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-2026-020880 CMS-1500 · 2026-10-30 | John Wood UHC-22176-71 | 2026-09-15 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $166.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032967 CMS-1500 · 2026-10-18 | Amber Howell UHC-88592-44 | 2026-09-18 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11403, 17110 | $956.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032335 CMS-1500 · 2026-10-18 | James Delgado UHC-83159-99 | 2026-09-29 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $186.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-024000 CMS-1500 · 2026-10-18 | Lawrence George UHC-17614-13 | 2026-10-03 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80061, 83036 | $137.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009947 CMS-1500 · 2026-10-18 | Melissa Tran UHC-46772-18 | 2026-10-08 Office | Canyon Counseling Center Behavioral Health · out of network | 90837 | $194.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026123 CMS-1500 · 2026-10-17 | William Simpson UHC-87572-94 | 2026-10-14 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 93000, 80053 | $135.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-019759 CMS-1500 · 2026-10-17 | Sofia Price UHC-91931-96 | 2026-10-11 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 80061, 83036 | $77.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-011023 CMS-1500 · 2026-10-17 | Nancy Hansen UHC-45838-06 | 2026-09-30 Office | Harbor Primary Care Associates Family Medicine · out of network | 99213 | $140.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009421 CMS-1500 · 2026-10-17 | Abigail Carr UHC-85206-38 | 2026-09-13 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $287.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-005997 CMS-1500 · 2026-10-17 | Christine Cooper UHC-90180-01 | 2026-10-10 Office | Sunrise Digestive Health Center Gastroenterology · out of network | 99214 | $324.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-026762 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-2026-015281 CMS-1500 · 2026-10-16 | Jonathan Lawson UHC-79224-89 | 2026-07-05 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $118.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-011852 CMS-1500 · 2026-10-16 | Heather Carpenter UHC-81594-70 | 2026-09-23 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80053, 85025 | $106.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009760 CMS-1500 · 2026-10-16 | Jose Vega UHC-35189-94 | 2026-09-12 Office | Canyon Counseling Center Behavioral Health · out of network | 90791 | $315.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009682 CMS-1500 · 2026-10-15 | Sandra Jackson UHC-78773-38 | 2026-10-09 Office | Valley Skin Care Associates Dermatology · out of network | 17110, 99213 | $480.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006258 CMS-1500 · 2026-10-15 | Jerry Jensen UHC-63050-35 | 2026-09-03 Office | Harbor Medical Group Internal Medicine · out of network | 99214, 80053 | $257.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001025 CMS-1500 · 2026-10-15 | Harold Patterson UHC-04603-36 | 2026-09-17 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $337.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-028107 CMS-1500 · 2026-10-14 | Dylan Parker UHC-07807-62 | 2026-09-28 Office | Canyon Counseling Center Behavioral Health · out of network | 90834, 90791 | $627.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-022432 CMS-1500 · 2026-10-14 | Steven Gilbert UHC-22739-27 | 2026-09-06 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90791, 90834 | $439.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-034571 CMS-1500 · 2026-10-13 | Elizabeth Schultz UHC-01992-56 | 2026-09-30 Office | Evergreen Medical Group Internal Medicine · out of network | 80053, 93000, 99215 | $530.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-028136 CMS-1500 · 2026-10-12 | Mason Garcia UHC-80156-07 | 2026-05-09 Office | Meadow Heart Institute Cardiology · out of network | 93224 | $438.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-011632 CMS-1500 · 2026-10-12 | Carlos Perkins UHC-67445-33 | 2026-09-02 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061, 83036, 87086 | $156.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010199 CMS-1500 · 2026-10-12 | Melissa Hudson UHC-49229-90 | 2026-09-23 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 83036 | $64.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-007527 CMS-1500 · 2026-10-12 | Deborah Wang UHC-09134-29 | 2026-10-09 Office | Riverside Internal Medicine Associates Internal Medicine · out of network | 99214, 80053 | $364.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001237 CMS-1500 · 2026-10-12 | Karen Anderson UHC-48865-86 | 2026-09-05 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086 | $64.