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-2026-026467 UB-04 · 2026-07-24 | Joseph Alexander UHC-43257-62 | 2026-07-21 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $28,967.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-012398 UB-04 · 2026-07-24 | Dylan Lynch UHC-13247-56 | 2026-06-16 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $31,253.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-001849 UB-04 · 2026-07-24 | Richard Patterson UHC-63925-81 | 2026-06-21 Inpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 27447 | $28,958.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-022053 UB-04 · 2026-07-23 | Christine Graham UHC-76301-38 | 2026-07-03 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $33,246.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-013212 UB-04 · 2026-07-23 | Ann Sullivan UHC-58187-57 | 2026-06-20 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $31,579.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-004531 UB-04 · 2026-07-21 | Jeffrey Aguilar UHC-33654-69 | 2026-07-15 Inpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 27447 | $36,233.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-033858 UB-04 · 2026-07-20 | Vincent Diaz UHC-09083-91 | 2026-07-04 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $45,619.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-025314 UB-04 · 2026-07-20 | Albert Payne UHC-86332-25 | 2026-05-27 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $30,618.00 | — | Left for review REPL HIGH | — | Needs review |
| CLM-2026-011836 UB-04 · 2026-07-20 | Gary Dominguez UHC-20825-25 | 2026-06-30 Inpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 27447 | $51,852.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-029784 UB-04 · 2026-07-19 | Sarah Barnes UHC-17925-71 | 2026-06-16 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $51,726.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-000343 UB-04 · 2026-07-19 | Vincent Diaz UHC-04169-42 | 2026-07-13 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $32,277.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-029070 UB-04 · 2026-07-18 | Arthur Peterson UHC-63949-28 | 2026-07-15 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $47,069.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-017956 UB-04 · 2026-07-18 | Jose Williamson UHC-42690-59 | 2026-07-06 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $42,624.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-021852 UB-04 · 2026-07-17 | Nanky Marquez UHC-40161-64 | 2026-06-25 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $29,569.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-028720 UB-04 · 2026-07-15 | Jonathan Foster UHC-88767-60 | 2026-07-13 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $45,059.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-022599 UB-04 · 2026-07-13 | Elijah Allen UHC-15522-20 | 2026-07-05 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $36,204.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-005478 UB-04 · 2026-07-13 | Bryan Valez UHC-23489-04 | 2026-07-10 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $44,440.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-013254 UB-04 · 2026-07-12 | Gregory Delgado UHC-32595-69 | 2026-07-04 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $40,310.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-019235 UB-04 · 2026-07-11 | Sarah Dunn UHC-26514-98 | 2026-06-22 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $35,764.00 | — | Left for review HIGH | — | Needs review |
| 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-2026-007720 UB-04 · 2026-07-10 | Brian McCoy UHC-72352-98 | 2026-06-21 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $51,473.00 | — | Left for review HIGH | — | Needs review |
| 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-2026-010218 UB-04 · 2026-07-09 | Gregory Martin UHC-70503-20 | 2026-06-24 Inpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 27447 | $38,939.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-001538 UB-04 · 2026-07-08 | Cheryl Pierce UHC-79286-56 | 2026-06-02 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $39,815.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-032116 UB-04 · 2026-07-07 | Samuel Guerrero UHC-70261-24 | 2026-05-23 Inpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $50,607.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-025313 UB-04 · 2026-07-06 | Albert Payne UHC-86332-25 | 2026-05-27 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $30,618.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-031859 UB-04 · 2026-07-02 | Aaron Evans UHC-69781-33 | 2026-06-04 Inpatient hospital | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $34,250.00 | — | Left for review DUP HIGH | — | Needs review |
| CLM-2026-023861 UB-04 · 2026-07-02 | Bruce Garrett UHC-23825-38 | 2026-06-13 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $28,077.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-022077 UB-04 · 2026-07-02 | Lucia Fox UHC-54071-15 | 2026-05-26 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $38,748.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-014973 UB-04 · 2026-07-01 | Linda Martin UHC-16338-39 | 2026-05-21 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $46,740.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-007183 UB-04 · 2026-07-01 | Walter Santos UHC-32733-19 | 2026-05-21 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $41,906.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-025686 UB-04 · 2026-06-30 | Ryan Burke UHC-76409-12 | 2026-06-19 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $44,259.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027918 UB-04 · 2026-06-29 | Diego Tran UHC-63032-49 | 2026-06-04 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $31,987.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-015068 UB-04 · 2026-06-29 | Carl Kennedy UHC-27655-75 | 2026-06-01 Inpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 27447 | $47,617.00 | — | Left for review CO197 HIGH | — | Needs review |
| CLM-2026-025874 UB-04 · 2026-06-27 | Kelly Harris UHC-56453-10 | 2026-05-30 Inpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 27447 | $32,520.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-021521 UB-04 · 2026-06-27 | Carol Mendoza UHC-73382-64 | 2026-06-04 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $28,451.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-018107 UB-04 · 2026-06-27 | Julie Coleman UHC-45338-86 | 2026-05-17 Inpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 27447 | $43,730.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-009810 UB-04 · 2026-06-27 | Kathleen Graham UHC-53630-10 | 2026-05-24 Inpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $40,394.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-009673 UB-04 · 2026-06-26 | James Burke UHC-47425-07 | 2026-05-18 Inpatient hospital | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $28,762.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-015284 UB-04 · 2026-06-25 | Logan Powell UHC-51488-43 | 2026-06-02 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $31,907.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-019189 UB-04 · 2026-06-22 | Rebecca Miller UHC-93376-86 | 2026-06-12 Inpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 27447 | $45,719.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-012817 UB-04 · 2026-06-22 | Walter Carlson UHC-39159-19 | 2026-05-12 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $28,906.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-023413 UB-04 · 2026-06-21 | Austin Stone UHC-55219-48 | 2026-05-09 Inpatient hospital | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $37,461.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-014521 UB-04 · 2026-06-21 | Harold Fuller UHC-62981-14 | 2026-05-16 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $50,540.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027771 UB-04 · 2026-06-20 | Nancy Porter UHC-71964-53 | 2026-05-12 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $36,892.00 | — | Left for review DUP HIGH | — | Needs review |
| CLM-2026-025436 UB-04 · 2026-06-20 | Janet Dixon UHC-86590-78 | 2026-05-21 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $48,597.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-015263 UB-04 · 2026-06-20 | Rachel Flores UHC-97143-27 | 2026-05-24 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $37,387.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-006142 UB-04 · 2026-06-20 | Kevin Powell UHC-92591-12 | 2026-06-06 Inpatient hospital | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $51,109.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-031180 UB-04 · 2026-06-19 | Donald Hudson UHC-43303-53 | 2026-05-23 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $31,211.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027506 UB-04 · 2026-06-19 | Jessica Carter UHC-74848-26 | 2026-05-06 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $38,015.00 | — | 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.