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-2026-033652 CMS-1500 · 2026-10-18 | Tyler Moore UHC-71756-75 | 2026-09-03 Office | Evergreen Dermatology Clinic Dermatology · out of network | 11403, 99213 | $902.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-025606 CMS-1500 · 2026-10-18 | Lawrence Watson UHC-48583-08 | 2026-10-04 Office | Desert Cardiovascular Associates Cardiology · in network | 93224, 99214 | $516.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-024368 UB-04 · 2026-10-18 | Omar Holmes UHC-04491-04 | 2026-09-27 Outpatient hospital | Unity Diagnostic Imaging Radiology · in network | 74177, 70553 | $5,077.00 | — | Left for review CO50 CO97 | — | Needs review |
| CLM-2026-009966 CMS-1500 · 2026-10-18 | Abbby Wong UHC-74228-68 | 2026-09-20 Office | Canyon Medical Group Internal Medicine · in network | 80053, 99214 | $317.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-031941 UB-04 · 2026-10-17 | Mark Riley UHC-38683-19 | 2026-10-01 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 96374, 99284 | $1,564.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-007132 UB-04 · 2026-10-17 | Laura Reyes UHC-58818-28 | 2026-09-20 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284, 99283 | $2,378.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-034606 CMS-1500 · 2026-10-16 | Evelyn Ramos UHC-70497-07 | 2026-09-25 Office | Evergreen Medical Group Family Medicine · in network | 99395, 99213 | $411.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-020953 UB-04 · 2026-10-16 | Perry Arthur UHC-34387-88 | 2026-09-30 Outpatient hospital | Riverside GI Associates Gastroenterology · in network | 43239, 45378 | $4,992.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-017481 CMS-1500 · 2026-10-16 | Jeremy Bishop UHC-33995-12 | 2026-10-04 Office | Northgate Medical Group Family Medicine · in network | 99213, 99214 | $434.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-006396 UB-04 · 2026-10-16 | Jesse Kim UHC-45304-40 | 2026-09-04 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284, 99283 | $1,928.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023855 UB-04 · 2026-10-15 | Dennis Perez UHC-14032-93 | 2026-09-24 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306, 93458 | $10,569.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-019192 UB-04 · 2026-10-15 | Gloria Vargas UHC-65899-86 | 2026-09-13 Outpatient hospital | Mesa Cardiovascular Associates Cardiology · in network | 93458, 93306 | $6,391.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-013282 CMS-1500 · 2026-10-15 | Mason Porter UHC-76399-31 | 2026-09-20 Office | Canyon Cardiovascular Associates Cardiology · in network | 93224, 99214 | $740.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-004162 CMS-1500 · 2026-10-15 | Virginia Wong UHC-96611-25 | 2026-10-12 Office | Evergreen Medical Group Family Medicine · in network | 99203, 99213 | $351.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-011191 CMS-1500 · 2026-10-14 | Christopher Cooper UHC-06864-83 | 2026-10-09 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 99214, 99215 | $537.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-018491 UB-04 · 2026-10-13 | Peter McCoy UHC-64916-39 | 2026-09-24 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 76700, 70553 | $2,621.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-031767 CMS-1500 · 2026-10-12 | Lawrence Young UHC-86523-36 | 2026-09-23 Office | Pinecrest Medical Group Family Medicine · in network | 99395, 99213 | $502.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023742 UB-04 · 2026-10-12 | Adam Vega UHC-59055-13 | 2026-09-16 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 96374, 99285 | $2,954.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-013966 UB-04 · 2026-10-12 | Lauren Spencer UHC-15892-51 | 2026-08-28 Outpatient hospital | Cornerstone Cardiovascular Associates Cardiology · in network | 93458, 93306 | $9,038.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023112 CMS-1500 · 2026-10-11 | Melissa Tran UHC-46772-18 | 2026-09-22 Office | Heritage Primary Care Associates Family Medicine · in network | 99395, 99213 | $443.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-011835 UB-04 · 2026-10-11 | Matthew Gilbert UHC-74569-95 | 2026-09-27 Outpatient hospital | Valley Heart Institute Cardiology · in network | 93458, 93306 | $9,180.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023701 CMS-1500 · 2026-10-10 | Sarah Banks UHC-19530-96 | 2026-09-22 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 80053, 85025 | $121.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-017366 CMS-1500 · 2026-10-09 | John Sims UHC-98485-42 | 2026-08-28 Office | Mesa Family Practice Family Medicine · in network | 36415, 90471 | $55.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-026952 CMS-1500 · 2026-10-08 | David Wang UHC-66449-08 | 2026-09-11 Office | Canyon Medical Group Internal Medicine · in network | 99214, 80053 | $370.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-013701 CMS-1500 · 2026-10-08 | Elijah Gray UHC-73436-77 | 2026-08-26 Office | Evergreen Medical Group Family Medicine · in network | 90471, 99213 | $246.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-004256 UB-04 · 2026-10-08 | John Torres UHC-31945-76 | 2026-09-30 Emergency room | Unity Community Hospital Emergency Medicine · in network | 71046, 99283 | $1,265.