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-2026-010776 UB-04 · 2026-10-04 | Hiroshi Martinez UHC-21659-34 | 2026-09-11 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $51,314.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-004893 UB-04 · 2026-10-04 | Vincent Smith UHC-60680-60 | 2026-09-10 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 74177, 70553 | $4,225.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-000493 UB-04 · 2026-10-04 | Beverly Hughes UHC-84048-28 | 2026-09-28 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93015, 93306 | $1,601.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030692 UB-04 · 2026-10-03 | Kimberly Howard UHC-44964-12 | 2026-09-22 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99283, 99284 | $1,943.00 | $526.95 | Clean approval | — | Approved |
| CLM-2026-027294 UB-04 · 2026-10-03 | Jenifer Edwards UHC-36162-50 | 2026-09-01 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 77067 | $395.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-025572 UB-04 · 2026-10-03 | Diego Nguyen UHC-76302-57 | 2026-09-08 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99283 | $855.00 | $134.75 | Clean approval | — | Approved |
| CLM-2026-019141 UB-04 · 2026-10-03 | Anthony Perkins UHC-29134-84 | 2026-08-31 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $1,005.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-017600 UB-04 · 2026-10-03 | Ryan Wright UHC-72160-97 | 2026-08-26 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 71046 | $156.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-015437 UB-04 · 2026-10-03 | Joshua Harper UHC-85497-41 | 2026-08-19 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 71046, 99283 | $1,059.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-010133 UB-04 · 2026-10-03 | Pamela Harvey no member ID | 2026-09-01 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99284, 99283, 99285 | $3,759.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-001682 UB-04 · 2026-10-03 | Hannah Valdez UHC-12876-94 | 2026-09-30 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $47,130.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032353 UB-04 · 2026-10-02 | Cheryl Chavez UHC-63288-21 | 2026-08-26 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $1,307.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-023989 UB-04 · 2026-10-02 | Kelly Flores UHC-81413-97 | 2026-08-20 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93306 | $1,133.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-015230 UB-04 · 2026-10-02 | Shirley Harper UHC-21504-79 | 2026-09-19 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283, 96374 | $1,072.00 | $232.40 | Clean approval | — | Approved |
| CLM-2026-004772 UB-04 · 2026-10-02 | Bryan Ray UHC-15231-85 | 2026-09-28 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,734.00 | $430.30 | Clean approval | — | Approved |
| CLM-2026-030050 UB-04 · 2026-10-01 | Ruth Jordan UHC-16459-44 | 2026-09-08 Inpatient hospital | Mesa Internal Medicine Associates Internal Medicine · out of network | 99232 | $237.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-029825 UB-04 · 2026-10-01 | Mark Evans UHC-79386-51 | 2026-08-23 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177, 77067, 76700 | $2,577.00 | $293.11 | Clean approval | — | Approved |
| CLM-2026-028098 UB-04 · 2026-10-01 | Willie Garcia UHC-41138-39 | 2026-09-07 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 77067, 76700 | $546.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026359 UB-04 · 2026-10-01 | James Owens UHC-46110-34 | 2026-08-18 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283, 71046 | $1,013.00 | $105.85 | Clean approval | — | Approved |
| CLM-2026-021733 UB-04 · 2026-10-01 | Christopher Chen UHC-07924-36 | 2026-09-09 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283 | $843.00 | $29.35 | Clean approval | — | Approved |
| CLM-2026-012366 UB-04 · 2026-10-01 | Diego Matthews UHC-11271-69 | 2026-09-29 Inpatient hospital | Riverside Internal Medicine Associates Internal Medicine · out of network | 99232 | $217.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011304 UB-04 · 2026-10-01 | Elizabeth Dunn UHC-59946-17 | 2026-09-14 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93015 | $668.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-009793 UB-04 · 2026-10-01 | Joan Coleman UHC-76680-53 | 2026-08-29 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 71046 | $328.00 | — | Left for review NET | — | Needs review |
| CLM-2026-029170 UB-04 · 2026-09-30 | Edward Howard UHC-57201-34 | 2026-09-25 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 77067 | $304.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-027708 UB-04 · 2026-09-30 | Grace Ross UHC-85981-15 | 2026-09-23 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 43239 | $1,447.00 | $437.71 | Clean approval | — | Approved |
