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-2026-005366 CMS-1500 · 2026-07-08 | Sarah Fuller UHC-33174-34 | 2026-05-24 Office | Sunrise Medical Group Family Medicine · in network | 99214 | $252.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008357 CMS-1500 · 2026-07-07 | Hnnah Nelson UHC-90359-46 | 2026-06-21 Office | Riverside Medical Group Family Medicine · in network | 99395, 99214 | $593.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-031138 CMS-1500 · 2026-07-06 | Kelly Kelly UHC-69020-57 | 2026-06-19 Office | Meadow Primary Care Associates Family Medicine · in network | 90471, 99214, 36415 | $362.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-018348 CMS-1500 · 2026-07-06 | Anthony Gibson UHC-83521-36 | 2026-05-11 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 93000, 80053 | $179.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-001939 CMS-1500 · 2026-07-06 | Alice McDonald UHC-21511-16 | 2026-06-17 Independent laboratory | Pinecrest Clinical Laboratories Clinical Laboratory · in network | 87086, 80061 | $110.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-025067 CMS-1500 · 2026-07-05 | Jordan Mitchell UHC-41287-90 | 2026-05-30 Office | Canyon Primary Care Associates Family Medicine · in network | 99203, 90471, 99214 | $502.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-000401 CMS-1500 · 2026-07-05 | Diana Torres UHC-25888-68 | 2026-05-29 Independent laboratory | Sunrise Clinical Laboratories Clinical Laboratory · in network | 87086 | $36.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-013598 CMS-1500 · 2026-07-02 | Nathan Armstrong UHC-15778-11 | 2026-05-29 Office | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 20610 | $181.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-000051 UB-04 · 2026-07-02 | Judith Harris UHC-25584-49 | 2026-06-14 Outpatient hospital | Northgate Cardiovascular Associates Cardiology · in network | 93458 | $6,102.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-034178 CMS-1500 · 2026-07-01 | Amy Alvarado UHC-80360-58 | 2026-05-30 Office | Meadow Primary Care Associates Family Medicine · in network | 90471, 99214 | $335.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-020851 CMS-1500 · 2026-07-01 | Andrea Griffin UHC-70467-12 | 2026-06-11 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 80053, 85025 | $140.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008239 CMS-1500 · 2026-07-01 | Jonathan Kelly UHC-10931-15 | 2026-05-21 Office | Desert Primary Care Associates Family Medicine · in network | 36415, 90471, 99214 | $365.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-000699 CMS-1500 · 2026-06-30 | Harold Matthews UHC-47451-76 | 2026-05-25 Office | Pinecrest Cardiovascular Associates Cardiology · in network | 93224 | $301.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-024306 CMS-1500 · 2026-06-29 | Brittany Fowler UHC-05869-27 | 2026-06-09 Office | Meadow Physical Therapy Physical Therapy · in network | 97110, 97161, 97014 | $555.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-019384 CMS-1500 · 2026-06-29 | Juan Snyder UHC-15581-31 | 2026-05-30 Independent laboratory | Cornerstone Clinical Laboratories Clinical Laboratory · in network | 87086, 85025 | $87.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-017944 CMS-1500 · 2026-06-28 | Doris Elliott UHC-77204-58 | 2026-06-07 Office | Summit Counseling Center Behavioral Health · in network | 90834 | $191.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-014155 CMS-1500 · 2026-06-28 | Maria Castro UHC-41645-88 | 2026-06-17 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110, 97161 | $493.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-020321 CMS-1500 · 2026-06-27 | Jerry Torres UHC-90769-88 | 2026-05-30 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 93000 | $78.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-013321 UB-04 · 2026-06-27 | Emma Parker UHC-20425-50 | 2026-06-06 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 70553, 77067 | $3,056.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-022106 CMS-1500 · 2026-06-26 | Michelle Luna UHC-80345-60 | 2026-05-18 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 93000 | $101.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-012248 CMS-1500 · 2026-06-25 | Philip Castro UHC-67143-84 | 2026-05-16 Office | Meadow Primary Care Associates Family Medicine · in network | 99214, 99213, 99203 | $697.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003070 CMS-1500 · 2026-06-25 | Dennis Brown UHC-22981-87 | 2026-04-30 Office | Pinecrest Medical Group Family Medicine · in network | 99213, 90471, 36415 | $224.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-015615 UB-04 · 2026-06-24 | Marcus Brown UHC-58114-58 | 2026-06-08 Outpatient hospital | Summit Imaging Center Radiology · in network | 76700 | $525.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-009836 UB-04 · 2026-06-24 | Jean Perry UHC-02151-49 | 2026-05-24 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · in network | 99284, 99283 | $2,080.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-024705 CMS-1500 · 2026-06-23 | Jesse Miller UHC-45991-10 | 2026-05-11 Office | Valley Primary Care Associates Family Medicine · in network | 99395, 36415 | $278.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-023954 UB-04 · 2026-06-23 | Samul Ross UHC-33174-59 | 2026-05-16 Outpatient hospital | Desert Imaging Center Radiology · in network | 76700, 77067, 71046 | $964.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-019808 CMS-1500 · 2026-06-23 | Kyle Peters UHC-11956-50 | 2026-05-15 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $74.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-021410 UB-04 · 2026-06-22 | Laura Bennett UHC-69098-58 | 2026-05-23 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553 | $3,140.00 | — | Left for review REPL CO50 | — | Needs review |
