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-2026-024854 CMS-1500 · 2026-10-16 | Rebecca Aguilar no member ID | 2026-09-26 Office | Mesa Dermatology Clinic Dermatology · in network | 11102, 17110, 11403 | $1,057.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-024665 CMS-1500 · 2026-10-16 | Brandon Hanson UHC-59797-37 | 2026-09-08 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99215 | $420.00 | $235.40 | Clean approval | — | Approved |
| CLM-2026-024581 CMS-1500 · 2026-10-16 | Ahmed Vega UHC-10206-05 | 2026-09-06 Telehealth | Summit Counseling Center Behavioral Health · in network | 99214 | $315.00 | $135.30 | Clean approval | — | Approved |
| CLM-2026-024558 CMS-1500 · 2026-10-16 | Not attached | 2026-10-03 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 99214, 99215, 80053 | $712.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-024446 CMS-1500 · 2026-10-16 | Stewart Mateo UHC-20020-02 | 2026-10-09 Independent laboratory | Summit Clinical Laboratories Clinical Laboratory · in network | 80053, 85025, 80061 | $188.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023971 CMS-1500 · 2026-10-16 | Bryan Hanson UHC-44026-65 | 2026-10-05 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90837 | $243.00 | $110.66 | Clean approval | — | Approved |
| CLM-2026-023781 CMS-1500 · 2026-10-16 | Pamela Ruiz UHC-19463-21 | 2026-10-09 Office | Pinecrest Medical Group Family Medicine · in network | 99214, 36415 | $247.00 | $113.14 | Clean approval | — | Approved |
| CLM-2026-023687 CMS-1500 · 2026-10-16 | Betty Johnston UHC-31784-85 | 2026-09-26 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97161 | $379.00 | $209.98 | Clean approval | — | Approved |
| CLM-2026-023047 CMS-1500 · 2026-10-16 | Natalie Cruz UHC-78014-98 | 2026-10-03 Office | Mesa Family Practice Family Medicine · in network | 99203, 99213 | $380.00 | $210.60 | Clean approval | — | Approved |
| CLM-2026-022626 CMS-1500 · 2026-10-16 | Helen Gordon UHC-94111-71 | 2026-09-17 Office | Meadow Bone and Joint Center Orthopedic Surgery · in network | 99213 | $205.00 | $87.10 | Clean approval | — | Approved |
| CLM-2026-021952 CMS-1500 · 2026-10-16 | Anthony Fields UHC-31856-02 | 2026-10-10 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99215, 93000 | $395.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-021947 CMS-1500 · 2026-10-16 | Sean Lawrece UHC-49495-21 | 2026-09-20 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110 | $164.00 | $81.68 | Clean approval | — | Approved |
| CLM-2026-020625 CMS-1500 · 2026-10-16 | Bryan Burke UHC-87931-70 | 2026-09-10 Office | Valley Family Practice Family Medicine · in network | 99395 | $307.00 | $165.34 | Clean approval | — | Approved |
| CLM-2026-020542 CMS-1500 · 2026-10-16 | Olivia Maldonado UHC-41359-99 | 2026-10-09 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 83036 | $62.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-020181 CMS-1500 · 2026-10-16 | Heather Perez UHC-55402-81 | 2026-10-02 Office | Unity Digestive Health Center Gastroenterology · in network | 99214 | $313.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-020059 CMS-1500 · 2026-10-16 | Janet Graham UHC-25913-64 | 2026-09-22 Office | Sunrise Dermatology Clinic Dermatology · in network | 17110 | $219.00 | $95.78 | Clean approval | — | Approved |
| CLM-2026-019881 CMS-1500 · 2026-10-16 | Amanda Olson UHC-71463-79 | 2026-08-15 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $483.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-019678 CMS-1500 · 2026-10-16 | Christopher Mendez UHC-51704-12 | 2026-09-30 Office | Meadow Skin Care Associates Dermatology · in network | 11403 | $514.00 | $278.68 | Clean approval | — | Approved |
| CLM-2026-018324 CMS-1500 · 2026-10-16 | Nicole Owens UHC-86145-67 | 2026-09-28 Office | Meadow Primary Care Associates Family Medicine · in network | 90471, 99213 | $229.00 | $116.56 | Clean approval | — | Approved |
| CLM-2026-017804 CMS-1500 · 2026-10-16 | Maria Simpson UHC-29411-66 | 2026-09-11 Office | Sunrise Physical Therapy Physical Therapy · in network | 97110, 97140 | $441.00 | $243.42 | Clean approval | — | Approved |
| CLM-2026-017534 CMS-1500 · 2026-10-16 | Logan Turner UHC-66944-79 | 2026-10-04 Office | Canyon Internal Medicine Associates Internal Medicine · out of network | 99214 | $206.00 | $72.70 | Clean approval | — | Approved |
| CLM-2026-017481 CMS-1500 · 2026-10-16 | Jeremy Bishop UHC-33995-12 | 2026-10-04 Office | Northgate Medical Group Family Medicine · in network | 99213, 99214 | $434.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-017349 CMS-1500 · 2026-10-16 | Omar Webb UHC-96605-12 | 2026-10-09 Office | Valley Primary Care Associates Family Medicine · in network | 36415, 99203 | $270.00 | $157.48 | Clean approval | — | Approved |
| CLM-2026-017127 CMS-1500 · 2026-10-16 | Melissa Weber UHC-72009-07 | 2026-09-15 Office | Lakeside Skin Care Associates Dermatology · in network | 99213 | $202.00 | $65.24 | Clean approval | — | Approved |
| CLM-2026-016271 CMS-1500 · 2026-10-16 | Lauren Mason UHC-58084-93 | 2026-10-04 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99214 | $224.00 | $118.88 | Clean approval | — | Approved |
