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-2026-013409 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-2026-010648 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-2026-022569 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-2026-006852 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-2026-032523 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-2026-007999 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-2026-003189 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-2026-033417 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-2026-008130 CMS-1500 · 2026-09-25 | Not attached | 2026-09-15 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110, 97014 | $379.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-019327 CMS-1500 · 2026-09-24 | Nicholas Le UHC-49251-67 | 2026-09-21 Office | Unity Counseling Center Behavioral Health · in network | 90791 | $378.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-028059 CMS-1500 · 2026-09-23 | Alexander Evans UHC-74290-44 | 2026-08-14 Office | Meadow Primary Care Associates Family Medicine · in network | 99213, 99203, 99214 | $586.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-025947 CMS-1500 · 2026-09-23 | Danielle White UHC-49036-24 | 2026-08-19 Office | Heritage Family Practice Family Medicine · in network | 99203 | $242.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-012268 CMS-1500 · 2026-09-23 | Lawrence Nichhols UHC-93718-40 | 2026-09-06 Office | Northgate Heart Institute Cardiology · in network | 93224, 99214 | $589.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-011279 CMS-1500 · 2026-09-23 | Sharon Reynolds UHC-55069-69 | 2026-08-25 Office | Riverside Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $323.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-013429 CMS-1500 · 2026-09-22 | Not attached | 2026-09-04 Office | Desert Heart Institute Cardiology · in network | 93224 | $275.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-026636 CMS-1500 · 2026-09-21 | Amanda Chapman UHC-94916-77 | 2026-08-24 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140 | $247.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-014466 CMS-1500 · 2026-09-19 | Not attached | 2026-08-30 Office | Evergreen Medical Group Family Medicine · in network | 36415, 99395 | $290.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-026574 CMS-1500 · 2026-09-16 | Alexis Washington UHC-12260-84 | 2026-09-03 Office | Sunrise Skin Care Associates Dermatology · in network | 17110 | $195.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-015581 CMS-1500 · 2026-09-14 | Janet Lopez UHC-53522-23 | 2026-08-04 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 80061, 83036 | $105.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-033483 CMS-1500 · 2026-09-12 | Amanda Santos UHC-87211-30 | 2026-08-12 Office | Meadow Heart Institute Cardiology · out of network | 99214, 93224 | $679.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-001497 CMS-1500 · 2026-09-12 | Gary King UHC-19513-90 | 2026-08-18 Independent laboratory | Summit Clinical Laboratories Clinical Laboratory · in network | 83036, 87086 | $123.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-023697 CMS-1500 · 2026-09-11 | David Gibson UHC-69693-06 | 2026-08-02 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 83036, 80053 | $125.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-023310 CMS-1500 · 2026-09-11 | Joyce Johnson UHC-57438-80 | 2026-08-07 Office | Summit Internal Medicine Associates Internal Medicine · in network | 99215 | $398.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-032964 CMS-1500 · 2026-09-10 | Anna Dixon UHC-96020-28 | 2026-08-16 Office | Sunrise Medical Group Family Medicine · in network | 90471, 36415, 99214 | $328.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-013078 CMS-1500 · 2026-09-10 | Roy Wilson UHC-47553-11 | 2026-09-01 Office | Sunrise Dermatology Clinic Dermatology · out of network | 99213 | $206.00 | — | 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 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.