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-2026-013417 UB-04 · 2026-10-12 | John Cunningham UHC-37758-42 | 2026-08-16 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553 | $2,471.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-027261 UB-04 · 2026-10-10 | Brittany Holmes UHC-82722-34 | 2026-10-01 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93015 | $438.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013746 UB-04 · 2026-10-07 | Joe Dean no member ID | 2026-08-31 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 71046 | $220.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-005660 UB-04 · 2026-10-07 | Ashley Nunez UHC-90338-03 | 2026-10-04 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 88305 | $262.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010133 UB-04 · 2026-10-03 | Pamela Harvey no member ID | 2026-09-01 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99284, 99283, 99285 | $3,759.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-005200 UB-04 · 2026-09-24 | Sara Jimenez no member ID | 2026-08-25 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 74177, 71046 | $1,693.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-013416 UB-04 · 2026-09-22 | John Cunningham UHC-37758-42 | 2026-08-16 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553 | $2,471.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-027615 UB-04 · 2026-09-18 | Valentina Scott UHC-56762-01 | 2026-08-12 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 96374, 99283 | $922.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-016201 UB-04 · 2026-09-17 | Noah Burton UHC-87151-33 | 2026-08-13 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $2,395.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010132 UB-04 · 2026-09-14 | Pamela Harvey no member ID | 2026-09-01 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99284, 99283, 99285 | $3,759.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-024620 UB-04 · 2026-09-07 | Danel Mejia no member ID | 2026-08-19 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374 | $150.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-030127 UB-04 · 2026-09-01 | Isabella Reed UHC-03809-38 | 2026-08-05 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $1,532.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-006100 UB-04 · 2026-08-21 | Joan Lane no member ID | 2026-08-10 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $48,364.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-024618 UB-04 · 2026-08-20 | Kevin Rice no member ID | 2026-07-21 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93458 | $8,839.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-014416 UB-04 · 2026-08-08 | Mason Wells UHC-76605-77 | 2026-07-18 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 76700, 77067 | $604.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-001537 UB-04 · 2026-08-08 | Ryan Santos UHC-94423-25 | 2026-07-10 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 96374, 99285, 99283 | $2,930.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-007432 UB-04 · 2026-08-07 | Bobby Garcia UHC-37947-67 | 2026-07-30 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 76700 | $489.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-028556 UB-04 · 2026-08-04 | Daniel Austin UHC-34567-10 | 2026-06-27 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 77067 | $301.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-032721 UB-04 · 2026-08-03 | Charlees Murray no member ID | 2026-06-24 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700, 74177 | $2,717.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-029504 UB-04 · 2026-07-30 | Randy Long UHC-89497-69 | 2026-07-24 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99283 | $914.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-015723 UB-04 · 2026-07-28 | Nancy Peters UHC-86599-46 | 2026-07-14 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 71046 | $160.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-001793 UB-04 · 2026-07-22 | Jeremy Singh UHC-23990-52 | 2026-07-05 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 71046, 99283, 99285 | $3,594.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-012860 UB-04 · 2026-07-19 | Nicole Barnes UHC-03627-37 | 2026-06-04 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284, 99285, 99283 | $5,471.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-019355 UB-04 · 2026-07-18 | Wei Andrews UHC-89962-52 | 2026-06-04 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 71046, 70553, 74177 | $5,144.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-029325 UB-04 · 2026-07-14 | Patricia Hernandez UHC-44396-50 | 2026-06-17 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99284 | $1,416.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-024295 UB-04 · 2026-07-07 | Thomas Cox UHC-43029-59 | 2026-06-01 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99285, 71046, 99283 | $3,441.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030617 UB-04 · 2026-06-26 | Christina Garza UHC-89482-73 | 2026-05-14 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99283 | $806.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-010180 UB-04 · 2026-06-26 | Donna Hunter UHC-21504-45 | 2026-05-24 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 71046 | $336.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013413 UB-04 · 2026-06-25 | Charlotte Hansen UHC-81644-64 | 2026-05-14 Inpatient hospital | Mesa Internal Medicine Associates Internal Medicine · out of network | 99232 | $182.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-018102 UB-04 · 2026-06-22 | Ahmed Sanders UHC-57673-12 | 2026-06-09 Outpatient hospital | Unity Imaging Center Radiology · out of network | 77067, 74177 | $1,900.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-022955 UB-04 · 2026-06-21 | Ruth Vazquez UHC-11615-56 | 2026-05-19 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 96374, 71046 | $390.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-025987 UB-04 · 2026-06-19 | Kayla Jenkins no member ID | 2026-05-08 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 29881 | $7,743.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-018709 UB-04 · 2026-06-19 | Debra Jensen UHC-06981-22 | 2026-06-09 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285 | $1,766.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-015682 UB-04 · 2026-06-18 | Willie Gomez no member ID | 2026-05-15 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 73721 | $2,215.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-022320 UB-04 · 2026-06-16 | Keith Baker UHC-75693-01 | 2026-05-22 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $2,009.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-029999 UB-04 · 2026-06-14 | Nicholas Wilson no member ID | 2026-05-25 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $1,676.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-025243 UB-04 · 2026-06-11 | Lisa Campbell UHC-60740-82 | 2026-05-03 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 71046, 77067 | $576.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-028366 UB-04 · 2026-06-08 | David Wheeler no member ID | 2026-04-30 Outpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 29881 | $6,133.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-013702 UB-04 · 2026-06-07 | Eric Long no member ID | 2026-04-30 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 43239 | $1,555.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-019748 UB-04 · 2026-06-04 | Pamela Lawson UHC-19051-72 | 2026-05-18 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283 | $1,070.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-023809 UB-04 · 2026-06-03 | Amber Soto UHC-45707-34 | 2026-04-24 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285 | $2,801.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000425 UB-04 · 2026-06-03 | Brittany Kelley UHC-07098-28 | 2026-05-10 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283, 99284 | $2,369.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-007988 UB-04 · 2026-05-25 | Mason Carter UHC-49290-17 | 2026-04-23 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 77067, 76700, 71046 | $892.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-014514 UB-04 · 2026-05-11 | Joseph Flors no member ID | 2026-04-22 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 71046, 70553 | $3,773.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-026394 UB-04 · 2026-05-10 | Angela Wagner UHC-74137-63 | 2026-04-14 Outpatient hospital | Pinecrest Regional Medical Center Emergency Medicine · out of network | 70553 | $2,131.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-023145 UB-04 · 2026-05-09 | Virginia Ray UHC-17642-30 | 2026-04-12 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 71046 | $137.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-001100 UB-04 · 2026-05-06 | Billy Bailey UHC-36394-37 | 2026-03-27 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285 | $2,832.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-030898 UB-04 · 2026-04-30 | Sophia Cole no member ID | 2026-03-27 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $28,051.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-012244 UB-04 · 2026-04-29 | Teresa Larson no member ID | 2026-04-10 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285, 99284, 99283 | $4,969.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-005401 UB-04 · 2026-04-20 | Laura Alvarado no member ID | 2026-04-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283 | $891.00 | — | Pended by rule IDQ N30 | — | Pended |
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.