The claim as it was received

Availity clearinghouse · EDI 837P · received 07 Mar 2026 07:41 · 837P_20260307_947511.edi

Received

07 Mar 2026 07:41

Source

Availity clearinghouse · EDI 837P

File

837P_20260307_947511.edi

Interchange control

303454063

Claim control

CCN-1855355009

Storage

az://centene-audit/claims/2026/03/CLM-0000002.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-20260319-1755

Payment date 19 Mar 2026

Payer Centene

Payee Dr. Jane Smith

Payee NPI 1234567890

Billed $94.22

Allowed $94.22

Paid $94.22

Patient responsibility $0.00

The remittance matches the allowable on file. No variance identified.

Line detail

Code	Billed	Allowed	Paid	Should have allowed
99213	$94.22	$94.22	$94.22	$94.22

835 segments

BPR*I*94.22*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260319~

TRN*1*1429446433*1680000000~

DTM*405*20260319~

N1*PR*CENTENE~

N1*PE*DR. JANE SMITH*XX*1234567890~

LX*1~

CLP*CLM-0000002*1*94.22*94.22**CI*CCN-1855355009*11~