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-2026-003237 UB-04 · 2026-09-05 | Jesse Castillo UHC-64582-82 | 2026-07-29 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $34,728.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-034376 UB-04 · 2026-09-04 | Philip Nunez UHC-24443-17 | 2026-08-28 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $36,336.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-029289 UB-04 · 2026-09-04 | Sandra Davis UHC-90638-23 | 2026-08-18 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $30,408.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-010692 UB-04 · 2026-09-04 | Donna Schmidt UHC-88832-04 | 2026-08-30 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $38,434.00 | — | Left for review CO16 HIGH | — | Needs review |
| CLM-2026-015887 UB-04 · 2026-09-03 | Amber Perkins UHC-05855-16 | 2026-08-06 Inpatient hospital | Sunrise Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $50,145.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-007232 UB-04 · 2026-09-03 | Linda Kelly UHC-39290-06 | 2026-07-30 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $34,383.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-019449 UB-04 · 2026-09-01 | Megan Morrison UHC-40939-67 | 2026-07-29 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $29,637.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-030018 UB-04 · 2026-08-30 | Mason Vasquez UHC-56594-06 | 2026-08-17 Inpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 27447 | $39,267.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-013151 UB-04 · 2026-08-30 | Jordan Mitchell UHC-68540-72 | 2026-08-20 Inpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 27447 | $33,520.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-005193 UB-04 · 2026-08-30 | Keith Rice UHC-84777-32 | 2026-08-24 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $38,397.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-023522 UB-04 · 2026-08-29 | Lori Fowler UHC-41558-85 | 2026-08-19 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $43,974.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-005694 UB-04 · 2026-08-29 | Kathleen Cruz UHC-59287-85 | 2026-06-29 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $29,657.00 | — | Left for review DUP HIGH | — | Needs review |
| CLM-2026-025488 UB-04 · 2026-08-28 | Mariana Nguyen UHC-30578-85 | 2026-07-25 Inpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 27447 | $39,750.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-022815 UB-04 · 2026-08-27 | Samantha Walker UHC-63264-85 | 2026-07-20 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $33,052.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-010104 UB-04 · 2026-08-27 | Wayne Chavez UHC-99718-58 | 2026-08-12 Inpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $36,250.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-002978 UB-04 · 2026-08-27 | Jerry Freeman UHC-67528-45 | 2026-08-01 Inpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 27447 | $38,476.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-034186 UB-04 · 2026-08-25 | Charles Chapman UHC-47214-68 | 2026-07-15 Inpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 27447 | $50,835.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-010242 UB-04 · 2026-08-24 | Zachary Harvey UHC-58981-28 | 2026-08-03 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $42,881.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-016506 UB-04 · 2026-08-22 | Vincent Silva UHC-21678-20 | 2026-08-09 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $45,857.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-023425 UB-04 · 2026-08-21 | Noah Vasquez UHC-16757-75 | 2026-07-09 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $43,447.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-005436 UB-04 · 2026-08-21 | Cynthia Hughes UHC-65736-97 | 2026-08-02 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $37,603.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-034112 UB-04 · 2026-08-20 | Andrew Fisher UHC-49611-17 | 2026-07-06 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $48,462.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-017103 UB-04 · 2026-08-20 | Kathleen Gibson UHC-89929-38 | 2026-07-26 Inpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 27447 | $34,571.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-004386 UB-04 · 2026-08-20 | Charlotte Ross UHC-74607-96 | 2026-07-22 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $42,587.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-003702 UB-04 · 2026-08-20 | Justin Torres UHC-54319-47 | 2026-07-26 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $45,908.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-002838 UB-04 · 2026-08-20 | Raymond Schmidt UHC-32279-47 | 2026-07-08 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $51,424.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-005043 UB-04 · 2026-08-19 | Albert Delgado UHC-47612-02 | 2026-07-17 Inpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 27447 | $30,212.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-009580 UB-04 · 2026-08-17 | Lisa Dunn UHC-09379-62 | 2026-07-16 Inpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 27447 | $51,086.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-033736 UB-04 · 2026-08-15 | Aaron Hill UHC-02426-84 | 2026-07-08 Inpatient hospital | Sunrise Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $46,092.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-014580 UB-04 · 2026-08-15 | Philip Carroll UHC-25359-26 | 2026-07-28 Inpatient hospital | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $47,334.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-010629 UB-04 · 2026-08-15 | Arthur Rice UHC-69841-73 | 2026-07-02 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $37,047.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-011019 UB-04 · 2026-08-14 | Madison Salazar UHC-03727-81 | 2026-07-09 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $37,382.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-032042 UB-04 · 2026-08-13 | Ahmed Lewis UHC-62800-86 | 2026-08-10 Inpatient hospital | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $31,999.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-009544 UB-04 · 2026-08-11 | Mei Robertson UHC-47647-46 | 2026-07-18 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $44,579.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-034207 UB-04 · 2026-08-10 | Frank Daniels UHC-02600-13 | 2026-08-02 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447, 29881 | $39,675.00 | — | Left for review CO97 HIGH | — | Needs review |
| CLM-2026-005476 UB-04 · 2026-08-10 | Gloria Harper UHC-02195-39 | 2026-07-12 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $43,726.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-018458 UB-04 · 2026-08-09 | Abigail Lawrence UHC-25880-45 | 2026-07-25 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $33,913.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-005693 UB-04 · 2026-08-08 | Kathleen Cruz UHC-59287-85 | 2026-06-29 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $29,657.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-028209 UB-04 · 2026-08-07 | Brandon Lane UHC-12070-15 | 2026-08-01 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $41,973.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-029685 UB-04 · 2026-08-06 | Evelyn Austin UHC-82037-47 | 2026-08-04 Inpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 27447 | $51,988.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-028090 UB-04 · 2026-08-06 | Jose Day UHC-65678-01 | 2026-07-28 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $49,064.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-019185 UB-04 · 2026-08-05 | Juan Kim UHC-49008-92 | 2026-07-12 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $40,594.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-019008 UB-04 · 2026-08-03 | Timothy Howell UHC-63319-69 | 2026-07-11 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $35,888.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-013535 UB-04 · 2026-08-03 | Sara Gordon UHC-17238-13 | 2026-07-27 Inpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $36,138.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-007878 UB-04 · 2026-08-03 | Nancy Rios UHC-76965-35 | 2026-06-30 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $40,697.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-003464 UB-04 · 2026-08-03 | Diana Bell UHC-46851-26 | 2026-07-21 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $35,413.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-020604 UB-04 · 2026-07-31 | Harold Green UHC-22405-40 | 2026-07-09 Inpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 27447 | $31,699.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-031167 UB-04 · 2026-07-30 | Amber Guerrero UHC-95217-49 | 2026-06-23 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $38,652.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-010010 UB-04 · 2026-07-28 | Betty Lonng UHC-18001-61 | 2026-06-27 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $51,628.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-028529 UB-04 · 2026-07-24 | Jason Yang UHC-26238-79 | 2026-06-23 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $38,027.00 | — | Left for review HIGH | — | 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.