Payment integrity Source document
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Audit queue/ CLM-0000008/ Source document
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Source document

The claim as it was received

Availity clearinghouse · EDI 837P · received 23 Mar 2026 08:16 · 837P_20260323_174013.edi

Received
23 Mar 2026 08:16
Source
Availity clearinghouse · EDI 837P
File
837P_20260323_174013.edi
Interchange control
210017053
Claim control
CCN-1436910325
Storage
az://centene-audit/claims/2026/03/CLM-0000008.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-64220913
2
Patient's name
Adeyemi, Amara
3
Patient's birth date / sex
—— (not disclosed on this demo)
4
Insured's name
Same as patient
11
Insured's policy group
Behavioral health
12
Patient's signature
Signature on file
17
Referring provider
—
21
Diagnosis or nature of illness
A. F33.1
28
Total charge
$152.44
29
Amount paid
$0.00
31
Signature of physician
Meridian Counseling Services
32
Service facility
Meridian Counseling Services
33
Billing provider
Meridian Counseling Services · NPI 1660271934
21. Diagnosis or nature of illness or injury
A. F33.1 Major depressive disorder, recurrent, moderate
24A. Date(s) of service B. POS D. CPT/HCPCS Modifier E. Dx ptr F. $ charges G. Units J. Rendering NPI
03 20 26 — 03 20 26 11 90837 — A $152.44 1 1660271934
28. Total charge $152.44
33. Billing provider Meridian Counseling Services · NPI 1660271934