The claim as it was received

Availity clearinghouse · EDI 837P · received 14 Mar 2026 11:16 · 837P_20260314_602993.edi

Received

14 Mar 2026 11:16

Source

Availity clearinghouse · EDI 837P

File

837P_20260314_602993.edi

Interchange control

603230890

Claim control

CCN-3910990557

Storage

az://centene-audit/claims/2026/03/CLM-0000004.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-20260327-3029

Payment date 27 Mar 2026

Payer Centene

Payee Cypress Family Care Associates

Payee NPI 1223887640

Billed $135.42

Allowed $135.42

Paid $135.42

Patient responsibility $0.00

The remittance shows the full $135.42 allowed with no adjustment taken. The audit identified $67.71 that should not have been paid.

Line detail

Code	Billed	Allowed	Paid	Should have allowed
20610	$135.42	$135.42	$135.42	$67.71

835 segments

BPR*I*135.42*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260327~

TRN*1*5204925222*1680000000~

DTM*405*20260327~

N1*PR*CENTENE~

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

LX*1~

CLP*CLM-0000004*1*135.42*135.42**CI*CCN-3910990557*11~