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-2026-028513 UB-04 · 2026-11-08 | Steven Wheeler UHC-11820-74 | 2026-09-27 Inpatient hospital | Canyon Medical Group Internal Medicine · in network | 99232 | $251.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-011097 UB-04 · 2026-11-06 | Joan Rivera UHC-22799-76 | 2026-10-05 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284 | $1,665.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-008055 UB-04 · 2026-11-06 | Terry Cooper no member ID | 2026-09-26 Emergency room | Harbor Regional Medical Center Emergency Medicine · in network | 71046 | $246.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-005318 UB-04 · 2026-11-05 | Helen Snyder UHC-08676-93 | 2026-10-01 Outpatient hospital | Meadow Imaging Center Radiology · in network | 70553, 76700 | $3,998.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014845 UB-04 · 2026-11-04 | Albert Alvarez UHC-42353-95 | 2026-09-28 Outpatient hospital | Summit Heart Institute Cardiology · in network | 93306, 93015, 93458 | $11,010.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-017567 UB-04 · 2026-10-30 | Gabriel Shew no member ID | 2026-09-28 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 43239 | $1,993.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-030817 UB-04 · 2026-10-28 | Carl Smith UHC-10143-60 | 2026-10-02 Outpatient hospital | Heritage Digestive Health Center Gastroenterology · in network | 45378 | $2,697.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-025027 UB-04 · 2026-10-26 | Edward Dunn UHC-58248-42 | 2026-10-01 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 88305, 45378 | $2,697.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-028753 UB-04 · 2026-10-25 | Sandra Powell UHC-02733-47 | 2026-09-14 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99283, 71046 | $1,010.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007493 UB-04 · 2026-10-25 | Maria Snyder UHC-84820-97 | 2026-09-01 Outpatient hospital | Harbor Imaging Center Radiology · in network | 74177 | $2,458.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-024889 UB-04 · 2026-10-24 | Eric Robertson UHC-01745-78 | 2026-08-28 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $31,691.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-003352 UB-04 · 2026-10-24 | Amy Simpson no member ID | 2026-08-25 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $235.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-002070 UB-04 · 2026-10-22 | Ana Jackson UHC-71686-49 | 2026-09-23 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $29,621.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-029204 UB-04 · 2026-10-21 | Jesse Price UHC-05475-09 | 2026-08-29 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 71046, 99283 | $910.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-007624 UB-04 · 2026-10-21 | James Cox UHC-14257-05 | 2026-09-25 Outpatient hospital | Harbor Diagnostic Imaging Radiology · in network | 71046, 70553 | $2,856.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-014800 UB-04 · 2026-10-18 | Shirley Gordon UHC-16318-59 | 2026-09-24 Outpatient hospital | Unity Digestive Health Center Gastroenterology · in network | 43239 | $2,507.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-004773 UB-04 · 2026-10-18 | Bryan Ray UHC-15231-85 | 2026-09-28 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99284 | $1,734.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-013745 UB-04 · 2026-10-16 | Billy Reid UHC-17079-68 | 2026-09-19 Outpatient hospital | Heritage Imaging Center Radiology · in network | 77067, 70553 | $2,364.00 | — | Denied by rule CO18 | — | Denied |
| 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-2026-032825 UB-04 · 2026-10-12 | Aisha Cole UHC-86878-50 | 2026-09-07 Emergency room | Valley Regional Medical Center Emergency Medicine · in network | 99283 | $1,083.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-018964 UB-04 · 2026-10-12 | Charles Burton UHC-47128-17 | 2026-09-07 Outpatient hospital | Riverside Imaging Center Radiology · in network | 77067 | $342.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-016133 UB-04 · 2026-10-12 | Richard Clark UHC-54936-57 | 2026-09-05 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99285 | $2,496.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-032272 UB-04 · 2026-10-11 | Eugeene Reyes UHC-32191-16 | 2026-08-25 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $7,356.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-025789 UB-04 · 2026-10-10 | Sarah Smith no member ID | 2026-09-12 Emergency room | Unity Community Hospital Emergency Medicine · in network | 96374 | $220.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022511 UB-04 · 2026-10-04 | Melissa Anderson UHC-00123-95 | 2026-08-20 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 88305 | $224.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022157 UB-04 · 2026-10-03 | Mary Contreras UHC-87904-93 | 2026-09-05 Outpatient hospital | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $10,210.