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-2026-010612 CMS-1500 · 2026-10-26 | Not attached | 2026-09-05 Office | Canyon Counseling Center Behavioral Health · out of network | 90791 | $375.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-022570 CMS-1500 · 2026-10-21 | Not attached | 2026-10-04 Office | Mesa Family Practice Family Medicine · in network | 99214, 36415, 90471 | $348.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-025618 UB-04 · 2026-10-18 | Janet Delgado UHC-86657-86 | 2026-10-13 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 43239, 88305 | $1,736.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-013409 CMS-1500 · 2026-10-18 | Heather Hudson UHC-13473-34 | 2026-09-16 Office | Mesa Family Practice Family Medicine · in network | 90471 | $44.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-010611 CMS-1500 · 2026-10-18 | Not attached | 2026-09-05 Office | Northgate Counseling Center Behavioral Health · in network | 90791 | $375.00 | — | Pended by rule CO16 | — | Pended |
| 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-2026-024558 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-2026-026316 CMS-1500 · 2026-10-15 | Patrick Jordan UHC-27638-29 | 2026-10-06 Office | Evergreen Medical Group Family Medicine · in network | 99213, 99395 | $467.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-022820 CMS-1500 · 2026-10-14 | Dorothy Vega UHC-62516-28 | 2026-09-29 Office | Unity Primary Care Associates Family Medicine · in network | 99213 | $173.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-025482 CMS-1500 · 2026-10-12 | Ralph Harper UHC-54586-42 | 2026-10-08 Office | Canyon Counseling Center Behavioral Health · out of network | 90837 | $246.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-011493 CMS-1500 · 2026-10-12 | Samantah Castillo UHC-23757-47 | 2026-09-25 Office | Riverside Family Practice Family Medicine · in network | 99213, 36415 | $161.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-002317 CMS-1500 · 2026-10-12 | Henry Espinoza UHC-08632-94 | 2026-09-21 Office | Valley Medical Group Internal Medicine · in network | 99214, 80053, 93000 | $354.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-022262 UB-04 · 2026-10-11 | Justin Pena UHC-23865-08 | 2026-10-01 Inpatient hospital | Unity Internal Medicine Associates Internal Medicine · out of network | 99232 | $218.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-010648 CMS-1500 · 2026-10-11 | Judy Gilbert UHC-05548-84 | 2026-09-28 Independent laboratory | Evergreen Clinical Laboratories Clinical Laboratory · in network | 83036, 87086 | $116.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-003697 CMS-1500 · 2026-10-11 | Carl Clark UHC-07708-62 | 2026-09-07 Office | Canyon Counseling Center Behavioral Health · out of network | 90837, 90791, 90834 | $933.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-034363 CMS-1500 · 2026-10-10 | Philip Vasquez UHC-19675-29 | 2026-10-06 Office | Cornerstone Digestive Health Center Gastroenterology · in network | 99214 | $321.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-010826 UB-04 · 2026-10-10 | Evelyn Wilson UHC-19839-19 | 2026-09-02 Outpatient hospital | Valley Imaging Center Radiology · in network | 70553, 71046 | $2,389.00 | — | Left for review CO50 CO16 | — | Needs review |
| CLM-2026-022569 CMS-1500 · 2026-10-09 | Not attached | 2026-10-04 Office | Riverside Medical Group Family Medicine · in network | 99214, 36415, 90471 | $348.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-012779 UB-04 · 2026-10-09 | Kenneth Fisher UHC-65531-04 | 2026-09-21 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $174.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-006852 CMS-1500 · 2026-10-09 | Theresa Torres UHC-55258-87 | 2026-09-22 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $405.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-030480 CMS-1500 · 2026-10-08 | Not attached | 2026-09-01 Office | Valley Cardiovascular Associates Cardiology · in network | 99214 | $220.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-010129 CMS-1500 · 2026-10-08 | Scott Ward UHC-40403-01 | 2026-09-26 Office | Sunrise Digestive Health Center Gastroenterology · in network | 99214 | $229.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-014773 CMS-1500 · 2026-10-07 | Joe Crawford UHC-55441-33 | 2026-09-18 Office | Sunrise GI Associates Gastroenterology · in network | 99214 | $284.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-016276 CMS-1500 · 2026-10-06 | Ethan Ramirez UHC-26954-75 | 2026-09-13 Office | Canyon Primary Care Associates Family Medicine · in network | 99214 | $268.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-015560 UB-04 · 2026-10-06 | Not attached | 2026-09-26 Outpatient hospital | Pinecrest Heart Institute Cardiology · in network | 93015 | $689.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-032523 CMS-1500 · 2026-10-05 | David Shaw UHC-39003-12 | 2026-08-25 Office | Valley Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $335.