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-2026-014950 UB-04 · 2026-09-26 | Jesse Morrison UHC-56221-72 | 2026-09-13 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 29881, 73721 | $12,709.00 | $4,990.77 | Clean approval | — | Approved |
| CLM-2026-011597 UB-04 · 2026-09-26 | Kayla Williamson UHC-28782-70 | 2026-08-28 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99285, 71046 | $2,042.00 | $568.90 | Clean approval | — | Approved |
| CLM-2026-000066 UB-04 · 2026-09-26 | Roy Marquez UHC-81106-25 | 2026-08-23 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 70553, 93458 | $11,792.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-034276 UB-04 · 2026-09-25 | Hannah Howell UHC-24927-91 | 2026-08-31 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99283, 71046 | $984.00 | $117.00 | Clean approval | — | Approved |
| CLM-2026-027763 UB-04 · 2026-09-25 | Olivia Padilla no member ID | 2026-09-08 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283 | $862.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-013312 UB-04 · 2026-09-25 | Hiroshi Meyer UHC-79807-84 | 2026-09-09 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553 | $3,101.00 | $865.27 | Clean approval | — | Approved |
| CLM-2026-010462 UB-04 · 2026-09-25 | Larry Dean UHC-23098-85 | 2026-09-04 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $2,323.00 | $695.35 | Clean approval | — | Approved |
| CLM-2026-030479 UB-04 · 2026-09-24 | Katherine Simmons UHC-12054-24 | 2026-08-18 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881, 73721 | $7,904.00 | $2,222.21 | Clean approval | — | Approved |
| CLM-2026-026406 UB-04 · 2026-09-24 | Joshua White UHC-26246-17 | 2026-08-19 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $8,877.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-023585 UB-04 · 2026-09-24 | Janice Washington UHC-80769-32 | 2026-08-11 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · out of network | 93015 | $454.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-018713 UB-04 · 2026-09-24 | Charlotte Burns UHC-74235-33 | 2026-08-12 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553 | $3,021.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-017794 UB-04 · 2026-09-24 | Bryan Ferguson UHC-51134-40 | 2026-09-01 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283 | $1,049.00 | $122.05 | Clean approval | — | Approved |
| CLM-2026-013002 UB-04 · 2026-09-24 | Michael Reyes UHC-84549-13 | 2026-09-09 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 43239 | $1,845.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-012628 UB-04 · 2026-09-24 | Gary Fields UHC-65382-80 | 2026-09-03 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378, 88305, 43239 | $3,858.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-009019 UB-04 · 2026-09-24 | Patrick Foster UHC-07454-34 | 2026-08-29 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99284, 71046, 99285 | $3,495.00 | $1,422.75 | Clean approval | — | Approved |
| CLM-2026-005200 UB-04 · 2026-09-24 | Sara Jimenez no member ID | 2026-08-25 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 74177, 71046 | $1,693.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-004019 UB-04 · 2026-09-24 | Betty Soto UHC-28968-52 | 2026-08-31 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 71046, 96374 | $368.00 | $69.30 | Clean approval | — | Approved |
| CLM-2026-001998 UB-04 · 2026-09-24 | Lori Dixon UHC-20645-16 | 2026-08-29 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99285 | $2,519.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-026403 UB-04 · 2026-09-23 | Amy Laron UHC-55275-97 | 2026-09-19 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285, 96374 | $2,822.00 | $1,019.90 | Clean approval | — | Approved |
| CLM-2026-021506 UB-04 · 2026-09-23 | Joshua Gordon UHC-19807-30 | 2026-09-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99284, 99285 | $3,441.00 | $1,198.45 | Clean approval | — | Approved |
| CLM-2026-017248 UB-04 · 2026-09-23 | Sandra Patel no member ID | 2026-09-09 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93458, 93306 | $10,495.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-011913 UB-04 · 2026-09-23 | Douglas Morales UHC-93164-60 | 2026-09-20 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 77067 | $288.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-009151 UB-04 · 2026-09-23 | Logan Bradley UHC-10378-53 | 2026-09-01 Outpatient hospital | Desert Reference Lab Clinical Laboratory · out of network | 70553 | $2,380.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-000436 UB-04 · 2026-09-23 | Patrick Boyd UHC-93836-29 | 2026-08-10 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93306 | $1,313.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-033969 UB-04 · 2026-09-22 | Charlotte Edwards UHC-97135-95 | 2026-09-19 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $9,204.00 | $2,987.07 | Clean approval | — | Approved |
