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
3,664
50 with an AI recommendation
Pended
2,586
awaiting information or identity
Approved
23,942
$6,757,768.45 plan paid
Denied
4,454
with remittance reason codes
Examiner decided
0
167 not attached to an identity
| Claim | Member | Service | Provider | Procedures | Billed | Plan pays | Rules | AI | Status |
|---|---|---|---|---|---|---|---|---|---|
| CLM-2026-033650 UB-04 · 2026-10-18 | Anna Knight UHC-17139-80 | 2026-09-06 Outpatient hospital | Northgate Cardiovascular Associates Cardiology · in network | 93015 | $448.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-029120 UB-04 · 2026-10-18 | Ethan Stephens UHC-27099-22 | 2026-09-06 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $239.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-028761 UB-04 · 2026-10-18 | Laura Gonzales UHC-58273-59 | 2026-10-16 Outpatient hospital | Harbor Cardiovascular Associates Cardiology · in network | 93015, 93458 | $10,065.00 | $2,580.79 | Clean approval | — | Approved |
| CLM-2026-028512 UB-04 · 2026-10-18 | Steven Wheeler UHC-11820-74 | 2026-09-27 Inpatient hospital | Canyon Medical Group Internal Medicine · in network | 99232 | $251.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-026930 UB-04 · 2026-10-18 | Cynthia Silva UHC-94337-87 | 2026-10-09 Emergency room | Summit Community Hospital Emergency Medicine · in network | 71046 | $148.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-024838 UB-04 · 2026-10-18 | Gloria Simpson UHC-36962-36 | 2026-10-01 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 77067, 74177 | $2,662.00 | $865.05 | Clean approval | — | Approved |
| CLM-2026-024711 UB-04 · 2026-10-18 | Kenneth Henry UHC-27427-73 | 2026-09-17 Outpatient hospital | Unity Imaging Center Radiology · out of network | 77067, 71046, 76700 | $982.00 | $39.38 | Clean approval | — | Approved |
| CLM-2026-024653 UB-04 · 2026-10-18 | Keith Jones UHC-95396-91 | 2026-09-17 Outpatient hospital | Valley Imaging Center Radiology · in network | 71046, 74177 | $1,959.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-024333 UB-04 · 2026-10-18 | Thomas Walker UHC-98355-06 | 2026-09-15 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 45378, 88305 | $2,964.00 | $1,076.06 | Clean approval | — | Approved |
| CLM-2026-023996 UB-04 · 2026-10-18 | Frank Richards UHC-92254-86 | 2026-09-29 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 96374, 71046 | $468.00 | $122.10 | Clean approval | — | Approved |
| CLM-2026-023366 UB-04 · 2026-10-18 | Paul Marshall UHC-10623-89 | 2026-09-29 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 93015 | $418.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-020927 UB-04 · 2026-10-18 | Lauren Hoffman UHC-16769-64 | 2026-09-11 Outpatient hospital | Evergreen Cardiovascular Associates Cardiology · in network | 93458, 93015 | $5,623.00 | $543.26 | Clean approval | — | Approved |
| CLM-2026-019971 UB-04 · 2026-10-18 | Vincent Bell UHC-71011-63 | 2026-09-15 Outpatient hospital | Valley Digestive Health Center Gastroenterology · in network | 88305, 43239 | $2,936.00 | $354.44 | Clean approval | — | Approved |
| CLM-2026-018696 UB-04 · 2026-10-18 | Kyle Garcia UHC-39892-95 | 2026-09-06 Outpatient hospital | Canyon GI Associates Gastroenterology · in network | 88305, 43239, 45378 | $4,748.00 | $1,426.52 | Clean approval | — | Approved |
| CLM-2026-018059 UB-04 · 2026-10-18 | Donald Gonzales UHC-12549-84 | 2026-09-16 Emergency room | Riverside Regional Medical Center Emergency Medicine · out of network | 99284, 99283 | $2,310.00 | $789.50 | Clean approval | — | Approved |
| CLM-2026-017571 UB-04 · 2026-10-18 | Jeffrey Wagner UHC-02624-89 | 2026-09-16 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 45378, 88305 | $3,102.00 | $1,056.89 | Clean approval | — | Approved |
