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-2026-032919 UB-04 · 2026-10-06 | Sam Pierce UHC-33483-59 | 2026-08-30 Outpatient hospital | Unity Diagnostic Imaging Radiology · in network | 70553 | $2,534.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-002416 UB-04 · 2026-10-05 | Jean Nelson UHC-20738-64 | 2026-08-28 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881, 73721 | $8,574.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-031719 UB-04 · 2026-09-28 | Joshua Cook UHC-57439-68 | 2026-08-28 Outpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 29881, 73721 | $11,810.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-005699 UB-04 · 2026-09-21 | Sue Castillo UHC-58894-75 | 2026-08-26 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 45378 | $2,153.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-031034 UB-04 · 2026-08-29 | Patrick Lawrence UHC-40638-05 | 2026-07-22 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 74177 | $2,560.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-021837 UB-04 · 2026-08-29 | Marc Matthews UHC-28870-27 | 2026-07-24 Outpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · in network | 29881, 73721 | $7,798.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-011884 UB-04 · 2026-08-29 | Joe Bishop UHC-31239-05 | 2026-08-06 Outpatient hospital | Unity Digestive Health Center Gastroenterology · in network | 43239 | $2,104.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-030508 UB-04 · 2026-08-20 | Jacqueline Soto UHC-59864-67 | 2026-07-10 Outpatient hospital | Unity Diagnostic Imaging Radiology · in network | 76700, 74177 | $2,297.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-026608 UB-04 · 2026-08-20 | Lauren Graham UHC-12369-48 | 2026-07-12 Outpatient hospital | Summit Imaging Center Radiology · in network | 70553, 76700 | $3,605.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-023633 UB-04 · 2026-08-18 | Sara Butler UHC-52657-16 | 2026-07-14 Outpatient hospital | Northgate Cardiovascular Associates Cardiology · in network | 93458, 93306 | $8,610.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-014540 UB-04 · 2026-08-17 | Adam Contreras UHC-75072-26 | 2026-07-18 Outpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 29881 | $9,191.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-020138 UB-04 · 2026-08-16 | Judith Maldonado UHC-84739-37 | 2026-07-08 Outpatient hospital | Valley Imaging Center Radiology · in network | 71046, 70553 | $2,862.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-028199 UB-04 · 2026-07-11 | Nathan Payne UHC-93464-65 | 2026-06-16 Outpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,604.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-016962 UB-04 · 2026-07-07 | Emma Tucker UHC-67045-13 | 2026-06-17 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,824.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-002648 UB-04 · 2026-07-01 | Janet Lewis UHC-35740-35 | 2026-06-25 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 88305, 45378 | $2,457.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-015068 UB-04 · 2026-06-29 | Carl Kennedy UHC-27655-75 | 2026-06-01 Inpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 27447 | $47,617.00 | — | Left for review CO197 HIGH | — | Needs review |
| CLM-2026-019977 UB-04 · 2026-05-28 | Roger Contreras UHC-06935-90 | 2026-04-13 Outpatient hospital | Meadow Imaging Center Radiology · in network | 70553 | $3,017.00 | — | Left for review CO197 CO50 | — | Needs review |
| CLM-2026-010202 UB-04 · 2026-05-27 | Roger Sanders UHC-51097-26 | 2026-04-30 Outpatient hospital | Riverside GI Associates Gastroenterology · in network | 43239 | $2,391.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-026153 UB-04 · 2026-05-20 | Christian Vargas UHC-00336-95 | 2026-04-18 Outpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 73721 | $1,443.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-009273 UB-04 · 2026-05-06 | Nathan Morgan UHC-41203-84 | 2026-03-25 Outpatient hospital | Harbor Digestive Health Center Gastroenterology · in network | 43239, 45378 | $3,481.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-005557 UB-04 · 2026-05-04 | Robert Jordan UHC-39437-35 | 2026-04-30 Outpatient hospital | Unity Diagnostic Imaging Radiology · in network | 76700, 70553 | $3,159.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-032466 UB-04 · 2026-04-28 | Cheryl Chavez UHC-41463-71 | 2026-04-03 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 45378 | $2,036.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-004078 UB-04 · 2026-04-21 | Bryan Hicks UHC-57811-46 | 2026-04-11 Outpatient hospital | Riverside Cardiovascular Associates Cardiology · in network | 93458, 93015 | $5,707.00 | — | Left for review CO197 | — | 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-2026-000010 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-2026-002187 UB-04 · 2026-04-11 | James Hanson UHC-90765-54 | 2026-02-28 Outpatient hospital | Unity Digestive Health Center Gastroenterology · in network | 43239 | $1,736.