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-2026-031883 UB-04 · 2026-10-18 | Gary Rodriguez UHC-65603-12 | 2026-09-08 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $36,915.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006554 UB-04 · 2026-10-18 | Doris Alvarez UHC-77452-71 | 2026-10-12 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 43239, 88305 | $2,152.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-014444 UB-04 · 2026-10-17 | Helen Park UHC-24378-23 | 2026-09-18 Outpatient hospital | Harbor Medical Group Internal Medicine · out of network | 70553 | $2,002.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-030553 UB-04 · 2026-10-16 | Valentina Olson UHC-29563-18 | 2026-09-11 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $1,458.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-024279 UB-04 · 2026-10-16 | William Webb UHC-11907-97 | 2026-09-08 Outpatient hospital | Sunrise Community Hospital Emergency Medicine · out of network | 70553 | $1,854.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-007243 UB-04 · 2026-10-16 | Jesse Alexander UHC-98335-18 | 2026-10-08 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553, 71046 | $3,684.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-025650 UB-04 · 2026-10-15 | Rachel Lopez UHC-43524-49 | 2026-10-02 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $35,527.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-000582 UB-04 · 2026-10-15 | Arjun Santos UHC-17803-51 | 2026-09-03 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378 | $1,676.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-024818 UB-04 · 2026-10-14 | Aisha Nguyen UHC-89751-57 | 2026-09-10 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700 | $396.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-034284 UB-04 · 2026-10-13 | Mateo Perez UHC-46817-61 | 2026-09-23 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 70553, 76700 | $3,143.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-025302 UB-04 · 2026-10-13 | Helen Singh UHC-90545-25 | 2026-09-09 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 71046, 77067 | $499.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009027 UB-04 · 2026-10-13 | Jacob Fields UHC-76092-02 | 2026-09-02 Outpatient hospital | Unity Imaging Center Radiology · out of network | 71046, 77067, 76700 | $928.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001871 UB-04 · 2026-10-13 | Vincent Howard UHC-15428-40 | 2026-09-11 Inpatient hospital | Harbor Medical Group Internal Medicine · out of network | 99232 | $181.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-034365 UB-04 · 2026-10-11 | Vincent Thomas UHC-37542-71 | 2026-10-09 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177, 77067 | $1,752.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-025852 UB-04 · 2026-10-10 | Karen Rodriguez UHC-78012-31 | 2026-09-20 Inpatient hospital | Riverside Internal Medicine Associates Internal Medicine · out of network | 99232 | $187.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010448 UB-04 · 2026-10-10 | Judy Rose UHC-80661-85 | 2026-09-26 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 43239, 88305, 45378 | $4,718.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-011074 UB-04 · 2026-10-09 | Anna Harvey UHC-53608-54 | 2026-09-15 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378, 43239 | $4,163.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-024844 UB-04 · 2026-10-06 | Teresa Reid UHC-23512-04 | 2026-08-22 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $42,542.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-007086 UB-04 · 2026-10-06 | Shirley Vasquez UHC-30097-39 | 2026-09-25 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553 | $3,371.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-024380 UB-04 · 2026-10-05 | Elijah Aguilar UHC-11836-39 | 2026-09-14 Outpatient hospital | Unity Imaging Center Radiology · out of network | 71046, 70553 | $2,673.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-010776 UB-04 · 2026-10-04 | Hiroshi Martinez UHC-21659-34 | 2026-09-11 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $51,314.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-004893 UB-04 · 2026-10-04 | Vincent Smith UHC-60680-60 | 2026-09-10 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 74177, 70553 | $4,225.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-027294 UB-04 · 2026-10-03 | Jenifer Edwards UHC-36162-50 | 2026-09-01 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 77067 | $395.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001682 UB-04 · 2026-10-03 | Hannah Valdez UHC-12876-94 | 2026-09-30 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $47,130.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032353 UB-04 · 2026-10-02 | Cheryl Chavez UHC-63288-21 | 2026-08-26 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $1,307.