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-2026-024711 UB-04 · 2026-10-18 | Kenneth Henry UHC-27427-73 | 2026-09-17 Outpatient hospital | Unity Imaging Center Radiology · out of network | 77067, 71046, 76700 | $982.00 | $39.38 | Clean approval | — | Approved |
| CLM-2026-018059 UB-04 · 2026-10-18 | Donald Gonzales UHC-12549-84 | 2026-09-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99284, 99283 | $2,310.00 | $789.50 | Clean approval | — | Approved |
| CLM-2026-012213 UB-04 · 2026-10-18 | Joyce Hunt UHC-86921-20 | 2026-10-05 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $2,901.00 | $955.45 | Clean approval | — | Approved |
| CLM-2026-004454 UB-04 · 2026-10-18 | Madison Chavez UHC-00823-42 | 2026-09-11 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 29881 | $8,215.00 | $2,195.72 | Clean approval | — | Approved |
| CLM-2026-002847 UB-04 · 2026-10-18 | Philip Bradley UHC-47879-82 | 2026-09-11 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 71046 | $114.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-002598 UB-04 · 2026-10-18 | Lawrence Ellis UHC-63165-77 | 2026-09-26 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 96374 | $246.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032950 UB-04 · 2026-10-17 | Charlotte Sanchez UHC-10300-72 | 2026-09-23 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283 | $890.00 | $50.50 | Clean approval | — | Approved |
| CLM-2026-025168 UB-04 · 2026-10-17 | Justin Gordon UHC-82612-26 | 2026-09-13 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283, 99284, 99285 | $4,063.00 | $1,678.35 | Clean approval | — | Approved |
| CLM-2026-013988 UB-04 · 2026-10-17 | James Chen UHC-30142-52 | 2026-09-19 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93306, 93458 | $7,222.00 | $2,457.84 | Clean approval | — | Approved |
| CLM-2026-001942 UB-04 · 2026-10-17 | Wayne Jones UHC-18856-20 | 2026-09-02 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 74177 | $1,623.00 | $140.85 | Clean approval | — | Approved |
| CLM-2026-014992 UB-04 · 2026-10-16 | Patricia Hayes UHC-59679-50 | 2026-10-03 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99285, 96374, 99284 | $4,868.00 | $1,840.60 | Clean approval | — | Approved |
| CLM-2026-034327 UB-04 · 2026-10-15 | Mary Baker UHC-41912-65 | 2026-09-02 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 71046 | $157.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-006356 UB-04 · 2026-10-15 | Julie Martinez UHC-50684-90 | 2026-09-28 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99285 | $2,503.00 | $776.35 | Clean approval | — | Approved |
| CLM-2026-004341 UB-04 · 2026-10-15 | Victoria Gray UHC-19111-25 | 2026-09-04 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $826.00 | $298.80 | Clean approval | — | Approved |
| CLM-2026-033243 UB-04 · 2026-10-14 | Joan Hoffman UHC-38218-33 | 2026-09-18 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284, 99283, 96374 | $2,659.00 | $846.55 | Clean approval | — | Approved |
| CLM-2026-011058 UB-04 · 2026-10-14 | Justin Palmer UHC-44225-20 | 2026-09-13 Inpatient hospital | Mesa Internal Medicine Associates Internal Medicine · out of network | 99232 | $234.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023222 UB-04 · 2026-10-13 | Joshua Walsh UHC-33244-92 | 2026-10-11 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93306, 93015 | $2,038.00 | $453.33 | Clean approval | — | Approved |
| CLM-2026-012144 UB-04 · 2026-10-12 | Sandra McCoy UHC-43501-97 | 2026-08-30 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 76700 | $328.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-007608 UB-04 · 2026-10-12 | Kimberly Vazquez UHC-88315-80 | 2026-09-10 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $1,119.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-031356 UB-04 · 2026-10-11 | Barbara Cooper UHC-62320-38 | 2026-09-02 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99284 | $1,392.00 | $476.40 | Clean approval | — | Approved |
| CLM-2026-016853 UB-04 · 2026-10-11 | Donald Chapman UHC-04060-56 | 2026-10-06 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 77067 | $345.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-000109 UB-04 · 2026-10-11 | Brian Bell UHC-05015-78 | 2026-08-30 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285, 96374 | $1,873.00 | $692.85 | Clean approval | — | Approved |
| CLM-2026-008737 UB-04 · 2026-10-10 | Camila Coleman UHC-30287-02 | 2026-09-01 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93015, 93458 | $9,840.00 | $3,371.37 | Clean approval | — | Approved |
| CLM-2026-002122 UB-04 · 2026-10-10 | Jon Oliver UHC-44697-32 | 2026-09-06 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 96374, 71046 | $409.00 | $79.65 | Clean approval | — | Approved |
