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-2026-032994 UB-04 · 2026-10-16 | Betty Stephens UHC-08557-91 | 2026-10-04 Outpatient hospital | Summit Medical Group Internal Medicine · in network | 70553 | $2,557.00 | — | Left for review CO50 | — | Needs review |
| 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-2026-032345 UB-04 · 2026-10-16 | Carol Pierce UHC-80359-24 | 2026-10-11 Outpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 70553 | $2,131.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-032100 UB-04 · 2026-10-16 | Angela Salazar UHC-63436-64 | 2026-10-06 Outpatient hospital | Desert Imaging Center Radiology · in network | 70553 | $2,469.00 | $0.00 | 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-2026-030634 UB-04 · 2026-10-16 | Yuki Stone UHC-81424-76 | 2026-09-10 Outpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 29881, 73721 | $10,915.00 | $3,656.09 | Clean approval | — | Approved |
| CLM-2026-030553 UB-04 · 2026-10-16 | Valentina Olson UHC-29563-18 | 2026-09-11 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $1,458.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-029645 UB-04 · 2026-10-16 | Marilyn Wallace UHC-97767-95 | 2026-09-01 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 70553, 77067, 74177 | $4,854.00 | — | Denied by rule CO197 | — | Denied |
| 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-2026-028846 UB-04 · 2026-10-16 | Dylan Butler UHC-22460-47 | 2026-09-28 Outpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 29881 | $8,467.00 | $2,803.22 | 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-2026-027854 UB-04 · 2026-10-16 | Maria Martin UHC-06183-65 | 2026-09-11 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 76700, 70553 | $3,166.00 | $177.33 | 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-2026-026095 UB-04 · 2026-10-16 | Cheryl Sanchez UHC-38922-46 | 2026-09-08 Outpatient hospital | Sunrise GI Associates Gastroenterology · in network | 88305, 45378 | $2,435.00 | $0.00 | Clean approval | — | Approved |
| 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 |
| 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-2026-024821 UB-04 · 2026-10-16 | Angela Sullivan no member ID | 2026-09-27 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285 | $2,083.00 | — | 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-2026-024336 UB-04 · 2026-10-16 | Sean Payne UHC-34145-90 | 2026-09-15 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99283 | $970.00 | — | Left for review NET | — | Needs review |
| CLM-2026-024279 UB-04 · 2026-10-16 | William Webb UHC-11907-97 | 2026-09-08 Outpatient hospital | Sunrise Community Hospital Emergency Medicine · out of network | 70553 | $1,854.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-020953 UB-04 · 2026-10-16 | Perry Arthur UHC-34387-88 | 2026-09-30 Outpatient hospital | Riverside GI Associates Gastroenterology · in network | 43239, 45378 | $4,992.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-020792 UB-04 · 2026-10-16 | Gregory Reid UHC-65879-07 | 2026-10-07 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $46,944.00 | — | Left for review HIGH | — | Needs review |
| 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 |
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.