| CLM-2026-026726 UB-04 · 2026-09-30 | Mary Daniels UHC-02753-64 | 2026-08-28 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $7,693.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-024402 UB-04 · 2026-09-30 | Aisha Kelley UHC-59132-34 | 2026-09-13 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93458, 93306 | $9,934.00 | $1,959.75 | Clean approval | — | Approved |
| CLM-2026-009624 UB-04 · 2026-09-30 | Karen Cook UHC-61680-99 | 2026-09-19 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 77067, 71046 | $472.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-008046 UB-04 · 2026-09-30 | Kimberly Mejia UHC-56315-91 | 2026-08-16 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99284, 99285 | $4,427.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-007995 UB-04 · 2026-09-30 | Sandra Morris UHC-98911-16 | 2026-08-26 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 71046, 99283, 96374 | $981.00 | — | Left for review NET | — | Needs review |
| CLM-2026-005144 UB-04 · 2026-09-30 | Gary Valdez UHC-70464-74 | 2026-09-02 Outpatient hospital | Canyon Reference Lab Clinical Laboratory · out of network | 70553 | $1,952.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-001843 UB-04 · 2026-09-30 | Karen Morrison UHC-03154-63 | 2026-08-22 Outpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,415.00 | $197.88 | Clean approval | — | Approved |
| CLM-2026-000535 UB-04 · 2026-09-30 | Kayla Wong UHC-96362-36 | 2026-08-29 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285 | $2,598.00 | $819.10 | Clean approval | — | Approved |
| CLM-2026-025562 UB-04 · 2026-09-29 | Carl Sandoval UHC-49946-01 | 2026-08-24 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 96374, 99284 | $1,716.00 | $690.30 | Clean approval | — | Approved |
| CLM-2026-024972 UB-04 · 2026-09-29 | David Brooks UHC-87270-42 | 2026-08-30 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378, 43239 | $3,580.00 | $744.16 | Clean approval | — | Approved |
| CLM-2026-017599 UB-04 · 2026-09-29 | Ryan Wright UHC-72160-97 | 2026-08-26 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 71046 | $156.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-014906 UB-04 · 2026-09-29 | Jeremy Snyder UHC-72167-18 | 2026-08-17 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283 | $1,009.00 | $204.05 | Clean approval | — | Approved |
| CLM-2026-013102 UB-04 · 2026-09-29 | Linda Wagner UHC-79792-87 | 2026-09-12 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284, 99283 | $1,857.00 | $585.65 | Clean approval | — | Approved |
| CLM-2026-012917 UB-04 · 2026-09-29 | 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 CO50 | — | Needs review |
| CLM-2026-012536 UB-04 · 2026-09-29 | Debra Le UHC-19184-97 | 2026-09-20 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 96374, 71046 | $477.00 | $110.70 | Clean approval | — | Approved |
| CLM-2026-006531 UB-04 · 2026-09-28 | Dinae Garrett UHC-57834-07 | 2026-08-08 Outpatient hospital | Unity Imaging Center Radiology · out of network | 76700, 77067 | $757.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006451 UB-04 · 2026-09-28 | Nathan Tran UHC-26240-33 | 2026-09-19 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378 | $2,766.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003919 UB-04 · 2026-09-28 | Richard Chapman UHC-28200-70 | 2026-08-17 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93458, 93015 | $5,559.00 | $55.77 | Clean approval | — | Approved |
| CLM-2026-000715 UB-04 · 2026-09-28 | Bruce Porter UHC-38921-20 | 2026-02-20 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $902.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-028830 UB-04 · 2026-09-27 | Dennis Morgan UHC-75155-83 | 2026-09-12 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93306, 93458 | $6,412.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-011150 UB-04 · 2026-09-27 | Judith Castillo UHC-17837-26 | 2026-09-02 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · out of network | 99232 | $175.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-002837 UB-04 · 2026-09-27 | Betsy Perez UHC-65690-96 | 2026-08-17 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 74177 | $1,545.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032775 UB-04 · 2026-09-26 | Terry Burns UHC-17911-64 | 2026-08-12 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · out of network | 93015 | $446.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-024458 UB-04 · 2026-09-26 | Robert Jacobs UHC-66748-29 | 2026-08-25 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285, 96374 | $2,119.00 | — | Left for review NET | — | Needs review |
| CLM-2026-019840 UB-04 · 2026-09-26 | Virginia Fernandez UHC-33328-14 | 2026-08-23 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93306 | $913.00 | $0.00 | 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.