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-2026-002531 UB-04 · 2026-10-18 | Margaret Hunter UHC-03826-60 | 2026-09-25 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177 | $1,203.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-026784 UB-04 · 2026-10-09 | Doris Brown UHC-03661-81 | 2026-09-01 Outpatient hospital | Mesa Regional Medical Center Emergency Medicine · out of network | 70553 | $2,433.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-012918 UB-04 · 2026-10-07 | Megan Williams UHC-64753-11 | 2026-08-24 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 77067, 71046, 74177 | $2,863.00 | — | Left for review REPL CO50 | — | Needs review |
| CLM-2026-000806 UB-04 · 2026-10-07 | Lori Austin UHC-45897-76 | 2026-09-23 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553, 71046 | $2,712.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-001270 UB-04 · 2026-10-05 | Brittany Shaw UHC-43130-16 | 2026-08-26 Outpatient hospital | Unity Imaging Center Radiology · out of network | 76700, 77067, 70553 | $3,764.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-005144 UB-04 · 2026-09-30 | Gary Valdez UHC-70464-74 | 2026-09-02 Outpatient hospital | Canyon Reference Lab Clinical Laboratory · out of network | 70553 | $1,952.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-012917 UB-04 · 2026-09-29 | Megan Williams UHC-64753-11 | 2026-08-24 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 77067, 71046, 74177 | $2,863.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-018713 UB-04 · 2026-09-24 | Charlotte Burns UHC-74235-33 | 2026-08-12 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553 | $3,021.00 | — | Left for review CO50 | — | Needs review |
| 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-2026-032019 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-2026-033713 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-2026-008075 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-2026-002936 UB-04 · 2026-09-04 | Julie Lewis UHC-04157-39 | 2026-08-14 Outpatient hospital | Lakeside Endocrine Associates Endocrinology · out of network | 70553 | $1,873.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-006333 UB-04 · 2026-09-03 | Maria Tran UHC-91217-99 | 2026-08-14 Outpatient hospital | Valley Skin Care Associates Dermatology · out of network | 70553 | $3,230.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-027084 UB-04 · 2026-08-30 | Ashley Mason UHC-45542-39 | 2026-08-03 Outpatient hospital | Sunrise Medical Group Internal Medicine · out of network | 70553 | $3,539.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-021908 UB-04 · 2026-08-24 | Kimberly Larson UHC-41371-87 | 2026-07-15 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 77067, 74177, 71046 | $2,594.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-017360 UB-04 · 2026-08-22 | Ahmed Welch UHC-38427-46 | 2026-08-02 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 70553 | $3,350.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-006770 UB-04 · 2026-08-17 | Raymond Castillo UHC-29214-49 | 2026-08-01 Outpatient hospital | Sunrise Community Hospital Emergency Medicine · out of network | 70553 | $2,286.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-018386 UB-04 · 2026-08-16 | Theresa Ryna UHC-59142-10 | 2026-08-10 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553 | $2,596.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-003533 UB-04 · 2026-08-09 | Jack Wheeler UHC-27972-26 | 2026-06-27 Outpatient hospital | Canyon Reference Lab Clinical Laboratory · out of network | 70553 | $2,071.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-020957 UB-04 · 2026-08-07 | Mariana Shaw UHC-69035-21 | 2026-07-19 Outpatient hospital | Sunrise Community Hospital Emergency Medicine · out of network | 70553 | $3,482.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-009838 UB-04 · 2026-08-07 | Bobby Powell UHC-35845-09 | 2026-07-25 Outpatient hospital | Canyon Community Hospital Emergency Medicine · out of network | 70553 | $2,356.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-017746 UB-04 · 2026-08-06 | Bruce Munoz UHC-93815-58 | 2026-06-30 Outpatient hospital | Mesa Internal Medicine Associates Internal Medicine · out of network | 70553 | $2,931.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-009931 UB-04 · 2026-08-04 | Elizabeth Alvarado UHC-06831-15 | 2026-07-28 Outpatient hospital | Harbor Clinical Laboratories Clinical Laboratory · out of network | 70553 | $2,472.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-020294 UB-04 · 2026-08-01 | Maria Stewart UHC-45508-52 | 2026-07-03 Outpatient hospital | Evergreen Medical Group Internal Medicine · out of network | 70553 | $3,240.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-010408 UB-04 · 2026-08-01 | Jesse Hudson UHC-83954-38 | 2026-06-17 Outpatient hospital | Heritage Medical Group Family Medicine · out of network | 70553 | $3,221.