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-2026-031883 UB-04 · 2026-10-18 | Gary Rodriguez UHC-65603-12 | 2026-09-08 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $36,915.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-024097 UB-04 · 2026-10-18 | Christine Wright UHC-27440-91 | 2026-09-15 Outpatient hospital | Heritage Digestive Health Center Gastroenterology · in network | 45378, 88305 | $1,824.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-022851 UB-04 · 2026-10-18 | Pamela Tran UHC-95837-67 | 2026-04-02 Outpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 29881 | $8,489.00 | — | Denied by rule CO29 | — | 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-2026-013424 UB-04 · 2026-10-18 | Jordan Thomas UHC-00688-86 | 2026-04-19 Emergency room | Mesa Regional Medical Center Emergency Medicine · out of network | 71046, 99285 | $2,289.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-012577 UB-04 · 2026-10-18 | Steven Brooks UHC-72425-74 | 2026-09-25 Outpatient hospital | Pinecrest Cardiovascular Associates Cardiology · in network | 93458 | $7,698.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-006554 UB-04 · 2026-10-18 | Doris Alvarez UHC-77452-71 | 2026-10-12 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 43239, 88305 | $2,152.00 | — | Denied by rule CO204 | — | 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-2026-004216 UB-04 · 2026-10-18 | Alexander Reid UHC-77022-69 | 2026-09-16 Outpatient hospital | Lakeside Imaging Center Radiology · in network | 71046, 70553 | $3,057.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-003164 UB-04 · 2026-10-18 | Nancy Wong UHC-74984-66 | 2026-09-13 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 88305, 45378 | $2,851.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-002809 UB-04 · 2026-10-18 | Olivia Armstrong UHC-25797-48 | 2026-05-27 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458, 93015 | $5,527.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-001208 UB-04 · 2026-10-18 | Alexander Robertson UHC-20832-08 | 2026-09-29 Outpatient hospital | Cornerstone Bone and Joint Center Orthopedic Surgery · in network | 29881 | $10,651.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-030671 UB-04 · 2026-10-17 | Peter Lane UHC-22452-89 | 2026-09-28 Inpatient hospital | Lakeside Bone and Joint Center Orthopedic Surgery · in network | 27447 | $35,985.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-022113 UB-04 · 2026-10-17 | Maria Moore UHC-93684-85 | 2026-10-07 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 76700, 74177 | $1,965.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-015188 UB-04 · 2026-10-17 | Jacqueline Willis UHC-69078-97 | 2026-09-29 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 76700, 74177 | $2,395.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-014444 UB-04 · 2026-10-17 | Helen Park UHC-24378-23 | 2026-09-18 Outpatient hospital | Harbor Medical Group Internal Medicine · out of network | 70553 | $2,002.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-004662 UB-04 · 2026-10-17 | Juan Franklin UHC-92188-10 | 2026-09-05 Outpatient hospital | Meadow Heart Institute Cardiology · in network | 93306, 93015 | $1,817.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-030553 UB-04 · 2026-10-16 | Valentina Olson UHC-29563-18 | 2026-09-11 Outpatient hospital | Meadow Heart Institute Cardiology · out of network | 93306 | $1,458.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-029645 UB-04 · 2026-10-16 | Marilyn Wallace UHC-97767-95 | 2026-09-01 Outpatient hospital | Evergreen Diagnostic Imaging Radiology · in network | 70553, 77067, 74177 | $4,854.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-024279 UB-04 · 2026-10-16 | William Webb UHC-11907-97 | 2026-09-08 Outpatient hospital | Sunrise Community Hospital Emergency Medicine · out of network | 70553 | $1,854.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-017831 UB-04 · 2026-10-16 | Gabriel Payne no member ID | 2026-09-23 Outpatient hospital | Sunrise Imaging Center Radiology · in network | 74177, 71046 | $2,565.00 | — | Denied by rule CO197 | — | 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-2026-007243 UB-04 · 2026-10-16 | Jesse Alexander UHC-98335-18 | 2026-10-08 Outpatient hospital | Unity Imaging Center Radiology · out of network | 70553, 71046 | $3,684.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-027414 UB-04 · 2026-10-15 | Gregory Hunt UHC-84710-60 | 2026-09-23 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 29881 | $6,359.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-025650 UB-04 · 2026-10-15 | Rachel Lopez UHC-43524-49 | 2026-10-02 Inpatient hospital | Cornerstone Orthopedic Specialists Orthopedic Surgery · out of network | 27447 | $35,527.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-018854 UB-04 · 2026-10-15 | Gloria Yang UHC-77975-62 | 2026-10-07 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 93458, 93306 | $10,394.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-007944 UB-04 · 2026-10-15 | Ryan Walker UHC-79552-94 | 2026-05-28 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283, 71046 | $1,287.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-004719 UB-04 · 2026-10-15 | Douglas Harris UHC-15357-52 | 2026-10-07 Inpatient hospital | Riverside Bone and Joint Center Orthopedic Surgery · out of network | 27447 | $39,961.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-003579 UB-04 · 2026-10-15 | Albert Tran no member ID | 2026-09-10 Outpatient hospital | Evergreen GI Associates Gastroenterology · in network | 45378 | $2,026.00 | — | Denied by rule CO197 | — | Denied |
| CLM-2026-000582 UB-04 · 2026-10-15 | Arjun Santos UHC-17803-51 | 2026-09-03 Outpatient hospital | Sunrise Digestive Health Center Gastroenterology · out of network | 45378 | $1,676.00 | — | Denied by rule CO204 | — | Denied |
| CLM-2026-034029 UB-04 · 2026-10-14 | Ryan Li UHC-59343-89 | 2026-06-24 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 88305 | $352.00 | — | Denied by rule CO29 | — | Denied |
| CLM-2026-029540 UB-04 · 2026-10-14 | Mary Munz UHC-13183-92 | 2026-10-10 Outpatient hospital | Heritage GI Associates Gastroenterology · in network | 43239, 45378 | $4,347.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-026234 UB-04 · 2026-10-14 | Victoria Richards UHC-93067-18 | 2026-09-04 Outpatient hospital | Cornerstone Imaging Center Radiology · in network | 77067, 74177, 71046 | $2,873.00 | — | Denied by rule CO27 | — | Denied |
| CLM-2026-024818 UB-04 · 2026-10-14 | Aisha Nguyen UHC-89751-57 | 2026-09-10 Outpatient hospital | Northgate Imaging Center Radiology · out of network | 76700 | $396.00 | — | Denied by rule CO204 | — | 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.