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-2026-027831 CMS-1500 · 2026-09-02 | Hiroshi Ortega UHC-36461-06 | 2026-08-11 Office | Harbor Medical Group Internal Medicine · in network | 99215 | $352.00 | $198.24 | Clean approval | — | Approved |
| CLM-2026-011639 CMS-1500 · 2026-07-27 | Hiroshi Ortega UHC-36461-06 | 2026-06-15 Independent laboratory | Mesa Reference Lab Clinical Laboratory · in network | 80061, 80053 | $88.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-006362 CMS-1500 · 2026-07-02 | Hiroshi Ortega UHC-36461-06 | 2026-05-27 Telehealth | Sunrise Counseling Center Behavioral Health · in network | 99214 | $291.00 | $140.42 | Clean approval | — | Approved |
| CLM-2026-005919 CMS-1500 · 2026-03-15 | Hiroshi Ortega UHC-36461-06 | 2026-03-10 Office | Pinecrest Behavioral Health Behavioral Health · in network | 90791 | $288.00 | $138.56 | 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.