medical Group Internal Medicine · in network | 99214, 99215 | $568.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-016714 CMS-1500 · 2026-10-14 | Matthew Day UHC-65445-38 | 2026-09-16 Office | Canyon Primary Care Associates Family Medicine · in network | 99203, 99395, 36415 | $452.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014338 CMS-1500 · 2026-10-14 | Ralph Cole UHC-07842-57 | 2026-09-22 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140, 97161 | $507.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-011031 UB-04 · 2026-10-14 | Omar Hunt UHC-97434-51 | 2026-10-03 Outpatient hospital | Heritage Imaging Center Radiology · in network | 76700, 70553 | $3,006.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-010733 CMS-1500 · 2026-10-14 | Gerald Ruiz UHC-14467-45 | 2026-10-07 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $232.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-007350 CMS-1500 · 2026-10-14 | Brandon Pena UHC-11986-61 | 2026-10-09 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99203, 99214 | $527.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-006344 CMS-1500 · 2026-10-14 | Noah Campbell UHC-25272-68 | 2026-10-06 Office | Sunrise Medical Group Family Medicine · in network | 99395, 99203 | $516.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-003642 CMS-1500 · 2026-10-14 | George Miller UHC-23025-90 | 2026-09-02 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 99215, 93000 | $411.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-034571 CMS-1500 · 2026-10-13 | Elizabeth Schultz UHC-01992-56 | 2026-09-30 Office | Evergreen Medical Group Internal Medicine · out of network | 80053, 93000, 99215 | $530.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-034284 UB-04 · 2026-10-13 | Mateo Perez UHC-46817-61 | 2026-09-23 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 70553, 76700 | $3,143.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-030736 CMS-1500 · 2026-10-13 | Ethan Vazquez UHC-36033-31 | 2026-08-25 Independent laboratory | Summit Reference Lab Clinical Laboratory · in network | 80061 | $46.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-030070 CMS-1500 · 2026-10-13 | Pamela Snadoval UHC-52330-59 | 2026-09-14 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99203 | $242.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028031 CMS-1500 · 2026-10-13 | Lucia Gomez UHC-42126-16 | 2026-03-20 Office | Meadow Heart Institute Cardiology · in network | 99214, 93224 | $630.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-026211 UB-04 · 2026-10-13 | Judy Wells UHC-84471-03 | 2026-10-10 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 70553, 74177 | $5,764.00 | — | 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.