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-2026-012577 UB-04 · 2026-10-18 | Steven Brooks UHC-72425-74 | 2026-09-25 Outpatient hospital | Pinecrest Cardiovascular Associates Cardiology · in network | 93458 | $7,698.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-003164 UB-04 · 2026-10-18 | Nancy Wong UHC-74984-66 | 2026-09-13 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 88305, 45378 | $2,851.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-030671 UB-04 · 2026-10-17 | Peter Lane UHC-22452-89 | 2026-09-28 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $35,985.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-022113 UB-04 · 2026-10-17 | Maria Moore UHC-93684-85 | 2026-10-07 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 76700, 74177 | $1,965.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-029645 UB-04 · 2026-10-16 | Marilyn Wallace UHC-97767-95 | 2026-09-01 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 70553, 77067, 74177 | $4,854.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-017831 UB-04 · 2026-10-16 | Gabriel Payne no member ID | 2026-09-23 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 74177, 71046 | $2,565.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-003579 UB-04 · 2026-10-15 | Albert Tran no member ID | 2026-09-10 Outpatient hospital | Evergreen GI Associates Gastroenterology · in network | 45378 | $2,026.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-020583 UB-04 · 2026-10-13 | Tyler Yang UHC-30040-50 | 2026-09-24 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $48,569.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-000447 UB-04 · 2026-10-13 | Austin Robinson UHC-83901-95 | 2026-09-07 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458 | $5,014.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-013391 UB-04 · 2026-10-12 | Nathan Singh UHC-25477-01 | 2026-09-07 Outpatient hospital | Desert Imaging Center Radiology · in network | 77067, 70553 | $2,676.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-032669 UB-04 · 2026-10-11 | Henry Hanson no member ID | 2026-09-23 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · in network | 45378 | $2,462.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-005668 UB-04 · 2026-10-11 | Diane Mendez UHC-02276-61 | 2026-09-04 Inpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 27447 | $43,670.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-007960 UB-04 · 2026-10-10 | Jordan Richards UHC-99630-40 | 2026-09-11 Outpatient hospital | Valley Cardiovascular Associates Cardiology · in network | 93458 | $8,484.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-027144 UB-04 · 2026-10-09 | Carlos Lucas UHC-26021-69 | 2026-09-05 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 73721 | $2,301.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-019387 UB-04 · 2026-10-08 | Jeffrey Chen UHC-36893-66 | 2026-09-29 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 71046, 74177 | $2,406.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-032919 UB-04 · 2026-10-06 | Sam Pierce UHC-33483-59 | 2026-08-30 Outpatient hospital | Unity Diagnostic Imaging Radiology · in network | 70553 | $2,534.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-028610 UB-04 · 2026-10-06 | Randy Graham UHC-32783-43 | 2026-09-04 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 76700, 70553 | $2,494.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-016384 UB-04 · 2026-10-06 | Ana Gutierrez UHC-95156-71 | 2026-10-04 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 43239 | $1,548.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-002416 UB-04 · 2026-10-05 | Jean Nelson UHC-20738-64 | 2026-08-28 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881, 73721 | $8,574.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-030072 UB-04 · 2026-10-04 | Janice Hunt UHC-20449-42 | 2026-09-02 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 76700, 70553 | $3,557.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-004058 UB-04 · 2026-10-04 | Marilyn Hill UHC-35136-12 | 2026-08-29 Outpatient hospital | Unity Cardiovascular Associates Cardiology · in network | 93458, 93015 | $7,673.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-033167 UB-04 · 2026-10-03 | Amber Harvey UHC-45573-36 | 2026-09-26 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 43239, 88305 | $2,312.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-024513 UB-04 · 2026-10-03 | Nancy Harvey UHC-47422-60 | 2026-08-29 Outpatient hospital | Summit Heart Institute Cardiology · in network | 93306, 93015, 93458 | $8,490.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-021341 UB-04 · 2026-10-03 | Kathryn Robinson UHC-69124-67 | 2026-08-27 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 45378 | $2,417.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-006035 UB-04 · 2026-10-03 | Bobby Carroll UHC-56827-60 | 2026-08-21 Outpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $10,912.