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-2026-021920 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-2026-014845 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-2026-006860 UB-04 · 2026-10-30 | Sara Wallace UHC-78913-28 | 2026-09-23 Outpatient hospital | Summit Digestive Health Center Gastroenterology · in network | 45378, 43239 | $3,976.00 | — | Left for review DUP | — | Needs review |
| 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-2026-009207 UB-04 · 2026-10-28 | Samantha Morris UHC-72872-02 | 2026-10-06 Outpatient hospital | Northgate Heart Institute Cardiology · in network | 93306, 93458 | $9,899.00 | — | Left for review DUP | — | 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-2026-025027 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-2026-033244 UB-04 · 2026-10-25 | Joan Hoffman UHC-38218-33 | 2026-09-18 Emergency room | Cornerstone Regional Medical Center Emergency Medicine · in network | 99284, 99283, 96374 | $2,659.00 | — | Left for review DUP | — | Needs review |
| 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-2026-034095 UB-04 · 2026-10-24 | Jacqueline Black no member ID | 2026-09-27 Outpatient hospital | Riverside Imaging Center Radiology · in network | 74177, 77067 | $1,850.00 | — | Pended by rule IDQ N30 | — | Pended |
| 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-2026-027220 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-2026-002070 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-2026-033650 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-2026-031883 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-2026-029120 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-2026-025618 UB-04 · 2026-10-18 | Janet Delgado UHC-86657-86 | 2026-10-13 Outpatient hospital | Cornerstone Digestive Health Center Gastroenterology · in network | 43239, 88305 | $1,736.00 | — | Left for review CO16 | — | Needs review |
| 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-2026-024368 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-2026-024333 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-2026-024099 UB-04 · 2026-10-18 | Roger Bennett UHC-51537-03 | 2026-10-11 Outpatient hospital | Evergreen Digestive Health Center Gastroenterology · in network | 70553 | $3,498.00 | — | Left for review CO50 | — | Needs review |
| 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-2026-023996 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-2026-023616 UB-04 · 2026-10-18 | Tyler Carter UHC-34633-94 | 2026-09-11 Outpatient hospital | Canyon Primary Care Associates Family Medicine · in network | 70553 | $3,097.00 | — | Left for review CO50 | — | Needs review |
| 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-2026-023208 UB-04 · 2026-10-18 | Austin Li UHC-41620-28 | 2026-09-03 Outpatient hospital | Canyon Regional Medical Center Emergency Medicine · in network | 70553 | $2,294.00 | — | Left for review CO50 | — | Needs review |
| 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-2026-020927 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-2026-018689 UB-04 · 2026-10-18 | Gabriel Sanders UHC-13138-62 | 2026-09-06 Outpatient hospital | Mesa Internal Medicine Associates Internal Medicine · in network | 70553 | $2,621.00 | — | Left for review CO50 | — | Needs review |
| 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-2026-017328 UB-04 · 2026-10-18 | Jerry Edwards UHC-51204-16 | 2026-09-15 Outpatient hospital | Lakeside Internal Medicine Associates Internal Medicine · in network | 70553 | $2,954.00 | — | Left for review CO50 | — | Needs review |
| CLM-2026-016730 UB-04 · 2026-10-18 | Kathlean Silva UHC-59277-27 | 2026-09-12 Outpatient hospital | Pinecrest Bone and Joint Center Orthopedic Surgery · in network | 70553 | $3,592.00 | — | Left for review CO50 | — | 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 REPL490
- 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.