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-028678 CMS-1500 · 2026-10-06 | Christopher Yang UHC-11124-73 | 2026-10-02 Telehealth | Sunrise Counseling Center Behavioral Health · in network | 99214, 90834 | $463.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-009541 CMS-1500 · 2026-10-06 | Gary Vargas UHC-01629-87 | 2026-09-10 Office | Heritage Primary Care Associates Family Medicine · in network | 99214, 36415, 99203 | $512.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-000356 CMS-1500 · 2026-10-06 | Gary Espinoza UHC-09582-44 | 2026-08-24 Office | Riverside Digestive Health Center Gastroenterology · in network | 99214, 43239 | $2,617.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-026705 CMS-1500 · 2026-10-05 | Michelle Walker UHC-76125-07 | 2026-09-18 Office | Heritage Medical Group Family Medicine · in network | 99203, 99213 | $358.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-033123 CMS-1500 · 2026-10-04 | Noah Oliver UHC-49295-92 | 2026-09-06 Independent laboratory | Northgate Clinical Laboratories Clinical Laboratory · in network | 80061, 80053 | $94.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-016997 CMS-1500 · 2026-10-04 | Abigail Reynolds UHC-56842-65 | 2026-09-14 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 83036, 80053 | $104.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-013455 CMS-1500 · 2026-10-04 | Carolyn Jordan UHC-84537-40 | 2026-09-24 Office | Pinecrest Medical Group Internal Medicine · in network | 93000, 80053, 99215 | $396.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-021310 CMS-1500 · 2026-10-02 | Hannah Gilbert UHC-12376-13 | 2026-09-30 Independent laboratory | Lakeside Reference Lab Clinical Laboratory · in network | 80061, 87086 | $97.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-011073 CMS-1500 · 2026-10-02 | Richard Bishop UHC-11474-59 | 2026-08-20 Office | Mesa Dermatology Clinic Dermatology · in network | 99213, 11102 | $390.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-009908 CMS-1500 · 2026-10-02 | Yuki Murphy UHC-24467-37 | 2026-09-15 Office | Lakeside Medical Group Family Medicine · out of network | 99203, 99213 | $351.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-025692 CMS-1500 · 2026-10-01 | Gregory Wagner UHC-51627-22 | 2026-09-28 Office | Pinecrest Medical Group Internal Medicine · in network | 99214, 80053 | $308.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-022396 CMS-1500 · 2026-10-01 | Virginia Ross UHC-66259-56 | 2026-09-07 Office | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 99213, 20610 | $457.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-019320 UB-04 · 2026-10-01 | Sharon Owens UHC-46430-01 | 2026-08-24 Inpatient hospital | Sunrise Internal Medicine Associates Internal Medicine · in network | 99232, 99215 | $591.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-020741 UB-04 · 2026-09-30 | Paul Russell UHC-55726-01 | 2026-09-28 Emergency room | Desert Regional Medical Center Emergency Medicine · in network | 99284, 71046 | $1,476.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-008486 UB-04 · 2026-09-30 | Nathan Greene UHC-46806-74 | 2026-09-10 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 71046, 76700 | $618.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-016700 CMS-1500 · 2026-09-29 | Lori Allen UHC-82292-56 | 2026-09-20 Office | Northgate Primary Care Associates Family Medicine · out of network | 99203, 99213 | $386.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-014785 UB-04 · 2026-09-29 | Lawrence Moore UHC-61864-11 | 2026-09-10 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 76700, 70553 | $2,925.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-000244 UB-04 · 2026-09-28 | Lauren Pierce UHC-58226-07 | 2026-09-20 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99284, 99283 | $2,218.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-031127 CMS-1500 · 2026-09-27 | Sarah Hamilton UHC-22904-19 | 2026-09-08 Office | Mesa Family Practice Family Medicine · in network | 90471, 99395, 99214 | $527.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-031389 CMS-1500 · 2026-09-26 | Martha Bailey UHC-06979-99 | 2026-09-11 Office | Pinecrest Medical Group Family Medicine · in network | 90471, 99213 | $224.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-030157 CMS-1500 · 2026-09-26 | Peter Smith UHC-20983-31 | 2026-09-09 Office | Northgate Medical Group Internal Medicine · in network | 93000, 99214 | $371.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-013570 CMS-1500 · 2026-09-26 | Debra Elliott UHC-29655-41 | 2026-09-02 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $288.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-000825 CMS-1500 · 2026-09-26 | Kayla Williamson UHC-28782-70 | 2026-08-21 Independent laboratory | Sunrise Clinical Laboratories Clinical Laboratory · in network | 80061, 87086, 80053 | $166.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-021220 CMS-1500 · 2026-09-25 | Santiago Allen UHC-39555-75 | 2026-09-18 Office | Valley Medical Group Family Medicine · in network | 99203, 90471 | $264.00 | — | Left for review CO97 | — | 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.