| CLM-2026-020596 UB-04 · 2026-06-22 | Christopher Meyer UHC-42589-19 | 2026-05-10 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378, 88305 | $1,998.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008561 CMS-1500 · 2026-06-21 | Christian Ruiz UHC-95544-56 | 2026-05-23 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $546.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029048 UB-04 · 2026-06-20 | Christopher George UHC-71164-91 | 2026-06-02 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 71046, 99285 | $1,928.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003348 CMS-1500 · 2026-06-19 | Carol Johnston UHC-93026-58 | 2026-05-13 Office | Northgate Medical Group Family Medicine · in network | 99395, 36415 | $347.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-006167 CMS-1500 · 2026-06-18 | Chritsian Daniels UHC-49258-37 | 2026-04-19 Office | Evergreen Primary Care Associates Family Medicine · in network | 36415, 99395 | $290.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-033493 CMS-1500 · 2026-06-17 | Lawrence Mitchell UHC-30433-13 | 2026-05-20 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110 | $86.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-026449 CMS-1500 · 2026-06-15 | Kyle Guzman UHC-29349-66 | 2026-05-21 Independent laboratory | Summit Reference Lab Clinical Laboratory · in network | 85025, 83036 | $77.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-025275 CMS-1500 · 2026-06-15 | Willie Hoffman UHC-26483-10 | 2026-05-23 Office | Harbor Bone and Joint Center Orthopedic Surgery · in network | 20610 | $256.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-021964 CMS-1500 · 2026-06-15 | Gary Weber UHC-46874-68 | 2026-04-27 Office | Riverside Primary Care Associates Family Medicine · in network | 36415 | $15.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-018127 CMS-1500 · 2026-06-15 | Carlos Estrada UHC-95033-99 | 2026-04-23 Office | Heritage Medical Group Internal Medicine · in network | 93000, 80053 | $188.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-009388 CMS-1500 · 2026-06-15 | Douglas Reynolds UHC-24207-80 | 2026-05-11 Office | Canyon Internal Medicine Associates Internal Medicine · in network | 99215, 80053 | $355.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-009090 CMS-1500 · 2026-06-15 | Laaura Stone UHC-63188-72 | 2026-04-30 Office | Desert Medical Group Family Medicine · in network | 99213 | $144.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003962 UB-04 · 2026-06-13 | Douglas Collins UHC-00437-78 | 2026-04-11 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $243.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-023974 CMS-1500 · 2026-06-11 | Deborah Banks UHC-57459-80 | 2026-04-19 Independent laboratory | Harbor Reference Lab Clinical Laboratory · in network | 85025 | $39.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-023949 CMS-1500 · 2026-06-11 | Samantha Gibson UHC-78095-11 | 2026-05-10 Office | Canyon Medical Group Internal Medicine · in network | 80053, 93000 | $144.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008363 CMS-1500 · 2026-06-11 | Juan Williamson UHC-85093-20 | 2026-04-15 Office | Evergreen Family Practice Family Medicine · in network | 99203, 99213 | $401.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-019793 CMS-1500 · 2026-06-10 | Austin Johnson UHC-23041-70 | 2026-05-18 Office | Lakeside Medical Group Family Medicine · out of network | 90471 | $27.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-000253 CMS-1500 · 2026-06-10 | Frances Ross UHC-49985-38 | 2026-05-11 Office | Evergreen Internal Medicine Associates Internal Medicine · in network | 93000 | $79.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-028324 CMS-1500 · 2026-06-09 | Kyle Watson UHC-64229-19 | 2026-04-23 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 85025, 83036 | $83.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-027129 UB-04 · 2026-06-09 | Madison McCoy UHC-54920-73 | 2026-05-27 Outpatient hospital | Unity Cardiovascular Associates Cardiology · in network | 93015 | $484.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-007628 CMS-1500 · 2026-06-09 | Nicholas Romero UHC-10303-10 | 2026-05-29 Office | Harbor Diabetes Center Endocrinology · in network | 99215 | $362.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-016498 UB-04 · 2026-06-07 | Shirley Bowman UHC-87847-39 | 2026-05-13 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 71046, 70553 | $2,466.00 | — | 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.