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-2026-013400 CMS-1500 · 2026-11-06 | Gregory Mendez UHC-93422-08 | 2026-09-25 Office | Sunrise Internal Medicine Associates Internal Medicine · in network | 93000, 80053 | $111.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008672 CMS-1500 · 2026-11-06 | Julie Walsh UHC-41401-24 | 2026-09-13 Office | Meadow Primary Care Associates Family Medicine · in network | 99203, 99213 | $366.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-030929 CMS-1500 · 2026-11-02 | Alexis Long UHC-64773-95 | 2026-10-10 Office | Unity Physical Therapy Physical Therapy · in network | 97110, 97014, 97161 | $540.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-002556 CMS-1500 · 2026-10-30 | Rachel Allen UHC-61641-27 | 2026-09-05 Office | Sunrise Dermatology Clinic Dermatology · in network | 11102 | $266.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-031133 CMS-1500 · 2026-10-28 | Diana Spencer UHC-15396-79 | 2026-08-30 Office | Riverside Family Practice Family Medicine · in network | 99203, 99214 | $519.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-021613 CMS-1500 · 2026-10-27 | Adam Garrett UHC-27878-40 | 2026-10-01 Office | Evergreen Medical Group Family Medicine · in network | 90471, 99203, 99214 | $538.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008970 CMS-1500 · 2026-10-25 | Gary Garza UHC-15058-98 | 2026-09-07 Office | Heritage Medical Group Internal Medicine · in network | 93000, 99214, 99215 | $695.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-024564 CMS-1500 · 2026-10-24 | Janice Luna UHC-02636-28 | 2026-09-14 Office | Unity Primary Care Associates Family Medicine · in network | 99213 | $166.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003099 CMS-1500 · 2026-10-24 | Wayne Garza UHC-17167-67 | 2026-10-15 Office | Evergreen GI Associates Gastroenterology · in network | 99214 | $289.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-018199 CMS-1500 · 2026-10-23 | Betty Warren UHC-12406-55 | 2026-08-25 Office | Heritage Primary Care Associates Family Medicine · in network | 99395, 99213 | $528.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-030532 CMS-1500 · 2026-10-21 | Logan James UHC-25785-59 | 2026-09-11 Office | Sunrise Medical Group Internal Medicine · in network | 99214, 99215, 80053 | $760.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-023357 CMS-1500 · 2026-10-21 | Keith Williamson UHC-70723-03 | 2026-09-09 Office | Desert Rehabilitation Center Physical Therapy · in network | 97110 | $56.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-001654 CMS-1500 · 2026-10-20 | Ana Robinson UHC-45904-17 | 2026-10-02 Office | Lakeside Internal Medicine Associates Internal Medicine · in network | 99214 | $236.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-005535 CMS-1500 · 2026-10-18 | Luri Bryant UHC-70153-08 | 2026-09-17 Office | Canyon Skin Care Associates Dermatology · in network | 99213 | $158.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029651 CMS-1500 · 2026-10-17 | Rachel Coleman UHC-34040-77 | 2026-09-26 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99215, 80053 | $437.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-004044 CMS-1500 · 2026-10-17 | Christian Gonzalez UHC-05076-98 | 2026-08-28 Office | Sunrise Medical Group Family Medicine · in network | 99203, 90471 | $220.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029892 CMS-1500 · 2026-10-16 | Sophia Alexander UHC-65817-15 | 2026-09-08 Office | Sunrise Behavioral Health Behavioral Health · in network | 90834, 90837 | $468.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008389 CMS-1500 · 2026-10-16 | Kyle Salazar UHC-42261-80 | 2026-09-07 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 80061 | $65.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-034301 CMS-1500 · 2026-10-15 | Alan Maldonado UHC-40405-98 | 2026-08-16 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90834, 90837, 90791 | $757.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-032122 CMS-1500 · 2026-10-14 | Charles Williams UHC-34565-98 | 2026-08-26 Independent laboratory | Meadow Reference Lab Clinical Laboratory · in network | 83036, 80061 | $135.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029616 CMS-1500 · 2026-10-13 | Anna Scott UHC-14025-28 | 2026-08-26 Office | Meadow Primary Care Associates Family Medicine · in network | 99395, 99214, 99203 | $724.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-004445 CMS-1500 · 2026-10-13 | Barbara Weber UHC-24739-99 | 2026-09-11 Office | Unity Digestive Health Center Gastroenterology · in network | 99214 | $306.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-002605 CMS-1500 · 2026-10-13 | Bradley Oliver UHC-67161-27 | 2026-09-19 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 99215 | $391.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-025155 CMS-1500 · 2026-10-12 | John Fox UHC-40679-15 | 2026-09-17 Office | Heritage Family Practice Family Medicine · in network | 36415, 99213 | $222.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-010142 CMS-1500 · 2026-10-12 | James Hanson UHC-90765-54 | 2026-08-26 Office | Riverside Primary Care Associates Family Medicine · in network | 99203, 36415 | $253.