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-2026-016265 CMS-1500 · 2026-10-18 | Barbara Mejia UHC-89568-77 | 2026-09-27 Office | Meadow Family Practice Family Medicine · in network | 99213 | $155.00 | $76.10 | Clean approval | — | Approved |
| CLM-2026-016197 CMS-1500 · 2026-10-18 | William Banks UHC-68954-36 | 2026-09-15 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · in network | 87086, 80053, 85025 | $175.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-016082 CMS-1500 · 2026-10-18 | Judith Jenkins UHC-83319-71 | 2026-10-09 Office | Unity Medical Group Internal Medicine · in network | 93000 | $76.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-015981 CMS-1500 · 2026-10-18 | Harold Rios UHC-13868-34 | 2026-09-23 Office | Lakeside Endocrine Associates Endocrinology · out of network | 95251 | $183.00 | $22.35 | Clean approval | — | Approved |
| CLM-2026-015776 CMS-1500 · 2026-10-18 | Christian Simmons UHC-65062-39 | 2026-09-06 Office | Unity Medical Group Internal Medicine · in network | 99214, 80053, 99215 | $661.00 | $379.82 | Clean approval | — | Approved |
| CLM-2026-015511 CMS-1500 · 2026-10-18 | Amy Myers UHC-78281-86 | 2026-09-27 Office | Lakeside Medical Group Family Medicine · in network | 99213 | $181.00 | $87.22 | Clean approval | — | Approved |
| CLM-2026-015335 CMS-1500 · 2026-10-18 | Barbara Cox UHC-93560-89 | 2026-10-02 Office | Heritage Medical Group Family Medicine · in network | 99213, 99203 | $400.00 | $208.00 | Clean approval | — | Approved |
| CLM-2026-014600 CMS-1500 · 2026-10-18 | Angela Bailey UHC-80041-28 | 2026-09-05 Office | Summit Endocrine Associates Endocrinology · in network | 99215, 83036 | $355.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014590 CMS-1500 · 2026-10-18 | Carolyn Richards UHC-36403-64 | 2026-09-10 Office | Sunrise GI Associates Gastroenterology · in network | 99214 | $299.00 | $110.38 | Clean approval | — | Approved |
| CLM-2026-014281 CMS-1500 · 2026-10-18 | Bobbby Robinson UHC-17176-34 | 2026-10-12 Office | Mesa Family Practice Family Medicine · in network | 99203 | $180.00 | $91.60 | Clean approval | — | Approved |
| CLM-2026-013409 CMS-1500 · 2026-10-18 | Heather Hudson UHC-13473-34 | 2026-09-16 Office | Mesa Family Practice Family Medicine · in network | 90471 | $44.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-013357 CMS-1500 · 2026-10-18 | Maria Russll UHC-17012-96 | 2026-09-04 Office | Harbor Diabetes Center Endocrinology · in network | 95251 | $201.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013139 CMS-1500 · 2026-10-18 | Joan Mason UHC-00755-30 | 2026-09-18 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99203, 99213 | $376.00 | $193.12 | Clean approval | — | Approved |
| CLM-2026-013042 CMS-1500 · 2026-10-18 | Sara Ortiz UHC-96234-58 | 2026-09-18 Office | Evergreen Internal Medicine Associates Internal Medicine · in network | 80053 | $43.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-012815 CMS-1500 · 2026-10-18 | Aaron Johnston UHC-54160-30 | 2026-09-13 Office | Evergreen Family Practice Family Medicine · in network | 99395 | $307.00 | $165.34 | Clean approval | — | Approved |
| CLM-2026-012046 CMS-1500 · 2026-10-18 | Maria Jordan UHC-32080-45 | 2026-09-07 Office | Riverside Family Practice Family Medicine · in network | 90471 | $42.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011634 CMS-1500 · 2026-10-18 | John Graham UHC-03219-23 | 2026-10-07 Office | Meadow Internal Medicine Associates Internal Medicine · in network | 99214, 80053, 99215 | $610.00 | $348.20 | Clean approval | — | Approved |
