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-2026-001185 UB-04 · 2026-10-15 | Wei Washington UHC-27182-89 | 2026-09-17 Outpatient hospital | Meadow Imaging Center Radiology · in network | 70553, 76700 | $3,938.00 | — | Pended by rule IDQ | — | Pended |
| CLM-2026-000582 UB-04 · 2026-10-15 | Arjun Santos UHC-17803-51 | 2026-09-03 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378 | $1,676.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-034140 UB-04 · 2026-10-14 | Donald Fernandez UHC-09849-83 | 2026-09-03 Outpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 73721 | $2,345.00 | $299.48 | Clean approval | — | Approved |
| CLM-2026-034029 UB-04 · 2026-10-14 | Ryan Li UHC-59343-89 | 2026-06-24 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 88305 | $352.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-033243 UB-04 · 2026-10-14 | Joan Hoffman UHC-38218-33 | 2026-09-18 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284, 99283, 96374 | $2,659.00 | $846.55 | Clean approval | — | Approved |
| CLM-2026-032152 UB-04 · 2026-10-14 | Jason Alexander UHC-25888-14 | 2026-09-18 Outpatient hospital | Harbor Digestive Health Center Gastroenterology · in network | 88305, 43239 | $1,807.00 | $656.52 | Clean approval | — | Approved |
| CLM-2026-031052 UB-04 · 2026-10-14 | Nathan Campbell UHC-33373-43 | 2026-10-04 Outpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,994.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030597 UB-04 · 2026-10-14 | Lori Santos UHC-54330-79 | 2026-09-17 Outpatient hospital | Mesa Dermatology Clinic Dermatology · in network | 70553 | $3,151.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-029740 UB-04 · 2026-10-14 | Bruce Garza UHC-63823-65 | 2026-09-12 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 74177, 71046 | $2,218.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-029540 UB-04 · 2026-10-14 | Mary Munz UHC-13183-92 | 2026-10-10 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 43239, 45378 | $4,347.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-028752 UB-04 · 2026-10-14 | Sandra Powell UHC-02733-47 | 2026-09-14 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99283, 71046 | $1,010.00 | $205.50 | Clean approval | — | Approved |
| CLM-2026-028254 UB-04 · 2026-10-14 | Judy Spencer UHC-59212-16 | 2026-09-23 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,184.00 | $313.58 | Clean approval | — | Approved |
| CLM-2026-028083 UB-04 · 2026-10-14 | Julia McCoy UHC-83978-41 | 2026-10-05 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $28,852.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027911 UB-04 · 2026-10-14 | Laura Weaver UHC-83781-90 | 2026-09-01 Outpatient hospital | Valley Imaging Center Radiology · in network | 70553, 77067 | $3,656.00 | $1,411.03 | Clean approval | — | Approved |
| CLM-2026-027649 UB-04 · 2026-10-14 | Janice Parker UHC-98137-03 | 2026-10-03 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · in network | 93458, 93015 | $6,541.00 | $2,289.72 | Clean approval | — | Approved |
| CLM-2026-026672 UB-04 · 2026-10-14 | Betty Butler UHC-72899-24 | 2026-08-24 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $51,185.00 | — | Left for review DUP HIGH | — | Needs review |
| CLM-2026-026234 UB-04 · 2026-10-14 | Victoria Richards UHC-93067-18 | 2026-09-04 Outpatient hospital | Cornerstone Imaging Center Radiology · in network | 77067, 74177, 71046 | $2,873.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-025233 UB-04 · 2026-10-14 | Steven Carroll UHC-89841-95 | 2026-09-20 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 88305 | $310.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-025174 UB-04 · 2026-10-14 | Katherine Stevens UHC-93932-26 | 2026-09-21 Outpatient hospital | Harbor Family Practice Family Medicine · in network | 70553 | $2,391.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-024940 UB-04 · 2026-10-14 | Jesse Wallace UHC-53717-54 | 2026-09-09 Emergency room | Sunrise Community Hospital Emergency Medicine · in network | 99284 | $1,089.00 | $348.95 | Clean approval | — | Approved |
| CLM-2026-024818 UB-04 · 2026-10-14 | Aisha Nguyen UHC-89751-57 | 2026-09-10 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700 | $396.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-023532 UB-04 · 2026-10-14 | Andrew Hicks UHC-20492-19 | 2026-03-30 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 70553, 71046 | $2,750.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-022753 UB-04 · 2026-10-14 | Jonathan Mason UHC-16686-90 | 2026-08-31 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 76700 | $496.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-021995 UB-04 · 2026-10-14 | Logan Wang UHC-37033-56 | 2026-09-27 Outpatient hospital | Meadow Primary Care Associates Family Medicine · in network | 70553 | $1,963.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-021919 UB-04 · 2026-10-14 | Joseph Daniels UHC-26322-25 | 2026-09-12 Inpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 27447 | $44,672.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-018733 UB-04 · 2026-10-14 | Susan Larson UHC-58072-95 | 2026-09-19 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $207.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-018519 UB-04 · 2026-10-14 | Steven Gilbert UHC-22739-27 | 2026-09-25 Emergency room | Riverside Community Hospital Emergency Medicine · in network | 96374 | $203.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-016524 UB-04 · 2026-10-14 | Jordan Willis UHC-82878-88 | 2026-09-30 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 43239, 88305 | $2,561.00 | $939.30 | Clean approval | — | Approved |