| CLM-2026-015644 CMS-1500 · 2026-10-16 | Amy Romero UHC-51754-58 | 2026-09-29 Office | Northgate Medical Group Internal Medicine · in network | 93000, 99214 | $408.00 | $227.96 | Clean approval | — | Approved |
| CLM-2026-015417 CMS-1500 · 2026-10-16 | Cynthia Hill UHC-85055-61 | 2026-10-12 Office | Mesa Family Practice Family Medicine · in network | 36415 | $13.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-015281 CMS-1500 · 2026-10-16 | Jonathan Lawson UHC-79224-89 | 2026-07-05 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $118.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-015011 CMS-1500 · 2026-10-16 | Isabella Lee UHC-43649-73 | 2026-09-11 Office | Canyon Medical Group Internal Medicine · in network | 99215 | $311.00 | $167.82 | Clean approval | — | Approved |
| CLM-2026-014421 CMS-1500 · 2026-10-16 | Rachel Bradley UHC-97573-46 | 2026-10-04 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110 | $224.00 | $108.88 | Clean approval | — | Approved |
| CLM-2026-014376 CMS-1500 · 2026-10-16 | Joan Torres UHC-36583-04 | 2026-09-18 Office | Evergreen Primary Care Associates Family Medicine · in network | 99213 | $196.00 | $96.52 | Clean approval | — | Approved |
| CLM-2026-014282 CMS-1500 · 2026-10-16 | Cheryl Welch UHC-07157-28 | 2026-09-16 Independent laboratory | Meadow Reference Lab Clinical Laboratory · in network | 80053, 85025 | $116.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-013868 CMS-1500 · 2026-10-16 | Heather Perez UHC-55402-81 | 2026-09-04 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 83036, 80061 | $119.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-013835 CMS-1500 · 2026-10-16 | Joshua Wallace UHC-93952-25 | 2026-09-15 Office | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 20610 | $291.00 | $105.42 | Clean approval | — | Approved |
| CLM-2026-013202 CMS-1500 · 2026-10-16 | Alan Larson UHC-15650-15 | 2026-09-04 Office | Meadow Primary Care Associates Family Medicine · in network | 36415, 99214 | $276.00 | $158.10 | Clean approval | — | Approved |
| CLM-2026-012522 CMS-1500 · 2026-10-16 | Logan Knight UHC-74188-59 | 2026-10-04 Office | Harbor Family Practice Family Medicine · in network | 99395, 99214 | $514.00 | $278.68 | Clean approval | — | Approved |
| CLM-2026-011998 CMS-1500 · 2026-10-16 | Vincent King UHC-03496-99 | 2026-09-28 Office | Sunrise Cardiovascular Associates Cardiology · in network | 93224 | $264.00 | $113.68 | Clean approval | — | Approved |
| CLM-2026-011852 CMS-1500 · 2026-10-16 | Heather Carpenter UHC-81594-70 | 2026-09-23 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80053, 85025 | $106.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-011604 CMS-1500 · 2026-10-16 | Andrea Lee no member ID | 2026-09-19 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110, 97140 | $243.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-011470 CMS-1500 · 2026-10-16 | Valentina Coleman UHC-82461-63 | 2026-07-09 Office | Riverside Internal Medicine Associates Internal Medicine · in network | 80053 | $54.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-011195 CMS-1500 · 2026-10-16 | Donna Allen UHC-09329-72 | 2026-09-10 Office | Mesa Family Practice Family Medicine · in network | 99395, 36415 | $287.00 | $137.94 | Clean approval | — | Approved |
| CLM-2026-011161 CMS-1500 · 2026-10-16 | Elijah Medina UHC-16726-86 | 2026-09-17 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 87086, 83036, 80053 | $172.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-010601 CMS-1500 · 2026-10-16 | Christian Wilson UHC-01879-27 | 2026-10-02 Office | Mesa Cardiovascular Associates Cardiology · in network | 99214 | $332.00 | $155.84 | Clean approval | — | Approved |
| CLM-2026-010312 CMS-1500 · 2026-10-16 | Christopher Adams UHC-88794-67 | 2026-09-21 Office | Unity Medical Group Internal Medicine · in network | 93000 | $74.00 | $25.88 | Clean approval | — | Approved |
| CLM-2026-009896 CMS-1500 · 2026-10-16 | Philip Dean UHC-52903-44 | 2026-09-26 Office | Summit Family Practice Family Medicine · in network | 99213, 99214 | $434.00 | $229.08 | Clean approval | — | Approved |
| CLM-2026-009871 CMS-1500 · 2026-10-16 | Joshua Payne UHC-40350-50 | 2026-09-27 Office | Meadow Physical Therapy Physical Therapy · in network | 97110, 97161 | $346.00 | $174.52 | Clean approval | — | Approved |
| CLM-2026-009760 CMS-1500 · 2026-10-16 | Jose Vega UHC-35189-94 | 2026-09-12 Office | Canyon Counseling Center Behavioral Health · out of network | 90791 | $315.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009675 CMS-1500 · 2026-10-16 | Jacqueline Brooks UHC-71813-52 | 2026-09-18 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 83036, 80053, 87086 | $209.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-009463 CMS-1500 · 2026-10-16 | Raymond Woods UHC-91976-08 | 2026-09-07 Office | Canyon Primary Care Associates Family Medicine · in network | 99203 | $236.00 | $116.32 | Clean approval | — | Approved |
| CLM-2026-009290 CMS-1500 · 2026-10-16 | Gary Simpson UHC-25382-23 | 2026-09-16 Office | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 99213 | $162.00 | $25.44 | 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.