| CLM-2026-010611 CMS-1500 · 2026-10-18 | Not attached | 2026-09-05 Office | Northgate Counseling Center Behavioral Health · in network | 90791 | $375.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-009966 CMS-1500 · 2026-10-18 | Abbby Wong UHC-74228-68 | 2026-09-20 Office | Canyon Medical Group Internal Medicine · in network | 80053, 99214 | $317.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-009947 CMS-1500 · 2026-10-18 | Melissa Tran UHC-46772-18 | 2026-10-08 Office | Canyon Counseling Center Behavioral Health · out of network | 90837 | $194.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009790 CMS-1500 · 2026-10-18 | Jacob Carr UHC-36540-95 | 2026-10-10 Office | Heritage Primary Care Associates Family Medicine · in network | 36415 | $13.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-009314 CMS-1500 · 2026-10-18 | Laura Rogers UHC-88922-66 | 2026-09-30 Independent laboratory | Pinecrest Reference Lab Clinical Laboratory · in network | 87086, 83036, 80061 | $173.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-008492 CMS-1500 · 2026-10-18 | Sophia Nunez UHC-17485-17 | 2026-09-25 Independent laboratory | Desert Reference Lab Clinical Laboratory · in network | 80053, 85025, 87086 | $185.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-008013 CMS-1500 · 2026-10-18 | Jason Hunt UHC-16244-46 | 2026-09-23 Office | Northgate Primary Care Associates Family Medicine · out of network | 90471, 99214 | $314.00 | $125.55 | Clean approval | — | Approved |
| CLM-2026-007716 CMS-1500 · 2026-10-18 | Jacqueline Mitchell UHC-85622-08 | 2026-08-23 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99214, 80053 | $350.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007711 CMS-1500 · 2026-10-18 | Aaron Vazquez UHC-12265-62 | 2026-09-25 Office | Unity Medical Group Family Medicine · in network | 99395, 36415 | $313.00 | $164.06 | Clean approval | — | Approved |
| CLM-2026-007459 CMS-1500 · 2026-10-18 | Priya Nelson UHC-65947-09 | 2026-09-28 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 80061, 87086 | $85.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-007172 CMS-1500 · 2026-10-18 | Luis Ford UHC-53020-24 | 2026-10-03 Office | Evergreen Medical Group Family Medicine · in network | 36415, 99214 | $309.00 | $177.94 | Clean approval | — | Approved |
| CLM-2026-005535 CMS-1500 · 2026-10-18 | Luri Bryant UHC-70153-08 | 2026-09-17 Office | Canyon Skin Care Associates Dermatology · in network | 99213 | $158.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-004819 CMS-1500 · 2026-10-18 | Steven Estrada UHC-77984-19 | 2026-09-07 Office | Cornerstone Diabetes Center Endocrinology · in network | 99215, 99214 | $725.00 | $399.50 | Clean approval | — | Approved |
| CLM-2026-004759 CMS-1500 · 2026-10-18 | Frank Woods UHC-50088-36 | 2026-09-23 Office | Meadow Medical Group Family Medicine · in network | 99395, 99213, 99203 | $775.00 | $450.50 | Clean approval | — | Approved |
| CLM-2026-004744 CMS-1500 · 2026-10-18 | Albert Weaver UHC-17326-17 | 2026-10-13 Office | Unity Medical Group Internal Medicine · in network | 80053 | $45.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003839 CMS-1500 · 2026-10-18 | Ahmed Wallace UHC-37460-16 | 2026-09-10 Office | Valley Medical Group Family Medicine · in network | 99214, 90471 | $274.00 | $149.88 | Clean approval | — | Approved |
