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-2026-011023 CMS-1500 · 2026-10-17 | Nancy Hansen UHC-45838-06 | 2026-09-30 Office | Harbor Primary Care Associates Family Medicine · out of network | 99213 | $140.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010885 CMS-1500 · 2026-10-17 | Bradley Weber UHC-45571-88 | 2026-09-09 Office | Valley Family Practice Family Medicine · in network | 36415 | $19.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-010771 CMS-1500 · 2026-10-17 | Sophia Roberts UHC-64051-25 | 2026-09-11 Office | Pinecrest Heart Institute Cardiology · in network | 99214 | $329.00 | $153.98 | Clean approval | — | Approved |
| CLM-2026-010643 CMS-1500 · 2026-10-17 | Angela Gordon UHC-91021-02 | 2026-09-05 Office | Meadow Primary Care Associates Family Medicine · in network | 90471 | $40.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-010243 CMS-1500 · 2026-10-17 | Vincent Gomez UHC-91184-90 | 2026-10-13 Independent laboratory | Mesa Reference Lab Clinical Laboratory · in network | 83036 | $40.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-009828 CMS-1500 · 2026-10-17 | Steven Cook UHC-87809-79 | 2026-10-10 Office | Unity Dermatology Clinic Dermatology · in network | 99213 | $211.00 | $80.82 | Clean approval | — | Approved |
| CLM-2026-009729 CMS-1500 · 2026-10-17 | Vincent Hanson UHC-95245-95 | 2026-09-21 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140 | $233.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-009421 CMS-1500 · 2026-10-17 | Abigail Carr UHC-85206-38 | 2026-09-13 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $287.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-008976 CMS-1500 · 2026-10-17 | Karen Wells UHC-21724-15 | 2026-10-09 Office | Lakeside Medical Group Internal Medicine · in network | 80053, 93000 | $184.00 | $74.08 | Clean approval | — | Approved |
| CLM-2026-008649 CMS-1500 · 2026-10-17 | Megan Richardson UHC-31006-11 | 2026-09-21 Office | Harbor Family Practice Family Medicine · in network | 99203 | $184.00 | $94.08 | Clean approval | — | Approved |
| CLM-2026-008250 CMS-1500 · 2026-10-17 | Gregory Walker UHC-01696-10 | 2026-09-24 Office | Summit Family Practice Family Medicine · in network | 99203, 99214 | $419.00 | $234.78 | Clean approval | — | Approved |
| CLM-2026-006423 CMS-1500 · 2026-10-17 | Aisha Sullivan UHC-03338-45 | 2026-09-26 Office | Evergreen Family Practice Family Medicine · in network | 99213 | $189.00 | $87.18 | Clean approval | — | Approved |
| CLM-2026-006204 CMS-1500 · 2026-10-17 | Diana Bradley UHC-06344-17 | 2026-10-15 Office | Harbor Medical Group Family Medicine · in network | 90471, 99203 | $278.00 | $152.52 | Clean approval | — | Approved |
| CLM-2026-005997 CMS-1500 · 2026-10-17 | Christine Cooper UHC-90180-01 | 2026-10-10 Office | Sunrise Digestive Health Center Gastroenterology · out of network | 99214 | $324.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004044 CMS-1500 · 2026-10-17 | Christian Gonzalez UHC-05076-98 | 2026-08-28 Office | Sunrise Medical Group Family Medicine · in network | 99203, 90471 | $220.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003861 CMS-1500 · 2026-10-17 | Virginia Hanson UHC-89231-07 | 2026-09-22 Office | Evergreen Medical Group Family Medicine · in network | 90471, 99214 | $295.00 | $162.44 | Clean approval | — | Approved |
