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
3,664
50 with an AI recommendation
Pended
2,586
awaiting information or identity
Approved
23,942
$6,757,768.45 plan paid
Denied
4,454
with remittance reason codes
Examiner decided
0
167 not attached to an identity
| Claim | Member | Service | Provider | Procedures | Billed | Plan pays | Rules | AI | Status |
|---|---|---|---|---|---|---|---|---|---|
| CLM-2026-011814 UB-04 · 2026-01-06 | Patricia Sandoval UHC-68939-94 | 2025-12-15 Outpatient hospital | Meadow Physical Therapy Physical Therapy · out of network | 70553 | $4,716.00 | — | Left for review CO50 | Denied confidence 0.95 | Needs review |
| CLM-2026-008128 UB-04 · 2026-01-06 | Gregory Reid UHC-65879-07 | 2025-12-06 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99284, 99283 | $2,491.00 | — | Left for review NET | Approved confidence 0.95 | Needs review |
| CLM-2026-021384 UB-04 · 2026-01-04 | Jose Mejia UHC-36493-03 | 2025-12-01 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $34,233.00 | — | Left for review HIGH | Approved confidence 0.95 | Needs review |
| CLM-2026-015314 UB-04 · 2026-01-02 | Albert Burton UHC-66153-74 | 2025-12-25 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553 | $2,589.00 | — | Left for review CO50 | Denied confidence 0.95 | Needs review |
| CLM-2026-029989 UB-04 · 2026-01-01 | Marilyn Fisher UHC-53466-53 | 2025-12-06 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $49,523.00 | — | Left for review HIGH | Approved confidence 0.95 | Needs review |
| CLM-2026-028216 CMS-1500 · 2026-01-01 | Diego West UHC-45695-22 | 2025-12-02 Office | Heritage Medical Group Family Medicine · out of network | 36415, 90471 | $54.00 | — | Left for review CO97 | Approved confidence 0.95 | Needs review |
| CLM-2026-025008 UB-04 · 2026-01-01 | Ralph Vargas UHC-63428-97 | 2025-11-21 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 71046, 99284 | $1,845.00 | — | Left for review NET CO97 | Approved confidence 0.95 | Needs review |
| CLM-2026-001501 CMS-1500 · 2026-01-01 | Martha Lewis UHC-83453-88 | 2025-11-26 Office | Unity Primary Care Associates Family Medicine · out of network | 99395 | $313.00 | — | Left for review CO16 | Pended confidence 0.95 | 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.