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-2026-019679 CMS-1500 · 2026-11-01 | Christopher Mendez UHC-51704-12 | 2026-09-30 Office | Meadow Skin Care Associates Dermatology · in network | 11403 | $514.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022762 CMS-1500 · 2026-10-31 | Amy Dominguez UHC-21901-22 | 2026-08-31 Office | Riverside Medical Group Family Medicine · in network | 99214, 90471, 99395 | $539.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-020844 CMS-1500 · 2026-10-31 | James Delgado UHC-33344-70 | 2026-09-24 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97014 | $359.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-019414 CMS-1500 · 2026-10-31 | Samuel Wheeler UHC-26647-40 | 2026-09-21 Office | Evergreen Medical Group Family Medicine · in network | 99214, 90471, 99213 | $462.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014747 CMS-1500 · 2026-10-31 | Becky George UHC-12353-35 | 2026-09-05 Office | Canyon Medical Group Internal Medicine · in network | 99214 | $317.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-011196 CMS-1500 · 2026-10-31 | Donna Allen UHC-09329-72 | 2026-09-10 Office | Mesa Family Practice Family Medicine · in network | 99395, 36415 | $287.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-018403 CMS-1500 · 2026-10-29 | Sara Jones UHC-75451-48 | 2026-09-14 Office | Lakeside Medical Group Family Medicine · in network | 99395, 90471, 99214 | $594.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028674 CMS-1500 · 2026-10-28 | Dylan Robertson UHC-45403-96 | 2026-10-11 Office | Valley Rehabilitation Center Physical Therapy · in network | 97110 | $225.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-026416 CMS-1500 · 2026-10-28 | Frank Alvarez UHC-05360-90 | 2026-09-15 Office | Pinecrest Medical Group Family Medicine · in network | 36415 | $15.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-010537 CMS-1500 · 2026-10-25 | Philip Williams UHC-13566-04 | 2026-09-03 Office | Cornerstone Diabetes Center Endocrinology · in network | 83036 | $42.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-000534 CMS-1500 · 2026-10-25 | Tyler Wilson UHC-59252-11 | 2026-09-02 Independent laboratory | Evergreen Clinical Laboratories Clinical Laboratory · in network | 85025, 80053, 83036 | $172.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-020823 CMS-1500 · 2026-10-24 | Kelly Powell UHC-57639-35 | 2026-10-03 Office | Canyon Primary Care Associates Family Medicine · in network | 99203, 99395 | $544.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-011635 CMS-1500 · 2026-10-24 | John Graham UHC-03219-23 | 2026-10-07 Office | Meadow Internal Medicine Associates Internal Medicine · in network | 99214, 80053, 99215 | $610.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-023083 CMS-1500 · 2026-10-23 | Hiroshi Fowler UHC-09603-43 | 2026-09-12 Office | Heritage Primary Care Associates Family Medicine · in network | 36415, 99203 | $217.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-013960 CMS-1500 · 2026-10-23 | Patrick Sanders UHC-58486-46 | 2026-10-07 Office | Canyon Skin Care Associates Dermatology · in network | 17110, 11403 | $650.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-017716 CMS-1500 · 2026-10-22 | Amber Delgado UHC-52060-85 | 2026-09-24 Independent laboratory | Unity Clinical Laboratories Clinical Laboratory · in network | 80053, 80061 | $147.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007191 CMS-1500 · 2026-10-22 | Ahmed Vega UHC-03347-26 | 2026-08-31 Independent laboratory | Mesa Reference Lab Clinical Laboratory · in network | 85025, 80061 | $89.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028764 CMS-1500 · 2026-10-21 | Edward Phillips UHC-73690-84 | 2026-08-21 Office | Lakeside Medical Group Family Medicine · out of network | 90471, 36415 | $58.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028212 CMS-1500 · 2026-10-21 | Virginia Graham UHC-41763-34 | 2026-08-25 Office | Harbor Physical Therapy Physical Therapy · in network | 97110 | $364.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-031856 CMS-1500 · 2026-10-20 | Carol Fowler UHC-12538-47 | 2026-08-24 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 80053, 93000 | $124.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-017158 CMS-1500 · 2026-10-20 | Alice Butler no member ID | 2026-09-20 Telehealth | Evergreen Counseling Center Behavioral Health · in network | 99214 | $233.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014290 CMS-1500 · 2026-10-20 | Amanda Espinoza UHC-65635-71 | 2026-09-17 Office | Evergreen Family Practice Family Medicine · in network | 36415, 99213, 90471 | $189.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007597 CMS-1500 · 2026-10-20 | Emma Mendez UHC-16028-30 | 2026-10-09 Office | Desert Internal Medicine Associates Internal Medicine · in network | 80053 | $85.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-003042 CMS-1500 · 2026-10-20 | Judith Sanchez UHC-37863-85 | 2026-10-02 Office | Riverside Primary Care Associates Family Medicine · in network | 99213, 36415 | $211.