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-2026-013148 UB-04 · 2026-10-17 | Christine Cook no member ID | 2026-09-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $1,157.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-012136 CMS-1500 · 2026-10-17 | Willie Delgado UHC-47830-16 | 2026-09-17 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99215 | $339.00 | $190.18 | Clean approval | — | Approved |
| CLM-2026-012001 CMS-1500 · 2026-10-17 | Juan Hall UHC-33938-14 | 2026-10-02 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110 | $162.00 | $75.44 | Clean approval | — | Approved |
| CLM-2026-011706 UB-04 · 2026-10-17 | Tyler Silva UHC-89750-63 | 2026-09-26 Outpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 70553 | $3,523.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-011596 CMS-1500 · 2026-10-17 | Bobby Wright UHC-74847-84 | 2026-10-14 Office | Sunrise Medical Group Family Medicine · in network | 99395, 99214, 99213 | $759.00 | $440.58 | Clean approval | — | Approved |
| CLM-2026-011486 CMS-1500 · 2026-10-17 | Steven Ortiz UHC-99424-41 | 2026-09-30 Office | Unity Primary Care Associates Family Medicine · in network | 36415 | $15.00 | $0.00 | Clean approval | — | Approved |
| 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-2026-010982 UB-04 · 2026-10-17 | Deborah Ramos UHC-13452-14 | 2026-09-07 Outpatient hospital | Unity Clinical Laboratories Clinical Laboratory · in network | 70553 | $2,722.00 | — | Left for review CO50 | — | Needs review |
| 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-2026-010759 UB-04 · 2026-10-17 | Beth Jimenez UHC-65211-83 | 2026-09-13 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $3,075.00 | — | Left for review NET | — | Needs review |
| 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-2026-009993 UB-04 · 2026-10-17 | Martha Medina UHC-68694-09 | 2026-09-03 Emergency room | Summit Community Hospital Emergency Medicine · in network | 99283 | $1,016.00 | $208.80 | 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-2026-009152 UB-04 · 2026-10-17 | Logan Gonzales UHC-19729-25 | 2026-09-30 Outpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 73721, 29881 | $9,620.00 | $1,398.66 | Clean approval | — | Approved |
| 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-2026-007331 UB-04 · 2026-10-17 | Hiroshi Powell UHC-87923-96 | 2026-10-02 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 88305 | $348.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-007132 UB-04 · 2026-10-17 | Laura Reyes UHC-58818-28 | 2026-09-20 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284, 99283 | $2,378.00 | — | Left for review CO97 | — | Needs review |
| 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-2026-004966 UB-04 · 2026-10-17 | Billy Palmer UHC-01676-73 | 2026-10-05 Outpatient hospital | Meadow GI Associates Gastroenterology · in network | 43239, 45378 | $3,776.00 | $857.53 | Clean approval | — | Approved |
| CLM-2026-004662 UB-04 · 2026-10-17 | Juan Franklin UHC-92188-10 | 2026-09-05 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306, 93015 | $1,817.00 | — | Denied by rule CO27 | — | 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-2026-002739 UB-04 · 2026-10-17 | William Howard no member ID | 2026-09-19 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99283 | $1,082.00 | — | Pended by rule N30 | — | Pended |
| 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-2026-002559 UB-04 · 2026-10-17 | Donald Lynch UHC-41325-80 | 2026-09-21 Emergency room | Desert Regional Medical Center Emergency Medicine · in network | 99284 | $1,726.00 | $799.30 | 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-2026-001942 UB-04 · 2026-10-17 | Wayne Jones UHC-18856-20 | 2026-09-02 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 74177 | $1,623.00 | $140.85 | Clean approval | — | Approved |
| CLM-2026-001809 UB-04 · 2026-10-17 | Timothy Myers UHC-88645-59 | 2026-09-11 Outpatient hospital | Desert Medical Group Internal Medicine · in network | 70553 | $2,478.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-001588 UB-04 · 2026-10-17 | Larry Banks UHC-47014-15 | 2026-09-18 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 88305 | $184.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-001371 UB-04 · 2026-10-17 | Jacqueline Richards UHC-71794-17 | 2026-09-27 Outpatient hospital | Riverside Imaging Center Radiology · in network | 76700, 71046, 74177 | $2,097.00 | $137.65 | Clean approval | — | Approved |
| CLM-2026-000967 UB-04 · 2026-10-17 | Virginia Roberts UHC-23292-08 | 2026-10-09 Outpatient hospital | Heritage Imaging Center Radiology · in network | 74177 | $1,611.00 | — | Left for review CO50 | — | Needs review |
| 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-2026-033094 UB-04 · 2026-10-16 | Alexander Rose UHC-33854-74 | 2026-10-12 Outpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 70553 | $3,192.00 | — | Left for review CO50 | — | Needs review |
| 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 |
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.