| CLM-2026-016030 UB-04 · 2026-10-14 | Timothy Phillips UHC-10844-40 | 2026-08-31 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 74177 | $1,779.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-015995 UB-04 · 2026-10-14 | Hiroshi Greene UHC-44535-99 | 2026-09-24 Outpatient hospital | Meadow Cardiovascular Associates Cardiology · in network | 93458 | $8,717.00 | $4,195.68 | Clean approval | — | Approved |
| CLM-2026-013940 UB-04 · 2026-10-14 | Sarah Gomez no member ID | 2026-10-06 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700, 71046, 74177 | $2,353.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-011058 UB-04 · 2026-10-14 | Justin Palmer UHC-44225-20 | 2026-09-13 Inpatient hospital | Mesa Internal Medicine Associates Internal Medicine · out of network | 99232 | $234.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-011031 UB-04 · 2026-10-14 | Omar Hunt UHC-97434-51 | 2026-10-03 Outpatient hospital | Heritage Imaging Center Radiology · in network | 76700, 70553 | $3,006.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-009653 UB-04 · 2026-10-14 | Kimberly Hernandez UHC-62431-46 | 2026-09-08 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 43239 | $2,413.00 | $495.87 | Clean approval | — | Approved |
| CLM-2026-008696 UB-04 · 2026-10-14 | Joan Duncan UHC-84887-28 | 2026-10-02 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 77067 | $373.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-008692 UB-04 · 2026-10-14 | Omar McCoy UHC-42002-69 | 2026-09-21 Outpatient hospital | Harbor Imaging Center Radiology · in network | 70553, 76700, 77067 | $3,572.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-007036 UB-04 · 2026-10-14 | Victoria Herrera UHC-13803-78 | 2026-09-16 Outpatient hospital | Riverside Imaging Center Radiology · in network | 70553 | $2,225.00 | — | Left for review DUP | — | Needs review |
| CLM-2026-006702 UB-04 · 2026-10-14 | Patricia Green UHC-31727-18 | 2026-09-23 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285, 71046, 99283 | $4,165.00 | $2,040.75 | Clean approval | — | Approved |
| CLM-2026-006611 UB-04 · 2026-10-14 | William Harris UHC-03532-97 | 2026-10-07 Outpatient hospital | Meadow GI Associates Gastroenterology · in network | 88305 | $342.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-005750 UB-04 · 2026-10-14 | Dennis Sims UHC-61431-40 | 2026-09-18 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99284, 99285 | $4,534.00 | $2,243.70 | Clean approval | — | Approved |
| CLM-2026-003422 UB-04 · 2026-10-14 | Pamela Hansen UHC-70145-78 | 2026-09-25 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93015 | $455.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003183 UB-04 · 2026-10-14 | Terry Yung UHC-16318-17 | 2026-09-06 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $201.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-003163 UB-04 · 2026-10-14 | Nicole Simpson UHC-07493-84 | 2026-10-07 Outpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 29881 | $6,370.00 | $2,462.50 | Clean approval | — | Approved |
| CLM-2026-001282 UB-04 · 2026-10-14 | Julia Castillo no member ID | 2026-10-06 Inpatient hospital | Canyon Medical Group Internal Medicine · in network | 99232 | $182.00 | — | Pended by rule N30 | — | Pended |
| CLM-2026-034284 UB-04 · 2026-10-13 | Mateo Perez UHC-46817-61 | 2026-09-23 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 70553, 76700 | $3,143.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-032486 UB-04 · 2026-10-13 | Willie Roberts UHC-15064-57 | 2026-10-03 Outpatient hospital | Valley Imaging Center Radiology · in network | 77067, 71046 | $534.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032073 UB-04 · 2026-10-13 | Danielle Austin UHC-75102-81 | 2026-10-02 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 71046, 70553, 77067 | $3,701.00 | $373.18 | Clean approval | — | Approved |
| CLM-2026-031527 UB-04 · 2026-10-13 | Arjun Anderson UHC-56313-59 | 2026-09-29 Inpatient hospital | Heritage Medical Group Internal Medicine · in network | 99232 | $240.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030823 UB-04 · 2026-10-13 | Justin Ray UHC-04481-51 | 2026-10-07 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 71046 | $124.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-029742 UB-04 · 2026-10-13 | Gloria Le UHC-07005-78 | 2026-09-03 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 77067 | $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.