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-031649 CMS-1500 · 2026-10-19 | Jonathan Marquez UHC-57626-40 | 2026-10-03 Office | Valley Skin Care Associates Dermatology · in network | 17110 | $215.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-000819 CMS-1500 · 2026-10-19 | Carol Fowler UHC-12538-47 | 2026-09-26 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 99215 | $344.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-025088 CMS-1500 · 2026-10-18 | Julie Hart UHC-16029-61 | 2026-09-02 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $310.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007716 CMS-1500 · 2026-10-18 | Jacqueline Mitchell UHC-85622-08 | 2026-08-23 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99214, 80053 | $350.00 | — | Denied by rule CO18 | — | Denied |
| 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-2026-019881 CMS-1500 · 2026-10-16 | Amanda Olson UHC-71463-79 | 2026-08-15 Office | Heritage Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $483.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-031999 CMS-1500 · 2026-10-15 | Dorothy Herrera UHC-12392-13 | 2026-09-16 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90834 | $191.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-031918 CMS-1500 · 2026-10-14 | Gary Armstrong UHC-04189-51 | 2026-09-05 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 85025 | $51.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-026540 CMS-1500 · 2026-10-14 | Samuel Obrien UHC-78534-34 | 2026-08-18 Independent laboratory | Summit Reference Lab Clinical Laboratory · in network | 80061, 85025 | $114.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014338 CMS-1500 · 2026-10-14 | Ralph Cole UHC-07842-57 | 2026-09-22 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140, 97161 | $507.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-030736 CMS-1500 · 2026-10-13 | Ethan Vazquez UHC-36033-31 | 2026-08-25 Independent laboratory | Summit Reference Lab Clinical Laboratory · in network | 80061 | $46.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-030070 CMS-1500 · 2026-10-13 | Pamela Snadoval UHC-52330-59 | 2026-09-14 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99203 | $242.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024891 CMS-1500 · 2026-10-13 | Doris Coleman UHC-38524-53 | 2026-09-08 Office | Desert Medical Group Internal Medicine · in network | 93000 | $92.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022834 CMS-1500 · 2026-10-12 | Charlotte Ortiz UHC-52389-49 | 2026-09-27 Office | Mesa Medical Group Internal Medicine · in network | 99214 | $272.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-003740 CMS-1500 · 2026-10-12 | Arjun Ward UHC-59588-89 | 2026-09-25 Office | Heritage Medical Group Internal Medicine · in network | 99215 | $299.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-021824 CMS-1500 · 2026-10-11 | Lawrence Rice UHC-99232-21 | 2026-08-27 Office | Sunrise Medical Group Family Medicine · in network | 99213, 36415 | $176.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014959 CMS-1500 · 2026-10-11 | Cunningham Omar UHC-84013-63 | 2026-08-13 Office | Riverside Bone and Joint Center Orthopedic Surgery · in network | 99213 | $208.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007811 CMS-1500 · 2026-10-11 | Santiago Gardner UHC-96725-82 | 2026-08-29 Office | Mesa Dermatology Clinic Dermatology · in network | 99213 | $177.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-029531 CMS-1500 · 2026-10-08 | Sophia Fox UHC-96989-32 | 2026-08-26 Office | Evergreen Internal Medicine Associates Internal Medicine · in network | 99215 | $351.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024080 CMS-1500 · 2026-10-08 | Theresa Ferguson UHC-72869-72 | 2026-08-24 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99214 | $204.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-015596 CMS-1500 · 2026-10-08 | Teresa Sims UHC-19809-99 | 2026-08-11 Office | Harbor Cardiovascular Associates Cardiology · in network | 99214 | $236.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-034077 CMS-1500 · 2026-10-07 | Brenda Ortiz UHC-96228-35 | 2026-08-30 Office | Harbor Physical Therapy Physical Therapy · in network | 97110, 97014 | $272.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022089 CMS-1500 · 2026-10-07 | Jacqueline Davis UHC-40454-55 | 2026-08-20 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90837 | $262.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022479 CMS-1500 · 2026-10-05 | Logan Green no member ID | 2026-08-13 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110, 97140 | $329.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-002331 CMS-1500 · 2026-10-05 | James Fernandez UHC-25043-68 | 2026-09-04 Independent laboratory | Canyon Reference Lab Clinical Laboratory · in network | 83036 | $74.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-029957 CMS-1500 · 2026-10-04 | Andrew Garza UHC-05082-55 | 2026-08-30 Office | Mesa Primary Care Associates Family Medicine · in network | 99395, 99203 | $469.00 | — | Denied by rule CO18 | — | 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.