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-2026-015188 UB-04 · 2026-10-17 | Jacqueline Willis UHC-69078-97 | 2026-09-29 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 76700, 74177 | $2,395.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014444 UB-04 · 2026-10-17 | Helen Park UHC-24378-23 | 2026-09-18 Outpatient hospital | Harbor Medical Group Internal Medicine · out of network | 70553 | $2,002.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-014171 UB-04 · 2026-10-17 | Amy Collins UHC-11297-50 | 2026-10-06 Outpatient hospital | Harbor Digestive Health Center Gastroenterology · in network | 45378 | $1,594.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-013988 UB-04 · 2026-10-17 | James Chen UHC-30142-52 | 2026-09-19 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93306, 93458 | $7,222.00 | $2,457.84 | Clean approval | — | Approved |
| CLM-2026-013148 UB-04 · 2026-10-17 | Christine Cook no member ID | 2026-09-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $1,157.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-011706 UB-04 · 2026-10-17 | Tyler Silva UHC-89750-63 | 2026-09-26 Outpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 70553 | $3,523.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-010982 UB-04 · 2026-10-17 | Deborah Ramos UHC-13452-14 | 2026-09-07 Outpatient hospital | Unity Clinical Laboratories Clinical Laboratory · in network | 70553 | $2,722.00 | — | 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-2026-009993 UB-04 · 2026-10-17 | Martha Medina UHC-68694-09 | 2026-09-03 Emergency room | Summit Community Hospital Emergency Medicine · in network | 99283 | $1,016.00 | $208.80 | Clean approval | — | Approved |
| CLM-2026-009152 UB-04 · 2026-10-17 | Logan Gonzales UHC-19729-25 | 2026-09-30 Outpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 73721, 29881 | $9,620.00 | $1,398.66 | Clean approval | — | Approved |
| CLM-2026-007331 UB-04 · 2026-10-17 | Hiroshi Powell UHC-87923-96 | 2026-10-02 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 88305 | $348.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-007132 UB-04 · 2026-10-17 | Laura Reyes UHC-58818-28 | 2026-09-20 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284, 99283 | $2,378.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-004966 UB-04 · 2026-10-17 | Billy Palmer UHC-01676-73 | 2026-10-05 Outpatient hospital | Meadow GI Associates Gastroenterology · in network | 43239, 45378 | $3,776.00 | $857.53 | Clean approval | — | Approved |
| CLM-2026-004662 UB-04 · 2026-10-17 | Juan Franklin UHC-92188-10 | 2026-09-05 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306, 93015 | $1,817.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-002739 UB-04 · 2026-10-17 | William Howard no member ID | 2026-09-19 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99283 | $1,082.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-002559 UB-04 · 2026-10-17 | Donald Lynch UHC-41325-80 | 2026-09-21 Emergency room | Desert Regional Medical Center Emergency Medicine · in network | 99284 | $1,726.00 | $799.30 | Clean approval | — | Approved |
| CLM-2026-001942 UB-04 · 2026-10-17 | Wayne Jones UHC-18856-20 | 2026-09-02 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 74177 | $1,623.00 | $140.85 | Clean approval | — | Approved |
| CLM-2026-001809 UB-04 · 2026-10-17 | Timothy Myers UHC-88645-59 | 2026-09-11 Outpatient hospital | Desert Medical Group Internal Medicine · in network | 70553 | $2,478.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-001588 UB-04 · 2026-10-17 | Larry Banks UHC-47014-15 | 2026-09-18 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 88305 | $184.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-001371 UB-04 · 2026-10-17 | Jacqueline Richards UHC-71794-17 | 2026-09-27 Outpatient hospital | Riverside Imaging Center Radiology · in network | 76700, 71046, 74177 | $2,097.00 | $137.65 | Clean approval | — | Approved |
| CLM-2026-000967 UB-04 · 2026-10-17 | Virginia Roberts UHC-23292-08 | 2026-10-09 Outpatient hospital | Heritage Imaging Center Radiology · in network | 74177 | $1,611.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-033094 UB-04 · 2026-10-16 | Alexander Rose UHC-33854-74 | 2026-10-12 Outpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 70553 | $3,192.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-032994 UB-04 · 2026-10-16 | Betty Stephens UHC-08557-91 | 2026-10-04 Outpatient hospital | Summit Medical Group Internal Medicine · in network | 70553 | $2,557.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-032345 UB-04 · 2026-10-16 | Carol Pierce UHC-80359-24 | 2026-10-11 Outpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 70553 | $2,131.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-032100 UB-04 · 2026-10-16 | Angela Salazar UHC-63436-64 | 2026-10-06 Outpatient hospital | Desert Imaging Center Radiology · in network | 70553 | $2,469.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030634 UB-04 · 2026-10-16 | Yuki Stone UHC-81424-76 | 2026-09-10 Outpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 29881, 73721 | $10,915.00 | $3,656.09 | Clean approval | — | Approved |
