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-2026-024889 UB-04 · 2026-10-24 | Eric Robertson UHC-01745-78 | 2026-08-28 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $31,691.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-029204 UB-04 · 2026-10-21 | Jesse Price UHC-05475-09 | 2026-08-29 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 71046, 99283 | $910.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-004773 UB-04 · 2026-10-18 | Bryan Ray UHC-15231-85 | 2026-09-28 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,734.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-021022 UB-04 · 2026-08-24 | Elijah Cox UHC-15378-08 | 2026-07-03 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285 | $1,695.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-032678 UB-04 · 2026-08-21 | Gabriel Gray UHC-14318-72 | 2026-07-15 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99283 | $694.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-019104 UB-04 · 2026-08-10 | Olivia Campbell no member ID | 2026-06-30 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 99284, 71046 | $1,628.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024264 UB-04 · 2026-07-17 | Jerry Dominguez UHC-34607-27 | 2026-06-05 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 77067, 70553 | $3,381.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-012754 UB-04 · 2026-07-09 | Maria Edwadrs UHC-34778-96 | 2026-06-03 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177, 76700 | $1,881.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-031344 UB-04 · 2026-07-01 | Donald Castro UHC-60762-21 | 2026-05-10 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93306, 93015 | $1,690.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-015056 UB-04 · 2026-06-27 | Joshua Armstrong UHC-90508-70 | 2026-06-06 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93458 | $5,638.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-016912 UB-04 · 2026-06-18 | Sott Jensen UHC-67218-05 | 2026-05-19 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283, 96374 | $1,059.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-004271 UB-04 · 2026-06-06 | Mateo Espinoza UHC-22304-73 | 2026-04-24 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 71046, 99285 | $2,135.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-003973 UB-04 · 2026-06-05 | Ruth Black UHC-63053-46 | 2026-05-20 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93306 | $1,039.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-012745 UB-04 · 2026-05-13 | Tyler Fisher UHC-12257-40 | 2026-04-07 Outpatient hospital | Unity Imaging Center Radiology · out of network | 77067, 71046 | $464.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-009713 UB-04 · 2026-05-12 | Jack Kelley no member ID | 2026-04-25 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,840.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-012658 UB-04 · 2026-05-07 | Yuki Boyd UHC-23434-82 | 2026-04-11 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285, 96374 | $2,675.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-005402 UB-04 · 2026-05-05 | Laura Alvarado no member ID | 2026-04-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283 | $891.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-021192 UB-04 · 2026-04-30 | Austin Hughes UHC-81540-49 | 2026-04-05 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 88305, 45378 | $2,676.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014954 UB-04 · 2026-04-30 | Ana Wong UHC-13625-76 | 2026-03-03 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,639.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-000182 UB-04 · 2026-04-30 | Gabriel Gonzalez UHC-78358-58 | 2026-03-31 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 71046, 99284 | $1,506.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-013720 UB-04 · 2026-04-29 | Heather Munoz UHC-96240-40 | 2026-04-18 Outpatient hospital | Unity Imaging Center Radiology · out of network | 74177 | $1,964.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-027348 UB-04 · 2026-03-20 | Anna Medina UHC-37749-59 | 2026-02-25 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 88305 | $259.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028231 UB-04 · 2026-03-19 | Benjamin Webb UHC-91181-73 | 2026-01-31 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 74177 | $2,044.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-001771 UB-04 · 2026-03-11 | Arjun Graham UHC-79356-55 | 2026-01-15 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 71046, 99284 | $1,229.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-005568 UB-04 · 2026-02-23 | Paul Lynch UHC-76821-72 | 2026-02-17 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378 | $2,070.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-016052 UB-04 · 2026-02-22 | Rebecca Armstrong UHC-19886-09 | 2026-01-31 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046 | $183.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-033703 UB-04 · 2026-02-17 | Luis Richards UHC-82338-95 | 2026-02-02 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 43239, 88305 | $1,938.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-027266 UB-04 · 2026-02-13 | Nicole Vasquez UHC-78209-60 | 2026-01-12 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93458 | $7,741.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007440 UB-04 · 2026-02-11 | Gabriel Gonzalez UHC-48725-02 | 2025-12-16 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285, 71046 | $3,240.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-029698 UB-04 · 2026-01-26 | Gary Gutierrez UHC-65560-71 | 2025-12-12 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046, 99283, 99284 | $2,659.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-034298 UB-04 · 2026-01-14 | Joe Welkh UHC-33507-83 | 2025-12-30 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $9,627.00 | — | Denied by rule CO18 | — | Denied |
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.