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-023989 UB-04 · 2026-10-02 | Kelly Flores UHC-81413-97 | 2026-08-20 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93306 | $1,133.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-030050 UB-04 · 2026-10-01 | Ruth Jordan UHC-16459-44 | 2026-09-08 Inpatient hospital | Mesa Internal Medicine Associates Internal Medicine · out of network | 99232 | $237.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-028098 UB-04 · 2026-10-01 | Willie Garcia UHC-41138-39 | 2026-09-07 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 77067, 76700 | $546.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006531 UB-04 · 2026-09-28 | Dinae Garrett UHC-57834-07 | 2026-08-08 Outpatient hospital | Unity Imaging Center Radiology · out of network | 76700, 77067 | $757.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-000715 UB-04 · 2026-09-28 | Bruce Porter UHC-38921-20 | 2026-02-20 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $902.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-028830 UB-04 · 2026-09-27 | Dennis Morgan UHC-75155-83 | 2026-09-12 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93306, 93458 | $6,412.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-011150 UB-04 · 2026-09-27 | Judith Castillo UHC-17837-26 | 2026-09-02 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · out of network | 99232 | $175.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-002837 UB-04 · 2026-09-27 | Betsy Perez UHC-65690-96 | 2026-08-17 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 74177 | $1,545.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-000066 UB-04 · 2026-09-26 | Roy Marquez UHC-81106-25 | 2026-08-23 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 70553, 93458 | $11,792.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026406 UB-04 · 2026-09-24 | Joshua White UHC-26246-17 | 2026-08-19 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $8,877.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009151 UB-04 · 2026-09-23 | Logan Bradley UHC-10378-53 | 2026-09-01 Outpatient hospital | Desert Reference Lab Clinical Laboratory · out of network | 70553 | $2,380.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-003589 UB-04 · 2026-09-18 | Bryan Black UHC-11439-98 | 2026-09-03 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 74177 | $3,641.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-028007 UB-04 · 2026-09-17 | Michael Schultz UHC-55567-38 | 2026-08-03 Outpatient hospital | Unity Imaging Center Radiology · out of network | 74177, 71046 | $1,932.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-001413 UB-04 · 2026-09-17 | Teresa Cunningham UHC-56407-99 | 2026-08-30 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,969.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026367 UB-04 · 2026-09-16 | Denise Jackson UHC-63308-42 | 2026-08-13 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306, 93015 | $1,845.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010845 UB-04 · 2026-09-16 | Jenkins Bryan UHC-40066-17 | 2026-09-02 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 74177, 70553, 76700 | $5,626.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-030902 UB-04 · 2026-09-15 | Karen Warren UHC-82850-96 | 2026-08-24 Outpatient hospital | Cornerstone Reference Lab Clinical Laboratory · out of network | 70553 | $2,169.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-015672 UB-04 · 2026-09-15 | Debra Collins UHC-86010-85 | 2026-08-28 Inpatient hospital | Sunrise Medical Group Internal Medicine · out of network | 99232 | $235.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-017985 UB-04 · 2026-09-14 | Santiago Johnston UHC-65660-37 | 2026-08-21 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $1,229.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-018448 UB-04 · 2026-09-13 | Anna Wallace UHC-03491-04 | 2026-08-04 Outpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,377.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-011854 UB-04 · 2026-09-13 | Randy Sullyvan UHC-42995-56 | 2026-09-01 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 70553, 77067 | $3,400.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009605 UB-04 · 2026-09-13 | Jonathan Price UHC-44743-32 | 2026-08-29 Inpatient hospital | Sunrise Medical Group Internal Medicine · out of network | 99232 | $193.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-005225 UB-04 · 2026-09-13 | Aaron Johnson UHC-30422-67 | 2026-08-21 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93458, 93015 | $5,475.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-027011 UB-04 · 2026-09-12 | Nathan Shaw UHC-44338-93 | 2026-09-08 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378, 88305 | $1,739.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-024931 UB-04 · 2026-09-12 | Tyelr Ortiz UHC-19323-44 | 2026-08-22 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 71046, 70553, 74177 | $5,698.00 | — | 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.