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-2026-022262 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-2026-009704 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-2026-002465 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-2026-019141 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-2026-005361 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-2026-029002 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-2026-029710 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-2026-029001 UB-04 · 2026-09-09 | 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-2026-010692 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-2026-011700 UB-04 · 2026-08-06 | Zachary Greene UHC-69793-13 | 2026-07-25 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283 | $746.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-003305 UB-04 · 2026-08-06 | Not attached | 2026-07-10 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283 | $917.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-030482 UB-04 · 2026-07-08 | Deny Parker UHC-00717-49 | 2026-07-05 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 71046, 77067 | $503.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-030973 UB-04 · 2026-06-24 | Paul Ward UHC-06878-76 | 2026-05-18 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378 | $2,091.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-016675 UB-04 · 2026-06-15 | Juhn Sullivan UHC-14129-58 | 2026-06-06 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 71046, 76700 | $705.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-021712 UB-04 · 2026-06-11 | Not attached | 2026-04-17 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $1,220.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-018169 UB-04 · 2026-06-03 | Linda Obrien UHC-52970-96 | 2026-05-25 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553 | $3,576.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-021711 UB-04 · 2026-05-22 | Not attached | 2026-04-17 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $1,220.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-004218 UB-04 · 2026-05-16 | Kevin Powell UHC-92591-12 | 2026-04-01 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $2,506.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-012552 UB-04 · 2026-05-10 | Not attached | 2026-04-02 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378 | $2,234.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-025929 UB-04 · 2026-04-08 | Amy Reed UHC-39326-26 | 2026-03-09 Inpatient hospital | Evergreen Medical Group Internal Medicine · out of network | 99232 | $162.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-023123 UB-04 · 2026-03-23 | Robert Dominguez UHC-72381-88 | 2026-03-17 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $5,796.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-032389 UB-04 · 2026-03-20 | Sophia Martinez UHC-22861-85 | 2026-03-07 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $1,580.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-016282 UB-04 · 2026-02-07 | George Schultz UHC-55554-57 | 2026-01-03 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 71046, 99283 | $1,257.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-010970 UB-04 · 2026-01-22 | Olivia Tran UHC-76853-38 | 2025-12-16 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99285 | $2,204.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-028277 UB-04 · 2026-01-08 | Gary Matthews UHC-27209-51 | 2025-12-19 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177 | $1,935.00 | — | Left for review CO16 | Pended confidence 0.80 | 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.