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-2026-021920 UB-04 · 2026-11-04 | Joseph Daniels UHC-26322-25 | 2026-09-12 Inpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 27447 | $44,672.00 | — | Left for review REPL HIGH | — | Needs review |
| CLM-2026-012567 UB-04 · 2026-10-18 | Melissa Gardner UHC-62350-59 | 2026-09-07 Inpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 27447 | $39,811.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-000165 UB-04 · 2026-10-18 | Bradley Russell UHC-45171-11 | 2026-09-28 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $38,503.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-020792 UB-04 · 2026-10-16 | Gregory Reid UHC-65879-07 | 2026-10-07 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $46,944.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-029862 UB-04 · 2026-10-15 | Anna Morris UHC-60990-54 | 2026-09-05 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $51,290.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027833 UB-04 · 2026-10-15 | Juan Medina UHC-12396-73 | 2026-10-06 Inpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 27447 | $32,984.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-028083 UB-04 · 2026-10-14 | Julia McCoy UHC-83978-41 | 2026-10-05 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $28,852.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-026672 UB-04 · 2026-10-14 | Betty Butler UHC-72899-24 | 2026-08-24 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $51,185.00 | — | Left for review DUP HIGH | — | Needs review |
| CLM-2026-021919 UB-04 · 2026-10-14 | Joseph Daniels UHC-26322-25 | 2026-09-12 Inpatient hospital | Unity Bone and Joint Center Orthopedic Surgery · in network | 27447 | $44,672.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-024888 UB-04 · 2026-10-12 | Eric Robertson UHC-01745-78 | 2026-08-28 Inpatient hospital | Northgate Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $31,691.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-024560 UB-04 · 2026-10-12 | Hiroshi Schultz UHC-49624-39 | 2026-08-26 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $36,744.00 | — | Left for review REPL HIGH | — | Needs review |
| CLM-2026-024453 UB-04 · 2026-10-11 | Grace Kennedy UHC-94262-16 | 2026-09-28 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $38,659.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-030384 UB-04 · 2026-10-10 | Jeffrey Padilla UHC-92939-82 | 2026-09-25 Inpatient hospital | Valley Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $37,665.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-030052 UB-04 · 2026-10-10 | Bradley Fernandez UHC-37198-75 | 2026-10-05 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $44,057.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-007564 UB-04 · 2026-10-10 | Julie Kelly UHC-04129-50 | 2026-08-31 Inpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 27447 | $43,866.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-002673 UB-04 · 2026-10-09 | Omar Castro UHC-27170-07 | 2026-09-24 Inpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $40,011.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-002069 UB-04 · 2026-10-08 | Ana Jackson UHC-71686-49 | 2026-09-23 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $29,621.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-031902 UB-04 · 2026-10-06 | Willie Wang UHC-91164-38 | 2026-08-31 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $45,180.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-024559 UB-04 · 2026-10-04 | Hiroshi Schultz UHC-49624-39 | 2026-08-26 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $36,744.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-020698 UB-04 · 2026-10-02 | Jacqueline Fowler UHC-41947-43 | 2026-09-13 Inpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 27447 | $34,061.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-026671 UB-04 · 2026-10-01 | Betty Butler UHC-72899-24 | 2026-08-24 Inpatient hospital | Sunrise Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $51,185.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-025065 UB-04 · 2026-10-01 | Michelle Tucker UHC-99041-10 | 2026-09-08 Inpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 27447 | $33,909.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-018005 UB-04 · 2026-10-01 | Patricia Le UHC-15651-83 | 2026-09-26 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $46,395.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-013270 UB-04 · 2026-10-01 | Theresa Garcia UHC-73103-71 | 2026-09-07 Inpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 27447 | $31,691.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-026374 UB-04 · 2026-09-30 | Lawrence Ramirez UHC-12458-11 | 2026-08-20 Inpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 27447 | $45,493.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-024072 UB-04 · 2026-09-29 | Jacob Gomez UHC-45306-71 | 2026-09-18 Inpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 27447 | $44,276.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-022696 UB-04 · 2026-09-29 | Steven Brooks UHC-72425-74 | 2026-09-21 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $35,439.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-019443 UB-04 · 2026-09-27 | Sharon Martin UHC-49913-33 | 2026-08-26 Inpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 27447 | $35,705.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-014163 UB-04 · 2026-09-27 | Ralph Gray UHC-72876-61 | 2026-09-08 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $33,551.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-004105 UB-04 · 2026-09-24 | Christine Wallace UHC-56875-41 | 2026-09-09 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $35,290.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-010866 UB-04 · 2026-09-21 | Kayla Knight UHC-65232-63 | 2026-08-25 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $35,611.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-014429 UB-04 · 2026-09-19 | Katherine Payne UHC-90245-36 | 2026-09-15 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $49,343.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-016808 UB-04 · 2026-09-18 | Lisa Stevens UHC-13790-13 | 2026-08-27 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $40,579.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-028805 UB-04 · 2026-09-17 | Rachel Adams UHC-34375-78 | 2026-08-27 Inpatient hospital | Sunrise Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $28,758.00 | — | Left for review DUP HIGH | — | Needs review |
| CLM-2026-027982 UB-04 · 2026-09-17 | Brenda Porter UHC-42540-74 | 2026-09-04 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $36,991.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027928 UB-04 · 2026-09-17 | Martha Campbell UHC-30282-20 | 2026-09-04 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $39,992.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-022870 UB-04 · 2026-09-16 | Anna Carr UHC-83901-86 | 2026-09-02 Inpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 27447 | $42,840.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-031977 UB-04 · 2026-09-14 | Luis Garcia UHC-82957-73 | 2026-08-05 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $47,650.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-024698 UB-04 · 2026-09-14 | Terry Snyder UHC-52224-90 | 2026-09-01 Inpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 27447 | $51,971.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-011768 UB-04 · 2026-09-13 | Maria Wells UHC-83588-76 | 2026-08-31 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $33,484.00 | — | Left for review HIGH | — | 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-2026-012640 UB-04 · 2026-09-12 | Brian Torres UHC-82191-10 | 2026-09-01 Inpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $46,146.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-028804 UB-04 · 2026-09-11 | Rachel Adams UHC-34375-78 | 2026-08-27 Inpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 27447 | $28,758.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-026379 UB-04 · 2026-09-11 | Marcus Jacobs UHC-04044-52 | 2026-08-04 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $35,422.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-021375 UB-04 · 2026-09-11 | Theresa Hanson UHC-26185-79 | 2026-09-04 Inpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 27447 | $51,623.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-011002 UB-04 · 2026-09-10 | Jdy Wells UHC-65896-08 | 2026-08-01 Inpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $38,455.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-012111 UB-04 · 2026-09-09 | Victoria Herrera UHC-13803-78 | 2026-07-27 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $48,486.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-027606 UB-04 · 2026-09-08 | Anna Vega UHC-73708-80 | 2026-07-31 Inpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 27447 | $48,514.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-015038 UB-04 · 2026-09-08 | Jackie Gomez UHC-28088-09 | 2026-07-25 Inpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 27447 | $47,970.00 | — | Left for review HIGH | — | Needs review |
| CLM-2026-033879 UB-04 · 2026-09-07 | Joe Chen UHC-82668-02 | 2026-08-24 Inpatient hospital | Harbor Bone and Joint Center Orthopedic Surgery · in network | 27447 | $39,861.00 | — | Left for review HIGH | — | 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.