| CLM-2026-003706 CMS-1500 · 2026-10-17 | Jordan Fowler UHC-84332-87 | 2026-09-15 Office | Mesa Diabetes Center Endocrinology · in network | 83036, 95251, 99215 | $578.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-003523 CMS-1500 · 2026-10-17 | Pamela Hicks UHC-20829-55 | 2026-09-07 Office | Sunrise Medical Group Family Medicine · in network | 99395 | $276.00 | $141.12 | Clean approval | — | Approved |
| CLM-2026-003098 CMS-1500 · 2026-10-17 | Wayne Garza UHC-17167-67 | 2026-10-15 Office | Evergreen GI Associates Gastroenterology · in network | 99214 | $289.00 | $119.18 | Clean approval | — | Approved |
| CLM-2026-002994 CMS-1500 · 2026-10-17 | Richard Phillips UHC-68324-20 | 2026-09-10 Independent laboratory | Meadow Reference Lab Clinical Laboratory · in network | 80053, 85025, 80061 | $161.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-002671 CMS-1500 · 2026-10-17 | Mariana Shaw UHC-69035-21 | 2026-09-30 Office | Heritage Medical Group Family Medicine · in network | 90471 | $41.00 | $5.42 | Clean approval | — | Approved |
| CLM-2026-002543 CMS-1500 · 2026-10-17 | Jonathan Wang UHC-79770-03 | 2026-10-04 Office | Harbor Medical Group Internal Medicine · out of network | 99215, 93000 | $428.00 | $162.60 | Clean approval | — | Approved |
| CLM-2026-002084 CMS-1500 · 2026-10-17 | Benjamin Ross UHC-35042-30 | 2026-10-09 Office | Canyon Cardiovascular Associates Cardiology · out of network | 99214 | $246.00 | $70.70 | Clean approval | — | Approved |
| CLM-2026-000041 CMS-1500 · 2026-10-17 | Doris Bell UHC-49343-44 | 2026-09-13 Office | Heritage Family Practice Family Medicine · in network | 90471 | $39.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-034606 CMS-1500 · 2026-10-16 | Evelyn Ramos UHC-70497-07 | 2026-09-25 Office | Evergreen Medical Group Family Medicine · in network | 99395, 99213 | $411.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-034127 CMS-1500 · 2026-10-16 | Jordan Walker UHC-96381-04 | 2026-09-18 Office | Harbor Primary Care Associates Family Medicine · in network | 99395, 99213, 99214 | $715.00 | $423.30 | Clean approval | — | Approved |
| CLM-2026-034061 CMS-1500 · 2026-10-16 | Marilyn Patterson UHC-43471-66 | 2026-10-02 Office | Lakeside Medical Group Family Medicine · in network | 36415 | $21.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-033040 CMS-1500 · 2026-10-16 | Edward Delgado UHC-98565-10 | 2026-10-04 Office | Canyon Medical Group Internal Medicine · in network | 99215, 80053, 99214 | $736.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-032987 CMS-1500 · 2026-10-16 | Albert Salazar UHC-68627-66 | 2026-09-27 Office | Sunrise Dermatology Clinic Dermatology · in network | 17110, 99213 | $414.00 | $196.68 | Clean approval | — | Approved |
| CLM-2026-031751 CMS-1500 · 2026-10-16 | Vincent Foster UHC-05668-53 | 2026-09-08 Office | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 99213 | $214.00 | $92.68 | Clean approval | — | Approved |
| CLM-2026-031586 CMS-1500 · 2026-10-16 | David Hill UHC-60032-97 | 2026-09-03 Independent laboratory | Harbor Reference Lab Clinical Laboratory · in network | 80053 | $41.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-031433 CMS-1500 · 2026-10-16 | Adam Harper UHC-81160-12 | 2026-09-05 Office | Canyon Primary Care Associates Family Medicine · in network | 36415, 99203, 99214 | $461.00 | $272.18 | Clean approval | — | Approved |
