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-2026-014844 UB-04 · 2026-10-18 | Albert Alvarez UHC-42353-95 | 2026-09-28 Outpatient hospital | Summit Heart Institute Cardiology · in network | 93306, 93015, 93458 | $11,010.00 | $3,937.05 | Clean approval | — | Approved |
| CLM-2026-014800 UB-04 · 2026-10-18 | Shirley Gordon UHC-16318-59 | 2026-09-24 Outpatient hospital | Unity Digestive Health Center Gastroenterology · in network | 43239 | $2,507.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014170 UB-04 · 2026-10-18 | Justin Crawford UHC-67392-45 | 2026-10-02 Inpatient hospital | Meadow Medical Group Internal Medicine · in network | 99232 | $235.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-014084 UB-04 · 2026-10-18 | Sean Young UHC-33599-32 | 2026-09-10 Outpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 73721 | $2,073.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-014054 UB-04 · 2026-10-18 | Danielle Gomez UHC-89338-09 | 2026-09-11 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 71046 | $141.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-013424 UB-04 · 2026-10-18 | Jordan Thomas UHC-00688-86 | 2026-04-19 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 71046, 99285 | $2,289.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-012577 UB-04 · 2026-10-18 | Steven Brooks UHC-72425-74 | 2026-09-25 Outpatient hospital | Pinecrest Cardiovascular Associates Cardiology · in network | 93458 | $7,698.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-012567 UB-04 · 2026-10-18 | Melissa Gardner UHC-62350-59 | 2026-09-07 Inpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 27447 | $39,811.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-012388 UB-04 · 2026-10-18 | Catherine Simpson UHC-22875-45 | 2026-09-18 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458, 93015 | $9,810.00 | $4,160.71 | 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-2026-010644 UB-04 · 2026-10-18 | Zachary Baker UHC-62292-08 | 2026-09-09 Outpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $9,591.00 | $1,952.59 | Clean approval | — | Approved |
| CLM-2026-006554 UB-04 · 2026-10-18 | Doris Alvarez UHC-77452-71 | 2026-10-12 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 43239, 88305 | $2,152.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006143 UB-04 · 2026-10-18 | Emma McDonald UHC-14703-77 | 2026-10-05 Outpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $8,786.00 | $3,046.11 | Clean approval | — | Approved |
| CLM-2026-005878 UB-04 · 2026-10-18 | Sara Welch UHC-01909-90 | 2026-09-24 Emergency room | Riverside Community Hospital Emergency Medicine · in network | 96374, 99284 | $1,809.00 | $910.25 | Clean approval | — | Approved |
| CLM-2026-005773 UB-04 · 2026-10-18 | Emily Silva UHC-43687-71 | 2026-09-30 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 74177 | $2,419.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-004773 UB-04 · 2026-10-18 | Bryan Ray UHC-15231-85 | 2026-09-28 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,734.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-004489 UB-04 · 2026-10-18 | Thomas Walker UHC-98355-06 | 2026-09-25 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 77067, 76700 | $759.00 | $105.86 | 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-2026-004216 UB-04 · 2026-10-18 | Alexander Reid UHC-77022-69 | 2026-09-16 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 71046, 70553 | $3,057.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-003431 UB-04 · 2026-10-18 | Emily Palmer UHC-80821-83 | 2026-09-08 Outpatient hospital | Pinecrest Heart Institute Cardiology · in network | 93458 | $5,465.00 | $888.96 | Clean approval | — | Approved |
| CLM-2026-003164 UB-04 · 2026-10-18 | Nancy Wong UHC-74984-66 | 2026-09-13 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 88305, 45378 | $2,851.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-002928 UB-04 · 2026-10-18 | Roy Burns UHC-22217-24 | 2026-09-07 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $178.00 | $0.00 | 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-2026-002809 UB-04 · 2026-10-18 | Olivia Armstrong UHC-25797-48 | 2026-05-27 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458, 93015 | $5,527.00 | — | Denied by rule CO29 | — | Denied |
