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-2026-006551 UB-04 · 2026-05-03 | Frances Ruiz UHC-20383-93 | 2026-04-26 Inpatient hospital | Sunrise Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $44,799.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-012843 UB-04 · 2026-05-02 | Donald Matthews UHC-95205-05 | 2026-04-02 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $36,393.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-008254 UB-04 · 2026-05-02 | Julie Singh UHC-47477-34 | 2026-04-06 Inpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 27447 | $50,974.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-024996 UB-04 · 2026-04-30 | Denise Robertson UHC-42523-92 | 2026-04-14 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $35,424.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-021869 UB-04 · 2026-04-29 | Noah Bryant UHC-89912-12 | 2026-03-29 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $37,173.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-034373 UB-04 · 2026-04-28 | Kathryn Schmidt UHC-18595-46 | 2026-04-07 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $34,828.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027818 UB-04 · 2026-04-28 | Richard Tucker UHC-83126-16 | 2026-04-19 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $39,853.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-012858 UB-04 · 2026-04-27 | Lawrence Ortega UHC-39292-35 | 2026-04-09 Inpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 27447 | $32,485.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-019335 UB-04 · 2026-04-26 | Amber Guerrero UHC-95217-49 | 2026-03-17 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $50,230.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-012837 UB-04 · 2026-04-26 | Wyane Hansen UHC-12007-74 | 2026-04-23 Inpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 27447 | $32,002.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-015426 UB-04 · 2026-04-24 | Hiroshi Payne UHC-37270-06 | 2026-03-20 Inpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 27447 | $36,395.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-019936 UB-04 · 2026-04-23 | Nancy Contreras UHC-44710-83 | 2026-04-05 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447, 29881 | $60,410.00 | — | Left for review CO97 HIGH | — | Needs review |
| CLM-2026-019797 UB-04 · 2026-04-21 | Paul Lopez UHC-40853-63 | 2026-03-27 Inpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 27447 | $42,813.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-016561 UB-04 · 2026-04-20 | Ahmed Watkins UHC-52231-59 | 2026-02-21 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $44,872.00 | — | Left for review DUP HIGH | — | Needs review |
| CLM-2026-008268 UB-04 · 2026-04-20 | Thomas Luna UHC-95083-87 | 2026-03-24 Inpatient hospital | Sunrise Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $42,606.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-032000 UB-04 · 2026-04-18 | Bruce Chavez UHC-59211-88 | 2026-04-11 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $38,148.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-002168 UB-04 · 2026-04-18 | Madison Moreno UHC-82109-72 | 2026-04-12 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $37,937.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-025887 UB-04 · 2026-04-17 | Madison Stephens UHC-13108-98 | 2026-03-30 Inpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 27447 | $43,441.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-020151 UB-04 · 2026-04-16 | Andrea Fuller UHC-87746-30 | 2026-03-07 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $46,785.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-005684 UB-04 · 2026-04-16 | Charlotte Clark UHC-71305-39 | 2026-03-17 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $48,216.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-026445 UB-04 · 2026-04-15 | Christian Lynch UHC-89218-09 | 2026-03-25 Inpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 27447 | $32,859.00 | — | Left for review CO197 HIGH | — | Needs review |
| CLM-2026-030107 UB-04 · 2026-04-14 | Kayla Roberts UHC-69967-07 | 2026-03-19 Inpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 27447 | $32,728.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-000010 UB-04 · 2026-04-13 | Pamela Yang UHC-06553-73 | 2026-03-08 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $47,694.00 | — | Left for review CO197 HIGH | — | Needs review |
| CLM-2026-027087 UB-04 · 2026-04-12 | Daniel Wood UHC-16055-58 | 2026-03-28 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $46,377.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-011430 UB-04 · 2026-04-12 | Joseph Obrien UHC-03406-45 | 2026-04-06 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $38,175.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-008634 UB-04 · 2026-04-12 | Sandra Scott UHC-00116-94 | 2026-04-10 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $30,536.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-029745 UB-04 · 2026-04-10 | Lisa Vargas UHC-03351-44 | 2026-03-31 Inpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 27447 | $38,134.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-005616 UB-04 · 2026-04-10 | Keith Burns UHC-28763-39 | 2026-03-15 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $33,933.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-029580 UB-04 · 2026-04-09 | Margaret Alarado UHC-17047-71 | 2026-02-23 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $30,278.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-015472 UB-04 · 2026-04-07 | Emily Peterson UHC-82743-71 | 2026-03-13 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $30,094.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-013902 UB-04 · 2026-04-07 | Henry Austin UHC-64407-01 | 2026-03-01 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $42,251.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-003148 UB-04 · 2026-04-07 | Elizabeth Kelley UHC-56547-09 | 2026-02-28 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $48,291.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-034520 UB-04 · 2026-04-06 | Wei Obrien UHC-75656-22 | 2026-03-26 Inpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 27447 | $35,091.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-011869 UB-04 · 2026-04-06 | Santiago Hudson UHC-21919-41 | 2026-03-27 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $44,761.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-014634 UB-04 · 2026-04-04 | Deborah Simpson UHC-69380-61 | 2026-03-22 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $48,483.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-002366 UB-04 · 2026-04-04 | Peter Hernandez UHC-11079-43 | 2026-03-31 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $43,818.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-034489 UB-04 · 2026-04-03 | Adam Richards UHC-56502-17 | 2026-02-28 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $29,318.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027211 UB-04 · 2026-04-03 | Wayne Reed UHC-80993-98 | 2026-03-06 Inpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 27447 | $44,758.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-012780 UB-04 · 2026-04-03 | Ethan Jackson UHC-62313-89 | 2026-03-29 Inpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $28,146.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-029963 UB-04 · 2026-04-01 | Rachel Nichols UHC-39062-02 | 2026-02-24 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $47,192.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-016560 UB-04 · 2026-04-01 | Ahmed Watkins UHC-52231-59 | 2026-02-21 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $44,872.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-011753 UB-04 · 2026-04-01 | Jason Cox UHC-09193-61 | 2026-02-17 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 27447, 29881 | $40,665.00 | — | Left for review CO97 HIGH | — | Needs review |
| CLM-2026-004483 UB-04 · 2026-04-01 | Edward Olliver UHC-36016-90 | 2026-02-19 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $49,541.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-028833 UB-04 · 2026-03-31 | Judy Henry UHC-61460-03 | 2026-03-18 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $37,075.00 | — | Left for review DUP HIGH | — | Needs review |
| CLM-2026-019208 UB-04 · 2026-03-31 | Joan Anderson UHC-17288-64 | 2026-03-04 Inpatient hospital | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $34,419.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-016234 UB-04 · 2026-03-31 | Valentina Duncan UHC-56934-35 | 2026-02-26 Inpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $32,034.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-017010 UB-04 · 2026-03-30 | Alexis Hill UHC-64036-10 | 2026-03-18 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $29,110.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-001484 UB-04 · 2026-03-30 | Sandra Morgan UHC-28897-69 | 2026-03-24 Inpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 27447 | $39,494.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-023035 UB-04 · 2026-03-29 | Dennis Ray UHC-11585-25 | 2026-03-01 Inpatient hospital | Sunrise Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $42,280.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-005169 UB-04 · 2026-03-28 | Marilyn King UHC-52925-80 | 2026-03-16 Inpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $36,896.00 | — | 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.