Payment integrity Source document
Centene · payment integrity
Audit queue/ CLM-0000009/ Source document
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Source document

The claim as it was received

Availity clearinghouse · EDI 837P · received 21 Mar 2026 06:32 · 837P_20260321_435639.edi

Received
21 Mar 2026 06:32
Source
Availity clearinghouse · EDI 837P
File
837P_20260321_435639.edi
Interchange control
135969315
Claim control
CCN-5362471102
Storage
az://centene-audit/claims/2026/03/CLM-0000009.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

837P transaction, as received

ISA*00* *00* *ZZ*AVAILITY *ZZ*CENTENE *260321*0632*^*00501*135969315*0*P*:~ Interchange header — submitter, receiver, control number
GS*HC*AVAILITY*CENTENE*20260321*0632*405355*X*005010X222A1~ Functional group — health care claim, 837P version
ST*837*6666*005010X222A1~ Transaction set header
BHT*0019*00*517311*20260321*0632*CH~ Beginning of hierarchical transaction — CH = chargeable
NM1*41*2*AVAILITY LLC*****46*AV01~ Submitter
NM1*40*2*CENTENE*****46*68069~ Receiver
HL*1**20*1~ Billing provider hierarchical level
NM1*85*2*NORTHSIDE CLINICAL LABORATORY*****XX*1447706632~ Billing provider — NPI 1447706632
N3*1 MEDICAL PLAZA~ Billing provider address
N4*HOUSTON*TX*77002~ Billing provider city / state / ZIP
REF*EI*531293150~ Employer identification number
PRV*BI*PXC*291U00000X~ Taxonomy — Clinical Laboratory
HL*2*1*22*0~ Subscriber hierarchical level
SBR*P*18*******CI~ Subscriber — primary, self, commercial insurance
NM1*IL*1*OKAFOR*DANIEL****MI*MBR-51902264~ Subscriber — member id MBR-51902264
N3*100 MAIN STREET~ Subscriber address
N4*HOUSTON*TX*77002~ Subscriber city / state / ZIP
NM1*PR*2*CENTENE*****PI*68069~ Payer
CLM*CLM-0000009*14.49***11:B:1*Y*A*Y*I~ Claim — total charge $14.49, place of service 11 (office)
HI*ABK:E119~ Diagnoses — ABK principal, ABF secondary, decimals removed
LX*1~ Service line 1
SV1*HC:80053*10.56*UN*1***1~ 80053 — charged $10.56, 1 unit
DTP*472*D8*20260318~ Date of service 18 Mar 2026
LX*2~ Service line 2
SV1*HC:82947*3.93*UN*1***1~ 82947 — charged $3.93, 1 unit
DTP*472*D8*20260318~ Date of service 18 Mar 2026
SE*25*6666~ Transaction set trailer — segment count from ST to SE
GE*1*405355~ Functional group trailer
IEA*1*135969315~ Interchange trailer