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-2026-028513 UB-04 · 2026-11-08 | Steven Wheeler UHC-11820-74 | 2026-09-27 Inpatient hospital | Canyon Medical Group Internal Medicine · in network | 99232 | $251.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-011097 UB-04 · 2026-11-06 | Joan Rivera UHC-22799-76 | 2026-10-05 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284 | $1,665.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-008055 UB-04 · 2026-11-06 | Terry Cooper no member ID | 2026-09-26 Emergency room | Harbor Regional Medical Center Emergency Medicine · in network | 71046 | $246.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-005318 UB-04 · 2026-11-05 | Helen Snyder UHC-08676-93 | 2026-10-01 Outpatient hospital | Meadow Imaging Center Radiology · in network | 70553, 76700 | $3,998.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014845 UB-04 · 2026-11-04 | Albert Alvarez UHC-42353-95 | 2026-09-28 Outpatient hospital | Summit Heart Institute Cardiology · in network | 93306, 93015, 93458 | $11,010.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-017567 UB-04 · 2026-10-30 | Gabriel Shew no member ID | 2026-09-28 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 43239 | $1,993.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-030817 UB-04 · 2026-10-28 | Carl Smith UHC-10143-60 | 2026-10-02 Outpatient hospital | Heritage Digestive Health Center Gastroenterology · in network | 45378 | $2,697.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-025027 UB-04 · 2026-10-26 | Edward Dunn UHC-58248-42 | 2026-10-01 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 88305, 45378 | $2,697.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028753 UB-04 · 2026-10-25 | Sandra Powell UHC-02733-47 | 2026-09-14 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99283, 71046 | $1,010.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007493 UB-04 · 2026-10-25 | Maria Snyder UHC-84820-97 | 2026-09-01 Outpatient hospital | Harbor Imaging Center Radiology · in network | 74177 | $2,458.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-003352 UB-04 · 2026-10-24 | Amy Simpson no member ID | 2026-08-25 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $235.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-002070 UB-04 · 2026-10-22 | Ana Jackson UHC-71686-49 | 2026-09-23 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $29,621.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007624 UB-04 · 2026-10-21 | James Cox UHC-14257-05 | 2026-09-25 Outpatient hospital | Harbor Diagnostic Imaging Radiology · in network | 71046, 70553 | $2,856.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024097 UB-04 · 2026-10-18 | Christine Wright UHC-27440-91 | 2026-09-15 Outpatient hospital | Heritage Digestive Health Center Gastroenterology · in network | 45378, 88305 | $1,824.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014800 UB-04 · 2026-10-18 | Shirley Gordon UHC-16318-59 | 2026-09-24 Outpatient hospital | Unity Digestive Health Center Gastroenterology · in network | 43239 | $2,507.00 | — | Denied by rule CO18 | — | Denied |
| 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-2026-004216 UB-04 · 2026-10-18 | Alexander Reid UHC-77022-69 | 2026-09-16 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 71046, 70553 | $3,057.00 | — | Denied by rule CO27 | — | 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-2026-002809 UB-04 · 2026-10-18 | Olivia Armstrong UHC-25797-48 | 2026-05-27 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458, 93015 | $5,527.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-001208 UB-04 · 2026-10-18 | Alexander Robertson UHC-20832-08 | 2026-09-29 Outpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,651.00 | — | Denied by rule CO27 | — | 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-2026-004662 UB-04 · 2026-10-17 | Juan Franklin UHC-92188-10 | 2026-09-05 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306, 93015 | $1,817.00 | — | Denied by rule CO27 | — | 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-2026-013745 UB-04 · 2026-10-16 | Billy Reid UHC-17079-68 | 2026-09-19 Outpatient hospital | Heritage Imaging Center Radiology · in network | 77067, 70553 | $2,364.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-008361 UB-04 · 2026-10-16 | Judy Payne UHC-70825-08 | 2026-09-23 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 71046 | $137.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-027414 UB-04 · 2026-10-15 | Gregory Hunt UHC-84710-60 | 2026-09-23 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $6,359.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-018854 UB-04 · 2026-10-15 | Gloria Yang UHC-77975-62 | 2026-10-07 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 93458, 93306 | $10,394.00 | — | Denied by rule CO27 | — | 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-2026-034029 UB-04 · 2026-10-14 | Ryan Li UHC-59343-89 | 2026-06-24 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 88305 | $352.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-029540 UB-04 · 2026-10-14 | Mary Munz UHC-13183-92 | 2026-10-10 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 43239, 45378 | $4,347.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-026234 UB-04 · 2026-10-14 | Victoria Richards UHC-93067-18 | 2026-09-04 Outpatient hospital | Cornerstone Imaging Center Radiology · in network | 77067, 74177, 71046 | $2,873.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-023532 UB-04 · 2026-10-14 | Andrew Hicks UHC-20492-19 | 2026-03-30 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 70553, 71046 | $2,750.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-011031 UB-04 · 2026-10-14 | Omar Hunt UHC-97434-51 | 2026-10-03 Outpatient hospital | Heritage Imaging Center Radiology · in network | 76700, 70553 | $3,006.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-026211 UB-04 · 2026-10-13 | Judy Wells UHC-84471-03 | 2026-10-10 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 70553, 74177 | $5,764.00 | — | Denied by rule CO27 | — | 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-2026-032825 UB-04 · 2026-10-12 | Aisha Cole UHC-86878-50 | 2026-09-07 Emergency room | Valley Regional Medical Center Emergency Medicine · in network | 99283 | $1,083.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-018964 UB-04 · 2026-10-12 | Charles Burton UHC-47128-17 | 2026-09-07 Outpatient hospital | Riverside Imaging Center Radiology · in network | 77067 | $342.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-016133 UB-04 · 2026-10-12 | Richard Clark UHC-54936-57 | 2026-09-05 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99285 | $2,496.00 | — | Denied by rule CO18 | — | 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-2026-032272 UB-04 · 2026-10-11 | Eugeene Reyes UHC-32191-16 | 2026-08-25 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $7,356.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028562 UB-04 · 2026-10-11 | Douglas Kim UHC-49616-13 | 2026-09-29 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285 | $1,664.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-024112 UB-04 · 2026-10-11 | Daniel Thomas UHC-78647-56 | 2026-09-09 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 74177, 77067 | $2,456.00 | — | Denied by rule CO27 | — | 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-2026-029178 UB-04 · 2026-10-10 | Lucia Soto UHC-71796-85 | 2026-09-15 Outpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 70553, 73721 | $5,854.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-025789 UB-04 · 2026-10-10 | Sarah Smith no member ID | 2026-09-12 Emergency room | Unity Community Hospital Emergency Medicine · in network | 96374 | $220.00 | — | Denied by rule CO18 | — | 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 |
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.