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-014322 UB-04 · 2026-10-02 | Emily Adams UHC-15907-13 | 2026-09-24 Outpatient hospital | Lakeside Heart Institute Cardiology · in network | 93015, 93458 | $9,696.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-014079 UB-04 · 2026-10-02 | Omar Allen UHC-06383-65 | 2026-09-06 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 74177, 71046 | $2,492.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-031990 UB-04 · 2026-10-01 | Olivia Davis UHC-46336-83 | 2026-09-25 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 70553 | $2,925.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-022629 UB-04 · 2026-10-01 | Diane Dominguez UHC-17276-55 | 2026-08-28 Outpatient hospital | Pinecrest Heart Institute Cardiology · in network | 93458 | $8,639.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-016694 UB-04 · 2026-10-01 | Kayla Gardner UHC-87728-37 | 2026-09-12 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 70553, 74177 | $4,607.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-033678 UB-04 · 2026-09-28 | Sandra Smith UHC-19366-24 | 2026-09-18 Outpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $9,250.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-031719 UB-04 · 2026-09-28 | Joshua Cook UHC-57439-68 | 2026-08-28 Outpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 29881, 73721 | $11,810.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-004183 UB-04 · 2026-09-28 | Ann Williamson UHC-19399-24 | 2026-08-22 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 74177 | $1,811.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-000574 UB-04 · 2026-09-28 | Marcus Lawson UHC-23031-42 | 2026-09-13 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 74177, 71046 | $2,004.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-012228 UB-04 · 2026-09-26 | Angela Bronw UHC-89858-94 | 2026-08-23 Outpatient hospital | Meadow Imaging Center Radiology · in network | 74177 | $1,619.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-006558 UB-04 · 2026-09-26 | Sarah Hall UHC-42069-39 | 2026-08-30 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 43239 | $2,492.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-008991 UB-04 · 2026-09-25 | Amanda Hicks UHC-66518-56 | 2026-08-25 Outpatient hospital | Valley Digestive Health Center Gastroenterology · in network | 43239 | $2,498.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-000123 UB-04 · 2026-09-25 | Daaniel Snyder UHC-45484-10 | 2026-09-07 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 76700, 71046, 70553 | $3,747.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-032638 UB-04 · 2026-09-24 | Gregory Kennedy UHC-80526-03 | 2026-08-21 Outpatient hospital | Northgate Cardiovascular Associates Cardiology · in network | 93458, 93015 | $5,773.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-007162 UB-04 · 2026-09-24 | Timothy Robinson UHC-06199-48 | 2026-09-14 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 73721 | $2,140.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-011781 UB-04 · 2026-09-21 | Timothy Clark UHC-35369-94 | 2026-09-03 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 70553, 76700, 74177 | $5,061.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-005699 UB-04 · 2026-09-21 | Sue Castillo UHC-58894-75 | 2026-08-26 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 45378 | $2,153.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-013501 UB-04 · 2026-09-20 | Arjun Lopez UHC-85521-93 | 2026-09-15 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 43239, 45378 | $3,843.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-011525 UB-04 · 2026-09-20 | Maria Hederson UHC-45267-14 | 2026-08-12 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 74177, 76700 | $2,703.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-005013 UB-04 · 2026-09-20 | Shirley Gilbert UHC-05399-64 | 2026-08-21 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458 | $4,964.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-026381 UB-04 · 2026-09-19 | Joseph Vargas UHC-78519-23 | 2026-08-22 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 43239, 88305 | $2,835.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-002095 UB-04 · 2026-09-19 | Aaron Aguilar UHC-55513-50 | 2026-08-06 Outpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,562.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-011367 UB-04 · 2026-09-18 | Martha Henderson UHC-24638-57 | 2026-09-11 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $36,345.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-008074 UB-04 · 2026-09-18 | Christopher Stewart UHC-13389-59 | 2026-08-24 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · in network | 93458 | $4,922.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-006910 UB-04 · 2026-09-18 | Cynthia Chapman UHC-75673-50 | 2026-08-07 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 93015, 93458 | $9,047.00 | — | Denied by rule CO197 | — | 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.