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-2026-026744 UB-04 · 2026-10-27 | Ryan Austin UHC-79286-61 | 2026-09-14 Emergency room | Sunrise Community Hospital Emergency Medicine · in network | 96374 | $233.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-027220 UB-04 · 2026-10-23 | Amber Walker UHC-76429-95 | 2026-09-19 Outpatient hospital | Desert Cardiovascular Associates Cardiology · in network | 93015 | $596.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-014055 UB-04 · 2026-10-23 | Danielle Gomez UHC-89338-09 | 2026-09-11 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 71046 | $141.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-032479 UB-04 · 2026-10-17 | Ralph Garza UHC-69417-14 | 2026-09-30 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $203.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-013898 UB-04 · 2026-10-16 | Walter Stewart UHC-24161-31 | 2026-09-01 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 76700 | $381.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-018275 UB-04 · 2026-10-15 | Billy Le UHC-22687-90 | 2026-09-28 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99285, 99284, 99283 | $5,093.00 | — | Left for review REPL | — | 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-2026-007837 UB-04 · 2026-10-10 | Samantha Lawrence UHC-39266-73 | 2026-09-16 Outpatient hospital | Unity Diagnostic Imaging Radiology · in network | 77067, 74177 | $1,653.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-007677 UB-04 · 2026-10-10 | Joseph Porter UHC-81468-86 | 2026-09-02 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 70553 | $2,918.00 | — | Left for review REPL CO50 | — | Needs review |
| CLM-2026-030866 UB-04 · 2026-10-09 | Mari Park UHC-74024-31 | 2026-08-25 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 74177 | $1,301.00 | — | Left for review REPL CO50 | — | Needs review |
| CLM-2026-033080 UB-04 · 2026-10-07 | Jason Gray UHC-15887-53 | 2026-08-21 Outpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 29881, 73721 | $9,059.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-012918 UB-04 · 2026-10-07 | Megan Williams UHC-64753-11 | 2026-08-24 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 77067, 71046, 74177 | $2,863.00 | — | Left for review REPL CO50 | — | Needs review |
| CLM-2026-008354 UB-04 · 2026-10-05 | Christina Sandoval UHC-51663-15 | 2026-09-04 Outpatient hospital | Mesa Cardiovascular Associates Cardiology · in network | 93015, 93306 | $2,024.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-033728 UB-04 · 2026-10-04 | Melissa Park UHC-93563-20 | 2026-09-08 Outpatient hospital | Unity Cardiovascular Associates Cardiology · in network | 93306 | $1,000.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029415 UB-04 · 2026-10-03 | Michelle Harper UHC-59426-45 | 2026-08-28 Inpatient hospital | Valley Medical Group Internal Medicine · in network | 99232 | $197.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-024577 UB-04 · 2026-10-03 | Mei Carter UHC-88572-18 | 2026-09-10 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306 | $1,449.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-017600 UB-04 · 2026-10-03 | Ryan Wright UHC-72160-97 | 2026-08-26 Outpatient hospital | Meadow Diagnostic Imaging Radiology · out of network | 71046 | $156.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-015437 UB-04 · 2026-10-03 | Joshua Harper UHC-85497-41 | 2026-08-19 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 71046, 99283 | $1,059.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-010035 UB-04 · 2026-10-03 | Kathy Watkins UHC-19886-37 | 2026-08-13 Outpatient hospital | Valley Imaging Center Radiology · in network | 70553, 71046, 74177 | $4,440.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-028440 UB-04 · 2026-10-01 | Ahmed Cooper UHC-91936-31 | 2026-08-19 Outpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 73721 | $1,196.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-026720 UB-04 · 2026-09-29 | Dylan Taylor UHC-33407-72 | 2026-08-18 Outpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,949.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-006451 UB-04 · 2026-09-28 | Nathan Tran UHC-26240-33 | 2026-09-19 Outpatient hospital | Meadow GI Associates Gastroenterology · out of network | 45378 | $2,766.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029077 UB-04 · 2026-09-27 | Hiroshi Webb UHC-42260-19 | 2026-08-28 Outpatient hospital | Desert Imaging Center Radiology · in network | 77067 | $256.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-024994 UB-04 · 2026-09-27 | Noah Dixon UHC-37800-54 | 2026-08-28 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 93458 | $9,040.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-002579 UB-04 · 2026-09-27 | Jordan Ellis UHC-92342-99 | 2026-08-27 Emergency room | Harbor Regional Medical Center Emergency Medicine · in network | 96374, 99283 | $1,106.