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-033989 CMS-1500 · 2026-10-11 | Diana Phillips UHC-60258-47 | 2026-08-27 Office | Sunrise Medical Group Internal Medicine · out of network | 99214, 93000, 99215 | $715.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-033721 CMS-1500 · 2026-10-11 | Terry Gomez UHC-19314-17 | 2026-09-10 Office | Valley Skin Care Associates Dermatology · out of network | 11403, 11102 | $843.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032985 CMS-1500 · 2026-10-11 | Billy Contreras UHC-74899-95 | 2026-09-22 Office | Cornerstone Family Practice Family Medicine · out of network | 99213, 90471 | $211.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-017261 CMS-1500 · 2026-10-11 | Marilyn Ferguson UHC-33529-32 | 2026-09-21 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061 | $80.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010386 CMS-1500 · 2026-10-11 | Noah Coleman UHC-80842-13 | 2026-09-03 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11403, 99213 | $537.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-006310 CMS-1500 · 2026-10-11 | Santiago Johnston UHC-07734-93 | 2026-09-03 Office | Lakeside Behavioral Health Behavioral Health · out of network | 90837 | $216.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006231 CMS-1500 · 2026-10-11 | Debra Powell UHC-90874-75 | 2026-09-13 Office | Harbor Medical Group Internal Medicine · out of network | 93000, 80053 | $148.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-031974 CMS-1500 · 2026-10-10 | Terry Walker UHC-13254-77 | 2026-09-04 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · out of network | 83036, 80053 | $98.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-014578 CMS-1500 · 2026-10-10 | Victoria Knight UHC-33507-96 | 2026-09-27 Office | Sunrise Dermatology Clinic Dermatology · out of network | 99213, 11102, 17110 | $719.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-013376 CMS-1500 · 2026-10-10 | Martha Williamson UHC-86118-06 | 2026-09-20 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 83036, 80053 | $119.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009169 CMS-1500 · 2026-10-10 | Omar Harvey UHC-08537-63 | 2026-10-06 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 85025, 80053 | $108.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004597 CMS-1500 · 2026-10-10 | Betty Le UHC-26618-68 | 2026-10-02 Office | Canyon Internal Medicine Associates Internal Medicine · out of network | 93000, 99215 | $384.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-003296 CMS-1500 · 2026-10-10 | Mason Santos UHC-10432-64 | 2026-09-03 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · out of network | 80053 | $89.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-015276 CMS-1500 · 2026-10-09 | Jerry Price UHC-62204-46 | 2026-08-28 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 20610 | $278.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-013189 CMS-1500 · 2026-10-08 | Camila Jensen UHC-66295-51 | 2026-08-27 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086, 83036, 85025 | $171.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010694 CMS-1500 · 2026-10-08 | Mary George UHC-99908-37 | 2026-10-03 Office | Sunrise Cardiovascular Associates Cardiology · out of network | 99214 | $315.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001794 CMS-1500 · 2026-10-08 | Frances Wilson UHC-38544-97 | 2026-10-01 Office | Lakeside Medical Group Family Medicine · out of network | 99395, 99213 | $468.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026693 CMS-1500 · 2026-10-07 | Janet Grant UHC-09003-41 | 2026-10-04 Office | Cornerstone Family Practice Family Medicine · out of network | 99214, 90471 | $266.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004676 CMS-1500 · 2026-10-07 | Walter Hoffman UHC-83616-67 | 2026-09-30 Office | Valley Primary Care Associates Family Medicine · out of network | 99213, 99203 | $441.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-028782 CMS-1500 · 2026-10-05 | Judith Cunningham UHC-73518-90 | 2026-08-30 Office | Lakeside Medical Group Family Medicine · out of network | 99395, 99214, 99213 | $743.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-016622 CMS-1500 · 2026-10-05 | Christopher Ruiz UHC-69936-01 | 2026-09-15 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 87086, 83036, 80053 | $160.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-008072 CMS-1500 · 2026-10-05 | Peter Wong UHC-98692-59 | 2026-10-03 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 83036, 80061, 87086 | $157.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004443 CMS-1500 · 2026-10-05 | Diana Ramos UHC-98291-09 | 2026-09-15 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $296.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-025172 CMS-1500 · 2026-10-04 | Brandon Valdez UHC-15383-35 | 2026-09-01 Office | Canyon Counseling Center Behavioral Health · out of network | 90837, 90791 | $646.00 | — | Denied by rule CO204 | — | 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.