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-2026-011700 UB-04 · 2026-08-06 | Zachary Greene UHC-69793-13 | 2026-07-25 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283 | $746.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-003305 UB-04 · 2026-08-06 | Not attached | 2026-07-10 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283 | $917.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-000539 UB-04 · 2026-08-06 | Not attached | 2026-06-27 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · in network | 93306, 93015 | $1,820.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-034071 UB-04 · 2026-08-05 | Mei Nguyen UHC-95381-17 | 2026-07-27 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 96374, 99284 | $1,648.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-022468 UB-04 · 2026-08-04 | Not attached | 2026-07-15 Outpatient hospital | Summit Imaging Center Radiology · in network | 77067, 70553 | $2,817.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-011241 UB-04 · 2026-08-02 | Carl Rian UHC-07924-72 | 2026-07-15 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 70553, 71046, 74177 | $4,376.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-021633 UB-04 · 2026-07-31 | Not attached | 2026-06-18 Inpatient hospital | Heritage Internal Medicine Associates Internal Medicine · in network | 99232 | $216.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-010637 UB-04 · 2026-07-31 | Linda Torres UHC-32071-63 | 2026-07-01 Inpatient hospital | Sunrise Internal Medicine Associates Internal Medicine · in network | 99232 | $260.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-027742 UB-04 · 2026-07-30 | Kevin Willis UHC-76668-92 | 2026-07-18 Emergency room | Harbor Regional Medical Center Emergency Medicine · in network | 99284, 99283 | $2,562.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-019543 UB-04 · 2026-07-30 | Douglas Salazar UHC-42879-41 | 2026-07-17 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 43239, 45378 | $4,349.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-011469 UB-04 · 2026-07-26 | Not attached | 2026-06-19 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,113.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-012882 UB-04 · 2026-07-25 | Joyce Ryan UHC-02549-23 | 2026-06-14 Outpatient hospital | Unity Cardiovascular Associates Cardiology · in network | 93458, 93306 | $8,912.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-006051 UB-04 · 2026-07-24 | Not attached | 2026-06-23 Outpatient hospital | Summit Digestive Health Center Gastroenterology · in network | 88305 | $256.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-002890 UB-04 · 2026-07-23 | Juan Carlson UHC-78684-93 | 2026-06-15 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 71046, 77067 | $548.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-021091 UB-04 · 2026-07-20 | Not attached | 2026-06-15 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $213.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-023675 UB-04 · 2026-07-15 | Daniel Wbeb UHC-96158-05 | 2026-05-31 Outpatient hospital | Meadow GI Associates Gastroenterology · in network | 45378, 88305 | $2,287.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-001574 UB-04 · 2026-07-15 | Not attached | 2026-06-15 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 77067, 70553 | $2,837.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-002029 UB-04 · 2026-07-11 | Eugene Watkins UHC-86450-26 | 2026-06-22 Inpatient hospital | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $49,852.00 | — | Left for review CO16 HIGH | — | Needs review |
| CLM-2026-012305 UB-04 · 2026-07-10 | Not attached | 2026-07-08 Outpatient hospital | Valley Regional Medical Center Emergency Medicine · in network | 70553 | $3,121.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-031460 UB-04 · 2026-07-09 | Roy Powell UHC-89409-50 | 2026-06-13 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $47,248.00 | — | Left for review CO16 HIGH | — | Needs review |
| CLM-2026-025793 UB-04 · 2026-07-09 | Valentina Ramos UHC-69832-38 | 2026-06-05 Outpatient hospital | Riverside Imaging Center Radiology · in network | 71046, 70553 | $3,775.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-022347 UB-04 · 2026-07-09 | Marilyn Miller UHC-47254-57 | 2026-06-17 Outpatient hospital | Harbor Cardiovascular Associates Cardiology · in network | 93458 | $6,578.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-030482 UB-04 · 2026-07-08 | Deny Parker UHC-00717-49 | 2026-07-05 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 71046, 77067 | $503.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-016901 UB-04 · 2026-07-06 | Dennis Sims UHC-98893-34 | 2026-05-29 Outpatient hospital | Riverside Imaging Center Radiology · in network | 76700, 74177 | $2,295.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-030457 UB-04 · 2026-07-05 | Not attached | 2026-06-15 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $37,882.