| CLM-2026-031371 CMS-1500 · 2026-10-16 | Ann Berry UHC-79552-37 | 2026-10-14 Independent laboratory | Harbor Clinical Laboratories Clinical Laboratory · out of network | 80061, 85025 | $95.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-031241 CMS-1500 · 2026-10-16 | Joshua Payne UHC-40350-50 | 2026-09-23 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053 | $45.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030826 CMS-1500 · 2026-10-16 | Diana Black UHC-19098-18 | 2026-10-03 Office | Valley Internal Medicine Associates Internal Medicine · in network | 99214 | $252.00 | $131.24 | Clean approval | — | Approved |
| CLM-2026-030414 CMS-1500 · 2026-10-16 | David Wheeler UHC-83567-23 | 2026-09-04 Office | Lakeside Digestive Health Center Gastroenterology · in network | 99214 | $225.00 | $89.50 | Clean approval | — | Approved |
| CLM-2026-029947 CMS-1500 · 2026-10-16 | Alan Gomez UHC-96329-04 | 2026-08-15 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90837, 90791 | $700.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-029892 CMS-1500 · 2026-10-16 | Sophia Alexander UHC-65817-15 | 2026-09-08 Office | Sunrise Behavioral Health Behavioral Health · in network | 90834, 90837 | $468.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029744 CMS-1500 · 2026-10-16 | Marilyn Patterson UHC-43471-66 | 2026-09-06 Office | Evergreen Family Practice Family Medicine · in network | 99203, 90471 | $275.00 | $150.50 | Clean approval | — | Approved |
| CLM-2026-029159 CMS-1500 · 2026-10-16 | Debra Olson UHC-20571-53 | 2026-09-18 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99215, 80053 | $370.00 | $199.40 | Clean approval | — | Approved |
| CLM-2026-029025 CMS-1500 · 2026-10-16 | Elijah Medina UHC-63153-94 | 2026-10-05 Independent laboratory | Desert Reference Lab Clinical Laboratory · in network | 85025 | $59.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-028488 CMS-1500 · 2026-10-16 | Joseph Flores UHC-55754-19 | 2026-09-08 Office | Heritage Primary Care Associates Family Medicine · in network | 99203, 99213, 99395 | $678.00 | $380.36 | Clean approval | — | Approved |
| CLM-2026-027900 CMS-1500 · 2026-10-16 | Ahmed Adams UHC-27067-82 | 2026-09-08 Office | Mesa Diabetes Center Endocrinology · in network | 83036 | $67.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-027730 CMS-1500 · 2026-10-16 | Luis Wilson UHC-54875-60 | 2026-09-30 Office | Evergreen Medical Group Family Medicine · in network | 99203 | $236.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-026762 CMS-1500 · 2026-10-16 | Timothy Soto UHC-93230-87 | 2026-09-20 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 20610, 99213 | $469.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026740 CMS-1500 · 2026-10-16 | Logan Knight UHC-74188-59 | 2026-10-13 Office | Summit Medical Group Internal Medicine · in network | 80053, 93000 | $169.00 | $64.78 | Clean approval | — | Approved |
| CLM-2026-026623 CMS-1500 · 2026-10-16 | Megan Mejia UHC-65430-50 | 2026-09-04 Independent laboratory | Valley Reference Lab Clinical Laboratory · in network | 80061 | $53.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-026161 CMS-1500 · 2026-10-16 | Carol Owens UHC-59852-07 | 2026-05-21 Office | Harbor Endocrine Associates Endocrinology · in network | 95251, 99214 | $439.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-025209 CMS-1500 · 2026-10-16 | Scott Gibson UHC-52419-70 | 2026-10-01 Office | Desert Family Practice Family Medicine · in network | 36415, 99395, 99213 | $475.00 | $279.62 | Clean approval | — | Approved |
| CLM-2026-025170 CMS-1500 · 2026-10-16 | Michael Gutierrez UHC-45944-04 | 2026-09-14 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 99214, 80053, 93000 | $384.00 | $218.08 | 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.