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
3,664
50 with an AI recommendation
Pended
2,586
awaiting information or identity
Approved
23,942
$6,757,768.45 plan paid
Denied
4,454
with remittance reason codes
Examiner decided
0
167 not attached to an identity
| Claim | Member | Service | Provider | Procedures | Billed | Plan pays | Rules | AI | Status |
|---|---|---|---|---|---|---|---|---|---|
| CLM-2026-009538 UB-04 · 2026-05-18 | Christian Yang UHC-31026-34 | 2025-11-28 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285, 71046 | $2,857.00 | — | Denied by rule N30 CO29 | — | Denied |
| CLM-2026-006848 UB-04 · 2026-05-14 | Nicole Carter UHC-16666-12 | 2025-11-23 Emergency room | Canyon Regional Medical Center Emergency Medicine · in network | 71046, 99283 | $1,011.00 | — | Denied by rule N30 CO29 | — | Denied |
| CLM-2026-006808 CMS-1500 · 2026-04-28 | Julie Fernandez UHC-84577-80 | 2025-10-15 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99215 | $314.00 | — | Denied by rule N30 CO29 | — | Denied |
| CLM-2026-018875 CMS-1500 · 2026-02-22 | Sara Wood UHC-63850-64 | 2025-08-25 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 99215, 99214 | $551.00 | — | Denied by rule N30 CO29 | — | Denied |
| CLM-2026-004068 CMS-1500 · 2026-02-16 | Kyle Burns UHC-52612-93 | 2025-08-15 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110, 97140, 97014 | $283.00 | — | Denied by rule N30 CO29 | — | Denied |
| CLM-2026-005565 CMS-1500 · 2026-01-29 | Daniel Matthews UHC-84431-15 | 2025-08-21 Office | Mesa Family Practice Family Medicine · in network | 90471 | $26.00 | — | Denied by rule N30 CO29 | — | Denied |
| CLM-2026-003729 CMS-1500 · 2026-01-25 | Betty Vega UHC-40806-34 | 2025-08-14 Office | Evergreen Family Practice Family Medicine · in network | 36415, 99203 | $244.00 | — | Denied by rule N30 CO29 | — | Denied |
| CLM-2026-025428 UB-04 · 2026-01-13 | Sandra White UHC-81034-29 | 2025-06-11 Outpatient hospital | Summit Imaging Center Radiology · in network | 74177, 70553 | $4,554.00 | — | Denied by rule N30 CO29 | — | Denied |
| CLM-2026-026126 UB-04 · 2026-01-10 | Brian Cox UHC-39816-02 | 2025-11-28 Outpatient hospital | Pinecrest Cardiovascular Associates Cardiology · in network | 93458, 93015 | $9,501.00 | — | Denied by rule N30 | — | Denied |
| CLM-2026-010684 CMS-1500 · 2026-01-10 | Danielle Ruiz UHC-31158-95 | 2025-11-30 Office | Heritage Medical Group Internal Medicine · in network | 99214 | $230.00 | — | Denied by rule N30 | — | Denied |
| CLM-2026-017030 UB-04 · 2026-01-07 | Matthew Li UHC-62155-73 | 2025-06-08 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306, 93458 | $6,254.00 | — | Denied by rule N30 CO29 | — | Denied |
| CLM-2026-016263 CMS-1500 · 2026-01-02 | Daniel Duncan UHC-24935-31 | 2025-11-24 Office | Unity Physical Therapy Physical Therapy · in network | 97110 | $222.00 | — | Denied by rule N30 | — | Denied |
| CLM-2026-027208 CMS-1500 · 2026-01-01 | Frances Carpenter UHC-94353-46 | 2025-08-18 Office | Unity Dermatology Clinic Dermatology · in network | 99213, 17110 | $466.00 | — | Denied by rule N30 CO29 | — | Denied |
| CLM-2026-016881 CMS-1500 · 2026-01-01 | Harold Bishop UHC-58284-64 | 2025-06-24 Office | Evergreen Primary Care Associates Family Medicine · in network | 99213, 36415 | $200.00 | — | Denied by rule N30 CO29 | — | 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.