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
3,664
50 with an AI recommendation
Pended
2,586
awaiting information or identity
Approved
23,942
$6,757,768.45 plan paid
Denied
4,454
with remittance reason codes
Examiner decided
0
167 not attached to an identity
| Claim | Member | Service | Provider | Procedures | Billed | Plan pays | Rules | AI | Status |
|---|---|---|---|---|---|---|---|---|---|
| CLM-2026-000907 CMS-1500 · 2026-08-06 | Mark Howell UHC-59331-75 | 2026-07-24 Independent laboratory | Desert Reference Lab Clinical Laboratory · in network | 80053, 83036, 87086 | $185.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-025849 CMS-1500 · 2026-08-05 | Peter Hart UHC-61611-95 | 2026-07-10 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 80053, 93000, 99215 | $445.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-025245 CMS-1500 · 2026-08-05 | Sara Burton UHC-95297-67 | 2026-06-13 Independent laboratory | Sunrise Clinical Laboratories Clinical Laboratory · in network | 85025 | $49.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-010949 CMS-1500 · 2026-08-05 | Dorothy Sandoval UHC-73203-21 | 2026-06-13 Office | Summit Family Practice Family Medicine · in network | 99214, 99203 | $422.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-005552 CMS-1500 · 2026-08-05 | Sophia Long UHC-32948-05 | 2026-06-25 Office | Heritage Medical Group Family Medicine · out of network | 99213 | $188.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-007187 CMS-1500 · 2026-08-04 | Donald Daniels UHC-31510-08 | 2026-06-21 Office | Lakeside Heart Institute Cardiology · in network | 99214 | $301.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-005790 CMS-1500 · 2026-08-04 | Susan Greene UHC-10018-12 | 2026-07-20 Office | Unity Internal Medicine Associates Internal Medicine · out of network | 80053 | $87.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-015371 CMS-1500 · 2026-08-03 | Aaron Rojas UHC-11544-93 | 2026-07-05 Office | Mesa Medical Group Family Medicine · in network | 99203, 36415, 99214 | $432.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-009066 CMS-1500 · 2026-08-03 | Aisha Butler UHC-74011-36 | 2026-06-11 Office | Northgate Heart Institute Cardiology · in network | 93224 | $386.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003007 CMS-1500 · 2026-08-02 | Maria King UHC-23433-66 | 2026-07-12 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97140 | $451.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-034573 CMS-1500 · 2026-08-01 | Debra Schmidt UHC-39182-52 | 2026-06-16 Office | Riverside Primary Care Associates Family Medicine · in network | 99214 | $315.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-030156 CMS-1500 · 2026-07-31 | Adam Taylor UHC-10122-04 | 2026-06-12 Office | Mesa Family Practice Family Medicine · in network | 99214, 99395 | $630.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-005941 CMS-1500 · 2026-07-31 | Gloria Burke UHC-56404-96 | 2026-06-24 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 80061 | $45.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-000205 CMS-1500 · 2026-07-31 | Valentina Thomas UHC-90800-20 | 2026-06-13 Office | Meadow Heart Institute Cardiology · out of network | 99214 | $331.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-033644 CMS-1500 · 2026-07-30 | Matthew Lewis UHC-42467-38 | 2026-06-22 Independent laboratory | Unity Reference Lab Clinical Laboratory · in network | 87086 | $55.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029519 UB-04 · 2026-07-30 | Amber Clark UHC-93868-90 | 2026-06-04 Inpatient hospital | Desert Medical Group Internal Medicine · in network | 99232 | $190.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-006183 CMS-1500 · 2026-07-30 | Ashley Park UHC-77999-99 | 2026-06-26 Office | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 20610, 99213 | $479.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-005089 CMS-1500 · 2026-07-30 | Paul Martinez UHC-85993-86 | 2026-06-26 Office | Heritage Family Practice Family Medicine · in network | 36415, 90471 | $58.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003035 CMS-1500 · 2026-07-30 | Jonathan Bell UHC-75396-89 | 2026-06-12 Office | Lakeside Skin Care Associates Dermatology · in network | 11403, 99213 | $598.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003414 UB-04 · 2026-07-29 | Teresa Woods UHC-42550-05 | 2026-06-11 Outpatient hospital | Northgate Cardiovascular Associates Cardiology · in network | 93458 | $7,786.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-027174 CMS-1500 · 2026-07-27 | Gloria Guerrero UHC-00519-84 | 2026-06-25 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 80053, 85025 | $106.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-025829 UB-04 · 2026-07-27 | Sue Brown UHC-88779-73 | 2026-06-14 Outpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,147.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-023652 CMS-1500 · 2026-07-26 | Jacqueline Padilla UHC-58059-62 | 2026-05-31 Office | Harbor Diabetes Center Endocrinology · in network | 99214, 95251 | $481.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-004859 UB-04 · 2026-07-26 | Roger Luna UHC-68542-23 | 2026-06-16 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283, 71046 | $1,201.