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-000391 UB-04 · 2026-07-30 | Gloria Bailey UHC-58214-02 | 2026-07-28 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 70553, 71046, 77067 | $3,826.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-010324 UB-04 · 2026-07-29 | Virginia Hoffman UHC-79617-30 | 2026-07-08 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 70553, 43239, 45378 | $7,734.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-025571 UB-04 · 2026-07-28 | Nathan Turner UHC-95699-59 | 2026-06-14 Outpatient hospital | Canyon Counseling Center Behavioral Health · out of network | 70553 | $2,083.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-002896 UB-04 · 2026-07-28 | Betty Brooks UHC-46475-01 | 2026-06-13 Outpatient hospital | Mesa Regional Medical Center Emergency Medicine · out of network | 70553 | $2,679.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-015081 UB-04 · 2026-07-27 | Angela Nelson UHC-42015-33 | 2026-07-03 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 76700 | $3,058.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-002909 UB-04 · 2026-07-27 | Marcus Scott UHC-58921-89 | 2026-06-19 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177, 76700 | $1,899.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-031494 UB-04 · 2026-07-26 | Sean Watkins UHC-94342-84 | 2026-06-21 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 70553, 45378 | $3,782.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-013353 UB-04 · 2026-07-22 | Marcus Carr UHC-56477-42 | 2026-06-26 Outpatient hospital | Mesa Clinical Laboratories Clinical Laboratory · out of network | 70553 | $3,172.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-010552 UB-04 · 2026-07-21 | Ronald Long UHC-17595-06 | 2026-07-02 Outpatient hospital | Harbor Primary Care Associates Family Medicine · out of network | 70553 | $3,265.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-002609 UB-04 · 2026-07-19 | Kelly Morris UHC-78551-07 | 2026-07-01 Outpatient hospital | Canyon Reference Lab Clinical Laboratory · out of network | 70553 | $2,552.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-032309 UB-04 · 2026-07-09 | Angela Ellis UHC-75200-93 | 2026-05-28 Outpatient hospital | Cornerstone Family Practice Family Medicine · out of network | 70553 | $3,499.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-021726 UB-04 · 2026-07-07 | Albert Herrera UHC-78925-85 | 2026-06-07 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177 | $2,345.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-013692 UB-04 · 2026-07-04 | Denise Ortega UHC-19461-15 | 2026-06-26 Outpatient hospital | Cornerstone Family Practice Family Medicine · out of network | 70553 | $3,507.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-006631 UB-04 · 2026-07-04 | Cynthia Chen UHC-28065-94 | 2026-06-04 Outpatient hospital | Riverside Regional Medical Center Emergency Medicine · out of network | 70553 | $2,530.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-028982 UB-04 · 2026-06-28 | Justin Hernandez UHC-93913-12 | 2026-06-06 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 74177, 76700 | $2,069.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-009499 UB-04 · 2026-06-28 | Gary Thompson UHC-81856-96 | 2026-05-21 Outpatient hospital | Valley Primary Care Associates Family Medicine · out of network | 70553 | $3,143.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-027866 UB-04 · 2026-06-24 | Jerry Day UHC-84480-65 | 2026-05-26 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 71046, 70553 | $2,160.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-021410 UB-04 · 2026-06-22 | Laura Bennett UHC-69098-58 | 2026-05-23 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553 | $3,140.00 | — | Left for review REPL CO50 | — | Needs review |
| CLM-2026-004534 UB-04 · 2026-06-19 | Arthur Vasquez UHC-91248-73 | 2026-05-28 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 70553 | $2,875.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-033178 UB-04 · 2026-06-17 | Melissa Ruiz UHC-05094-92 | 2026-05-09 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 70553 | $2,749.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-031319 UB-04 · 2026-06-17 | Andrea Lawson UHC-82604-10 | 2026-06-10 Outpatient hospital | Sunrise Dermatology Clinic Dermatology · out of network | 70553 | $2,306.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-005809 UB-04 · 2026-06-17 | Teresa Chavez UHC-91472-66 | 2026-05-23 Outpatient hospital | Pinecrest Regional Medical Center Emergency Medicine · out of network | 70553 | $2,807.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-030429 UB-04 · 2026-06-16 | Kathryn Stephens UHC-35933-47 | 2026-05-14 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 70553, 43239 | $4,013.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-011438 UB-04 · 2026-06-16 | Cheryl Castro UHC-39022-48 | 2026-05-25 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 70553, 88305 | $2,278.00 | — | Left for review CO50 | — | 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.