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
3,664
50 with an AI recommendation
Pended
2,586
awaiting information or identity
Approved
23,942
$6,757,768.45 plan paid
Denied
4,454
with remittance reason codes
Examiner decided
0
167 not attached to an identity
| Claim | Member | Service | Provider | Procedures | Billed | Plan pays | Rules | AI | Status |
|---|---|---|---|---|---|---|---|---|---|
| CLM-2026-008361 UB-04 · 2026-10-16 | Judy Payne UHC-70825-08 | 2026-09-23 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 71046 | $137.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-008054 UB-04 · 2026-10-16 | Terry Cooper no member ID | 2026-09-26 Emergency room | Harbor Regional Medical Center Emergency Medicine · in network | 71046 | $246.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-007243 UB-04 · 2026-10-16 | Jesse Alexander UHC-98335-18 | 2026-10-08 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553, 71046 | $3,684.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-006859 UB-04 · 2026-10-16 | Sara Wallace UHC-78913-28 | 2026-09-23 Outpatient hospital | Evergreen GI Associates Gastroenterology · in network | 45378, 43239 | $3,976.00 | $401.38 | Clean approval | — | Approved |
| CLM-2026-006836 UB-04 · 2026-10-16 | Nancy Simpson UHC-55422-71 | 2026-10-14 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 71046 | $176.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-006396 UB-04 · 2026-10-16 | Jesse Kim UHC-45304-40 | 2026-09-04 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284, 99283 | $1,928.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-006148 UB-04 · 2026-10-16 | Scott Mills UHC-95658-73 | 2026-09-27 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 77067, 71046 | $562.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003399 UB-04 · 2026-10-16 | Philip Willis UHC-00426-62 | 2026-09-09 Outpatient hospital | Desert Imaging Center Radiology · in network | 71046, 76700 | $472.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003168 UB-04 · 2026-10-16 | Denise Mills UHC-44700-43 | 2026-09-29 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 71046, 96374 | $465.00 | $142.45 | Clean approval | — | Approved |
| CLM-2026-001711 UB-04 · 2026-10-16 | Kimberly Bell UHC-86763-22 | 2026-10-06 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 70553 | $3,278.00 | $472.54 | Clean approval | — | Approved |
| CLM-2026-034327 UB-04 · 2026-10-15 | Mary Baker UHC-41912-65 | 2026-09-02 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 71046 | $157.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-033302 UB-04 · 2026-10-15 | Elizabeth Edwards UHC-73277-83 | 2026-09-01 Outpatient hospital | Pinecrest Cardiovascular Associates Cardiology · in network | 93458 | $8,888.00 | $2,940.33 | Clean approval | — | Approved |
| CLM-2026-031620 UB-04 · 2026-10-15 | Gabriel Ward UHC-91327-36 | 2026-09-01 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 88305 | $245.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030326 UB-04 · 2026-10-15 | Mateo Carlson UHC-62488-93 | 2026-10-06 Outpatient hospital | Meadow Physical Therapy Physical Therapy · in network | 70553 | $8,862.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-029862 UB-04 · 2026-10-15 | Anna Morris UHC-60990-54 | 2026-09-05 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $51,290.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-029535 UB-04 · 2026-10-15 | Jordan Gardner UHC-58120-60 | 2026-10-07 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 74177 | $2,355.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-029162 UB-04 · 2026-10-15 | Albert Sanders UHC-40942-62 | 2026-09-08 Outpatient hospital | Riverside Family Practice Family Medicine · in network | 70553 | $2,255.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-028287 UB-04 · 2026-10-15 | Jesse Lewis UHC-25390-99 | 2026-10-12 Outpatient hospital | Evergreen GI Associates Gastroenterology · in network | 88305, 45378 | $3,143.00 | $626.97 | Clean approval | — | Approved |
| CLM-2026-027833 UB-04 · 2026-10-15 | Juan Medina UHC-12396-73 | 2026-10-06 Inpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 27447 | $32,984.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027777 UB-04 · 2026-10-15 | Jean Phillips UHC-92483-07 | 2026-09-30 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 70553, 71046, 74177 | $4,811.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-027769 UB-04 · 2026-10-15 | Philip Willis UHC-00426-62 | 2026-09-06 Inpatient hospital | Harbor Medical Group Internal Medicine · in network | 99232 | $207.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-027414 UB-04 · 2026-10-15 | Gregory Hunt UHC-84710-60 | 2026-09-23 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $6,359.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-027343 UB-04 · 2026-10-15 | Carolyn Gutierrez UHC-61047-79 | 2026-10-08 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 96374 | $142.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-025650 UB-04 · 2026-10-15 | Rachel Lopez UHC-43524-49 | 2026-10-02 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $35,527.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-025622 UB-04 · 2026-10-15 | George Tucker UHC-44073-63 | 2026-09-28 Outpatient hospital | Mesa Cardiovascular Associates Cardiology · in network | 93015 | $612.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-025026 UB-04 · 2026-10-15 | Edward Dunn UHC-58248-42 | 2026-10-01 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 88305, 45378 | $2,697.00 | $686.45 | Clean approval | — | Approved |