| CLM-2026-001118 UB-04 · 2026-10-10 | Vazquez Mei UHC-53731-44 | 2026-08-27 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 96374 | $203.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-033895 UB-04 · 2026-10-09 | Joan Phillips UHC-75598-35 | 2026-09-14 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $1,754.00 | $439.30 | Clean approval | — | Approved |
| CLM-2026-029203 UB-04 · 2026-10-09 | Jesse Price UHC-05475-09 | 2026-08-29 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 71046, 99283 | $910.00 | $295.65 | Clean approval | — | Approved |
| CLM-2026-013054 UB-04 · 2026-10-09 | Charles Lynch UHC-82241-22 | 2026-09-30 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93015 | $517.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-027178 UB-04 · 2026-10-07 | Ryan Hunter UHC-48235-63 | 2026-09-16 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285, 99284, 96374 | $4,448.00 | $1,851.60 | Clean approval | — | Approved |
| CLM-2026-013727 UB-04 · 2026-10-07 | Amanda Guerrero UHC-02982-66 | 2026-10-05 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306, 93015 | $1,529.00 | $507.06 | Clean approval | — | Approved |
| CLM-2026-007431 UB-04 · 2026-10-07 | Sean Varrgas UHC-30722-64 | 2026-09-15 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285, 71046 | $3,333.00 | $1,349.85 | Clean approval | — | Approved |
| CLM-2026-019813 UB-04 · 2026-10-06 | Heather Gardner UHC-30555-67 | 2026-09-23 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700 | $634.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-012939 UB-04 · 2026-10-06 | Nicole Rice UHC-22461-47 | 2026-10-04 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 70553, 74177 | $5,115.00 | $700.26 | Clean approval | — | Approved |
| CLM-2026-000941 UB-04 · 2026-10-06 | Mason Ramirez UHC-04462-47 | 2026-09-15 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046 | $226.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-025490 UB-04 · 2026-10-05 | Susan Garrett UHC-86282-68 | 2026-08-30 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 71046 | $211.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-020243 UB-04 · 2026-10-05 | George Torres UHC-42020-09 | 2026-08-29 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283, 96374 | $1,046.00 | $120.70 | Clean approval | — | Approved |
| CLM-2026-030008 UB-04 · 2026-10-04 | Nathan Palmer UHC-78327-09 | 2026-08-25 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285 | $1,925.00 | $616.25 | Clean approval | — | Approved |
| CLM-2026-014273 UB-04 · 2026-10-04 | James Chen UHC-30142-52 | 2026-09-27 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 74177 | $1,634.00 | $194.71 | Clean approval | — | Approved |
| CLM-2026-000493 UB-04 · 2026-10-04 | Beverly Hughes UHC-84048-28 | 2026-09-28 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93015, 93306 | $1,601.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030692 UB-04 · 2026-10-03 | Kimberly Howard UHC-44964-12 | 2026-09-22 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99283, 99284 | $1,943.00 | $526.95 | Clean approval | — | Approved |
| CLM-2026-025572 UB-04 · 2026-10-03 | Diego Nguyen UHC-76302-57 | 2026-09-08 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99283 | $855.00 | $134.75 | Clean approval | — | Approved |
| CLM-2026-015230 UB-04 · 2026-10-02 | Shirley Harper UHC-21504-79 | 2026-09-19 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283, 96374 | $1,072.00 | $232.40 | Clean approval | — | Approved |
| CLM-2026-004772 UB-04 · 2026-10-02 | Bryan Ray UHC-15231-85 | 2026-09-28 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,734.00 | $430.30 | Clean approval | — | Approved |
| CLM-2026-029825 UB-04 · 2026-10-01 | Mark Evans UHC-79386-51 | 2026-08-23 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 74177, 77067, 76700 | $2,577.00 | $293.11 | Clean approval | — | Approved |
| CLM-2026-026359 UB-04 · 2026-10-01 | James Owens UHC-46110-34 | 2026-08-18 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283, 71046 | $1,013.00 | $105.85 | Clean approval | — | Approved |
| CLM-2026-021733 UB-04 · 2026-10-01 | Christopher Chen UHC-07924-36 | 2026-09-09 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283 | $843.00 | $29.35 | Clean approval | — | Approved |
| CLM-2026-012366 UB-04 · 2026-10-01 | Diego Matthews UHC-11271-69 | 2026-09-29 Inpatient hospital | Riverside Internal Medicine Associates Internal Medicine · out of network | 99232 | $217.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011304 UB-04 · 2026-10-01 | Elizabeth Dunn UHC-59946-17 | 2026-09-14 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93015 | $668.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-029170 UB-04 · 2026-09-30 | Edward Howard UHC-57201-34 | 2026-09-25 Outpatient hospital | Mesa Imaging Center Radiology · out of network | 77067 | $304.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-027708 UB-04 · 2026-09-30 | Grace Ross UHC-85981-15 | 2026-09-23 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 43239 | $1,447.00 | $437.71 | Clean approval | — | Approved |
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.