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
3,664
50 with an AI recommendation
Pended
2,586
awaiting information or identity
Approved
23,942
$6,757,768.45 plan paid
Denied
4,454
with remittance reason codes
Examiner decided
0
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-2026-010759 UB-04 · 2026-10-17 | Beth Jimenez UHC-65211-83 | 2026-09-13 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $3,075.00 | — | Left for review NET | — | Needs review |
| CLM-2026-024336 UB-04 · 2026-10-16 | Sean Payne UHC-34145-90 | 2026-09-15 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99283 | $970.00 | — | Left for review NET | — | Needs review |
| CLM-2026-012988 UB-04 · 2026-10-15 | Sanitago Franklin UHC-54865-20 | 2026-09-04 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99284, 71046, 99285 | $4,024.00 | — | Left for review NET | — | Needs review |
| 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-2026-019721 UB-04 · 2026-10-13 | Susan Snyder UHC-74817-71 | 2026-09-13 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283 | $745.00 | — | Left for review NET | — | 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-2026-022262 UB-04 · 2026-10-11 | Justin Pena UHC-23865-08 | 2026-10-01 Inpatient hospital | Unity Internal Medicine Associates Internal Medicine · out of network | 99232 | $218.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-032543 UB-04 · 2026-10-10 | Brittany Alvarado UHC-89357-17 | 2026-08-30 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 96374, 99285 | $2,580.00 | — | Left for review NET | — | 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-2026-012757 UB-04 · 2026-10-10 | Russell King UHC-80971-11 | 2026-09-16 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99285, 99284 | $4,796.00 | — | Left for review NET | — | 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-2026-005070 UB-04 · 2026-10-09 | Logan Greene UHC-34472-84 | 2026-10-06 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 96374 | $170.00 | — | Left for review NET | — | Needs review |
| CLM-2026-029982 UB-04 · 2026-10-08 | Maria Hansen UHC-86468-12 | 2026-09-13 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283 | $725.00 | — | Left for review NET | — | Needs review |
| CLM-2026-029044 UB-04 · 2026-10-07 | Maira Kim UHC-95297-64 | 2026-08-25 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $2,579.00 | — | Left for review NET | — | 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-2026-021597 UB-04 · 2026-10-06 | Kelly Tucker UHC-00488-72 | 2026-09-07 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283, 99284, 99285 | $4,892.00 | — | Left for review NET | — | Needs review |
| CLM-2026-009704 UB-04 · 2026-10-05 | William Walsh UHC-07070-34 | 2026-08-31 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · out of network | 99232 | $236.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-005618 UB-04 · 2026-10-05 | Emma Harrison UHC-63140-98 | 2026-09-07 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99283 | $737.00 | — | Left for review NET | — | Needs review |
| CLM-2026-002465 UB-04 · 2026-10-05 | Patricia Robertson UHC-63151-88 | 2026-09-02 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284, 96374, 99285 | $3,674.00 | — | Left for review CO16 | — | 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-2026-019141 UB-04 · 2026-10-03 | Anthony Perkins UHC-29134-84 | 2026-08-31 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $1,005.00 | — | Left for review CO16 | — | 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-2026-009793 UB-04 · 2026-10-01 | Joan Coleman UHC-76680-53 | 2026-08-29 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 71046 | $328.00 | — | Left for review NET | — | Needs review |
| CLM-2026-008046 UB-04 · 2026-09-30 | Kimberly Mejia UHC-56315-91 | 2026-08-16 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99284, 99285 | $4,427.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-007995 UB-04 · 2026-09-30 | Sandra Morris UHC-98911-16 | 2026-08-26 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 71046, 99283, 96374 | $981.00 | — | Left for review NET | — | 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-2026-006451 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-2026-024458 UB-04 · 2026-09-26 | Robert Jacobs UHC-66748-29 | 2026-08-25 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285, 96374 | $2,119.00 | — | Left for review NET | — | 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-2026-012628 UB-04 · 2026-09-24 | Gary Fields UHC-65382-80 | 2026-09-03 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378, 88305, 43239 | $3,858.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-032028 UB-04 · 2026-09-19 | Hannah Wlliams UHC-36369-69 | 2026-09-03 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 99285, 99284, 96374 | $4,065.00 | — | Left for review NET | — | 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-2026-031359 UB-04 · 2026-09-18 | Maria Carlson UHC-01702-71 | 2026-09-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046 | $130.00 | — | Left for review NET | — | Needs review |
| CLM-2026-027728 UB-04 · 2026-09-17 | Carlos Nguyen UHC-33573-55 | 2026-08-23 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 71046 | $226.00 | — | Left for review NET | — | Needs review |
| CLM-2026-016646 UB-04 · 2026-09-17 | Arjun Sullivan UHC-69356-13 | 2026-08-16 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99285 | $2,470.00 | — | Left for review NET | — | 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-2026-026488 UB-04 · 2026-09-15 | Stephanie Porter UHC-07006-03 | 2026-08-31 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 71046 | $130.00 | — | Left for review NET | — | Needs review |
| CLM-2026-018761 UB-04 · 2026-09-15 | Ahmed Sims UHC-36382-81 | 2026-08-02 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · out of network | 93458 | $8,823.00 | — | Left for review DUP | — | 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-2026-011920 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-2026-008640 UB-04 · 2026-09-13 | Keith Gray UHC-41667-97 | 2026-08-20 Inpatient hospital | Riverside Internal Medicine Associates Internal Medicine · out of network | 99232 | $197.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-011939 UB-04 · 2026-09-12 | Keith Torres UHC-89886-91 | 2026-08-29 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284 | $1,730.00 | — | Left for review NET | — | 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-2026-006548 UB-04 · 2026-09-12 | Hannah McDonald UHC-37231-04 | 2026-09-10 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 96374 | $211.00 | — | Left for review NET | — | 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.