| CLM-2026-023855 UB-04 · 2026-10-15 | Dennis Perez UHC-14032-93 | 2026-09-24 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306, 93458 | $10,569.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-022529 UB-04 · 2026-10-15 | Jesse Baker UHC-05897-89 | 2026-10-05 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 70553, 71046 | $2,150.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-020313 UB-04 · 2026-10-15 | Samuel West UHC-29799-48 | 2026-10-10 Outpatient hospital | Meadow Primary Care Associates Family Medicine · in network | 70553 | $2,486.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-019962 UB-04 · 2026-10-15 | Elijah Brooks UHC-25287-21 | 2026-10-03 Outpatient hospital | Pinecrest Cardiovascular Associates Cardiology · in network | 93015, 93306 | $1,422.00 | $304.42 | Clean approval | — | Approved |
| CLM-2026-019192 UB-04 · 2026-10-15 | Gloria Vargas UHC-65899-86 | 2026-09-13 Outpatient hospital | Mesa Cardiovascular Associates Cardiology · in network | 93458, 93306 | $6,391.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-018854 UB-04 · 2026-10-15 | Gloria Yang UHC-77975-62 | 2026-10-07 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 93458, 93306 | $10,394.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-018275 UB-04 · 2026-10-15 | Billy Le UHC-22687-90 | 2026-09-28 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285, 99284, 99283 | $5,093.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-015970 UB-04 · 2026-10-15 | George Kelley UHC-50392-85 | 2026-10-01 Outpatient hospital | Valley Imaging Center Radiology · in network | 70553, 74177 | $4,486.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-015835 UB-04 · 2026-10-15 | Angela Sanders UHC-47771-45 | 2026-09-25 Outpatient hospital | Heritage Primary Care Associates Family Medicine · in network | 70553 | $2,840.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-014761 UB-04 · 2026-10-15 | Peterson Laura UHC-01699-49 | 2026-09-06 Outpatient hospital | Mesa Clinical Laboratories Clinical Laboratory · in network | 70553 | $3,003.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-013268 UB-04 · 2026-10-15 | Bruce Foster UHC-80846-56 | 2026-10-10 Outpatient hospital | Meadow Imaging Center Radiology · in network | 76700 | $615.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-012988 UB-04 · 2026-10-15 | Sanitago Franklin UHC-54865-20 | 2026-09-04 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99284, 71046, 99285 | $4,024.00 | — | Left for review NET | — | Needs review |
| CLM-2026-012741 UB-04 · 2026-10-15 | Raymond Alvarado UHC-63639-31 | 2026-09-12 Outpatient hospital | Pinecrest Primary Care Associates Family Medicine · in network | 70553 | $3,358.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-012574 UB-04 · 2026-10-15 | Juan Graham no member ID | 2026-10-02 Inpatient hospital | Canyon Medical Group Internal Medicine · in network | 99232 | $185.00 | — | Pended by rule IDQ N30 | — | Pended |
| CLM-2026-010424 UB-04 · 2026-10-15 | Adm Torres UHC-94361-64 | 2026-10-03 Outpatient hospital | Cornerstone Imaging Center Radiology · in network | 77067, 71046 | $553.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-007944 UB-04 · 2026-10-15 | Ryan Walker UHC-79552-94 | 2026-05-28 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283, 71046 | $1,287.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-006483 UB-04 · 2026-10-15 | John Cox no member ID | 2026-09-24 Outpatient hospital | Summit Heart Institute Cardiology · in network | 93015 | $583.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-006356 UB-04 · 2026-10-15 | Julie Martinez UHC-50684-90 | 2026-09-28 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99285 | $2,503.00 | $776.35 | Clean approval | — | Approved |
| CLM-2026-005317 UB-04 · 2026-10-15 | Helen Snyder UHC-08676-93 | 2026-10-01 Outpatient hospital | Meadow Imaging Center Radiology · in network | 70553, 76700 | $3,998.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-004719 UB-04 · 2026-10-15 | Douglas Harris UHC-15357-52 | 2026-10-07 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $39,961.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-004341 UB-04 · 2026-10-15 | Victoria Gray UHC-19111-25 | 2026-09-04 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $826.00 | $298.80 | Clean approval | — | Approved |
| CLM-2026-003712 UB-04 · 2026-10-15 | Kimberly Delgado UHC-27985-96 | 2026-09-21 Outpatient hospital | Sunrise GI Associates Gastroenterology · in network | 45378, 43239 | $4,787.00 | $1,175.59 | Clean approval | — | Approved |
| CLM-2026-003579 UB-04 · 2026-10-15 | Albert Tran no member ID | 2026-09-10 Outpatient hospital | Evergreen GI Associates Gastroenterology · in network | 45378 | $2,026.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-002146 UB-04 · 2026-10-15 | Kevin Scott UHC-95333-52 | 2026-10-02 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 70553 | $3,296.00 | $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.