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-030822 UB-04 · 2026-09-24 | Stephanie Ruiz UHC-02243-45 | 2026-08-06 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 43239, 88305, 45378 | $4,244.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-028175 UB-04 · 2026-09-23 | Ahmed Hicks UHC-09142-06 | 2026-08-10 Emergency room | Summit Regional Medical Center Emergency Medicine · in network | 99284, 99285 | $3,474.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-023940 UB-04 · 2026-09-21 | Linda Nelson UHC-41466-73 | 2026-08-13 Inpatient hospital | Desert Internal Medicine Associates Internal Medicine · in network | 99232 | $175.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-012497 UB-04 · 2026-09-21 | Omar Arnold UHC-09544-10 | 2026-08-14 Outpatient hospital | Desert Imaging Center Radiology · in network | 74177, 77067 | $2,256.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003621 UB-04 · 2026-09-15 | Arthur Alexander UHC-11557-51 | 2026-08-01 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · in network | 99283, 96374 | $1,081.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-011920 UB-04 · 2026-09-13 | Sara Cox UHC-33317-40 | 2026-08-23 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 70553, 76700 | $2,603.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-023418 UB-04 · 2026-09-12 | Brenda Garrett UHC-01984-24 | 2026-07-18 Outpatient hospital | Summit Imaging Center Radiology · in network | 70553 | $3,449.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-019371 UB-04 · 2026-09-05 | Nancy Mills UHC-50104-81 | 2026-08-06 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99284, 71046 | $1,405.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-032083 UB-04 · 2026-09-02 | Diane Lewis UHC-27291-77 | 2026-08-02 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 71046 | $126.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-015209 UB-04 · 2026-09-02 | Deborah Holmes UHC-69891-65 | 2026-08-09 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 70553 | $2,965.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-022284 UB-04 · 2026-08-28 | Sharon Olson UHC-00596-77 | 2026-08-11 Outpatient hospital | Sunrise Heart Institute Cardiology · in network | 93015 | $552.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-011655 UB-04 · 2026-08-27 | Andrea Carroll UHC-45950-02 | 2026-07-16 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 93306, 93458 | $6,431.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-005471 UB-04 · 2026-08-27 | Bobby Sanders UHC-87099-72 | 2026-07-21 Outpatient hospital | Mesa Bone and Joint Center Orthopedic Surgery · in network | 73721 | $1,466.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-011178 UB-04 · 2026-08-26 | Morgan Denny UHC-75155-83 | 2026-07-13 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 88305 | $342.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-008808 UB-04 · 2026-08-25 | Catherine Chapman UHC-76419-68 | 2026-06-24 Emergency room | Riverside Community Hospital Emergency Medicine · in network | 96374 | $209.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-031748 UB-04 · 2026-08-20 | Robert Russell UHC-82569-89 | 2026-07-23 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · in network | 71046, 99284 | $1,288.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-003575 UB-04 · 2026-08-19 | Emma Silva UHC-22819-36 | 2026-07-11 Outpatient hospital | Cornerstone Imaging Center Radiology · in network | 74177 | $1,624.00 | — | Left for review REPL CO50 | — | Needs review |
| CLM-2026-018375 UB-04 · 2026-08-17 | Yuki Perkins UHC-55774-23 | 2026-08-06 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $247.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-014886 UB-04 · 2026-08-14 | Mark Evans UHC-79386-51 | 2026-07-21 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93458 | $5,898.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-010355 UB-04 · 2026-08-13 | Samantha Romero UHC-89166-23 | 2026-07-08 Outpatient hospital | Riverside Orthopedic Specialists Orthopedic Surgery · in network | 73721 | $1,530.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-028706 UB-04 · 2026-08-12 | Nancy George UHC-95306-31 | 2026-07-09 Outpatient hospital | Valley Imaging Center Radiology · in network | 74177, 77067 | $1,800.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-017917 UB-04 · 2026-08-12 | Ralph Larson UHC-56641-79 | 2026-07-15 Emergency room | Desert Regional Medical Center Emergency Medicine · in network | 96374, 99284 | $1,973.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-018800 UB-04 · 2026-08-07 | Christina Fields UHC-16525-76 | 2026-06-18 Emergency room | Riverside Community Hospital Emergency Medicine · in network | 71046, 99284 | $1,347.00 | — | Left for review REPL | — | Needs review |
| CLM-2026-029519 UB-04 · 2026-07-30 | Amber Clark UHC-93868-90 | 2026-06-04 Inpatient hospital | Desert Medical Group Internal Medicine · in network | 99232 | $190.00 | — | Left for review REPL | — | 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.