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-2026-017107 UB-04 · 2026-09-17 | Jeffrey Phillips UHC-08341-30 | 2026-08-24 Inpatient hospital | Sunrise Medical Group Internal Medicine · out of network | 99232 | $209.00 | $0.00 | Clean approval | — | Approved |
| 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-2026-016201 UB-04 · 2026-09-17 | Noah Burton UHC-87151-33 | 2026-08-13 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $2,395.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-008834 UB-04 · 2026-09-17 | Terry Le UHC-29632-13 | 2026-08-29 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378 | $1,643.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-005951 UB-04 · 2026-09-17 | George Sims UHC-90175-74 | 2026-08-10 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93306, 93015 | $1,865.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003573 UB-04 · 2026-09-17 | Dylan Robinson UHC-25806-40 | 2026-09-13 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 77067 | $330.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-001413 UB-04 · 2026-09-17 | Teresa Cunningham UHC-56407-99 | 2026-08-30 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,969.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-026367 UB-04 · 2026-09-16 | Denise Jackson UHC-63308-42 | 2026-08-13 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306, 93015 | $1,845.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-016270 UB-04 · 2026-09-16 | Judy Schmidt UHC-10609-39 | 2026-09-10 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285, 96374, 99283 | $3,005.00 | $1,202.25 | Clean approval | — | Approved |
| CLM-2026-010845 UB-04 · 2026-09-16 | Jenkins Bryan UHC-40066-17 | 2026-09-02 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 74177, 70553, 76700 | $5,626.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-030902 UB-04 · 2026-09-15 | Karen Warren UHC-82850-96 | 2026-08-24 Outpatient hospital | Cornerstone Reference Lab Clinical Laboratory · out of network | 70553 | $2,169.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-027577 UB-04 · 2026-09-15 | Angela Johnston UHC-84082-76 | 2026-04-07 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $48,024.00 | — | Denied by rule CO29 | — | Denied |
| 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-2026-015672 UB-04 · 2026-09-15 | Debra Collins UHC-86010-85 | 2026-08-28 Inpatient hospital | Sunrise Medical Group Internal Medicine · out of network | 99232 | $235.00 | — | Denied by rule CO27 CO204 | — | Denied |
| CLM-2026-012671 UB-04 · 2026-09-15 | Bowman Bowman UHC-86900-82 | 2026-08-31 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046, 99283 | $1,318.00 | $485.55 | Clean approval | — | Approved |
| CLM-2026-012191 UB-04 · 2026-09-15 | Margaret Spencer UHC-91658-38 | 2026-08-08 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99284, 99283, 71046 | $2,961.00 | $1,182.45 | Clean approval | — | Approved |
| CLM-2026-004663 UB-04 · 2026-09-15 | Randy Robinson UHC-80582-02 | 2026-08-07 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 71046, 99284, 99283 | $2,389.00 | $1,018.35 | Clean approval | — | Approved |
| 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-2026-031315 UB-04 · 2026-09-14 | Debbie Powell UHC-05099-83 | 2026-08-28 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,635.00 | $269.60 | Clean approval | — | Approved |
| CLM-2026-028609 UB-04 · 2026-09-14 | Brittany Campbell UHC-99813-04 | 2026-09-06 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $1,765.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-017985 UB-04 · 2026-09-14 | Santiago Johnston UHC-65660-37 | 2026-08-21 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $1,229.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-010132 UB-04 · 2026-09-14 | 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-2026-008045 UB-04 · 2026-09-14 | Kimberly Mejia UHC-56315-91 | 2026-08-16 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284, 99285 | $4,427.00 | $1,642.15 | Clean approval | — | Approved |
| CLM-2026-023496 UB-04 · 2026-09-13 | Christine Hawkins no member ID | 2026-09-05 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $1,185.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-018448 UB-04 · 2026-09-13 | Anna Wallace UHC-03491-04 | 2026-08-04 Outpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,377.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-016098 UB-04 · 2026-09-13 | Joe Salazar UHC-98084-25 | 2026-08-23 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284, 96374 | $1,840.00 | $478.00 | Clean approval | — | Approved |
| CLM-2026-011995 UB-04 · 2026-09-13 | Paul Perez UHC-31595-01 | 2026-08-29 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283, 99284 | $2,186.00 | $733.70 | Clean approval | — | Approved |
| 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-2026-011854 UB-04 · 2026-09-13 | Randy Sullyvan UHC-42995-56 | 2026-09-01 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 70553, 77067 | $3,400.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009605 UB-04 · 2026-09-13 | Jonathan Price UHC-44743-32 | 2026-08-29 Inpatient hospital | Sunrise Medical Group Internal Medicine · out of network | 99232 | $193.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-009312 UB-04 · 2026-09-13 | Beverly Sanchez UHC-57625-59 | 2026-09-11 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 71046, 99284 | $1,366.00 | $506.70 | Clean approval | — | Approved |
| 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-2026-005225 UB-04 · 2026-09-13 | Aaron Johnson UHC-30422-67 | 2026-08-21 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93458, 93015 | $5,475.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004286 UB-04 · 2026-09-13 | Priya Bowman UHC-20261-11 | 2026-08-03 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 29881 | $6,820.00 | $1,772.58 | Clean approval | — | Approved |
| CLM-2026-003966 UB-04 · 2026-09-13 | William Perry UHC-95896-51 | 2026-08-16 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285 | $2,020.00 | $659.00 | Clean approval | — | Approved |
| CLM-2026-031121 UB-04 · 2026-09-12 | Russell Cox UHC-24189-14 | 2026-08-20 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $1,032.00 | $376.65 | Clean approval | — | Approved |
| CLM-2026-027829 UB-04 · 2026-09-12 | Anthony Rios UHC-38512-88 | 2026-07-31 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378 | $1,583.00 | $140.92 | Clean approval | — | Approved |
| CLM-2026-027011 UB-04 · 2026-09-12 | Nathan Shaw UHC-44338-93 | 2026-09-08 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378, 88305 | $1,739.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-024931 UB-04 · 2026-09-12 | Tyelr Ortiz UHC-19323-44 | 2026-08-22 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 71046, 70553, 74177 | $5,698.00 | — | Denied by rule CO204 | — | Denied |
| 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-2026-002156 UB-04 · 2026-09-12 | Ronald Fowler UHC-11532-40 | 2026-07-31 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · out of network | 93306 | $1,593.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-033069 UB-04 · 2026-09-11 | Larry Garcia UHC-28303-69 | 2026-08-15 Inpatient hospital | Evergreen Medical Group Internal Medicine · out of network | 99232 | $196.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-022605 UB-04 · 2026-09-11 | Jeffrey Santos UHC-37212-67 | 2026-08-08 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 71046, 74177 | $1,502.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-016330 UB-04 · 2026-09-11 | Denise Adams no member ID | 2026-08-18 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 70553 | $1,975.00 | — | Denied by rule CO197 | — | Denied |
| 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 |
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.