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-017095 CMS-1500 · 2026-10-05 | Not attached | 2026-09-02 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97161, 97014 | $613.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-009704 UB-04 · 2026-10-05 | William Walsh UHC-07070-34 | 2026-08-31 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · out of network | 99232 | $236.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-006638 UB-04 · 2026-10-05 | Sara Murphy UHC-72812-48 | 2026-09-05 Outpatient hospital | Pinecrest GI Associates Gastroenterology · in network | 45378 | $1,434.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-002465 UB-04 · 2026-10-05 | Patricia Robertson UHC-63151-88 | 2026-09-02 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284, 96374, 99285 | $3,674.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-000032 UB-04 · 2026-10-05 | Not attached | 2026-09-25 Outpatient hospital | Pinecrest Heart Institute Cardiology · in network | 93306 | $1,401.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-001091 UB-04 · 2026-10-04 | Amy Hanson UHC-09703-59 | 2026-08-27 Outpatient hospital | Sunrise Heart Institute Cardiology · in network | 93015 | $478.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-019141 UB-04 · 2026-10-03 | Anthony Perkins UHC-29134-84 | 2026-08-31 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $1,005.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-018920 UB-04 · 2026-10-03 | Lauren Lynch UHC-13897-33 | 2026-08-23 Outpatient hospital | Valley Cardiovascular Associates Cardiology · in network | 93015, 93458 | $8,424.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-007999 CMS-1500 · 2026-10-03 | Theresa Ferguson UHC-72869-72 | 2026-08-30 Office | Heritage Family Practice Family Medicine · in network | 36415, 90471 | $53.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-005746 UB-04 · 2026-10-03 | Heather Fuller UHC-97671-82 | 2026-10-01 Outpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $8,777.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-003189 CMS-1500 · 2026-10-03 | Lori Li UHC-86987-56 | 2026-09-12 Office | Evergreen Medical Group Family Medicine · in network | 99395, 90471 | $328.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-022552 CMS-1500 · 2026-10-02 | Not attached | 2026-09-23 Office | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $217.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-025721 CMS-1500 · 2026-10-01 | Philip Simmons UHC-94170-33 | 2026-09-15 Office | Lakeside Medical Group Family Medicine · out of network | 36415, 99203, 90471 | $286.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-008131 CMS-1500 · 2026-10-01 | Not attached | 2026-09-15 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97014 | $379.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-007964 CMS-1500 · 2026-09-30 | Kyle Miller UHC-06290-50 | 2026-09-28 Office | Lakeside Dermatology Clinic Dermatology · in network | 17110, 11102 | $531.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-020860 UB-04 · 2026-09-29 | Matthew Rice UHC-07938-13 | 2026-08-17 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285 | $2,521.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-018189 UB-04 · 2026-09-29 | Not attached | 2026-08-16 Outpatient hospital | Valley Heart Institute Cardiology · in network | 70553 | $2,348.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-007065 UB-04 · 2026-09-29 | Maria Dixon UHC-59100-04 | 2026-09-16 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 76700 | $468.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-033417 CMS-1500 · 2026-09-28 | Wei Austin UHC-88017-51 | 2026-09-13 Office | Evergreen Rehabilitation Center Physical Therapy · in network | 97110 | $252.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-023322 CMS-1500 · 2026-09-28 | Natalie Harrison UHC-82848-19 | 2026-08-18 Office | Summit Family Practice Family Medicine · in network | 99213 | $176.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-024681 CMS-1500 · 2026-09-27 | Timothy Hunt UHC-84563-77 | 2026-09-22 Office | Harbor Medical Group Family Medicine · in network | 99213 | $220.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-033972 CMS-1500 · 2026-09-26 | Jeremy Garrett UHC-79001-22 | 2026-08-23 Independent laboratory | Lakeside Clinical Laboratories Clinical Laboratory · in network | 87086, 80061 | $96.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-032887 CMS-1500 · 2026-09-26 | Mary Brown UHC-11560-96 | 2026-09-14 Office | Evergreen Counseling Center Behavioral Health · in network | 90837 | $230.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-009702 UB-04 · 2026-09-25 | Brittany Alvarez UHC-71038-53 | 2026-09-19 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 70553 | $3,117.00 | — | Left for review CO16 | — | Needs review |
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 REPL490
- 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.