Payment integrity
Source document
Centene · payment integrity
Source document
The claim as it was received
Availity clearinghouse · EDI 837P · received 28 Mar 2026 13:46 · 837P_20260328_592055.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.
FROM: DR. JANE SMITH TO: CENTENE CLAIMS
28 Mar 2026 13:46 P.001
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
CENTENE
PO BOX 4000
FARMINGTON MO 63640
PO BOX 4000
FARMINGTON MO 63640
1a
Insured's ID number
MBR-12345
2
Patient's name
Whitfield, Jordan
3
Patient's birth date / sex
—— (not disclosed on this demo)
4
Insured's name
Same as patient
11
Insured's policy group
Marketplace
12
Patient's signature
Signature on file
17
Referring provider
—
21
Diagnosis or nature of illness
A. Z00.00
28
Total charge
$4,280.00
29
Amount paid
$0.00
31
Signature of physician
Dr. Jane Smith
32
Service facility
Dr. Jane Smith
33
Billing provider
Dr. Jane Smith · NPI 1234567890
21. Diagnosis or nature of illness or injury
A.
Z00.00
Encounter for general adult medical examination without abnormal findings
| 24A. Date(s) of service | B. POS | D. CPT/HCPCS | Modifier | E. Dx ptr | F. $ charges | G. Units | J. Rendering NPI |
|---|---|---|---|---|---|---|---|
| 03 25 26 — 03 25 26 | 11 | 99215 | — | A | $4,280.00 | 1 | 1234567890 |
28. Total charge
$4,280.00
33. Billing provider
Dr. Jane Smith · NPI 1234567890
A rendering of the same generated claim with fax artefacts applied — not an image of a real document. Nothing in this demo is scanned from anywhere.