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-2026-034365 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-2026-031356 UB-04 · 2026-10-11 | Barbara Cooper UHC-62320-38 | 2026-09-02 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99284 | $1,392.00 | $476.40 | Clean approval | — | Approved |
| CLM-2026-024453 UB-04 · 2026-10-11 | Grace Kennedy UHC-94262-16 | 2026-09-28 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $38,659.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-022262 UB-04 · 2026-10-11 | Justin Pena UHC-23865-08 | 2026-10-01 Inpatient hospital | Unity Internal Medicine Associates Internal Medicine · out of network | 99232 | $218.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-016853 UB-04 · 2026-10-11 | Donald Chapman UHC-04060-56 | 2026-10-06 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 77067 | $345.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-000109 UB-04 · 2026-10-11 | Brian Bell UHC-05015-78 | 2026-08-30 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285, 96374 | $1,873.00 | $692.85 | Clean approval | — | Approved |
| CLM-2026-032543 UB-04 · 2026-10-10 | Brittany Alvarado UHC-89357-17 | 2026-08-30 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 96374, 99285 | $2,580.00 | — | Left for review NET | — | Needs review |
| CLM-2026-030384 UB-04 · 2026-10-10 | Jeffrey Padilla UHC-92939-82 | 2026-09-25 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $37,665.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027261 UB-04 · 2026-10-10 | Brittany Holmes UHC-82722-34 | 2026-10-01 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93015 | $438.00 | — | Pended by rule IDQ | — | Pended |
| 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-2026-014643 UB-04 · 2026-10-10 | Wayne Williamson UHC-45751-58 | 2026-10-06 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553, 76700 | $2,815.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-012757 UB-04 · 2026-10-10 | Russell King UHC-80971-11 | 2026-09-16 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99285, 99284 | $4,796.00 | — | Left for review NET | — | Needs review |
| 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-2026-008737 UB-04 · 2026-10-10 | Camila Coleman UHC-30287-02 | 2026-09-01 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93015, 93458 | $9,840.00 | $3,371.37 | Clean approval | — | Approved |
| CLM-2026-002122 UB-04 · 2026-10-10 | Jon Oliver UHC-44697-32 | 2026-09-06 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 96374, 71046 | $409.00 | $79.65 | Clean approval | — | Approved |
| CLM-2026-001118 UB-04 · 2026-10-10 | Vazquez Mei UHC-53731-44 | 2026-08-27 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 96374 | $203.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-033895 UB-04 · 2026-10-09 | Joan Phillips UHC-75598-35 | 2026-09-14 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $1,754.00 | $439.30 | Clean approval | — | Approved |
| CLM-2026-029203 UB-04 · 2026-10-09 | Jesse Price UHC-05475-09 | 2026-08-29 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 71046, 99283 | $910.00 | $295.65 | Clean approval | — | Approved |
| CLM-2026-026784 UB-04 · 2026-10-09 | Doris Brown UHC-03661-81 | 2026-09-01 Outpatient hospital | Mesa Regional Medical Center Emergency Medicine · out of network | 70553 | $2,433.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-013714 UB-04 · 2026-10-09 | Gerald Bowman no member ID | 2026-10-05 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553 | $2,319.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013054 UB-04 · 2026-10-09 | Charles Lynch UHC-82241-22 | 2026-09-30 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93015 | $517.00 | $0.00 | Clean approval | — | Approved |
| 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-2026-005070 UB-04 · 2026-10-09 | Logan Greene UHC-34472-84 | 2026-10-06 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 96374 | $170.00 | — | Left for review NET | — | Needs review |
| CLM-2026-029982 UB-04 · 2026-10-08 | Maria Hansen UHC-86468-12 | 2026-09-13 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283 | $725.00 | — | Left for review NET | — | Needs review |
| CLM-2026-029044 UB-04 · 2026-10-07 | Maira Kim UHC-95297-64 | 2026-08-25 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $2,579.00 | — | Left for review NET | — | Needs review |
