The claim as it was received

Availity clearinghouse · EDI 837P · received 12 Mar 2026 10:07 · 837P_20260312_710559.edi

Received

12 Mar 2026 10:07

Source

Availity clearinghouse · EDI 837P

File

837P_20260312_710559.edi

Interchange control

090320120

Claim control

CCN-3311605593

Storage

az://centene-audit/claims/2026/03/CLM-0000003.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-20260324-3415

Payment date 24 Mar 2026

Payer Centene

Payee Cypress Family Care Associates

Payee NPI 1223887640

Billed $16.03

Allowed $16.03

Paid $16.03

Patient responsibility $0.00

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

Line detail

Code	Billed	Allowed	Paid	Should have allowed
93000	$16.03	$16.03	$16.03	$16.03

835 segments

BPR*I*16.03*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260324~

TRN*1*6250321768*1680000000~

DTM*405*20260324~

N1*PR*CENTENE~

N1*PE*CYPRESS FAMILY CARE ASSOCIATES*XX*1223887640~

LX*1~

CLP*CLM-0000003*1*16.03*16.03**CI*CCN-3311605593*11~