| CLM-2026-030553 UB-04 · 2026-10-16 | Valentina Olson UHC-29563-18 | 2026-09-11 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $1,458.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-029645 UB-04 · 2026-10-16 | Marilyn Wallace UHC-97767-95 | 2026-09-01 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 70553, 77067, 74177 | $4,854.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-028846 UB-04 · 2026-10-16 | Dylan Butler UHC-22460-47 | 2026-09-28 Outpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 29881 | $8,467.00 | $2,803.22 | Clean approval | — | Approved |
| CLM-2026-027854 UB-04 · 2026-10-16 | Maria Martin UHC-06183-65 | 2026-09-11 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 76700, 70553 | $3,166.00 | $177.33 | Clean approval | — | Approved |
| CLM-2026-026095 UB-04 · 2026-10-16 | Cheryl Sanchez UHC-38922-46 | 2026-09-08 Outpatient hospital | Sunrise GI Associates Gastroenterology · in network | 88305, 45378 | $2,435.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-024821 UB-04 · 2026-10-16 | Angela Sullivan no member ID | 2026-09-27 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285 | $2,083.00 | — | Pended by rule N30 | — | Pended |
| 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-2026-024279 UB-04 · 2026-10-16 | William Webb UHC-11907-97 | 2026-09-08 Outpatient hospital | Sunrise Community Hospital Emergency Medicine · out of network | 70553 | $1,854.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-020953 UB-04 · 2026-10-16 | Perry Arthur UHC-34387-88 | 2026-09-30 Outpatient hospital | Riverside GI Associates Gastroenterology · in network | 43239, 45378 | $4,992.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-020792 UB-04 · 2026-10-16 | Gregory Reid UHC-65879-07 | 2026-10-07 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $46,944.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-019732 UB-04 · 2026-10-16 | Mason Hoffman UHC-12915-20 | 2026-10-05 Outpatient hospital | Riverside Imaging Center Radiology · in network | 70553, 74177 | $4,770.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-017921 UB-04 · 2026-10-16 | Justin Powell UHC-42263-27 | 2026-09-07 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 74177 | $1,563.00 | $455.80 | Clean approval | — | Approved |
| CLM-2026-017831 UB-04 · 2026-10-16 | Gabriel Payne no member ID | 2026-09-23 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 74177, 71046 | $2,565.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-015332 UB-04 · 2026-10-16 | Jonathan Rivera UHC-64480-79 | 2026-10-13 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 43239, 45378, 88305 | $4,730.00 | $1,953.26 | Clean approval | — | Approved |
| CLM-2026-014992 UB-04 · 2026-10-16 | Patricia Hayes UHC-59679-50 | 2026-10-03 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99285, 96374, 99284 | $4,868.00 | $1,840.60 | Clean approval | — | Approved |
| CLM-2026-014114 UB-04 · 2026-10-16 | Joseph Flores UHC-55754-19 | 2026-09-27 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 70553 | $3,583.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-013898 UB-04 · 2026-10-16 | Walter Stewart UHC-24161-31 | 2026-09-01 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 76700 | $381.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-013745 UB-04 · 2026-10-16 | Billy Reid UHC-17079-68 | 2026-09-19 Outpatient hospital | Heritage Imaging Center Radiology · in network | 77067, 70553 | $2,364.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-011721 UB-04 · 2026-10-16 | Jesse Dnn UHC-75305-22 | 2026-10-05 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99283 | $1,051.00 | $428.05 | Clean approval | — | Approved |
| CLM-2026-011170 UB-04 · 2026-10-16 | Grace Lawrence UHC-55097-42 | 2026-10-11 Inpatient hospital | Lakeside Medical Group Internal Medicine · in network | 99232 | $250.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011096 UB-04 · 2026-10-16 | Joan Rivera UHC-22799-76 | 2026-10-05 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284 | $1,665.00 | $565.75 | Clean approval | — | Approved |
| CLM-2026-010150 UB-04 · 2026-10-16 | Dennis Nelson UHC-45196-98 | 2026-09-13 Outpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,532.00 | $492.58 | Clean approval | — | Approved |
| CLM-2026-008593 UB-04 · 2026-10-16 | Daniel Marshall UHC-78984-90 | 2026-09-03 Outpatient hospital | Valley Cardiovascular Associates Cardiology · in network | 93306 | $1,002.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-008504 UB-04 · 2026-10-16 | Andrew Dean UHC-73405-81 | 2026-09-04 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,115.00 | $0.00 | 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.