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-2026-025302 UB-04 · 2026-10-13 | Helen Singh UHC-90545-25 | 2026-09-09 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 71046, 77067 | $499.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-024891 CMS-1500 · 2026-10-13 | Doris Coleman UHC-38524-53 | 2026-09-08 Office | Desert Medical Group Internal Medicine · in network | 93000 | $92.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-023629 CMS-1500 · 2026-10-13 | Sean Sean UHC-92857-60 | 2026-09-06 Office | Mesa Dermatology Clinic Dermatology · in network | 99213, 17110 | $350.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-020583 UB-04 · 2026-10-13 | Tyler Yang UHC-30040-50 | 2026-09-24 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $48,569.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-011878 CMS-1500 · 2026-10-13 | Kevin Patel UHC-81454-64 | 2026-09-16 Office | Unity Physical Therapy Physical Therapy · in network | 97110 | $372.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-009027 UB-04 · 2026-10-13 | Jacob Fields UHC-76092-02 | 2026-09-02 Outpatient hospital | Unity Imaging Center Radiology · out of network | 71046, 77067, 76700 | $928.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001871 UB-04 · 2026-10-13 | Vincent Howard UHC-15428-40 | 2026-09-11 Inpatient hospital | Harbor Medical Group Internal Medicine · out of network | 99232 | $181.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001195 CMS-1500 · 2026-10-13 | Ray Peters UHC-72190-33 | 2026-09-10 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 80053, 93000 | $172.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-000447 UB-04 · 2026-10-13 | Austin Robinson UHC-83901-95 | 2026-09-07 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458 | $5,014.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-032825 UB-04 · 2026-10-12 | Aisha Cole UHC-86878-50 | 2026-09-07 Emergency room | Valley Regional Medical Center Emergency Medicine · in network | 99283 | $1,083.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-032320 CMS-1500 · 2026-10-12 | Benjamin Contreras UHC-74433-78 | 2026-10-07 Office | Sunrise Behavioral Health Behavioral Health · in network | 90791, 90834 | $547.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-031122 CMS-1500 · 2026-10-12 | Janice Rose UHC-67004-45 | 2026-09-17 Office | Riverside Primary Care Associates Family Medicine · in network | 99395, 99214, 36415 | $575.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-028136 CMS-1500 · 2026-10-12 | Mason Garcia UHC-80156-07 | 2026-05-09 Office | Meadow Heart Institute Cardiology · out of network | 93224 | $438.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-022834 CMS-1500 · 2026-10-12 | Charlotte Ortiz UHC-52389-49 | 2026-09-27 Office | Mesa Medical Group Internal Medicine · in network | 99214 | $272.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-018964 UB-04 · 2026-10-12 | Charles Burton UHC-47128-17 | 2026-09-07 Outpatient hospital | Riverside Imaging Center Radiology · in network | 77067 | $342.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-016133 UB-04 · 2026-10-12 | Richard Clark UHC-54936-57 | 2026-09-05 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99285 | $2,496.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-013555 CMS-1500 · 2026-10-12 | Helen Hill UHC-07235-61 | 2026-09-12 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97161 | $399.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-013391 UB-04 · 2026-10-12 | Nathan Singh UHC-25477-01 | 2026-09-07 Outpatient hospital | Desert Imaging Center Radiology · in network | 77067, 70553 | $2,676.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-011632 CMS-1500 · 2026-10-12 | Carlos Perkins UHC-67445-33 | 2026-09-02 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061, 83036, 87086 | $156.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010199 CMS-1500 · 2026-10-12 | Melissa Hudson UHC-49229-90 | 2026-09-23 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 83036 | $64.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-007527 CMS-1500 · 2026-10-12 | Deborah Wang UHC-09134-29 | 2026-10-09 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 99214, 80053 | $364.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-005924 CMS-1500 · 2026-10-12 | Heather Lopez UHC-55811-29 | 2026-09-04 Office | Sunrise Diabetes Center Endocrinology · in network | 99215 | $296.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-004844 CMS-1500 · 2026-10-12 | Sean Chapman UHC-35561-40 | 2026-10-09 Office | Canyon Primary Care Associates Family Medicine · in network | 99395, 99214, 36415 | $587.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-003740 CMS-1500 · 2026-10-12 | Arjun Ward UHC-59588-89 | 2026-09-25 Office | Heritage Medical Group Internal Medicine · in network | 99215 | $299.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-003566 CMS-1500 · 2026-10-12 | Mark Gomez UHC-29262-82 | 2026-06-26 Office | Valley Internal Medicine Associates Internal Medicine · in network | 99215 | $420.