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-2026-030299 CMS-1500 · 2026-10-18 | Frances Reed UHC-43006-53 | 2026-10-14 Office | Cornerstone Cardiovascular Associates Cardiology · in network | 99214 | $272.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-024097 UB-04 · 2026-10-18 | Christine Wright UHC-27440-91 | 2026-09-15 Outpatient hospital | Heritage Digestive Health Center Gastroenterology · in network | 45378, 88305 | $1,824.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-017708 CMS-1500 · 2026-10-18 | Noah Rogers UHC-89314-56 | 2026-10-11 Office | Heritage Internal Medicine Associates Internal Medicine · in network | 80053, 93000 | $168.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-016082 CMS-1500 · 2026-10-18 | Judith Jenkins UHC-83319-71 | 2026-10-09 Office | Unity Medical Group Internal Medicine · in network | 93000 | $76.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014600 CMS-1500 · 2026-10-18 | Angela Bailey UHC-80041-28 | 2026-09-05 Office | Summit Endocrine Associates Endocrinology · in network | 99215, 83036 | $355.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-013042 CMS-1500 · 2026-10-18 | Sara Ortiz UHC-96234-58 | 2026-09-18 Office | Evergreen Internal Medicine Associates Internal Medicine · in network | 80053 | $43.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-007459 CMS-1500 · 2026-10-18 | Priya Nelson UHC-65947-09 | 2026-09-28 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 80061, 87086 | $85.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-004216 UB-04 · 2026-10-18 | Alexander Reid UHC-77022-69 | 2026-09-16 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 71046, 70553 | $3,057.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-003319 CMS-1500 · 2026-10-18 | Keith Vazquez UHC-01356-46 | 2026-10-06 Office | Unity Dermatology Clinic Dermatology · in network | 99213, 11403 | $760.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-002357 CMS-1500 · 2026-10-18 | Charles Nguyen UHC-11107-77 | 2026-09-12 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 85025, 80061 | $106.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-001208 UB-04 · 2026-10-18 | Alexander Robertson UHC-20832-08 | 2026-09-29 Outpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,651.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-017662 CMS-1500 · 2026-10-17 | Maria Cruz UHC-56006-43 | 2026-09-04 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 80053, 93000 | $174.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-017192 CMS-1500 · 2026-10-17 | Kenneth Morgan UHC-50444-71 | 2026-09-28 Office | Cornerstone Diabetes Center Endocrinology · in network | 99215 | $406.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-015188 UB-04 · 2026-10-17 | Jacqueline Willis UHC-69078-97 | 2026-09-29 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 76700, 74177 | $2,395.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014664 CMS-1500 · 2026-10-17 | Jacqueline Willis UHC-69078-97 | 2026-09-08 Office | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 99213 | $222.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-004662 UB-04 · 2026-10-17 | Juan Franklin UHC-92188-10 | 2026-09-05 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306, 93015 | $1,817.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-033040 CMS-1500 · 2026-10-16 | Edward Delgado UHC-98565-10 | 2026-10-04 Office | Canyon Medical Group Internal Medicine · in network | 99215, 80053, 99214 | $736.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-027730 CMS-1500 · 2026-10-16 | Luis Wilson UHC-54875-60 | 2026-09-30 Office | Evergreen Medical Group Family Medicine · in network | 99203 | $236.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-021952 CMS-1500 · 2026-10-16 | Anthony Fields UHC-31856-02 | 2026-10-10 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99215, 93000 | $395.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-020181 CMS-1500 · 2026-10-16 | Heather Perez UHC-55402-81 | 2026-10-02 Office | Unity Digestive Health Center Gastroenterology · in network | 99214 | $313.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-013868 CMS-1500 · 2026-10-16 | Heather Perez UHC-55402-81 | 2026-09-04 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 83036, 80061 | $119.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-001215 CMS-1500 · 2026-10-16 | Madison Jenkins UHC-28890-43 | 2026-09-11 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 83036 | $76.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-027414 UB-04 · 2026-10-15 | Gregory Hunt UHC-84710-60 | 2026-09-23 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $6,359.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-018854 UB-04 · 2026-10-15 | Gloria Yang UHC-77975-62 | 2026-10-07 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 93458, 93306 | $10,394.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-018704 CMS-1500 · 2026-10-15 | Emily Lucas UHC-12704-17 | 2026-10-07 Office | Heritage Primary Care Associates Family Medicine · in network | 99213 | $201.