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-2026-024368 UB-04 · 2026-10-18 | Omar Holmes UHC-04491-04 | 2026-09-27 Outpatient hospital | Unity Diagnostic Imaging Radiology · in network | 74177, 70553 | $5,077.00 | — | Left for review CO50 CO97 | — | Needs review |
| CLM-2026-031941 UB-04 · 2026-10-17 | Mark Riley UHC-38683-19 | 2026-10-01 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 96374, 99284 | $1,564.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-007132 UB-04 · 2026-10-17 | Laura Reyes UHC-58818-28 | 2026-09-20 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284, 99283 | $2,378.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-020953 UB-04 · 2026-10-16 | Perry Arthur UHC-34387-88 | 2026-09-30 Outpatient hospital | Riverside GI Associates Gastroenterology · in network | 43239, 45378 | $4,992.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-006396 UB-04 · 2026-10-16 | Jesse Kim UHC-45304-40 | 2026-09-04 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284, 99283 | $1,928.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023855 UB-04 · 2026-10-15 | Dennis Perez UHC-14032-93 | 2026-09-24 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306, 93458 | $10,569.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-019192 UB-04 · 2026-10-15 | Gloria Vargas UHC-65899-86 | 2026-09-13 Outpatient hospital | Mesa Cardiovascular Associates Cardiology · in network | 93458, 93306 | $6,391.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-018491 UB-04 · 2026-10-13 | Peter McCoy UHC-64916-39 | 2026-09-24 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 76700, 70553 | $2,621.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023742 UB-04 · 2026-10-12 | Adam Vega UHC-59055-13 | 2026-09-16 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 96374, 99285 | $2,954.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-013966 UB-04 · 2026-10-12 | Lauren Spencer UHC-15892-51 | 2026-08-28 Outpatient hospital | Cornerstone Cardiovascular Associates Cardiology · in network | 93458, 93306 | $9,038.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-011835 UB-04 · 2026-10-11 | Matthew Gilbert UHC-74569-95 | 2026-09-27 Outpatient hospital | Valley Heart Institute Cardiology · in network | 93458, 93306 | $9,180.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-004256 UB-04 · 2026-10-08 | John Torres UHC-31945-76 | 2026-09-30 Emergency room | Unity Community Hospital Emergency Medicine · in network | 71046, 99283 | $1,265.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-019320 UB-04 · 2026-10-01 | Sharon Owens UHC-46430-01 | 2026-08-24 Inpatient hospital | Sunrise Internal Medicine Associates Internal Medicine · in network | 99232, 99215 | $591.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-020741 UB-04 · 2026-09-30 | Paul Russell UHC-55726-01 | 2026-09-28 Emergency room | Desert Regional Medical Center Emergency Medicine · in network | 99284, 71046 | $1,476.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-008486 UB-04 · 2026-09-30 | Nathan Greene UHC-46806-74 | 2026-09-10 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 71046, 76700 | $618.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-014785 UB-04 · 2026-09-29 | Lawrence Moore UHC-61864-11 | 2026-09-10 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 76700, 70553 | $2,925.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-000244 UB-04 · 2026-09-28 | Lauren Pierce UHC-58226-07 | 2026-09-20 Emergency room | Unity Community Hospital Emergency Medicine · in network | 99284, 99283 | $2,218.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-032853 UB-04 · 2026-09-24 | Logan Delgado UHC-87471-01 | 2026-09-01 Emergency room | Lakeside Regional Medical Center Emergency Medicine · in network | 99285, 99283 | $2,630.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-018528 UB-04 · 2026-09-24 | George Jensen UHC-11856-62 | 2026-09-07 Outpatient hospital | Meadow Cardiovascular Associates Cardiology · in network | 93306, 93458 | $6,790.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-012628 UB-04 · 2026-09-24 | Gary Fields UHC-65382-80 | 2026-09-03 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378, 88305, 43239 | $3,858.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-028951 UB-04 · 2026-09-20 | Sean Evans UHC-66436-57 | 2026-09-01 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 71046, 70553, 76700 | $3,282.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-010920 UB-04 · 2026-09-19 | Olivia Thomas UHC-31622-35 | 2026-08-22 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 70553, 74177 | $4,626.00 | — | Left for review CO50 CO97 | — | Needs review |