| 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-2026-002531 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-2026-001442 UB-04 · 2026-10-18 | Sophia Howell UHC-51733-01 | 2026-09-26 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 43239, 45378, 88305 | $4,193.00 | $1,058.91 | Clean approval | — | Approved |
| CLM-2026-001208 UB-04 · 2026-10-18 | Alexander Robertson UHC-20832-08 | 2026-09-29 Outpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,651.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-000165 UB-04 · 2026-10-18 | Bradley Russell UHC-45171-11 | 2026-09-28 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $38,503.00 | — | Left for review HIGH | — | Needs review |
| 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-2026-032764 UB-04 · 2026-10-17 | Diana Williamson UHC-93292-52 | 2026-10-07 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 71046 | $172.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032717 UB-04 · 2026-10-17 | Victoria Padilla UHC-84331-08 | 2026-09-27 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 76700, 71046 | $614.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032479 UB-04 · 2026-10-17 | Ralph Garza UHC-69417-14 | 2026-09-30 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $203.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-031941 UB-04 · 2026-10-17 | Mark Riley UHC-38683-19 | 2026-10-01 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 96374, 99284 | $1,564.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-031465 UB-04 · 2026-10-17 | Steven Guzman UHC-15163-18 | 2026-10-01 Outpatient hospital | Valley Imaging Center Radiology · in network | 71046 | $143.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030816 UB-04 · 2026-10-17 | Carl Smith UHC-10143-60 | 2026-10-02 Outpatient hospital | Heritage Digestive Health Center Gastroenterology · in network | 45378 | $2,697.00 | $154.38 | Clean approval | — | Approved |
| CLM-2026-030671 UB-04 · 2026-10-17 | Peter Lane UHC-22452-89 | 2026-09-28 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $35,985.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-028239 UB-04 · 2026-10-17 | Christopher Mendez UHC-78590-93 | 2026-10-01 Outpatient hospital | Meadow Regional Medical Center Emergency Medicine · in network | 70553 | $2,335.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-027168 UB-04 · 2026-10-17 | Sharon Patterson UHC-01025-68 | 2026-10-07 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99283, 71046 | $1,247.00 | $535.85 | Clean approval | — | Approved |
| CLM-2026-026667 UB-04 · 2026-10-17 | Vincent Castillo UHC-39871-55 | 2026-10-13 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $203.00 | $10.80 | 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-2026-024880 UB-04 · 2026-10-17 | Ruth Dunn UHC-79382-41 | 2026-09-24 Inpatient hospital | Cornerstone Internal Medicine Associates Internal Medicine · in network | 99232 | $189.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-023184 UB-04 · 2026-10-17 | Joshua Campbell UHC-12728-30 | 2026-09-13 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 74177 | $1,255.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-022494 UB-04 · 2026-10-17 | Juan Jimenez UHC-84918-36 | 2026-09-06 Emergency room | Summit Community Hospital Emergency Medicine · in network | 71046 | $242.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-022113 UB-04 · 2026-10-17 | Maria Moore UHC-93684-85 | 2026-10-07 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 76700, 74177 | $1,965.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-020933 UB-04 · 2026-10-17 | Julie Alvarez UHC-08988-72 | 2026-09-04 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 45378 | $2,116.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-017884 UB-04 · 2026-10-17 | Wallace Betty UHC-94593-87 | 2026-09-03 Outpatient hospital | Meadow GI Associates Gastroenterology · in network | 88305 | $290.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-017124 UB-04 · 2026-10-17 | Jose Weber UHC-75597-59 | 2026-10-09 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93015 | $424.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-017001 UB-04 · 2026-10-17 | Bryan Guerrero UHC-44575-81 | 2026-10-06 Emergency room | Summit Community Hospital Emergency Medicine · in network | 99283, 71046 | $928.00 | $260.40 | Clean approval | — | Approved |
| CLM-2026-015855 UB-04 · 2026-10-17 | Ana Banks UHC-54583-90 | 2026-09-25 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 70553, 74177, 71046 | $3,749.00 | $1,067.71 | 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.