The claim as it was received

Availity clearinghouse · EDI 837P · received 30 Mar 2026 06:39 · 837P_20260330_454243.edi

Received

30 Mar 2026 06:39

Source

Availity clearinghouse · EDI 837P

File

837P_20260330_454243.edi

Interchange control

233143425

Claim control

CCN-9525401133

Storage

az://centene-audit/claims/2026/03/CLM-0000005.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-20260401-0991

Payment date 01 Apr 2026

Payer Centene

Payee Dr. Jane Smith

Payee NPI 1234567890

Billed $133.60

Allowed $133.60

Paid $133.60

Patient responsibility $0.00

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

Line detail

Code	Billed	Allowed	Paid	Should have allowed
99214	$133.60	$133.60	$133.60	$133.60

835 segments

BPR*I*133.60*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260401~

TRN*1*3723620079*1680000000~

DTM*405*20260401~

N1*PR*CENTENE~

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

LX*1~

CLP*CLM-0000005*1*133.60*133.60**CI*CCN-9525401133*11~