| CLM-2026-023347 UB-04 · 2026-09-14 | Mariana Matthews UHC-24776-39 | 2026-08-04 Outpatient hospital | Desert Diagnostic Imaging Radiology · in network | 74177, 70553 | $4,626.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-010819 UB-04 · 2026-09-13 | Priya Carroll UHC-18639-53 | 2026-09-02 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 45378, 43239 | $3,835.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-029060 UB-04 · 2026-09-11 | Thomas Matthews UHC-54543-72 | 2026-07-28 Outpatient hospital | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 29881, 73721 | $11,417.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-025626 UB-04 · 2026-09-11 | Fatima Bell UHC-10435-53 | 2026-07-29 Outpatient hospital | Evergreen GI Associates Gastroenterology · in network | 88305, 45378 | $1,825.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-009745 UB-04 · 2026-09-08 | Lauren Peters UHC-23575-28 | 2026-07-25 Emergency room | Cornerstone Regional Medical Center Emergency Medicine · in network | 96374, 71046 | $433.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-026884 UB-04 · 2026-09-06 | Hannah Andrews UHC-15893-43 | 2026-08-20 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284, 99285 | $3,561.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-016905 UB-04 · 2026-09-05 | Donald Adams UHC-26650-54 | 2026-08-21 Emergency room | Sunrise Community Hospital Emergency Medicine · in network | 99283, 99284 | $2,350.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-019965 UB-04 · 2026-09-04 | Hannah Rose UHC-38319-19 | 2026-08-09 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99283, 99285 | $2,618.00 | — | Left for review NET CO97 | — | Needs review |
| CLM-2026-010166 UB-04 · 2026-09-04 | Juan Kim UHC-49008-92 | 2026-07-23 Outpatient hospital | Lakeside Heart Institute Cardiology · in network | 93306, 93458 | $7,884.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-031823 UB-04 · 2026-09-03 | Margaret Chavez UHC-92419-11 | 2026-08-13 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 71046, 70553 | $2,256.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-019087 UB-04 · 2026-09-01 | Laura Rivera UHC-17261-47 | 2026-07-20 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 71046, 99283 | $1,279.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-012403 UB-04 · 2026-08-31 | Jonathan Davis UHC-33869-68 | 2026-08-18 Emergency room | Meadow Regional Medical Center Emergency Medicine · in network | 99283, 99284 | $2,328.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-018917 UB-04 · 2026-08-30 | Nathan Carpenter UHC-03837-93 | 2026-08-25 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 73721, 29881 | $12,666.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-018606 UB-04 · 2026-08-28 | Bruce Collins UHC-15097-94 | 2026-07-18 Outpatient hospital | Meadow Imaging Center Radiology · in network | 70553, 77067 | $2,978.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-034549 UB-04 · 2026-08-27 | Nathan Olson UHC-91260-88 | 2026-07-31 Emergency room | Riverside Community Hospital Emergency Medicine · in network | 99283, 99284 | $1,754.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-001370 UB-04 · 2026-08-25 | Gary Hamilton UHC-83880-59 | 2026-07-24 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306, 93015 | $2,194.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-017594 UB-04 · 2026-08-21 | Zachary Hudson UHC-04938-33 | 2026-08-12 Outpatient hospital | Heritage Orthopedic Specialists Orthopedic Surgery · in network | 29881, 73721 | $12,623.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-002862 UB-04 · 2026-08-21 | Luis Vega UHC-18828-56 | 2026-07-11 Emergency room | Riverside Community Hospital Emergency Medicine · in network | 99285, 99283 | $2,549.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023133 UB-04 · 2026-08-20 | Tyler Ross UHC-29708-97 | 2026-08-07 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 77067, 74177, 71046 | $2,453.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-022991 UB-04 · 2026-08-20 | Mateo Elliott UHC-10418-03 | 2026-07-22 Outpatient hospital | Heritage Imaging Center Radiology · in network | 71046, 70553 | $3,582.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-029527 UB-04 · 2026-08-19 | Joan Silva UHC-84623-38 | 2026-07-29 Outpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 73721, 29881 | $11,251.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023421 UB-04 · 2026-08-19 | Hannah Rivera UHC-32282-46 | 2026-07-21 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 77067, 71046 | $633.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-023379 UB-04 · 2026-08-19 | Matthew Cruz UHC-51746-95 | 2026-07-08 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · in network | 96374, 99283 | $1,295.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-016111 UB-04 · 2026-08-17 | Diana Chapman UHC-70981-11 | 2026-08-03 Outpatient hospital | Sunrise GI Associates Gastroenterology · in network | 43239, 45378 | $4,796.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-005295 UB-04 · 2026-08-17 | Catherine Coleman UHC-75249-39 | 2026-08-10 Outpatient hospital | Heritage Imaging Center Radiology · in network | 71046, 70553 | $3,437.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-002852 UB-04 · 2026-08-13 | Evelyn Ortega UHC-60381-37 | 2026-08-11 Inpatient hospital | Canyon Medical Group Internal Medicine · in network | 99232, 99215 | $511.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-001084 UB-04 · 2026-08-13 | Christina Nguyen UHC-52000-64 | 2026-07-25 Outpatient hospital | Evergreen Digestive Health Center Gastroenterology · in network | 45378, 43239 | $3,162.00 | — | Left for review CO97 | — | Needs review |
| CLM-2026-025739 UB-04 · 2026-08-12 | Brandon Bailey UHC-55395-79 | 2026-07-29 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 93458, 93306 | $7,781.00 | — | Left for review CO97 | — | 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.