| CLM-2026-014844 UB-04 · 2026-10-18 | Albert Alvarez UHC-42353-95 | 2026-09-28 Outpatient hospital | Summit Heart Institute Cardiology · in network | 93306, 93015, 93458 | $11,010.00 | $3,937.05 | Clean approval | — | Approved |
| CLM-2026-014084 UB-04 · 2026-10-18 | Sean Young UHC-33599-32 | 2026-09-10 Outpatient hospital | Sunrise Bone and Joint Center Orthopedic Surgery · in network | 73721 | $2,073.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-014054 UB-04 · 2026-10-18 | Danielle Gomez UHC-89338-09 | 2026-09-11 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 71046 | $141.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-012388 UB-04 · 2026-10-18 | Catherine Simpson UHC-22875-45 | 2026-09-18 Outpatient hospital | Sunrise Cardiovascular Associates Cardiology · in network | 93458, 93015 | $9,810.00 | $4,160.71 | Clean approval | — | Approved |
| CLM-2026-012213 UB-04 · 2026-10-18 | Joyce Hunt UHC-86921-20 | 2026-10-05 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 99285 | $2,901.00 | $955.45 | Clean approval | — | Approved |
| CLM-2026-010644 UB-04 · 2026-10-18 | Zachary Baker UHC-62292-08 | 2026-09-09 Outpatient hospital | Evergreen Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $9,591.00 | $1,952.59 | Clean approval | — | Approved |
| CLM-2026-006143 UB-04 · 2026-10-18 | Emma McDonald UHC-14703-77 | 2026-10-05 Outpatient hospital | Lakeside Orthopedic Specialists Orthopedic Surgery · in network | 29881 | $8,786.00 | $3,046.11 | Clean approval | — | Approved |
| CLM-2026-005878 UB-04 · 2026-10-18 | Sara Welch UHC-01909-90 | 2026-09-24 Emergency room | Riverside Community Hospital Emergency Medicine · in network | 96374, 99284 | $1,809.00 | $910.25 | Clean approval | — | Approved |
| CLM-2026-005773 UB-04 · 2026-10-18 | Emily Silva UHC-43687-71 | 2026-09-30 Outpatient hospital | Riverside Diagnostic Imaging Radiology · in network | 74177 | $2,419.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-004489 UB-04 · 2026-10-18 | Thomas Walker UHC-98355-06 | 2026-09-25 Outpatient hospital | Summit Diagnostic Imaging Radiology · in network | 77067, 76700 | $759.00 | $105.86 | Clean approval | — | Approved |
| CLM-2026-004454 UB-04 · 2026-10-18 | Madison Chavez UHC-00823-42 | 2026-09-11 Outpatient hospital | Mesa Orthopedic Specialists Orthopedic Surgery · out of network | 29881 | $8,215.00 | $2,195.72 | Clean approval | — | Approved |
| CLM-2026-003431 UB-04 · 2026-10-18 | Emily Palmer UHC-80821-83 | 2026-09-08 Outpatient hospital | Pinecrest Heart Institute Cardiology · in network | 93458 | $5,465.00 | $888.96 | Clean approval | — | Approved |
| CLM-2026-002928 UB-04 · 2026-10-18 | Roy Burns UHC-22217-24 | 2026-09-07 Inpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 99232 | $178.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-002847 UB-04 · 2026-10-18 | Philip Bradley UHC-47879-82 | 2026-09-11 Outpatient hospital | Sunrise Imaging Center Radiology · out of network | 71046 | $114.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-002598 UB-04 · 2026-10-18 | Lawrence Ellis UHC-63165-77 | 2026-09-26 Emergency room | Sunrise Community Hospital Emergency Medicine · out of network | 96374 | $246.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-001442 UB-04 · 2026-10-18 | Sophia Howell UHC-51733-01 | 2026-09-26 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 43239, 45378, 88305 | $4,193.00 | $1,058.91 | Clean approval | — | Approved |
| CLM-2026-032950 UB-04 · 2026-10-17 | Charlotte Sanchez UHC-10300-72 | 2026-09-23 Emergency room | Valley Community Hospital Emergency Medicine · out of network | 99283 | $890.00 | $50.50 | Clean approval | — | Approved |
