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-2026-022851 UB-04 · 2026-10-18 | Pamela Tran UHC-95837-67 | 2026-04-02 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 29881 | $8,489.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-013424 UB-04 · 2026-10-18 | Jordan Thomas UHC-00688-86 | 2026-04-19 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 71046, 99285 | $2,289.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-007944 UB-04 · 2026-10-15 | Ryan Walker UHC-79552-94 | 2026-05-28 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283, 71046 | $1,287.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-000715 UB-04 · 2026-09-28 | Bruce Porter UHC-38921-20 | 2026-02-20 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $902.00 | — | Denied by rule CO29 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-2026-027577 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-2026-020448 UB-04 · 2026-09-10 | Amanda Fox UHC-00623-39 | 2026-05-04 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721, 29881 | $8,998.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-034036 UB-04 · 2026-08-29 | Andrea Whhite UHC-79988-26 | 2026-04-22 Inpatient hospital | Harbor Medical Group Internal Medicine · out of network | 99232 | $219.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-010472 UB-04 · 2026-08-29 | Grace Mdeina UHC-02912-01 | 2026-03-29 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $8,795.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-018857 UB-04 · 2026-08-19 | Linda Munoz UHC-59937-01 | 2026-05-12 Outpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,335.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-017257 UB-04 · 2026-06-28 | Katherine Wang UHC-68477-97 | 2026-02-20 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99284, 99285, 99283 | $4,242.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-025193 UB-04 · 2026-06-11 | Kevin King UHC-00010-37 | 2025-12-14 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285 | $2,803.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-015919 UB-04 · 2026-06-01 | Christine Cunningham UHC-36095-33 | 2025-12-15 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177, 71046 | $1,489.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-033952 UB-04 · 2026-05-28 | Kyle Medina UHC-64058-26 | 2025-10-22 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99284, 99285 | $3,469.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-013911 UB-04 · 2026-05-20 | Jacqueline Ryan UHC-97443-27 | 2025-11-17 Inpatient hospital | Sunrise Medical Group Internal Medicine · out of network | 99232 | $203.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-025440 UB-04 · 2026-05-19 | Lawrrence Padilla UHC-99915-26 | 2025-11-18 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $1,014.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-011205 UB-04 · 2026-05-03 | Betty Rojas UHC-59588-79 | 2026-01-10 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · out of network | 99232 | $242.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-024294 UB-04 · 2026-04-29 | Lucia Sims UHC-14376-95 | 2026-01-18 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99283, 71046 | $893.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-020547 UB-04 · 2026-04-24 | Omar Pena UHC-29214-87 | 2025-09-21 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $37,830.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-021316 UB-04 · 2026-04-20 | Scott Santos UHC-17213-41 | 2025-09-15 Outpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $10,660.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-007465 UB-04 · 2026-04-04 | Gary Larson UHC-81991-36 | 2025-12-03 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 71046 | $1,960.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-028168 UB-04 · 2026-03-30 | Rebecca Gonzalez UHC-31410-51 | 2025-10-04 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 29881, 73721 | $11,530.00 | — | Denied by rule CO29 CO204 | — | Denied |
| CLM-2026-013684 UB-04 · 2026-03-23 | Julie Rios UHC-27625-41 | 2025-12-15 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99283 | $1,073.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-014859 UB-04 · 2026-03-16 | James Pierce UHC-01552-36 | 2025-09-20 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285, 96374, 99284 | $2,913.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-015153 UB-04 · 2026-02-24 | Judy Nguyen UHC-34093-90 | 2025-09-25 Inpatient hospital | Harbor Medical Group Internal Medicine · out of network | 99232 | $164.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-026869 UB-04 · 2026-02-11 | George Kennedy UHC-87028-23 | 2025-10-21 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 88305, 45378 | $2,864.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-007048 UB-04 · 2026-01-30 | Patrcia Murray UHC-35124-01 | 2025-10-05 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 96374, 71046 | $328.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-015073 UB-04 · 2026-01-21 | Sean Gordon UHC-57083-46 | 2025-10-04 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93306 | $1,298.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-018092 UB-04 · 2026-01-20 | Gloira Lynch UHC-57656-67 | 2025-09-06 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99284 | $1,299.00 | — | Denied by rule CO29 | — | 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.