Payment integrity Source document
Centene · payment integrity
Audit queue/ CLM-0000006/ Source document
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Source document

The claim as it was received

Availity clearinghouse · EDI 837P · received 16 Mar 2026 14:14 · 837P_20260316_032275.edi

Received
16 Mar 2026 14:14
Source
Availity clearinghouse · EDI 837P
File
837P_20260316_032275.edi
Interchange control
540521316
Claim control
CCN-3739131173
Storage
az://centene-audit/claims/2026/03/CLM-0000006.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-20260328-1123
Payment date 28 Mar 2026
Payer Centene
Payee Lakeview Surgical Group
Payee NPI 1902334815
Billed $512.88
Allowed $512.88
Paid $512.88
Patient responsibility $0.00
The remittance matches the allowable on file. No variance identified.

Line detail

CodeBilled AllowedPaid Should have allowed
29881 $512.88 $512.88 $512.88 $512.88

835 segments

BPR*I*512.88*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260328~
TRN*1*4432532535*1680000000~
DTM*405*20260328~
N1*PR*CENTENE~
N1*PE*LAKEVIEW SURGICAL GROUP*XX*1902334815~
LX*1~
CLP*CLM-0000006*1*512.88*512.88**CI*CCN-3739131173*11~