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-014605 CMS-1500 · 2026-07-25 | Linda Payne UHC-36742-54 | 2026-07-16 Office | Summit Family Practice Family Medicine · in network | 90471 | $40.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-017813 CMS-1500 · 2026-07-24 | Samuel Lynch UHC-18157-27 | 2026-05-25 Office | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 99213, 20610 | $381.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-013487 CMS-1500 · 2026-07-24 | Jeerry Green UHC-67734-23 | 2026-05-28 Office | Unity Physical Therapy Physical Therapy · in network | 97110 | $63.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-033410 CMS-1500 · 2026-07-23 | Bradley Oliver UHC-67161-27 | 2026-05-29 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 85025, 83036 | $87.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-015651 CMS-1500 · 2026-07-22 | Sarah Millar UHC-52058-49 | 2026-06-19 Office | Pinecrest Medical Group Family Medicine · in network | 99213 | $166.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-014703 CMS-1500 · 2026-07-22 | Edward Jensen UHC-23832-56 | 2026-06-20 Office | Meadow Family Practice Family Medicine · in network | 99203, 99214 | $461.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-011293 UB-04 · 2026-07-21 | Victoria Jensen UHC-65773-86 | 2026-05-30 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 77067, 74177 | $1,749.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-025551 CMS-1500 · 2026-07-20 | Roy Duncan UHC-19828-47 | 2026-07-07 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 87086 | $31.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-025314 UB-04 · 2026-07-20 | Albert Payne UHC-86332-25 | 2026-05-27 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $30,618.00 | — | Left for review REPL HIGH | — | Needs review |
| CLM-2026-013163 UB-04 · 2026-07-20 | Madison Nichols UHC-60294-10 | 2026-05-21 Outpatient hospital | Summit Imaging Center Radiology · in network | 77067 | $277.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-004879 CMS-1500 · 2026-07-20 | Charles Larson UHC-12794-92 | 2026-07-03 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 80053 | $86.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-001360 CMS-1500 · 2026-07-20 | Catherine Peterson UHC-33326-02 | 2026-05-18 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99215, 99214 | $714.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-023034 UB-04 · 2026-07-18 | Harold Clark UHC-35350-52 | 2026-06-19 Emergency room | Meadow Regional Medical Center Emergency Medicine · in network | 96374 | $195.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-021528 CMS-1500 · 2026-07-18 | Mariana Snyder UHC-66101-08 | 2026-06-11 Office | Evergreen Family Practice Family Medicine · in network | 99203 | $182.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-018752 CMS-1500 · 2026-07-17 | Mason Schultz UHC-06517-82 | 2026-06-09 Office | Evergreen Family Practice Family Medicine · in network | 99203 | $226.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-014286 CMS-1500 · 2026-07-17 | Henry Alexander UHC-31938-22 | 2026-06-05 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $56.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-000246 CMS-1500 · 2026-07-17 | Ralph Schultz UHC-47566-06 | 2026-06-07 Office | Unity Primary Care Associates Family Medicine · in network | 90471 | $39.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-030708 CMS-1500 · 2026-07-16 | Julia Banks UHC-28147-69 | 2026-06-15 Office | Desert Diabetes Center Endocrinology · in network | 83036 | $68.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-011124 CMS-1500 · 2026-07-15 | Sandra Butler UHC-50637-67 | 2026-06-13 Office | Mesa Medical Group Family Medicine · in network | 36415 | $19.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-002564 CMS-1500 · 2026-07-14 | Sophia Myers UHC-31513-50 | 2026-05-28 Telehealth | Canyon Counseling Center Behavioral Health · out of network | 99214 | $315.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-011793 UB-04 · 2026-07-13 | Roy Watson UHC-53548-27 | 2026-06-16 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 74177 | $1,549.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-024205 CMS-1500 · 2026-07-12 | Mei Miller UHC-86504-87 | 2026-07-02 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 85025, 80061 | $102.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-010364 CMS-1500 · 2026-07-11 | Sofia Anderson UHC-07135-27 | 2026-05-30 Office | Canyon Cardiovascular Associates Cardiology · in network | 93224 | $449.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-019329 CMS-1500 · 2026-07-10 | Alexander Thompson UHC-81966-47 | 2026-06-08 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 85025, 83036 | $95.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029684 UB-04 · 2026-07-09 | Mateo Salazar UHC-62782-53 | 2026-05-19 Outpatient hospital | Mesa Cardiovascular Associates Cardiology · in network | 93306 | $1,324.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-027250 UB-04 · 2026-07-09 | Joan Jimenez UHC-70453-27 | 2026-06-27 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 29881 | $8,762.00 | — | 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.