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-2026-004719 UB-04 · 2026-10-15 | Douglas Harris UHC-15357-52 | 2026-10-07 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $39,961.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-014643 UB-04 · 2026-10-10 | Wayne Williamson UHC-45751-58 | 2026-10-06 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553, 76700 | $2,815.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-016122 UB-04 · 2026-10-06 | Hansen Christopher no member ID | 2026-09-16 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553 | $3,219.00 | — | Denied by rule CO197 | — | Denied |
| 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-2026-013002 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-2026-017248 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-2026-029736 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-2026-004352 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-2026-016330 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-2026-010587 UB-04 · 2026-09-10 | Ryan Richards UHC-91216-27 | 2026-08-10 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $8,803.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-000840 UB-04 · 2026-09-06 | Dennis Spencer UHC-48894-38 | 2026-08-16 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 77067, 74177, 71046 | $2,729.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-016951 UB-04 · 2026-08-25 | Walter Moreno UHC-70397-76 | 2026-07-11 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553, 74177 | $3,949.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-014167 UB-04 · 2026-08-24 | Mei Harvey no member ID | 2026-07-29 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553, 74177 | $4,841.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-018290 UB-04 · 2026-08-16 | Santiago Day UHC-69311-39 | 2026-07-24 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93458 | $7,873.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-020795 UB-04 · 2026-08-08 | Jose Gordon UHC-27613-60 | 2026-07-01 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553 | $2,949.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-017758 UB-04 · 2026-08-08 | Amanda Brooks UHC-53265-89 | 2026-07-24 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 71046, 74177 | $1,727.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-028235 UB-04 · 2026-07-17 | Mateo Park UHC-21681-06 | 2026-07-13 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 74177, 70553 | $3,409.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-031501 UB-04 · 2026-07-11 | Rachel Taylor UHC-30724-46 | 2026-06-14 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $2,021.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-015925 UB-04 · 2026-07-06 | Charlotte Coleman UHC-41854-94 | 2026-06-10 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881, 73721 | $11,527.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-020800 UB-04 · 2026-07-03 | Camila Green UHC-53157-96 | 2026-06-16 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 88305, 43239, 45378 | $4,617.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-002648 UB-04 · 2026-07-01 | Janet Lewis UHC-35740-35 | 2026-06-25 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 88305, 45378 | $2,457.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-012355 UB-04 · 2026-06-26 | Priya Ford UHC-66719-80 | 2026-05-19 Outpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $2,317.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-010335 UB-04 · 2026-06-23 | Rachel Griffin UHC-52956-07 | 2026-06-06 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 76700, 70553 | $2,473.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-005550 UB-04 · 2026-06-20 | Rachel Wagner UHC-27206-41 | 2026-06-13 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,704.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-007968 UB-04 · 2026-06-14 | Ralph Rogers no member ID | 2026-05-14 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $6,986.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-006260 UB-04 · 2026-06-14 | Julia Graham UHC-16313-77 | 2026-05-21 Outpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $2,397.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-000259 UB-04 · 2026-06-09 | Madison Knight UHC-85507-79 | 2026-05-30 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $7,673.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-006728 UB-04 · 2026-05-28 | Amber Castro UHC-44493-17 | 2026-05-12 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $2,115.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-021070 UB-04 · 2026-05-23 | Judy Robinson UHC-50698-88 | 2026-05-13 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $41,526.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-028717 UB-04 · 2026-05-13 | Brandon Delgado no member ID | 2026-04-11 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93015, 93458 | $9,484.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-009328 UB-04 · 2026-05-11 | Terry Snyder UHC-52224-90 | 2026-05-01 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 43239 | $2,532.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-033881 UB-04 · 2026-04-30 | Ahmed Garza UHC-17595-44 | 2026-04-26 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 29881 | $10,884.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-034349 UB-04 · 2026-04-29 | Charles Sullivan UHC-02731-78 | 2026-04-06 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $1,399.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-034057 UB-04 · 2026-04-22 | Ruth Flores UHC-39966-48 | 2026-04-01 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553, 71046, 76700 | $2,423.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-025002 UB-04 · 2026-04-22 | Vincent Reyes UHC-96719-08 | 2026-04-01 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 74177 | $4,785.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-033569 UB-04 · 2026-04-12 | Ashley Simpson UHC-68874-78 | 2026-03-22 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $46,648.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-021922 UB-04 · 2026-04-12 | Bryant Timothy UHC-71520-19 | 2026-03-27 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,226.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-033088 UB-04 · 2026-04-08 | Alice Hanson UHC-82049-78 | 2026-03-01 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 74177, 76700, 77067 | $2,913.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-030401 UB-04 · 2026-03-30 | Gabriel Dominguez UHC-64727-36 | 2026-03-09 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 77067 | $2,312.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-011870 UB-04 · 2026-03-30 | Jerry Banks UHC-69891-94 | 2026-03-12 Outpatient hospital | Unity Imaging Center Radiology · out of network | 71046, 70553 | $3,038.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-000933 UB-04 · 2026-03-30 | Eric Hall UHC-73484-68 | 2026-02-13 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · out of network | 93458, 93015 | $7,246.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-009560 UB-04 · 2026-02-08 | Christina Owens UHC-32060-55 | 2026-01-04 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $2,228.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-009655 UB-04 · 2026-01-29 | Juan Campbell no member ID | 2025-12-28 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $49,107.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-021625 UB-04 · 2026-01-16 | Timothy Weber UHC-91272-09 | 2025-12-31 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553 | $2,847.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-010088 UB-04 · 2026-01-11 | Steven Holmes UHC-19554-84 | 2025-12-27 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306, 93458 | $7,710.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-000312 UB-04 · 2026-01-06 | Gloria Ross UHC-95778-74 | 2025-12-14 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177, 71046, 70553 | $4,896.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-026561 UB-04 · 2026-01-01 | Ethan Jackson UHC-62313-89 | 2025-12-22 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $42,438.00 | — | Denied by rule CO197 | — | 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.