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-2026-012918 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-2026-017600 UB-04 · 2026-10-03 | Ryan Wright UHC-72160-97 | 2026-08-26 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 71046 | $156.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-015437 UB-04 · 2026-10-03 | Joshua Harper UHC-85497-41 | 2026-08-19 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 71046, 99283 | $1,059.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-006451 UB-04 · 2026-09-28 | Nathan Tran UHC-26240-33 | 2026-09-19 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378 | $2,766.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-011920 UB-04 · 2026-09-13 | Sara Cox UHC-33317-40 | 2026-08-23 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 76700 | $2,603.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-014886 UB-04 · 2026-08-14 | Mark Evans UHC-79386-51 | 2026-07-21 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93458 | $5,898.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-004859 UB-04 · 2026-07-26 | Roger Luna UHC-68542-23 | 2026-06-16 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283, 71046 | $1,201.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-011793 UB-04 · 2026-07-13 | Roy Watson UHC-53548-27 | 2026-06-16 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 74177 | $1,549.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-027250 UB-04 · 2026-07-09 | Joan Jimenez UHC-70453-27 | 2026-06-27 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 29881 | $8,762.00 | — | Left for review REPL | — | 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-2026-020596 UB-04 · 2026-06-22 | Christopher Meyer UHC-42589-19 | 2026-05-10 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378, 88305 | $1,998.00 | — | Left for review REPL | — | 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-2026-009448 UB-04 · 2026-05-20 | Lerry Richardson UHC-30947-57 | 2026-04-18 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99283, 71046, 96374 | $1,034.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-027625 UB-04 · 2026-05-16 | Dennis Ray UHC-11585-25 | 2026-04-14 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99284, 99283 | $2,494.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-002217 UB-04 · 2026-05-03 | Carl Murray UHC-43401-37 | 2026-03-28 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99283, 99285 | $3,706.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-018562 UB-04 · 2026-03-25 | Aisha Hanson UHC-09335-84 | 2026-02-27 Outpatient hospital | Unity Imaging Center Radiology · out of network | 71046, 76700, 77067 | $1,080.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-023662 UB-04 · 2026-02-25 | Judy Lawrence UHC-33684-39 | 2025-12-24 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 70553, 74177 | $4,920.00 | — | Left for review REPL CO50 | — | Needs review |
| CLM-2026-024937 UB-04 · 2026-02-19 | Anna Mejia UHC-23558-66 | 2026-01-15 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99283, 99284 | $1,936.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-021533 UB-04 · 2026-01-27 | Frances Payne UHC-09678-38 | 2026-01-14 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 71046 | $170.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-021498 UB-04 · 2026-01-23 | Kimberly Hart UHC-93318-25 | 2025-12-20 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 71046 | $125.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-015937 UB-04 · 2026-01-18 | Peter Kelly UHC-28833-25 | 2025-12-15 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700, 74177 | $2,069.00 | — | Left for review REPL CO50 | — | Needs review |
| CLM-2026-006914 UB-04 · 2026-01-11 | Nicole Arnold UHC-18919-15 | 2025-12-18 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 77067, 71046 | $2,570.00 | — | Left for review REPL | — | 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.