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-029709 UB-04 · 2026-09-30 | James Maldonado UHC-48927-65 | 2026-08-19 Outpatient hospital | Meadow Cardiovascular Associates Cardiology · in network | 93015 | $572.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-025383 UB-04 · 2026-09-30 | Abby Nichols UHC-31174-53 | 2026-08-27 Outpatient hospital | Meadow Cardiovascular Associates Cardiology · in network | 93458 | $7,824.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-021622 UB-04 · 2026-09-30 | Mariana Delgado UHC-65759-31 | 2026-08-03 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 43239 | $1,936.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-020729 UB-04 · 2026-09-30 | Jean Nunez no member ID | 2026-08-22 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99285, 96374, 99283 | $3,666.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-013473 UB-04 · 2026-09-30 | Peter Austin UHC-85220-86 | 2026-09-18 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93306 | $1,377.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-013770 UB-04 · 2026-09-29 | Cheryl Gibson UHC-20991-85 | 2026-09-08 Inpatient hospital | Mesa Medical Group Internal Medicine · in network | 99232 | $212.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-011839 UB-04 · 2026-09-29 | Amber Wells UHC-80479-97 | 2026-09-13 Inpatient hospital | Heritage Medical Group Internal Medicine · in network | 99232 | $163.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-005147 UB-04 · 2026-09-29 | Frank Gomez UHC-57895-27 | 2026-08-07 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 74177 | $1,520.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-022799 UB-04 · 2026-09-28 | Ryan Harvey UHC-08814-34 | 2026-08-21 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 74177, 71046, 77067 | $2,522.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-011558 UB-04 · 2026-09-28 | Jesse Green UHC-20267-72 | 2026-09-04 Outpatient hospital | Lakeside Digestive Health Center Gastroenterology · in network | 43239, 88305 | $2,403.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-034184 UB-04 · 2026-09-24 | William Weaver UHC-50237-81 | 2026-08-22 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284, 99285, 71046 | $3,997.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-001664 UB-04 · 2026-09-22 | Randy Barnes UHC-19730-93 | 2026-09-02 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306 | $1,144.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-000891 UB-04 · 2026-09-18 | Lauren Valdez UHC-73108-23 | 2026-08-20 Outpatient hospital | Desert Imaging Center Radiology · in network | 70553 | $3,414.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-012638 UB-04 · 2026-09-16 | Brian Burke UHC-98758-75 | 2026-09-07 Outpatient hospital | Riverside Imaging Center Radiology · in network | 76700, 71046, 70553 | $3,433.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-001451 UB-04 · 2026-09-12 | Edward Garcia UHC-82255-21 | 2026-08-02 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99284 | $1,740.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-015088 UB-04 · 2026-09-11 | Wei Riley UHC-77186-88 | 2026-07-20 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,304.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-031622 UB-04 · 2026-09-09 | Ana Gibson UHC-12515-95 | 2026-07-31 Outpatient hospital | Valley Heart Institute Cardiology · in network | 93306, 93015 | $1,543.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-023169 UB-04 · 2026-09-09 | Santiago Gonzales UHC-46097-50 | 2026-08-04 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 70553, 74177 | $4,442.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-026103 UB-04 · 2026-09-07 | Adam Dunn UHC-30181-71 | 2026-08-07 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99283, 71046 | $1,219.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-031088 UB-04 · 2026-09-06 | Ann Gonzalez UHC-34996-49 | 2026-07-20 Inpatient hospital | Summit Internal Medicine Associates Internal Medicine · in network | 99232 | $244.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-023754 UB-04 · 2026-09-06 | Laura Cllins UHC-74766-94 | 2026-08-01 Outpatient hospital | Meadow Cardiovascular Associates Cardiology · in network | 93015, 93306 | $1,888.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-033084 UB-04 · 2026-09-04 | Willie Delgado UHC-47830-16 | 2026-07-11 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 70553 | $3,132.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-027602 UB-04 · 2026-09-04 | Larry Morales UHC-93326-04 | 2026-07-27 Emergency room | Cornerstone Regional Medical Center Emergency Medicine · in network | 99284, 99285 | $3,453.00 | — | Denied by rule CO18 | — | Denied |
| CLM-2026-005122 UB-04 · 2026-09-04 | Aaron Ortiz no member ID | 2026-07-19 Outpatient hospital | Meadow Cardiovascular Associates Cardiology · in network | 93015 | $548.00 | — | Denied by rule CO18 | — | Denied |
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.