| CLM-2026-032764 UB-04 · 2026-10-17 | Diana Williamson UHC-93292-52 | 2026-10-07 Outpatient hospital | Canyon Diagnostic Imaging Radiology · in network | 71046 | $172.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-032717 UB-04 · 2026-10-17 | Victoria Padilla UHC-84331-08 | 2026-09-27 Outpatient hospital | Pinecrest Diagnostic Imaging Radiology · in network | 76700, 71046 | $614.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-031465 UB-04 · 2026-10-17 | Steven Guzman UHC-15163-18 | 2026-10-01 Outpatient hospital | Valley Imaging Center Radiology · in network | 71046 | $143.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-030816 UB-04 · 2026-10-17 | Carl Smith UHC-10143-60 | 2026-10-02 Outpatient hospital | Heritage Digestive Health Center Gastroenterology · in network | 45378 | $2,697.00 | $154.38 | Clean approval | — | Approved |
| CLM-2026-027168 UB-04 · 2026-10-17 | Sharon Patterson UHC-01025-68 | 2026-10-07 Emergency room | Heritage Community Hospital Emergency Medicine · in network | 99283, 71046 | $1,247.00 | $535.85 | Clean approval | — | Approved |
| CLM-2026-026667 UB-04 · 2026-10-17 | Vincent Castillo UHC-39871-55 | 2026-10-13 Inpatient hospital | Northgate Internal Medicine Associates Internal Medicine · in network | 99232 | $203.00 | $10.80 | Clean approval | — | Approved |
| CLM-2026-025168 UB-04 · 2026-10-17 | Justin Gordon UHC-82612-26 | 2026-09-13 Emergency room | Pinecrest Regional Medical Center Emergency Medicine · out of network | 99283, 99284, 99285 | $4,063.00 | $1,678.35 | Clean approval | — | Approved |
| CLM-2026-024880 UB-04 · 2026-10-17 | Ruth Dunn UHC-79382-41 | 2026-09-24 Inpatient hospital | Cornerstone Internal Medicine Associates Internal Medicine · in network | 99232 | $189.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-022494 UB-04 · 2026-10-17 | Juan Jimenez UHC-84918-36 | 2026-09-06 Emergency room | Summit Community Hospital Emergency Medicine · in network | 71046 | $242.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-020933 UB-04 · 2026-10-17 | Julie Alvarez UHC-08988-72 | 2026-09-04 Outpatient hospital | Riverside Digestive Health Center Gastroenterology · in network | 45378 | $2,116.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-017884 UB-04 · 2026-10-17 | Wallace Betty UHC-94593-87 | 2026-09-03 Outpatient hospital | Meadow GI Associates Gastroenterology · in network | 88305 | $290.00 | $0.00 | Clean approval | — | Approved |
| CLM-2026-017001 UB-04 · 2026-10-17 | Bryan Guerrero UHC-44575-81 | 2026-10-06 Emergency room | Summit Community Hospital Emergency Medicine · in network | 99283, 71046 | $928.00 | $260.40 | Clean approval | — | Approved |
| CLM-2026-015855 UB-04 · 2026-10-17 | Ana Banks UHC-54583-90 | 2026-09-25 Outpatient hospital | Sunrise Diagnostic Imaging Radiology · in network | 70553, 74177, 71046 | $3,749.00 | $1,067.71 | Clean approval | — | Approved |
| CLM-2026-013988 UB-04 · 2026-10-17 | James Chen UHC-30142-52 | 2026-09-19 Outpatient hospital | Canyon Heart Institute Cardiology · out of network | 93306, 93458 | $7,222.00 | $2,457.84 | Clean approval | — | Approved |
| CLM-2026-009993 UB-04 · 2026-10-17 | Martha Medina UHC-68694-09 | 2026-09-03 Emergency room | Summit Community Hospital Emergency Medicine · in network | 99283 | $1,016.00 | $208.80 | Clean approval | — | Approved |
| CLM-2026-009152 UB-04 · 2026-10-17 | Logan Gonzales UHC-19729-25 | 2026-09-30 Outpatient hospital | Meadow Bone and Joint Center Orthopedic Surgery · in network | 73721, 29881 | $9,620.00 | $1,398.66 | Clean approval | — | Approved |
| CLM-2026-007331 UB-04 · 2026-10-17 | Hiroshi Powell UHC-87923-96 | 2026-10-02 Outpatient hospital | Mesa GI Associates Gastroenterology · in network | 88305 | $348.00 | $0.00 | Clean approval | — | Approved |
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.