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Audit queue/ CLM-0000004/ Source document
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Source document

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
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
CENTENE
PO BOX 4000
FARMINGTON MO 63640
1a
Insured's ID number
MBR-30558129
2
Patient's name
Ruiz, Alma
3
Patient's birth date / sex
—— (not disclosed on this demo)
4
Insured's name
Same as patient
11
Insured's policy group
Medicaid · TX STAR
12
Patient's signature
Signature on file
17
Referring provider
—
21
Diagnosis or nature of illness
A. M17.11
28
Total charge
$135.42
29
Amount paid
$0.00
31
Signature of physician
Cypress Family Care Associates
32
Service facility
Cypress Family Care Associates
33
Billing provider
Cypress Family Care Associates · NPI 1223887640
21. Diagnosis or nature of illness or injury
A. M17.11 Unilateral primary osteoarthritis, right knee
24A. Date(s) of service B. POS D. CPT/HCPCS Modifier E. Dx ptr F. $ charges G. Units J. Rendering NPI
03 11 26 — 03 11 26 11 20610 — A $135.42 2 1223887640
28. Total charge $135.42
33. Billing provider Cypress Family Care Associates · NPI 1223887640