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-2026-003147 CMS-1500 · 2026-09-19 | Lisa Porter UHC-43480-38 | 2026-08-21 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 85025, 83036 | $123.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-031359 UB-04 · 2026-09-18 | Maria Carlson UHC-01702-71 | 2026-09-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046 | $130.00 | — | Left for review NET | — | Needs review |
| CLM-2026-027728 UB-04 · 2026-09-17 | Carlos Nguyen UHC-33573-55 | 2026-08-23 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 71046 | $226.00 | — | Left for review NET | — | Needs review |
| CLM-2026-027327 CMS-1500 · 2026-09-17 | Thomas Morales UHC-74441-71 | 2026-07-28 Office | Sunrise Dermatology Clinic Dermatology · out of network | 11403 | $719.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-016646 UB-04 · 2026-09-17 | Arjun Sullivan UHC-69356-13 | 2026-08-16 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285 | $2,470.00 | — | Left for review NET | — | Needs review |
| CLM-2026-020637 UB-04 · 2026-09-16 | Julie Hudson UHC-36730-68 | 2026-08-05 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 70553 | $3,334.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-032019 UB-04 · 2026-09-15 | Ralph Ruiz UHC-43941-81 | 2026-08-09 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 77067, 71046, 70553 | $2,809.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-026488 UB-04 · 2026-09-15 | Stephanie Porter UHC-07006-03 | 2026-08-31 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 71046 | $130.00 | — | Left for review NET | — | Needs review |
| CLM-2026-018761 UB-04 · 2026-09-15 | Ahmed Sims UHC-36382-81 | 2026-08-02 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93458 | $8,823.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-033713 UB-04 · 2026-09-14 | Roy Sanders UHC-81923-33 | 2026-08-18 Outpatient hospital | Valley Skin Care Associates Dermatology · out of network | 70553 | $2,149.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-022839 CMS-1500 · 2026-09-14 | Bruce Ray UHC-75568-84 | 2026-08-05 Independent laboratory | Meadow Reference Lab Clinical Laboratory · out of network | 85025, 80061 | $73.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-011920 UB-04 · 2026-09-13 | Sara Cox UHC-33317-40 | 2026-08-23 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 76700 | $2,603.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008908 CMS-1500 · 2026-09-13 | Raymond Cox UHC-58166-35 | 2026-08-07 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 80053, 83036 | $121.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-008640 UB-04 · 2026-09-13 | Keith Gray UHC-41667-97 | 2026-08-20 Inpatient hospital | Riverside Internal Medicine Associates Internal Medicine · out of network | 99232 | $197.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-033483 CMS-1500 · 2026-09-12 | Amanda Santos UHC-87211-30 | 2026-08-12 Office | Meadow Heart Institute Cardiology · out of network | 99214, 93224 | $679.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-011939 UB-04 · 2026-09-12 | Keith Torres UHC-89886-91 | 2026-08-29 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284 | $1,730.00 | — | Left for review NET | — | Needs review |
| CLM-2026-008075 UB-04 · 2026-09-12 | Ana Mejia UHC-35659-03 | 2026-08-26 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 77067, 74177 | $2,055.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-006548 UB-04 · 2026-09-12 | Hannah McDonald UHC-37231-04 | 2026-09-10 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 96374 | $211.00 | — | Left for review NET | — | Needs review |
| CLM-2026-029710 UB-04 · 2026-09-10 | Isabella Bell UHC-68295-82 | 2026-08-06 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · out of network | 99232 | $200.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-013078 CMS-1500 · 2026-09-10 | Roy Wilson UHC-47553-11 | 2026-09-01 Office | Sunrise Dermatology Clinic Dermatology · out of network | 99213 | $206.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-010253 CMS-1500 · 2026-09-10 | Amy Vasquez UHC-05827-31 | 2026-08-15 Office | Lakeside Medical Group Family Medicine · out of network | 99203 | $229.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-028367 UB-04 · 2026-09-08 | Walter Clark UHC-73064-35 | 2026-08-25 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285 | $1,736.00 | — | Left for review NET | — | Needs review |
| CLM-2026-019851 UB-04 · 2026-09-05 | Alexis Little UHC-97948-59 | 2026-08-16 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284, 99283 | $2,435.00 | — | Left for review NET | — | Needs review |
| CLM-2026-019965 UB-04 · 2026-09-04 | Hannah Rose UHC-38319-19 | 2026-08-09 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283, 99285 | $2,618.00 | — | Left for review NET CO97 | — | Needs review |
| CLM-2026-010692 UB-04 · 2026-09-04 | Donna Schmidt UHC-88832-04 | 2026-08-30 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $38,434.00 | — | Left for review CO16 HIGH | — | Needs review |
