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-2026-021920 UB-04 · 2026-11-04 | Joseph Daniels UHC-26322-25 | 2026-09-12 Inpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 27447 | $44,672.00 | — | Left for review REPL HIGH | — | 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-2026-010291 CMS-1500 · 2026-11-01 | Mariana Robertson UHC-59750-05 | 2026-09-18 Office | Harbor Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $485.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-018557 CMS-1500 · 2026-10-31 | Katherine Santiago UHC-57983-34 | 2026-10-09 Office | Heritage Primary Care Associates Family Medicine · in network | 99214 | $275.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-006860 UB-04 · 2026-10-30 | Sara Wallace UHC-78913-28 | 2026-09-23 Outpatient hospital | Summit Digestive Health Center Gastroenterology · in network | 45378, 43239 | $3,976.00 | — | Left for review DUP | — | 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-2026-025171 CMS-1500 · 2026-10-29 | Michael Gutierrez UHC-45944-04 | 2026-09-14 Office | Desert Medical Group Internal Medicine · in network | 99214, 80053, 93000 | $384.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-015047 CMS-1500 · 2026-10-29 | Joyce Wong UHC-83210-22 | 2026-09-10 Independent laboratory | Summit Clinical Laboratories Clinical Laboratory · in network | 83036, 85025 | $101.00 | — | Left for review DUP | — | 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-2026-011424 CMS-1500 · 2026-10-28 | Roy Butler UHC-83875-27 | 2026-09-25 Office | Summit Heart Institute Cardiology · in network | 99214, 93224 | $747.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-009207 UB-04 · 2026-10-28 | Samantha Morris UHC-72872-02 | 2026-10-06 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 93306, 93458 | $9,899.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-026744 UB-04 · 2026-10-27 | Ryan Austin UHC-79286-61 | 2026-09-14 Emergency room | Sunrise Community Hospital Emergency Medicine · in network | 96374 | $233.00 | — | 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-2026-009117 CMS-1500 · 2026-10-27 | Yuki Sullivan UHC-25113-73 | 2026-09-07 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97161 | $491.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-017350 CMS-1500 · 2026-10-26 | Omar Webb UHC-96605-12 | 2026-10-09 Office | Summit Family Practice Family Medicine · in network | 36415, 99203 | $270.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-033244 UB-04 · 2026-10-25 | Joan Hoffman UHC-38218-33 | 2026-09-18 Emergency room | Cornerstone Regional Medical Center Emergency Medicine · in network | 99284, 99283, 96374 | $2,659.00 | — | Left for review DUP | — | 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-2026-029104 CMS-1500 · 2026-10-24 | Andrea Harvey UHC-57312-65 | 2026-09-09 Independent laboratory | Unity Clinical Laboratories Clinical Laboratory · in network | 80061, 85025 | $76.00 | — | Left for review DUP | — | 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-2026-003673 CMS-1500 · 2026-10-24 | Nicole Banks UHC-03903-87 | 2026-09-01 Office | Meadow Family Practice Family Medicine · in network | 99203 | $251.00 | — | Left for review DUP | — | 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-2026-027220 UB-04 · 2026-10-23 | Amber Walker UHC-76429-95 | 2026-09-19 Outpatient hospital | Desert Cardiovascular Associates Cardiology · in network | 93015 | $596.00 | — | 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-2026-014055 UB-04 · 2026-10-23 | Danielle Gomez UHC-89338-09 | 2026-09-11 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 71046 | $141.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-025363 CMS-1500 · 2026-10-22 | Luis Clark UHC-84938-13 | 2026-09-14 Office | Desert Internal Medicine Associates Internal Medicine · in network | 99214 | $276.00 | — | Left for review DUP | — | 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-2026-030104 CMS-1500 · 2026-10-20 | Brenda Lee UHC-79610-84 | 2026-08-17 Office | Meadow Primary Care Associates Family Medicine · in network | 99395 | $290.00 | — | Left for review DUP | — | 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-2026-020910 CMS-1500 · 2026-10-19 | James Rodriguez UHC-66449-14 | 2026-09-18 Office | Evergreen Rehabilitation Center Physical Therapy · in network | 97110, 97161 | $444.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-019167 CMS-1500 · 2026-10-19 | Emily Martin UHC-23423-50 | 2026-08-30 Independent laboratory | Mesa Clinical Laboratories Clinical Laboratory · in network | 80061, 83036, 85025 | $145.00 | — | Left for review DUP | — | Needs review |
| 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-2026-025618 UB-04 · 2026-10-18 | Janet Delgado UHC-86657-86 | 2026-10-13 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 43239, 88305 | $1,736.00 | — | Left for review CO16 | — | 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-2026-024099 UB-04 · 2026-10-18 | Roger Bennett UHC-51537-03 | 2026-10-11 Outpatient hospital | Evergreen Digestive Health Center Gastroenterology · in network | 70553 | $3,498.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-023616 UB-04 · 2026-10-18 | Tyler Carter UHC-34633-94 | 2026-09-11 Outpatient hospital | Canyon Primary Care Associates Family Medicine · in network | 70553 | $3,097.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-023208 UB-04 · 2026-10-18 | Austin Li UHC-41620-28 | 2026-09-03 Outpatient hospital | Canyon Regional Medical Center Emergency Medicine · in network | 70553 | $2,294.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-018689 UB-04 · 2026-10-18 | Gabriel Sanders UHC-13138-62 | 2026-09-06 Outpatient hospital | Mesa Internal Medicine Associates Internal Medicine · in network | 70553 | $2,621.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-017328 UB-04 · 2026-10-18 | Jerry Edwards UHC-51204-16 | 2026-09-15 Outpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 70553 | $2,954.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-016730 UB-04 · 2026-10-18 | Kathlean Silva UHC-59277-27 | 2026-09-12 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 70553 | $3,592.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-013409 CMS-1500 · 2026-10-18 | Heather Hudson UHC-13473-34 | 2026-09-16 Office | Mesa Family Practice Family Medicine · in network | 90471 | $44.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-012567 UB-04 · 2026-10-18 | Melissa Gardner UHC-62350-59 | 2026-09-07 Inpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 27447 | $39,811.00 | — | Left for review HIGH | — | 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-2026-005535 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-2026-002531 UB-04 · 2026-10-18 | Margaret Hunter UHC-03826-60 | 2026-09-25 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177 | $1,203.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-000165 UB-04 · 2026-10-18 | Bradley Russell UHC-45171-11 | 2026-09-28 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $38,503.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-033611 CMS-1500 · 2026-10-17 | Sofa Weaver UHC-57114-29 | 2026-10-02 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97161 | $459.00 | — | Left for review DUP | — | 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.