Payment integrity Source document
Centene · payment integrity
Audit queue/ CLM-0000001/ Source document
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Source document

The claim as it was received

Availity clearinghouse · EDI 837P · received 28 Mar 2026 13:46 · 837P_20260328_592055.edi

Received
28 Mar 2026 13:46
Source
Availity clearinghouse · EDI 837P
File
837P_20260328_592055.edi
Interchange control
500520143
Claim control
CCN-0134662955
Storage
az://centene-audit/claims/2026/03/CLM-0000001.edi

Generated from the claim record on request — no file is stored. The storage path above is the hook for real blob storage; once wired it is what would be handed to the agent's document_uri input.

Claim form CMS-1500 (02/12) As received Fax image, 200 dpi EDI 837P 005010X222A1 Remittance EDI 835

What was paid

Check / EFT EFT-20260402-8444
Payment date 02 Apr 2026
Payer Centene
Payee Dr. Jane Smith
Payee NPI 1234567890
Billed $4,280.00
Allowed $4,280.00
Paid $4,280.00
Patient responsibility $0.00
The remittance shows the full $4,280.00 allowed with no adjustment taken. The audit identified $4,089.23 that should not have been paid.

Line detail

CodeBilled AllowedPaid Should have allowed
99215 $4,280.00 $4,280.00 $4,280.00 $190.77

835 segments

BPR*I*4280.00*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260402~
TRN*1*5115533168*1680000000~
DTM*405*20260402~
N1*PR*CENTENE~
N1*PE*DR. JANE SMITH*XX*1234567890~
LX*1~
CLP*CLM-0000001*1*4280.00*4280.00**CI*CCN-0134662955*11~