| CLM-2026-003319 CMS-1500 · 2026-10-18 | Keith Vazquez UHC-01356-46 | 2026-10-06 Office | Unity Dermatology Clinic Dermatology · in network | 99213, 11403 | $760.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-002915 CMS-1500 · 2026-10-18 | Joan Murphy UHC-51326-26 | 2026-10-16 Office | Sunrise Counseling Center Behavioral Health · in network | 90791, 90834 | $611.00 | $328.82 | Clean approval | — | Approved |
| CLM-2026-002469 CMS-1500 · 2026-10-18 | Brian Gonzalez UHC-11415-22 | 2026-09-18 Office | Unity Bone and Joint Center Orthopedic Surgery · in network | 99213 | $232.00 | $83.84 | Clean approval | — | Approved |
| CLM-2026-002464 CMS-1500 · 2026-10-18 | Raymond Washington UHC-78812-89 | 2026-09-03 Office | Harbor Medical Group Family Medicine · in network | 90471, 99203 | $276.00 | $146.12 | Clean approval | — | Approved |
| CLM-2026-002357 CMS-1500 · 2026-10-18 | Charles Nguyen UHC-11107-77 | 2026-09-12 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 85025, 80061 | $106.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-001670 CMS-1500 · 2026-10-18 | Anthony Johnston UHC-39804-89 | 2026-09-20 Office | Sunrise Medical Group Family Medicine · in network | 99213, 99395, 90471 | $506.00 | $273.72 | Clean approval | — | Approved |
| CLM-2026-000481 CMS-1500 · 2026-10-18 | Matthew Carpenter UHC-33751-82 | 2026-09-18 Office | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 99213 | $237.00 | $56.65 | Clean approval | — | Approved |
| CLM-2026-034428 CMS-1500 · 2026-10-17 | Omar Ortiz UHC-62827-27 | 2026-09-27 Office | Evergreen Family Practice Family Medicine · in network | 99395, 99214 | $433.00 | $243.46 | Clean approval | — | Approved |
| CLM-2026-033635 CMS-1500 · 2026-10-17 | Ashley Garza UHC-69569-85 | 2026-09-27 Office | Harbor Physical Therapy Physical Therapy · in network | 97110, 97140 | $308.00 | $165.96 | Clean approval | — | Approved |
| CLM-2026-033620 CMS-1500 · 2026-10-17 | Helen Johnson UHC-28850-11 | 2026-09-10 Office | Evergreen Primary Care Associates Family Medicine · in network | 99395 | $334.00 | $187.08 | Clean approval | — | Approved |
| CLM-2026-033611 CMS-1500 · 2026-10-17 | Sofa Weaver UHC-57114-29 | 2026-10-02 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97161 | $459.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-033256 CMS-1500 · 2026-10-17 | Scott Ward UHC-40403-01 | 2026-10-01 Office | Unity Primary Care Associates Family Medicine · out of network | 99214, 99213, 90471 | $453.00 | $173.85 | Clean approval | — | Approved |
| CLM-2026-032856 CMS-1500 · 2026-10-17 | Bruce Weaver UHC-97693-66 | 2026-09-25 Office | Riverside Bone and Joint Center Orthopedic Surgery · in network | 20610, 99213 | $461.00 | $210.82 | Clean approval | — | Approved |
| CLM-2026-032839 CMS-1500 · 2026-10-17 | Gregory Torres UHC-36621-45 | 2026-09-15 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 87086, 85025 | $71.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032797 CMS-1500 · 2026-10-17 | Noah Pena UHC-91234-26 | 2026-09-24 Office | Evergreen Dermatology Clinic Dermatology · in network | 11403 | $398.00 | $186.76 | Clean approval | — | Approved |
| CLM-2026-032076 CMS-1500 · 2026-10-17 | Charles Griffin UHC-79368-12 | 2026-09-02 Office | Evergreen Medical Group Internal Medicine · out of network | 99215 | $334.00 | $130.30 | Clean approval | — | Approved |
| CLM-2026-029651 CMS-1500 · 2026-10-17 | Rachel Coleman UHC-34040-77 | 2026-09-26 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99215, 80053 | $437.00 | — | Left for review REPL | — | Needs review |
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.