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014947 CMS-1500 · 2026-10-15 | Stephen Soto UHC-38096-98 | 2026-09-18 Office | Valley Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $461.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-034579 CMS-1500 · 2026-10-14 | Keith Vazquez UHC-01356-46 | 2026-09-09 Office | Lakeside Medical Group Family Medicine · in network | 99395, 99213 | $508.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-030339 CMS-1500 · 2026-10-14 | Jeremy Jacobs UHC-82894-81 | 2026-09-21 Office | Meadow Family Practice Family Medicine · in network | 99395, 36415 | $313.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-029540 UB-04 · 2026-10-14 | Mary Munz UHC-13183-92 | 2026-10-10 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 43239, 45378 | $4,347.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-028498 CMS-1500 · 2026-10-14 | Frances Jenkins UHC-08557-87 | 2026-10-04 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110 | $282.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-026234 UB-04 · 2026-10-14 | Victoria Richards UHC-93067-18 | 2026-09-04 Outpatient hospital | Cornerstone Imaging Center Radiology · in network | 77067, 74177, 71046 | $2,873.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-020836 CMS-1500 · 2026-10-14 | Matthew Day UHC-65445-38 | 2026-09-11 Office | Desert Medical Group Internal Medicine · in network | 99214, 99215 | $568.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-016714 CMS-1500 · 2026-10-14 | Matthew Day UHC-65445-38 | 2026-09-16 Office | Canyon Primary Care Associates Family Medicine · in network | 99203, 99395, 36415 | $452.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-011031 UB-04 · 2026-10-14 | Omar Hunt UHC-97434-51 | 2026-10-03 Outpatient hospital | Heritage Imaging Center Radiology · in network | 76700, 70553 | $3,006.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-007350 CMS-1500 · 2026-10-14 | Brandon Pena UHC-11986-61 | 2026-10-09 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99203, 99214 | $527.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-006344 CMS-1500 · 2026-10-14 | Noah Campbell UHC-25272-68 | 2026-10-06 Office | Sunrise Medical Group Family Medicine · in network | 99395, 99203 | $516.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-003642 CMS-1500 · 2026-10-14 | George Miller UHC-23025-90 | 2026-09-02 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 99215, 93000 | $411.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-026211 UB-04 · 2026-10-13 | Judy Wells UHC-84471-03 | 2026-10-10 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 70553, 74177 | $5,764.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-023629 CMS-1500 · 2026-10-13 | Sean Sean UHC-92857-60 | 2026-09-06 Office | Mesa Dermatology Clinic Dermatology · in network | 99213, 17110 | $350.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-001195 CMS-1500 · 2026-10-13 | Ray Peters UHC-72190-33 | 2026-09-10 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 80053, 93000 | $172.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-032320 CMS-1500 · 2026-10-12 | Benjamin Contreras UHC-74433-78 | 2026-10-07 Office | Sunrise Behavioral Health Behavioral Health · in network | 90791, 90834 | $547.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-031122 CMS-1500 · 2026-10-12 | Janice Rose UHC-67004-45 | 2026-09-17 Office | Riverside Primary Care Associates Family Medicine · in network | 99395, 99214, 36415 | $575.00 | — | Denied by rule CO27 | — | 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-2026-005924 CMS-1500 · 2026-10-12 | Heather Lopez UHC-55811-29 | 2026-09-04 Office | Sunrise Diabetes Center Endocrinology · in network | 99215 | $296.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-004844 CMS-1500 · 2026-10-12 | Sean Chapman UHC-35561-40 | 2026-10-09 Office | Canyon Primary Care Associates Family Medicine · in network | 99395, 99214, 36415 | $587.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-032376 CMS-1500 · 2026-10-11 | Wayne Diez UHC-82176-57 | 2026-10-01 Office | Mesa GI Associates Gastroenterology · in network | 99214 | $315.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-028562 UB-04 · 2026-10-11 | Douglas Kim UHC-49616-13 | 2026-09-29 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285 | $1,664.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-024112 UB-04 · 2026-10-11 | Daniel Thomas UHC-78647-56 | 2026-09-09 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 74177, 77067 | $2,456.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-017325 CMS-1500 · 2026-10-11 | Grace Burton UHC-52024-75 | 2026-09-30 Office | Canyon Medical Group Internal Medicine · in network | 80053, 99214 | $387.00 | — | Denied by rule CO27 | — | 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 |
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.