Payment integrity
Source document
Centene · payment integrity
Source document
The claim as it was received
Availity clearinghouse · EDI 837P · received 09 Mar 2026 12:46 · 837P_20260309_124934.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.
FROM: NORTHSIDE CLINICAL LABORATORY TO: CENTENE CLAIMS
09 Mar 2026 12:46 P.001
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
CENTENE
PO BOX 4000
FARMINGTON MO 63640
PO BOX 4000
FARMINGTON MO 63640
1a
Insured's ID number
MBR-88240117
2
Patient's name
Ellery, Marcus
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. D64.9
28
Total charge
$7.77
29
Amount paid
$0.00
31
Signature of physician
Northside Clinical Laboratory
32
Service facility
Northside Clinical Laboratory
33
Billing provider
Northside Clinical Laboratory · NPI 1447706632
21. Diagnosis or nature of illness or injury
A.
D64.9
Anemia, unspecified
| 24A. Date(s) of service | B. POS | D. CPT/HCPCS | Modifier | E. Dx ptr | F. $ charges | G. Units | J. Rendering NPI |
|---|---|---|---|---|---|---|---|
| 03 06 26 — 03 06 26 | 11 | 85025 | — | A | $7.77 | 1 | 1447706632 |
28. Total charge
$7.77
33. Billing provider
Northside Clinical Laboratory · NPI 1447706632
A rendering of the same generated claim with fax artefacts applied — not an image of a real document. Nothing in this demo is scanned from anywhere.