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-2026-021302 CMS-1500 · 2026-07-17 | Shirley Simpson UHC-57924-01 | 2026-06-04 Office | Unity Primary Care Associates Family Medicine · out of network | 99214 | $299.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-021301 CMS-1500 · 2026-07-06 | Shirley Simpson UHC-57924-01 | 2026-06-04 Office | Unity Primary Care Associates Family Medicine · out of network | 99214 | $299.00 | $104.55 | Clean approval | — | Approved |
| CLM-2026-028840 CMS-1500 · 2026-04-22 | Shirley Simpson UHC-57924-01 | 2026-03-10 Office | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 20610, 99213 | $397.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-028839 CMS-1500 · 2026-04-18 | Shirley Simpson UHC-57924-01 | 2026-03-10 Office | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 20610, 99213 | $397.00 | $206.14 | Clean approval | — | Approved |
| CLM-2026-011904 CMS-1500 · 2026-03-04 | Shirley Simpson UHC-57924-01 | 2026-01-21 Office | Northgate Primary Care Associates Family Medicine · out of network | 90471, 99395 | $294.00 | $119.25 | 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.