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-2026-019679 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-2026-010291 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-2026-022762 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-2026-018557 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-2026-014747 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-2026-002556 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-2026-018403 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-2026-015047 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-2026-028674 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-2026-011424 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-2026-021613 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-2026-010612 CMS-1500 · 2026-10-26 | Not attached | 2026-09-05 Office | Canyon Counseling Center Behavioral Health · out of network | 90791 | $375.00 | — | Pended by rule CO16 | — | Pended |
| 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-2026-008970 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-2026-000534 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-2026-029104 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-2026-020823 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-2026-003673 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-2026-023083 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-2026-018199 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-2026-013960 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-2026-025363 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-2026-017716 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-2026-030532 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-2026-028764 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-2026-023357 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-2026-022570 CMS-1500 · 2026-10-21 | Not attached | 2026-10-04 Office | Mesa Family Practice Family Medicine · in network | 99214, 36415, 90471 | $348.00 | — | Pended by rule CO16 | — | Pended |
| 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-2026-030104 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-2026-017158 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 |
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.