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-2026-019679 CMS-1500 · 2026-11-01 | Christopher Mendez UHC-51704-12 | 2026-09-30 Office | Meadow Skin Care Associates Dermatology · in network | 11403 | $514.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022762 CMS-1500 · 2026-10-31 | Amy Dominguez UHC-21901-22 | 2026-08-31 Office | Riverside Medical Group Family Medicine · in network | 99214, 90471, 99395 | $539.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-020844 CMS-1500 · 2026-10-31 | James Delgado UHC-33344-70 | 2026-09-24 Office | Mesa Physical Therapy Physical Therapy · in network | 97110, 97014 | $359.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-019414 CMS-1500 · 2026-10-31 | Samuel Wheeler UHC-26647-40 | 2026-09-21 Office | Evergreen Medical Group Family Medicine · in network | 99214, 90471, 99213 | $462.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014747 CMS-1500 · 2026-10-31 | Becky George UHC-12353-35 | 2026-09-05 Office | Canyon Medical Group Internal Medicine · in network | 99214 | $317.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-011196 CMS-1500 · 2026-10-31 | Donna Allen UHC-09329-72 | 2026-09-10 Office | Mesa Family Practice Family Medicine · in network | 99395, 36415 | $287.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-020880 CMS-1500 · 2026-10-30 | John Wood UHC-22176-71 | 2026-09-15 Office | Meadow Physical Therapy Physical Therapy · out of network | 97110 | $166.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-018403 CMS-1500 · 2026-10-29 | Sara Jones UHC-75451-48 | 2026-09-14 Office | Lakeside Medical Group Family Medicine · in network | 99395, 90471, 99214 | $594.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028674 CMS-1500 · 2026-10-28 | Dylan Robertson UHC-45403-96 | 2026-10-11 Office | Valley Rehabilitation Center Physical Therapy · in network | 97110 | $225.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-026416 CMS-1500 · 2026-10-28 | Frank Alvarez UHC-05360-90 | 2026-09-15 Office | Pinecrest Medical Group Family Medicine · in network | 36415 | $15.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-010537 CMS-1500 · 2026-10-25 | Philip Williams UHC-13566-04 | 2026-09-03 Office | Cornerstone Diabetes Center Endocrinology · in network | 83036 | $42.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-000534 CMS-1500 · 2026-10-25 | Tyler Wilson UHC-59252-11 | 2026-09-02 Independent laboratory | Evergreen Clinical Laboratories Clinical Laboratory · in network | 85025, 80053, 83036 | $172.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-020823 CMS-1500 · 2026-10-24 | Kelly Powell UHC-57639-35 | 2026-10-03 Office | Canyon Primary Care Associates Family Medicine · in network | 99203, 99395 | $544.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-011635 CMS-1500 · 2026-10-24 | John Graham UHC-03219-23 | 2026-10-07 Office | Meadow Internal Medicine Associates Internal Medicine · in network | 99214, 80053, 99215 | $610.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-023083 CMS-1500 · 2026-10-23 | Hiroshi Fowler UHC-09603-43 | 2026-09-12 Office | Heritage Primary Care Associates Family Medicine · in network | 36415, 99203 | $217.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-013960 CMS-1500 · 2026-10-23 | Patrick Sanders UHC-58486-46 | 2026-10-07 Office | Canyon Skin Care Associates Dermatology · in network | 17110, 11403 | $650.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-017716 CMS-1500 · 2026-10-22 | Amber Delgado UHC-52060-85 | 2026-09-24 Independent laboratory | Unity Clinical Laboratories Clinical Laboratory · in network | 80053, 80061 | $147.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007191 CMS-1500 · 2026-10-22 | Ahmed Vega UHC-03347-26 | 2026-08-31 Independent laboratory | Mesa Reference Lab Clinical Laboratory · in network | 85025, 80061 | $89.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028764 CMS-1500 · 2026-10-21 | Edward Phillips UHC-73690-84 | 2026-08-21 Office | Lakeside Medical Group Family Medicine · out of network | 90471, 36415 | $58.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028212 CMS-1500 · 2026-10-21 | Virginia Graham UHC-41763-34 | 2026-08-25 Office | Harbor Physical Therapy Physical Therapy · in network | 97110 | $364.