| CLM-2026-002936 UB-04 · 2026-09-04 | Julie Lewis UHC-04157-39 | 2026-08-14 Outpatient hospital | Lakeside Endocrine Associates Endocrinology · out of network | 70553 | $1,873.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-030852 UB-04 · 2026-09-03 | Omar Smith UHC-23045-19 | 2026-08-27 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285, 99283 | $3,427.00 | — | Left for review NET | — | Needs review |
| CLM-2026-006333 UB-04 · 2026-09-03 | Maria Tran UHC-91217-99 | 2026-08-14 Outpatient hospital | Valley Skin Care Associates Dermatology · out of network | 70553 | $3,230.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-001040 UB-04 · 2026-09-03 | Aisha Santos UHC-20680-09 | 2026-08-14 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 71046 | $124.00 | — | Left for review NET | — | Needs review |
| CLM-2026-033677 UB-04 · 2026-09-02 | Tyler Kelley UHC-71559-70 | 2026-08-25 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99284 | $1,050.00 | — | Left for review NET | — | Needs review |
| CLM-2026-034434 CMS-1500 · 2026-09-01 | Maria Patterson UHC-97217-21 | 2026-08-07 Independent laboratory | Desert Reference Lab Clinical Laboratory · out of network | 87086, 85025 | $66.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-019087 UB-04 · 2026-09-01 | Laura Rivera UHC-17261-47 | 2026-07-20 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046, 99283 | $1,279.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-010454 UB-04 · 2026-09-01 | Danielle Carter UHC-75129-77 | 2026-08-20 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99283, 99285, 99284 | $5,396.00 | — | Left for review NET | — | Needs review |
| CLM-2026-027084 UB-04 · 2026-08-30 | Ashley Mason UHC-45542-39 | 2026-08-03 Outpatient hospital | Sunrise Medical Group Internal Medicine · out of network | 70553 | $3,539.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-009477 CMS-1500 · 2026-08-30 | Ashley Perry UHC-75552-09 | 2026-08-16 Office | Unity Primary Care Associates Family Medicine · out of network | 99203, 99213 | $421.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-005193 UB-04 · 2026-08-30 | Keith Rice UHC-84777-32 | 2026-08-24 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $38,397.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-009504 UB-04 · 2026-08-28 | Frank Parker UHC-66409-87 | 2026-08-12 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99283, 71046 | $1,304.00 | — | Left for review NET | — | Needs review |
| CLM-2026-022815 UB-04 · 2026-08-27 | Samantha Walker UHC-63264-85 | 2026-07-20 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $33,052.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027042 UB-04 · 2026-08-26 | Shirley Ellis UHC-40576-59 | 2026-07-22 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99283 | $644.00 | — | Left for review NET | — | Needs review |
| CLM-2026-023696 CMS-1500 · 2026-08-26 | Danielle Pierce UHC-91432-68 | 2026-08-24 Office | Lakeside Medical Group Family Medicine · out of network | 90471, 99213 | $187.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-019013 UB-04 · 2026-08-26 | Walter Clark UHC-73064-35 | 2026-08-03 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 71046, 99284 | $2,031.00 | — | Left for review NET | — | Needs review |
| CLM-2026-004417 CMS-1500 · 2026-08-26 | Philip Johnston UHC-61230-27 | 2026-08-15 Office | Harbor Medical Group Internal Medicine · out of network | 99215, 99214 | $551.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-022678 UB-04 · 2026-08-24 | Lawrence Hoffman UHC-12016-65 | 2026-07-20 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374 | $175.00 | — | Left for review NET | — | Needs review |
| CLM-2026-021908 UB-04 · 2026-08-24 | Kimberly Larson UHC-41371-87 | 2026-07-15 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 77067, 74177, 71046 | $2,594.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-025405 CMS-1500 · 2026-08-23 | Eugene Cox UHC-38773-39 | 2026-07-21 Independent laboratory | Valley Clinical Laboratories Clinical Laboratory · out of network | 87086 | $43.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-000629 CMS-1500 · 2026-08-23 | Lauren Gutierrez UHC-72049-97 | 2026-08-15 Independent laboratory | Summit Reference Lab Clinical Laboratory · out of network | 85025, 83036, 80053 | $178.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-028374 UB-04 · 2026-08-22 | Christina Garcia UHC-73700-75 | 2026-07-11 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285 | $2,636.00 | — | Left for review NET | — | Needs review |
| CLM-2026-017360 UB-04 · 2026-08-22 | Ahmed Welch UHC-38427-46 | 2026-08-02 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 70553 | $3,350.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-015347 UB-04 · 2026-08-22 | Richard Espinoza UHC-63534-92 | 2026-07-28 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 96374, 99283 | $1,003.00 | — | Left for review NET | — | Needs review |
| CLM-2026-033462 UB-04 · 2026-08-21 | Valentina Reed UHC-49323-16 | 2026-08-09 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99285 | $3,144.00 | — | Left for review NET | — | 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.