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

What was paid

Check / EFT EFT-20260331-8845

Payment date 31 Mar 2026

Payer Centene

Payee Northside Clinical Laboratory

Payee NPI 1447706632

Billed $14.49

Allowed $14.49

Paid $14.49

Patient responsibility $0.00

The remittance shows the full $14.49 allowed with no adjustment taken. The audit identified $3.93 that should not have been paid.

Line detail

Code	Billed	Allowed	Paid	Should have allowed
80053	$10.56	$10.56	$10.56	$10.56
82947	$3.93	$3.93	$3.93	$0.00

835 segments

BPR*I*14.49*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260331~

TRN*1*5613157062*1680000000~

DTM*405*20260331~

N1*PR*CENTENE~

N1*PE*NORTHSIDE CLINICAL LABORATORY*XX*1447706632~

LX*1~

CLP*CLM-0000009*1*14.49*14.49**CI*CCN-5362471102*11~