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-000231 UB-04 · 2026-04-08 | Keith Alvarez UHC-14541-33 | 2026-04-04 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93015, 93458 | $7,675.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-009149 UB-04 · 2026-03-27 | Jacob Myers UHC-18643-77 | 2026-03-12 Outpatient hospital | Unity Digestive Health Center Gastroenterology · in network | 45378, 88305 | $2,208.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-007282 UB-04 · 2026-03-27 | Briaan Johnson UHC-87060-63 | 2026-03-05 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 88305, 43239 | $1,897.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-005017 UB-04 · 2026-03-24 | Justin Parker UHC-60302-08 | 2026-03-21 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 71046, 70553 | $3,784.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-022637 UB-04 · 2026-03-23 | Aisha Rojas UHC-94886-33 | 2026-02-19 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · in network | 93458, 93015 | $8,761.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-014655 UB-04 · 2026-03-13 | Ashley Bowman UHC-55178-78 | 2026-03-02 Inpatient hospital | Northgate Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $46,290.00 | — | Left for review CO197 HIGH | — | Needs review |
| CLM-2026-005805 UB-04 · 2026-03-09 | Brian Reed UHC-65423-74 | 2026-02-11 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · in network | 93458 | $9,344.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-022472 UB-04 · 2026-03-06 | Christine Hunter UHC-88464-16 | 2026-02-11 Outpatient hospital | Evergreen Digestive Health Center Gastroenterology · in network | 45378 | $2,082.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-017168 UB-04 · 2026-03-05 | Cynthia Ryan UHC-86329-70 | 2026-02-20 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93015, 93458 | $9,126.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-013638 UB-04 · 2026-03-05 | Debra Stone UHC-91983-24 | 2026-01-22 Outpatient hospital | Desert Imaging Center Radiology · in network | 74177 | $1,918.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-027760 UB-04 · 2026-02-26 | Jean Carpenter UHC-69541-09 | 2026-02-18 Outpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,865.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-000552 UB-04 · 2026-02-17 | Martha Campbell UHC-49054-08 | 2026-02-07 Outpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $10,195.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-016576 UB-04 · 2026-02-14 | John Ellis UHC-60213-77 | 2026-01-04 Outpatient hospital | Canyon Cardiovascular Associates Cardiology · in network | 93458 | $5,631.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-008270 UB-04 · 2026-01-30 | Frank Armstrong UHC-73728-14 | 2025-12-23 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 43239 | $2,380.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-014419 UB-04 · 2026-01-29 | Arthur Little UHC-02842-96 | 2025-12-28 Outpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 73721 | $2,139.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-028278 UB-04 · 2026-01-25 | Sara Palmer UHC-47320-20 | 2025-12-15 Outpatient hospital | Harbor Digestive Health Center Gastroenterology · in network | 43239 | $2,501.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-026544 UB-04 · 2026-01-20 | Carl George UHC-98825-70 | 2026-01-01 Outpatient hospital | Cornerstone Imaging Center Radiology · in network | 70553, 76700, 74177 | $5,324.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-009839 UB-04 · 2026-01-14 | Michael Flores UHC-18243-61 | 2025-12-30 Outpatient hospital | Desert Heart Institute Cardiology · in network | 93458 | $6,810.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-007376 UB-04 · 2026-01-14 | Gregory Martinez UHC-78137-30 | 2025-12-27 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 70553 | $2,983.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-028234 UB-04 · 2026-01-13 | Karen Reynolds UHC-41791-25 | 2026-01-03 Outpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 73721 | $1,502.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-006366 UB-04 · 2026-01-11 | Karen Mitchell UHC-80730-37 | 2025-12-11 Outpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 29881 | $9,610.00 | — | Left for review CO197 | — | Needs review |
| CLM-2026-016865 UB-04 · 2026-01-04 | Douglas Howell UHC-59326-05 | 2025-12-13 Outpatient hospital | Northgate Cardiovascular Associates Cardiology · in network | 93458 | $7,608.00 | — | Left for review CO197 | Pended confidence 0.95 | Needs review |
| CLM-2026-012816 UB-04 · 2026-01-02 | Ruth Pierce UHC-19964-20 | 2025-12-26 Outpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 29881 | $5,855.00 | — | Left for review CO197 | Pended confidence 0.95 | 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.