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-2026-025618 UB-04 · 2026-10-18 | Janet Delgado UHC-86657-86 | 2026-10-13 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 43239, 88305 | $1,736.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-022262 UB-04 · 2026-10-11 | Justin Pena UHC-23865-08 | 2026-10-01 Inpatient hospital | Unity Internal Medicine Associates Internal Medicine · out of network | 99232 | $218.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-010826 UB-04 · 2026-10-10 | Evelyn Wilson UHC-19839-19 | 2026-09-02 Outpatient hospital | Valley Imaging Center Radiology · in network | 70553, 71046 | $2,389.00 | — | Left for review CO50 CO16 | — | Needs review |
| CLM-2026-012779 UB-04 · 2026-10-09 | Kenneth Fisher UHC-65531-04 | 2026-09-21 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $174.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-015560 UB-04 · 2026-10-06 | Not attached | 2026-09-26 Outpatient hospital | Pinecrest Heart Institute Cardiology · in network | 93015 | $689.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-009704 UB-04 · 2026-10-05 | William Walsh UHC-07070-34 | 2026-08-31 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · out of network | 99232 | $236.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-006638 UB-04 · 2026-10-05 | Sara Murphy UHC-72812-48 | 2026-09-05 Outpatient hospital | Pinecrest GI Associates Gastroenterology · in network | 45378 | $1,434.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-002465 UB-04 · 2026-10-05 | Patricia Robertson UHC-63151-88 | 2026-09-02 Emergency room | Canyon Community Hospital Emergency Medicine · out of network | 99284, 96374, 99285 | $3,674.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-000032 UB-04 · 2026-10-05 | Not attached | 2026-09-25 Outpatient hospital | Pinecrest Heart Institute Cardiology · in network | 93306 | $1,401.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-001091 UB-04 · 2026-10-04 | Amy Hanson UHC-09703-59 | 2026-08-27 Outpatient hospital | Sunrise Heart Institute Cardiology · in network | 93015 | $478.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-019141 UB-04 · 2026-10-03 | Anthony Perkins UHC-29134-84 | 2026-08-31 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 96374, 99283 | $1,005.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-018920 UB-04 · 2026-10-03 | Lauren Lynch UHC-13897-33 | 2026-08-23 Outpatient hospital | Valley Cardiovascular Associates Cardiology · in network | 93015, 93458 | $8,424.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-005746 UB-04 · 2026-10-03 | Heather Fuller UHC-97671-82 | 2026-10-01 Outpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $8,777.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-020860 UB-04 · 2026-09-29 | Matthew Rice UHC-07938-13 | 2026-08-17 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285 | $2,521.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-018189 UB-04 · 2026-09-29 | Not attached | 2026-08-16 Outpatient hospital | Valley Heart Institute Cardiology · in network | 70553 | $2,348.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-007065 UB-04 · 2026-09-29 | Maria Dixon UHC-59100-04 | 2026-09-16 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 76700 | $468.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-009702 UB-04 · 2026-09-25 | Brittany Alvarez UHC-71038-53 | 2026-09-19 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 70553 | $3,117.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-019291 UB-04 · 2026-09-23 | Nicole Carlson UHC-64211-07 | 2026-08-19 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93015, 93306 | $1,739.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-010836 UB-04 · 2026-09-23 | Gary Kelly UHC-44852-79 | 2026-08-30 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · in network | 43239 | $2,296.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-005361 UB-04 · 2026-09-22 | Not attached | 2026-09-19 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99285 | $3,094.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-029002 UB-04 · 2026-09-21 | Not attached | 2026-08-31 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,744.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-008606 UB-04 · 2026-09-16 | Jonathan Hughes UHC-60893-02 | 2026-08-18 Outpatient hospital | Harbor Digestive Health Center Gastroenterology · in network | 45378 | $1,984.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-030209 UB-04 · 2026-09-15 | Diana McDonald UHC-97280-61 | 2026-08-06 Outpatient hospital | Valley Imaging Center Radiology · in network | 74177 | $1,278.00 | — | Left for review CO50 CO16 | — | Needs review |
| CLM-2026-013540 UB-04 · 2026-09-14 | Denise Hamilton UHC-25159-90 | 2026-08-23 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285, 71046 | $2,107.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-033913 UB-04 · 2026-09-12 | Saa Harper UHC-71898-36 | 2026-09-04 Inpatient hospital | Mesa Medical Group Internal Medicine · in network | 99232 | $230.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-025635 UB-04 · 2026-09-12 | Alex Munoz UHC-78751-46 | 2026-08-14 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $42,944.00 | — | Left for review CO16 HIGH | — | Needs review |