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-031856 CMS-1500 · 2026-10-20 | Carol Fowler UHC-12538-47 | 2026-08-24 Office | Mesa Internal Medicine Associates Internal Medicine · in network | 80053, 93000 | $124.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-017158 CMS-1500 · 2026-10-20 | Alice Butler no member ID | 2026-09-20 Telehealth | Evergreen Counseling Center Behavioral Health · in network | 99214 | $233.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014290 CMS-1500 · 2026-10-20 | Amanda Espinoza UHC-65635-71 | 2026-09-17 Office | Evergreen Family Practice Family Medicine · in network | 36415, 99213, 90471 | $189.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007597 CMS-1500 · 2026-10-20 | Emma Mendez UHC-16028-30 | 2026-10-09 Office | Desert Internal Medicine Associates Internal Medicine · in network | 80053 | $85.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-003042 CMS-1500 · 2026-10-20 | Judith Sanchez UHC-37863-85 | 2026-10-02 Office | Riverside Primary Care Associates Family Medicine · in network | 99213, 36415 | $211.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-031649 CMS-1500 · 2026-10-19 | Jonathan Marquez UHC-57626-40 | 2026-10-03 Office | Valley Skin Care Associates Dermatology · in network | 17110 | $215.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-000819 CMS-1500 · 2026-10-19 | Carol Fowler UHC-12538-47 | 2026-09-26 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 99215 | $344.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-032967 CMS-1500 · 2026-10-18 | Amber Howell UHC-88592-44 | 2026-09-18 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11403, 17110 | $956.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032473 CMS-1500 · 2026-10-18 | Arjun Cruz UHC-63818-91 | 2026-09-03 Office | Lakeside Physical Therapy Physical Therapy · in network | 97110, 97140 | $401.00 | — | Denied by rule LIM | — | Denied |
| CLM-2026-032335 CMS-1500 · 2026-10-18 | James Delgado UHC-83159-99 | 2026-09-29 Office | Valley Bone and Joint Center Orthopedic Surgery · out of network | 99213 | $186.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-025088 CMS-1500 · 2026-10-18 | Julie Hart UHC-16029-61 | 2026-09-02 Office | Pinecrest Internal Medicine Associates Internal Medicine · in network | 93000, 99214 | $310.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024000 CMS-1500 · 2026-10-18 | Lawrence George UHC-17614-13 | 2026-10-03 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 80061, 83036 | $137.00 | — | Denied by rule CO204 | — | 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-2026-017564 CMS-1500 · 2026-10-18 | Henry Espinoza UHC-50850-98 | 2026-05-19 Office | Cornerstone Internal Medicine Associates Internal Medicine · in network | 93000 | $90.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-017491 CMS-1500 · 2026-10-18 | Joyce Roberts UHC-91571-60 | 2026-10-16 Office | Mesa Physical Therapy Physical Therapy · in network | 97110 | $180.00 | — | Denied by rule LIM | — | 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-2026-009947 CMS-1500 · 2026-10-18 | Melissa Tran UHC-46772-18 | 2026-10-08 Office | Canyon Counseling Center Behavioral Health · out of network | 90837 | $194.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-007716 CMS-1500 · 2026-10-18 | Jacqueline Mitchell UHC-85622-08 | 2026-08-23 Office | Northgate Internal Medicine Associates Internal Medicine · in network | 99214, 80053 | $350.00 | — | Denied by rule CO18 | — | 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-2026-003319 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-2026-026123 CMS-1500 · 2026-10-17 | William Simpson UHC-87572-94 | 2026-10-14 Office | Mesa Internal Medicine Associates Internal Medicine · out of network | 93000, 80053 | $135.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-019759 CMS-1500 · 2026-10-17 | Sofia Price UHC-91931-96 | 2026-10-11 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 80061, 83036 | $77.00 | — | Denied by rule CO204 | — | 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-2026-014664 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-2026-011023 CMS-1500 · 2026-10-17 | Nancy Hansen UHC-45838-06 | 2026-09-30 Office | Harbor Primary Care Associates Family Medicine · out of network | 99213 | $140.00 | — | Denied by rule 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.