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-2026-027468 UB-04 · 2026-06-19 | Wayne Wells UHC-44029-86 | 2026-05-15 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $29,622.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-031858 UB-04 · 2026-06-17 | Aaron Evans UHC-69781-33 | 2026-06-04 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $34,250.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-011370 UB-04 · 2026-06-17 | Donna Black UHC-71648-50 | 2026-05-14 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $28,075.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027770 UB-04 · 2026-06-16 | Nancy Porter UHC-71964-53 | 2026-05-12 Inpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $36,892.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-020857 UB-04 · 2026-06-15 | Thomas Chapman UHC-12402-61 | 2026-05-18 Inpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $50,331.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-020109 UB-04 · 2026-06-15 | Gabriel Owens UHC-71828-02 | 2026-05-13 Inpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 27447 | $45,183.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-005059 UB-04 · 2026-06-13 | Dorothy Bailey UHC-42273-50 | 2026-06-07 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $42,796.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-019477 UB-04 · 2026-06-12 | Paul Washington UHC-15231-47 | 2026-05-12 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $48,478.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-001864 UB-04 · 2026-06-12 | Judith Castillo UHC-17837-26 | 2026-06-01 Inpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 27447 | $49,475.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-020684 UB-04 · 2026-06-10 | Linda Wood UHC-88685-49 | 2026-05-01 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $38,567.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-001410 UB-04 · 2026-06-10 | Douglas Smith UHC-05345-58 | 2026-05-09 Inpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 27447 | $37,477.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-003583 UB-04 · 2026-06-09 | Valentina Santiago UHC-48471-74 | 2026-04-28 Inpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $33,315.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-031577 UB-04 · 2026-06-08 | Carlos Gray UHC-64484-73 | 2026-06-05 Inpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 27447 | $29,759.00 | — | Left for review HIGH | — | 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-2026-033987 UB-04 · 2026-06-05 | Dylan Dominguez UHC-56390-60 | 2026-05-09 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $38,506.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-022771 UB-04 · 2026-06-05 | Ronald Henry UHC-15188-94 | 2026-05-04 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $41,493.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-015420 UB-04 · 2026-06-04 | Sara Garcia UHC-25901-27 | 2026-04-25 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $51,514.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-014926 UB-04 · 2026-06-04 | Amber Valdez UHC-35139-26 | 2026-05-11 Inpatient hospital | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $32,207.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-028276 UB-04 · 2026-06-02 | Aisha Maldonado UHC-43714-18 | 2026-05-08 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $34,988.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-016545 UB-04 · 2026-06-02 | Peter Lane UHC-22452-89 | 2026-05-08 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $44,046.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-020278 UB-04 · 2026-06-01 | Gregory Vasquez UHC-23843-06 | 2026-05-19 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $28,227.00 | — | Left for review REPL HIGH | — | Needs review |
| CLM-2026-009459 UB-04 · 2026-06-01 | Wayne Roberts UHC-40291-13 | 2026-05-07 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $49,580.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-024671 UB-04 · 2026-05-31 | Martha Ellis UHC-36344-06 | 2026-04-20 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $49,137.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-032902 UB-04 · 2026-05-29 | Brittany Flores UHC-97409-85 | 2026-05-02 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $38,172.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-020659 UB-04 · 2026-05-29 | Willie Medina UHC-66180-38 | 2026-05-23 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $49,930.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-005182 UB-04 · 2026-05-26 | Bobby Chapman UHC-80403-78 | 2026-05-16 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $29,148.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-020277 UB-04 · 2026-05-23 | Gregory Vasquez UHC-23843-06 | 2026-05-19 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $28,227.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-002467 UB-04 · 2026-05-23 | Austin Valdez UHC-47191-35 | 2026-05-19 Inpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 27447 | $35,785.00 | — | Left for review CO16 HIGH | — | Needs review |
| CLM-2026-000723 UB-04 · 2026-05-23 | Judy Castro UHC-14119-09 | 2026-04-10 Inpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 27447 | $51,824.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-015780 UB-04 · 2026-05-21 | Bradley Armstrong UHC-84578-81 | 2026-04-21 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $41,630.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-002899 UB-04 · 2026-05-21 | Frances Rojas UHC-82208-39 | 2026-05-06 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $45,581.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-029322 UB-04 · 2026-05-20 | Wayne Lopez UHC-76174-84 | 2026-05-05 Inpatient hospital | Sunrise Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $41,075.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-024925 UB-04 · 2026-05-20 | Betty Hwell UHC-12924-59 | 2026-04-09 Inpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 27447 | $50,069.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-020189 UB-04 · 2026-05-20 | Roy Ortega UHC-49200-73 | 2026-05-17 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $29,267.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-018569 UB-04 · 2026-05-20 | Michael Hanson UHC-75772-33 | 2026-05-14 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $33,450.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-009948 UB-04 · 2026-05-20 | Scott Nguyen UHC-55213-44 | 2026-04-24 Inpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 27447 | $47,664.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-028436 UB-04 · 2026-05-15 | Debra Singh UHC-43089-48 | 2026-04-01 Inpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 27447 | $31,484.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-012208 UB-04 · 2026-05-15 | Natalie Harris UHC-37941-06 | 2026-04-02 Inpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 27447 | $41,851.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-022205 UB-04 · 2026-05-14 | Albert Ellis UHC-85432-06 | 2026-04-28 Inpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 27447 | $29,679.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-012673 UB-04 · 2026-05-13 | Kimberly Roberts UHC-33561-79 | 2026-04-13 Inpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 27447 | $41,673.00 | — | Left for review CO16 HIGH | — | Needs review |
| CLM-2026-007541 UB-04 · 2026-05-12 | Bobby Gilbert UHC-19167-90 | 2026-04-30 Inpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 27447 | $33,633.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-025515 UB-04 · 2026-05-11 | Bryan Flores UHC-43147-53 | 2026-04-22 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $28,268.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-010652 UB-04 · 2026-05-11 | Carl Hunt UHC-78785-52 | 2026-04-17 Inpatient hospital | Sunrise Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $34,463.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-009055 UB-04 · 2026-05-09 | Ashley Davis UHC-48670-60 | 2026-04-15 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447, 29881 | $43,712.00 | — | Left for review CO97 HIGH | — | Needs review |
| CLM-2026-003130 UB-04 · 2026-05-09 | Raymond Woods UHC-91976-08 | 2026-04-26 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $48,688.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-029122 UB-04 · 2026-05-08 | Kathryn Henderson UHC-09847-52 | 2026-05-04 Inpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 27447 | $49,158.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-031616 UB-04 · 2026-05-07 | Susan Rojas UHC-20787-07 | 2026-03-30 Inpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 27447 | $35,854.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-012537 UB-04 · 2026-05-07 | Diane McDonald UHC-59434-66 | 2026-04-21 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $37,665.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-023591 UB-04 · 2026-05-05 | Kyle Romero UHC-90669-86 | 2026-04-10 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $48,009.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-001534 UB-04 · 2026-05-04 | Arthur Ryan UHC-78348-45 | 2026-04-07 Inpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 27447 | $46,111.00 | — | 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.