| CLM-2026-029710 UB-04 · 2026-09-10 | Isabella Bell UHC-68295-82 | 2026-08-06 Inpatient hospital | Canyon Internal Medicine Associates Internal Medicine · out of network | 99232 | $200.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-029001 UB-04 · 2026-09-09 | Not attached | 2026-08-31 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,744.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-028883 UB-04 · 2026-09-08 | Edward Powell UHC-15445-60 | 2026-08-17 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · in network | 99284 | $1,045.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-025355 UB-04 · 2026-09-05 | Jonathan Reynolds UHC-90138-55 | 2026-08-04 Emergency room | Desert Regional Medical Center Emergency Medicine · in network | 96374, 99285 | $2,511.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-010692 UB-04 · 2026-09-04 | Donna Schmidt UHC-88832-04 | 2026-08-30 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $38,434.00 | — | Left for review CO16 HIGH | — | Needs review |
| CLM-2026-004370 UB-04 · 2026-09-03 | Robert Nichols UHC-85970-41 | 2026-07-31 Outpatient hospital | Meadow Cardiovascular Associates Cardiology · in network | 93458, 93306 | $7,548.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-002101 UB-04 · 2026-09-02 | Sandra Owens UHC-89246-62 | 2026-08-23 Outpatient hospital | Desert Imaging Center Radiology · in network | 76700, 71046 | $630.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-006522 UB-04 · 2026-09-01 | Lawrence Harvey UHC-80234-32 | 2026-08-04 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 70553, 71046 | $2,580.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-017933 UB-04 · 2026-08-31 | Richard Kelley UHC-11767-95 | 2026-07-25 Emergency room | Sunrise Community Hospital Emergency Medicine · in network | 71046, 99285, 99283 | $4,017.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-003514 UB-04 · 2026-08-31 | Anthony Walsh UHC-21787-35 | 2026-07-23 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · in network | 99284, 71046 | $1,577.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-024682 UB-04 · 2026-08-29 | Not attached | 2026-07-31 Outpatient hospital | Lakeside Medical Group Internal Medicine · in network | 70553 | $2,959.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-005265 UB-04 · 2026-08-28 | Not attached | 2026-08-25 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 71046 | $225.00 | — | Pended by rule CO16 | — | Pended |
| CLM-2026-025033 UB-04 · 2026-08-27 | Not attached | 2026-07-26 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99285, 71046 | $2,179.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-032461 UB-04 · 2026-08-26 | Zachary Greene UHC-69793-13 | 2026-08-13 Outpatient hospital | Summit Imaging Center Radiology · in network | 71046 | $148.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-027020 UB-04 · 2026-08-26 | Santiago Reed UHC-53248-15 | 2026-08-16 Outpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 29881, 73721 | $8,284.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-021300 UB-04 · 2026-08-26 | Carol Jordan UHC-04959-09 | 2026-07-20 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 45378 | $1,715.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-012629 UB-04 · 2026-08-23 | Donald Griffin UHC-74616-95 | 2026-07-29 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 45378 | $2,338.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-026409 UB-04 · 2026-08-20 | Samuel Mitchell UHC-84599-11 | 2026-08-04 Emergency room | Meadow Regional Medical Center Emergency Medicine · in network | 71046, 99283, 96374 | $1,381.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-005337 UB-04 · 2026-08-17 | Carl Gardner UHC-45737-62 | 2026-08-07 Outpatient hospital | Harbor Diagnostic Imaging Radiology · in network | 76700 | $549.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-030802 UB-04 · 2026-08-16 | Elijah Vega UHC-68333-42 | 2026-07-05 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 45378, 43239 | $3,431.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-001120 UB-04 · 2026-08-16 | James Henderson UHC-00613-90 | 2026-07-10 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 43239, 45378, 88305 | $3,675.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-000866 UB-04 · 2026-08-09 | Not attached | 2026-07-25 Outpatient hospital | Riverside Imaging Center Radiology · in network | 76700 | $611.00 | — | Pended by rule CO16 N30 | — | Pended |
| CLM-2026-024475 UB-04 · 2026-08-07 | Mason Rios UHC-58394-45 | 2026-06-30 Inpatient hospital | Lakeside Medical Group Internal Medicine · in network | 99232 | $215.00 | — | Left for review CO16 | — | Needs review |
| CLM-2026-021178 UB-04 · 2026-08-06 | Not attached | 2026-07-26 Outpatient hospital | Desert Imaging Center Radiology · in network | 71046 | $200.00 | — | Pended by rule CO16 N30 | — | Pended |
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.