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-022726 UB-04 · 2026-07-05 | Not attached | 2026-06-18 Emergency room | Lakeside Regional Medical Center Emergency Medicine · in network | 71046, 99284 | $1,264.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-004698 UB-04 · 2026-07-05 | Not attached | 2026-05-22 Inpatient hospital | Summit Medical Group Internal Medicine · in network | 99232 | $162.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-005411 UB-04 · 2026-07-01 | Donald Lene UHC-25028-43 | 2026-06-11 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 71046, 76700 | $686.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-018862 UB-04 · 2026-06-30 | Not attached | 2026-06-09 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,271.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-011036 UB-04 · 2026-06-26 | Charlotte Sanders UHC-11316-19 | 2026-05-12 Emergency room | Unity Community Hospital Emergency Medicine · in network | 96374, 99283 | $1,029.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-026655 UB-04 · 2026-06-25 | Christina Daniels UHC-59560-45 | 2026-06-20 Outpatient hospital | Cornerstone Imaging Center Radiology · in network | 74177, 71046, 70553 | $5,070.00 | — | Left for review CO50 CO16 | — | Needs review |
| CLM-2026-030973 UB-04 · 2026-06-24 | Paul Ward UHC-06878-76 | 2026-05-18 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378 | $2,091.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-030288 UB-04 · 2026-06-19 | Not attached | 2026-06-14 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99283, 71046, 99284 | $2,329.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-001387 UB-04 · 2026-06-19 | Daniel Robertson UHC-23818-80 | 2026-05-27 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 74177 | $2,374.00 | — | Left for review CO50 CO16 | — | Needs review |
| CLM-2026-028518 UB-04 · 2026-06-17 | Bruce Adams UHC-74963-28 | 2026-05-17 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $249.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-003297 UB-04 · 2026-06-17 | Not attached | 2026-05-20 Outpatient hospital | Pinecrest Physical Therapy Physical Therapy · in network | 70553 | $10,944.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-013537 UB-04 · 2026-06-16 | Jason Robinson UHC-21040-87 | 2026-05-23 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 71046, 74177 | $1,614.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-016675 UB-04 · 2026-06-15 | Juhn Sullivan UHC-14129-58 | 2026-06-06 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 71046, 76700 | $705.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-009389 UB-04 · 2026-06-14 | Keith Vazquez UHC-01356-46 | 2026-05-20 Inpatient hospital | Lakeside Medical Group Internal Medicine · in network | 99232 | $198.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-004978 UB-04 · 2026-06-12 | Kevin Gray UHC-41944-42 | 2026-05-05 Emergency room | Summit Community Hospital Emergency Medicine · in network | 96374 | $141.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-021712 UB-04 · 2026-06-11 | Not attached | 2026-04-17 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 73721 | $1,220.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-006969 UB-04 · 2026-06-11 | Not attached | 2026-05-18 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 76700 | $351.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-002813 UB-04 · 2026-06-10 | Gloria Grant UHC-18393-21 | 2026-06-01 Outpatient hospital | Desert Imaging Center Radiology · in network | 70553, 71046 | $2,621.00 | — | Left for review CO50 CO16 | — | Needs review |
| CLM-2026-026339 UB-04 · 2026-06-09 | Not attached | 2026-05-16 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 88305 | $264.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-028400 UB-04 · 2026-06-07 | Not attached | 2026-06-05 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 77067 | $267.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-025285 UB-04 · 2026-06-07 | Jean Bell UHC-44976-64 | 2026-05-07 Outpatient hospital | Unity Cardiovascular Associates Cardiology · in network | 93306 | $900.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-025480 UB-04 · 2026-06-06 | Catherine Collins UHC-00056-21 | 2026-05-27 Inpatient hospital | Sunrise Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $35,644.00 | — | Left for review CO16 HIGH | — | Needs review |
| CLM-2026-017953 UB-04 · 2026-06-06 | Not attached | 2026-04-26 Outpatient hospital | Meadow GI Associates Gastroenterology · in network | 45378 | $1,904.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-023070 UB-04 · 2026-06-05 | Bryan Jenkins UHC-40066-17 | 2026-05-08 Inpatient hospital | Valley Medical Group Internal Medicine · in network | 99232 | $226.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-005885 UB-04 · 2026-06-05 | Jacob Evans UHC-47768-24 | 2026-05-25 Emergency room | Riverside Community Hospital Emergency Medicine · in network | 99284, 99285 | $4,652.00 | — | Left for review CO16 | — | 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.