| CLM-2026-029736 UB-04 · 2026-09-22 | David Moreno UHC-71942-05 | 2026-09-01 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93458 | $8,820.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-022545 UB-04 · 2026-09-22 | Alan Lane UHC-36065-99 | 2026-09-05 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285, 96374 | $2,474.00 | $963.30 | Clean approval | — | Approved |
| CLM-2026-013416 UB-04 · 2026-09-22 | John Cunningham UHC-37758-42 | 2026-08-16 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553 | $2,471.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-006983 UB-04 · 2026-09-22 | Carl Hill UHC-13848-92 | 2026-09-20 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $9,739.00 | $1,418.37 | Clean approval | — | Approved |
| CLM-2026-006305 UB-04 · 2026-09-22 | Mary Hansen UHC-80131-43 | 2026-09-05 Outpatient hospital | Unity Imaging Center Radiology · out of network | 77067, 76700 | $766.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-005361 UB-04 · 2026-09-22 | Not attached | 2026-09-19 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285 | $3,094.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-004352 UB-04 · 2026-09-22 | Albert Castro UHC-91693-71 | 2026-09-05 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93458, 93306 | $7,867.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-029002 UB-04 · 2026-09-21 | Not attached | 2026-08-31 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,744.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-022465 UB-04 · 2026-09-21 | Lauren Sandoval UHC-88391-59 | 2026-09-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046 | $230.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-015629 UB-04 · 2026-09-21 | Austin Nelson UHC-77457-34 | 2026-08-21 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $3,114.00 | $1,051.30 | Clean approval | — | Approved |
| CLM-2026-006450 UB-04 · 2026-09-21 | Nathan Tran UHC-26240-33 | 2026-09-19 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378 | $2,766.00 | $344.74 | Clean approval | — | Approved |
| CLM-2026-017081 UB-04 · 2026-09-20 | Christine Powell UHC-91272-76 | 2026-08-17 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285 | $3,007.00 | $1,103.15 | Clean approval | — | Approved |
| CLM-2026-015436 UB-04 · 2026-09-20 | Joshua Harper UHC-85497-41 | 2026-08-19 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 71046, 99283 | $1,059.00 | $381.60 | Clean approval | — | Approved |
| CLM-2026-032028 UB-04 · 2026-09-19 | Hannah Wlliams UHC-36369-69 | 2026-09-03 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285, 99284, 96374 | $4,065.00 | — | Left for review NET | — | Needs review |
| CLM-2026-015245 UB-04 · 2026-09-19 | Camila Santos UHC-31286-37 | 2026-09-10 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 76700 | $3,424.00 | $565.80 | Clean approval | — | Approved |
| CLM-2026-014429 UB-04 · 2026-09-19 | Katherine Payne UHC-90245-36 | 2026-09-15 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $49,343.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-010561 UB-04 · 2026-09-19 | Michael Stone UHC-84625-12 | 2026-08-24 Inpatient hospital | Unity Internal Medicine Associates Internal Medicine · out of network | 99232 | $188.00 | $0.00 | Clean approval | — | Approved |
| 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-2026-027615 UB-04 · 2026-09-18 | Valentina Scott UHC-56762-01 | 2026-08-12 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 96374, 99283 | $922.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-014340 UB-04 · 2026-09-18 | Marcus Alexander UHC-89293-82 | 2026-08-13 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 71046 | $174.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-003589 UB-04 · 2026-09-18 | Bryan Black UHC-11439-98 | 2026-09-03 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 74177 | $3,641.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-034583 UB-04 · 2026-09-17 | Donald Mejia UHC-18967-39 | 2026-02-24 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046, 99285 | $2,180.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-028007 UB-04 · 2026-09-17 | Michael Schultz UHC-55567-38 | 2026-08-03 Outpatient hospital | Unity Imaging Center Radiology · out of network | 74177, 71046 | $1,932.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-018860 UB-04 · 2026-09-17 | Ahmed Wallace UHC-37460-16 | 2026-08-23 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553 | $2,270.00 | $635.67 | 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.