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-2026-026672 UB-04 · 2026-10-14 | Betty Butler UHC-72899-24 | 2026-08-24 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $51,185.00 | — | Left for review DUP HIGH | — | Needs review |
| CLM-2026-024888 UB-04 · 2026-10-12 | Eric Robertson UHC-01745-78 | 2026-08-28 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $31,691.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-024453 UB-04 · 2026-10-11 | Grace Kennedy UHC-94262-16 | 2026-09-28 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $38,659.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-030384 UB-04 · 2026-10-10 | Jeffrey Padilla UHC-92939-82 | 2026-09-25 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $37,665.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-014429 UB-04 · 2026-09-19 | Katherine Payne UHC-90245-36 | 2026-09-15 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $49,343.00 | — | Left for review HIGH | — | Needs review |
| 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-2026-005193 UB-04 · 2026-08-30 | Keith Rice UHC-84777-32 | 2026-08-24 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $38,397.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-022815 UB-04 · 2026-08-27 | Samantha Walker UHC-63264-85 | 2026-07-20 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $33,052.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-023425 UB-04 · 2026-08-21 | Noah Vasquez UHC-16757-75 | 2026-07-09 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $43,447.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-034112 UB-04 · 2026-08-20 | Andrew Fisher UHC-49611-17 | 2026-07-06 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $48,462.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-002838 UB-04 · 2026-08-20 | Raymond Schmidt UHC-32279-47 | 2026-07-08 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $51,424.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-010629 UB-04 · 2026-08-15 | Arthur Rice UHC-69841-73 | 2026-07-02 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $37,047.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-034207 UB-04 · 2026-08-10 | Frank Daniels UHC-02600-13 | 2026-08-02 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447, 29881 | $39,675.00 | — | Left for review CO97 HIGH | — | Needs review |
| CLM-2026-005693 UB-04 · 2026-08-08 | Kathleen Cruz UHC-59287-85 | 2026-06-29 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $29,657.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-028209 UB-04 · 2026-08-07 | Brandon Lane UHC-12070-15 | 2026-08-01 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $41,973.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-003464 UB-04 · 2026-08-03 | Diana Bell UHC-46851-26 | 2026-07-21 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $35,413.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-012398 UB-04 · 2026-07-24 | Dylan Lynch UHC-13247-56 | 2026-06-16 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $31,253.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-028720 UB-04 · 2026-07-15 | Jonathan Foster UHC-88767-60 | 2026-07-13 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $45,059.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-007720 UB-04 · 2026-07-10 | Brian McCoy UHC-72352-98 | 2026-06-21 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $51,473.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-022077 UB-04 · 2026-07-02 | Lucia Fox UHC-54071-15 | 2026-05-26 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $38,748.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027918 UB-04 · 2026-06-29 | Diego Tran UHC-63032-49 | 2026-06-04 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $31,987.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027506 UB-04 · 2026-06-19 | Jessica Carter UHC-74848-26 | 2026-05-06 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $38,015.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-028276 UB-04 · 2026-06-02 | Aisha Maldonado UHC-43714-18 | 2026-05-08 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $34,988.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-020278 UB-04 · 2026-06-01 | Gregory Vasquez UHC-23843-06 | 2026-05-19 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $28,227.00 | — | Left for review REPL HIGH | — | Needs review |
| CLM-2026-020659 UB-04 · 2026-05-29 | Willie Medina UHC-66180-38 | 2026-05-23 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $49,930.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-020277 UB-04 · 2026-05-23 | Gregory Vasquez UHC-23843-06 | 2026-05-19 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $28,227.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-025515 UB-04 · 2026-05-11 | Bryan Flores UHC-43147-53 | 2026-04-22 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $28,268.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-023591 UB-04 · 2026-05-05 | Kyle Romero UHC-90669-86 | 2026-04-10 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $48,009.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-002168 UB-04 · 2026-04-18 | Madison Moreno UHC-82109-72 | 2026-04-12 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $37,937.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-005684 UB-04 · 2026-04-16 | Charlotte Clark UHC-71305-39 | 2026-03-17 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $48,216.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-015472 UB-04 · 2026-04-07 | Emily Peterson UHC-82743-71 | 2026-03-13 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $30,094.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-011753 UB-04 · 2026-04-01 | Jason Cox UHC-09193-61 | 2026-02-17 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 27447, 29881 | $40,665.00 | — | Left for review CO97 HIGH | — | Needs review |
| CLM-2026-021267 UB-04 · 2026-03-23 | Madison Patel UHC-54352-44 | 2026-02-16 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $38,102.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-022349 UB-04 · 2026-03-21 | Lauren Wagner UHC-76656-69 | 2026-02-04 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447, 29881 | $50,948.00 | — | Left for review CO97 HIGH | — | Needs review |
| CLM-2026-010642 UB-04 · 2026-03-17 | Shirley Dominguez UHC-22993-45 | 2026-02-13 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $47,428.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-030003 UB-04 · 2026-03-07 | Priya Price UHC-37982-54 | 2026-02-22 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $45,750.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-023119 UB-04 · 2026-03-07 | Gabriel Hawkins UHC-32513-52 | 2026-02-10 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $42,859.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-017948 UB-04 · 2026-02-26 | Theresa West UHC-89238-83 | 2026-01-24 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $28,974.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-030698 UB-04 · 2026-02-22 | Mei Watkins UHC-62597-73 | 2026-02-11 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447, 29881 | $36,823.00 | — | Left for review CO97 HIGH | — | Needs review |
| CLM-2026-013258 UB-04 · 2026-02-12 | Emma Berry UHC-48557-53 | 2026-02-09 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $31,103.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027286 UB-04 · 2026-02-01 | Maria Meyer UHC-19767-52 | 2026-01-02 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $50,610.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-026841 UB-04 · 2026-02-01 | Michelle Elliott UHC-58397-47 | 2025-12-21 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $51,733.00 | — | Left for review DUP HIGH | — | Needs review |
| CLM-2026-013970 UB-04 · 2026-01-25 | Theresa Lewiis UHC-86460-92 | 2026-01-16 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $44,055.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-017077 UB-04 · 2026-01-19 | Olivia Padilla UHC-79554-60 | 2026-01-06 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $37,292.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-002281 UB-04 · 2026-01-07 | Andrew Harper UHC-15603-56 | 2025-12-25 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $47,343.00 | — | Left for review HIGH | Approved confidence 0.95 | Needs review |
| CLM-2026-021384 UB-04 · 2026-01-04 | Jose Mejia UHC-36493-03 | 2025-12-01 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $34,233.00 | — | Left for review HIGH | Approved confidence 0.95 | Needs review |
| CLM-2026-029989 UB-04 · 2026-01-01 | Marilyn Fisher UHC-53466-53 | 2025-12-06 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $49,523.00 | — | Left for review HIGH | Approved confidence 0.95 | 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.