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-2026-004216 UB-04 · 2026-10-18 | Alexander Reid UHC-77022-69 | 2026-09-16 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 71046, 70553 | $3,057.00 | — | Denied by rule CO27 | — | Denied |
| 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-2026-003431 UB-04 · 2026-10-18 | Emily Palmer UHC-80821-83 | 2026-09-08 Outpatient hospital | Pinecrest Heart Institute Cardiology · in network | 93458 | $5,465.00 | $888.96 | 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-2026-003164 UB-04 · 2026-10-18 | Nancy Wong UHC-74984-66 | 2026-09-13 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 88305, 45378 | $2,851.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-002928 UB-04 · 2026-10-18 | Roy Burns UHC-22217-24 | 2026-09-07 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $178.00 | $0.00 | Clean approval | — | Approved |
| 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-2026-002847 UB-04 · 2026-10-18 | Philip Bradley UHC-47879-82 | 2026-09-11 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 71046 | $114.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-002809 UB-04 · 2026-10-18 | Olivia Armstrong UHC-25797-48 | 2026-05-27 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458, 93015 | $5,527.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-002598 UB-04 · 2026-10-18 | Lawrence Ellis UHC-63165-77 | 2026-09-26 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 96374 | $246.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-002531 UB-04 · 2026-10-18 | Margaret Hunter UHC-03826-60 | 2026-09-25 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177 | $1,203.00 | — | Left for review CO50 | — | Needs review |
| 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-2026-001442 UB-04 · 2026-10-18 | Sophia Howell UHC-51733-01 | 2026-09-26 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 43239, 45378, 88305 | $4,193.00 | $1,058.91 | Clean approval | — | Approved |
| CLM-2026-001208 UB-04 · 2026-10-18 | Alexander Robertson UHC-20832-08 | 2026-09-29 Outpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,651.00 | — | Denied by rule CO27 | — | Denied |
| 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-2026-000165 UB-04 · 2026-10-18 | Bradley Russell UHC-45171-11 | 2026-09-28 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $38,503.00 | — | Left for review HIGH | — | Needs review |
| 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-2026-032950 UB-04 · 2026-10-17 | Charlotte Sanchez UHC-10300-72 | 2026-09-23 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283 | $890.00 | $50.50 | 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-2026-032764 UB-04 · 2026-10-17 | Diana Williamson UHC-93292-52 | 2026-10-07 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 71046 | $172.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032717 UB-04 · 2026-10-17 | Victoria Padilla UHC-84331-08 | 2026-09-27 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 76700, 71046 | $614.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032479 UB-04 · 2026-10-17 | Ralph Garza UHC-69417-14 | 2026-09-30 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $203.00 | — | Left for review REPL | — | Needs review |
| 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-2026-031941 UB-04 · 2026-10-17 | Mark Riley UHC-38683-19 | 2026-10-01 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 96374, 99284 | $1,564.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-031465 UB-04 · 2026-10-17 | Steven Guzman UHC-15163-18 | 2026-10-01 Outpatient hospital | Valley Imaging Center Radiology · in network | 71046 | $143.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030816 UB-04 · 2026-10-17 | Carl Smith UHC-10143-60 | 2026-10-02 Outpatient hospital | Heritage Digestive Health Center Gastroenterology · in network | 45378 | $2,697.00 | $154.38 | Clean approval | — | Approved |
| CLM-2026-030671 UB-04 · 2026-10-17 | Peter Lane UHC-22452-89 | 2026-09-28 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $35,985.00 | — | Denied by rule CO197 | — | Denied |
| 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 |
| CLM-2026-028704 CMS-1500 · 2026-10-17 | Pamela Scott UHC-72353-94 | 2026-10-07 Office | Sunrise Internal Medicine Associates Internal Medicine · in network | 99215 | $353.00 | $198.86 | Clean approval | — | Approved |
| CLM-2026-028673 CMS-1500 · 2026-10-17 | Dylan Robertson UHC-45403-96 | 2026-10-11 Office | Valley Rehabilitation Center Physical Therapy · in network | 97110 | $225.00 | $109.50 | Clean approval | — | Approved |
| CLM-2026-028489 CMS-1500 · 2026-10-17 | Deborah Vasquez UHC-04821-42 | 2026-09-23 Office | Desert Medical Group Internal Medicine · in network | 99215, 80053, 93000 | $440.00 | $232.80 | Clean approval | — | Approved |
| CLM-2026-028432 CMS-1500 · 2026-10-17 | Mary Jordan UHC-43821-91 | 2026-09-08 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 93000 | $69.00 | $12.78 | Clean approval | — | Approved |
| CLM-2026-028403 CMS-1500 · 2026-10-17 | Bobby Dominguez UHC-26590-88 | 2026-10-07 Office | Sunrise Skin Care Associates Dermatology · in network | 99213, 17110, 11403 | $858.00 | $456.96 | Clean approval | — | Approved |
| CLM-2026-028239 UB-04 · 2026-10-17 | Christopher Mendez UHC-78590-93 | 2026-10-01 Outpatient hospital | Meadow Regional Medical Center Emergency Medicine · in network | 70553 | $2,335.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-028236 CMS-1500 · 2026-10-17 | Maria Evans UHC-09452-22 | 2026-10-05 Office | Canyon Skin Care Associates Dermatology · in network | 17110 | $222.00 | $97.64 | Clean approval | — | Approved |
| CLM-2026-027168 UB-04 · 2026-10-17 | Sharon Patterson UHC-01025-68 | 2026-10-07 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99283, 71046 | $1,247.00 | $535.85 | Clean approval | — | Approved |
| CLM-2026-026788 CMS-1500 · 2026-10-17 | Michael Campbell UHC-94863-84 | 2026-09-07 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97161, 97014 | $335.00 | $187.70 | Clean approval | — | Approved |
| CLM-2026-026667 UB-04 · 2026-10-17 | Vincent Castillo UHC-39871-55 | 2026-10-13 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $203.00 | $10.80 | Clean approval | — | Approved |
| CLM-2026-026123 CMS-1500 · 2026-10-17 | William Simpson UHC-87572-94 | 2026-10-14 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 93000, 80053 | $135.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-025433 CMS-1500 · 2026-10-17 | Christian Cruz UHC-81334-28 | 2026-10-06 Office | Pinecrest Family Practice Family Medicine · in network | 36415, 99203 | $251.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025372 CMS-1500 · 2026-10-17 | Willie Martin UHC-69388-74 | 2026-09-18 Office | Heritage Medical Group Family Medicine · in network | 99395, 36415 | $323.00 | $175.26 | Clean approval | — | Approved |
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.