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-001237 CMS-1500 · 2026-10-12 | Karen Anderson UHC-48865-86 | 2026-09-05 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086 | $64.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-034365 UB-04 · 2026-10-11 | Vincent Thomas UHC-37542-71 | 2026-10-09 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177, 77067 | $1,752.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-033989 CMS-1500 · 2026-10-11 | Diana Phillips UHC-60258-47 | 2026-08-27 Office | Sunrise Medical Group Internal Medicine · out of network | 99214, 93000, 99215 | $715.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-033721 CMS-1500 · 2026-10-11 | Terry Gomez UHC-19314-17 | 2026-09-10 Office | Valley Skin Care Associates Dermatology · out of network | 11403, 11102 | $843.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-033226 CMS-1500 · 2026-10-11 | Ruth Weaver UHC-27012-03 | 2026-09-20 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $224.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-032985 CMS-1500 · 2026-10-11 | Billy Contreras UHC-74899-95 | 2026-09-22 Office | Cornerstone Family Practice Family Medicine · out of network | 99213, 90471 | $211.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032669 UB-04 · 2026-10-11 | Henry Hanson no member ID | 2026-09-23 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · in network | 45378 | $2,462.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-032440 CMS-1500 · 2026-10-11 | Robert Garcia UHC-56494-97 | 2026-06-29 Office | Canyon Primary Care Associates Family Medicine · in network | 99213, 99214 | $440.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-032376 CMS-1500 · 2026-10-11 | Wayne Diez UHC-82176-57 | 2026-10-01 Office | Mesa GI Associates Gastroenterology · in network | 99214 | $315.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-032272 UB-04 · 2026-10-11 | Eugeene Reyes UHC-32191-16 | 2026-08-25 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $7,356.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028562 UB-04 · 2026-10-11 | Douglas Kim UHC-49616-13 | 2026-09-29 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285 | $1,664.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-027111 CMS-1500 · 2026-10-11 | Natalie Fernandez UHC-04526-89 | 2026-07-01 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $228.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-024112 UB-04 · 2026-10-11 | Daniel Thomas UHC-78647-56 | 2026-09-09 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 74177, 77067 | $2,456.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-021824 CMS-1500 · 2026-10-11 | Lawrence Rice UHC-99232-21 | 2026-08-27 Office | Sunrise Medical Group Family Medicine · in network | 99213, 36415 | $176.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-017325 CMS-1500 · 2026-10-11 | Grace Burton UHC-52024-75 | 2026-09-30 Office | Canyon Medical Group Internal Medicine · in network | 80053, 99214 | $387.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-017261 CMS-1500 · 2026-10-11 | Marilyn Ferguson UHC-33529-32 | 2026-09-21 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061 | $80.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-014959 CMS-1500 · 2026-10-11 | Cunningham Omar UHC-84013-63 | 2026-08-13 Office | Riverside Bone and Joint Center Orthopedic Surgery · in network | 99213 | $208.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-010386 CMS-1500 · 2026-10-11 | Noah Coleman UHC-80842-13 | 2026-09-03 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11403, 99213 | $537.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-007811 CMS-1500 · 2026-10-11 | Santiago Gardner UHC-96725-82 | 2026-08-29 Office | Mesa Dermatology Clinic Dermatology · in network | 99213 | $177.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-006310 CMS-1500 · 2026-10-11 | Santiago Johnston UHC-07734-93 | 2026-09-03 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90837 | $216.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006231 CMS-1500 · 2026-10-11 | Debra Powell UHC-90874-75 | 2026-09-13 Office | Harbor Medical Group Internal Medicine · out of network | 93000, 80053 | $148.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-005668 UB-04 · 2026-10-11 | Diane Mendez UHC-02276-61 | 2026-09-04 Inpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 27447 | $43,670.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-002360 CMS-1500 · 2026-10-11 | Virginia Smith UHC-62024-73 | 2026-09-22 Office | Summit Family Practice Family Medicine · in network | 99395, 99214 | $533.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-031974 CMS-1500 · 2026-10-10 | Terry Walker UHC-13254-77 | 2026-09-04 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 83036, 80053 | $98.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-030438 CMS-1500 · 2026-10-10 | Scott Thomas UHC-23637-74 | 2026-09-30 Office | Lakeside Dermatology Clinic Dermatology · in network | 99213, 11403, 17110 | $986.00 | — | 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.