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-005725 CMS-1500 · 2026-10-12 | Joyce Reid UHC-05392-10 | 2026-08-30 Independent laboratory | Cornerstone Reference Lab Clinical Laboratory · in network | 83036, 80053 | $108.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-019729 CMS-1500 · 2026-10-10 | Abigail Montgomery UHC-74702-59 | 2026-09-13 Office | Riverside Family Practice Family Medicine · in network | 99213, 99214 | $422.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-011681 CMS-1500 · 2026-10-09 | Randy Bishop UHC-81792-57 | 2026-08-09 Independent laboratory | Desert Clinical Laboratories Clinical Laboratory · in network | 83036, 85025, 87086 | $140.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-028070 CMS-1500 · 2026-10-08 | Roy Wright UHC-76478-99 | 2026-09-09 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80061, 83036 | $116.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-022319 CMS-1500 · 2026-10-08 | Jason Ryan UHC-14330-97 | 2026-08-30 Office | Canyon Cardiovascular Associates Cardiology · out of network | 99214 | $259.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-014456 CMS-1500 · 2026-10-07 | Aan Ramos UHC-76630-85 | 2026-08-08 Office | Heritage Internal Medicine Associates Internal Medicine · in network | 80053 | $84.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-011181 CMS-1500 · 2026-10-06 | Aisha Fowler UHC-20279-26 | 2026-08-06 Office | Meadow Internal Medicine Associates Internal Medicine · in network | 80053 | $55.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-001124 CMS-1500 · 2026-10-05 | Heatheer George UHC-57264-54 | 2026-08-26 Office | Heritage Primary Care Associates Family Medicine · in network | 36415, 99395, 99214 | $569.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-022636 CMS-1500 · 2026-10-04 | Jordan Wood UHC-07231-79 | 2026-08-18 Office | Unity Primary Care Associates Family Medicine · in network | 99203, 99214 | $483.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-031871 CMS-1500 · 2026-10-01 | Carol Ruiz UHC-33407-76 | 2026-09-22 Office | Pinecrest Physical Therapy Physical Therapy · in network | 97110 | $80.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-014251 CMS-1500 · 2026-09-30 | Joseph Cole UHC-31831-74 | 2026-09-04 Office | Heritage GI Associates Gastroenterology · in network | 99214 | $328.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008876 CMS-1500 · 2026-09-29 | Isabella Murphy UHC-81397-53 | 2026-08-04 Office | Evergreen Family Practice Family Medicine · in network | 99203, 36415 | $259.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-021068 CMS-1500 · 2026-09-28 | Edward Watkins UHC-04151-64 | 2026-08-19 Office | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 99213 | $240.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029356 CMS-1500 · 2026-09-27 | Nancy Rios UHC-06953-52 | 2026-08-20 Independent laboratory | Canyon Clinical Laboratories Clinical Laboratory · in network | 80053, 83036 | $122.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-022521 CMS-1500 · 2026-09-25 | Sofia Mitchell UHC-25956-67 | 2026-08-26 Office | Pinecrest Primary Care Associates Family Medicine · in network | 99395, 99213 | $515.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-019566 CMS-1500 · 2026-09-25 | Sophia Hill UHC-72031-89 | 2026-09-02 Office | Northgate Counseling Center Behavioral Health · in network | 90791 | $460.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-019488 CMS-1500 · 2026-09-24 | Kelly Evans UHC-73587-33 | 2026-08-13 Office | Heritage Family Practice Family Medicine · in network | 36415, 99213 | $163.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-014197 CMS-1500 · 2026-09-24 | Judy Jimenez UHC-32177-75 | 2026-08-20 Independent laboratory | Heritage Clinical Laboratories Clinical Laboratory · in network | 85025, 80053 | $116.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-024434 CMS-1500 · 2026-09-22 | Donna Ward UHC-89367-54 | 2026-08-30 Office | Sunrise Orthopedic Specialists Orthopedic Surgery · in network | 99213 | $181.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-018658 CMS-1500 · 2026-09-22 | Virginia Marrtin UHC-82287-41 | 2026-09-07 Independent laboratory | Canyon Reference Lab Clinical Laboratory · out of network | 80053, 87086 | $145.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-012959 CMS-1500 · 2026-09-22 | Joan Edwards UHC-88614-34 | 2026-09-02 Office | Harbor Medical Group Internal Medicine · out of network | 99215, 99214, 93000 | $651.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008541 CMS-1500 · 2026-09-22 | Lawrence Ramirez UHC-95611-07 | 2026-08-06 Office | Harbor Medical Group Internal Medicine · out of network | 80053, 99215 | $429.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-020702 CMS-1500 · 2026-09-21 | Brian Ford UHC-83014-83 | 2026-09-15 Office | Meadow Family Practice Family Medicine · in network | 36415 | $24.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-007281 CMS-1500 · 2026-09-20 | Virginia Hughes UHC-52299-91 | 2026-08-15 Office | Evergreen Rehabilitation Center Physical Therapy · in network | 97110 | $82.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-006403 CMS-1500 · 2026-09-20 | Doris Ryan UHC-04166-33 | 2026-08-02 Office | Mesa Primary Care Associates Family Medicine · in network | 99214 | $223.00 | — | Left for review REPL | — | 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.