| CLM-2026-027178 UB-04 · 2026-10-07 | Ryan Hunter UHC-48235-63 | 2026-09-16 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285, 99284, 96374 | $4,448.00 | $1,851.60 | Clean approval | — | Approved |
| CLM-2026-024401 UB-04 · 2026-10-07 | Brandon Boyd UHC-74380-08 | 2026-09-26 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284 | $1,478.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-013746 UB-04 · 2026-10-07 | Joe Dean no member ID | 2026-08-31 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 71046 | $220.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-013727 UB-04 · 2026-10-07 | Amanda Guerrero UHC-02982-66 | 2026-10-05 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306, 93015 | $1,529.00 | $507.06 | Clean approval | — | Approved |
| CLM-2026-012918 UB-04 · 2026-10-07 | Megan Williams UHC-64753-11 | 2026-08-24 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 77067, 71046, 74177 | $2,863.00 | — | Left for review REPL CO50 | — | Needs review |
| CLM-2026-009890 UB-04 · 2026-10-07 | Albert Olson UHC-39661-50 | 2026-09-16 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $51,724.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-007431 UB-04 · 2026-10-07 | Sean Varrgas UHC-30722-64 | 2026-09-15 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285, 71046 | $3,333.00 | $1,349.85 | Clean approval | — | Approved |
| CLM-2026-005660 UB-04 · 2026-10-07 | Ashley Nunez UHC-90338-03 | 2026-10-04 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 88305 | $262.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000806 UB-04 · 2026-10-07 | Lori Austin UHC-45897-76 | 2026-09-23 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553, 71046 | $2,712.00 | — | Left for review CO50 | — | Needs review |
| 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-2026-021597 UB-04 · 2026-10-06 | Kelly Tucker UHC-00488-72 | 2026-09-07 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283, 99284, 99285 | $4,892.00 | — | Left for review NET | — | Needs review |
| CLM-2026-019813 UB-04 · 2026-10-06 | Heather Gardner UHC-30555-67 | 2026-09-23 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700 | $634.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-016122 UB-04 · 2026-10-06 | Hansen Christopher no member ID | 2026-09-16 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553 | $3,219.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-012939 UB-04 · 2026-10-06 | Nicole Rice UHC-22461-47 | 2026-10-04 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 70553, 74177 | $5,115.00 | $700.26 | Clean approval | — | Approved |
| 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-2026-000941 UB-04 · 2026-10-06 | Mason Ramirez UHC-04462-47 | 2026-09-15 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046 | $226.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-025490 UB-04 · 2026-10-05 | Susan Garrett UHC-86282-68 | 2026-08-30 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 71046 | $211.00 | $0.00 | Clean approval | — | Approved |
| 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-2026-020243 UB-04 · 2026-10-05 | George Torres UHC-42020-09 | 2026-08-29 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283, 96374 | $1,046.00 | $120.70 | Clean approval | — | Approved |
| CLM-2026-009704 UB-04 · 2026-10-05 | William Walsh UHC-07070-34 | 2026-08-31 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · out of network | 99232 | $236.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-005618 UB-04 · 2026-10-05 | Emma Harrison UHC-63140-98 | 2026-09-07 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99283 | $737.00 | — | Left for review NET | — | Needs review |
| CLM-2026-002465 UB-04 · 2026-10-05 | Patricia Robertson UHC-63151-88 | 2026-09-02 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284, 96374, 99285 | $3,674.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-001270 UB-04 · 2026-10-05 | Brittany Shaw UHC-43130-16 | 2026-08-26 Outpatient hospital | Unity Imaging Center Radiology · out of network | 76700, 77067, 70553 | $3,764.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-030008 UB-04 · 2026-10-04 | Nathan Palmer UHC-78327-09 | 2026-08-25 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285 | $1,925.00 | $616.25 | Clean approval | — | Approved |
| CLM-2026-014273 UB-04 · 2026-10-04 | James Chen UHC-30142-52 | 2026-09-27 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 74177 | $1,634.00 | $194.71 | Clean approval | — | Approved |
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.