The claim as it was received

Availity clearinghouse · EDI 837P · received 05 Mar 2026 12:32 · 837P_20260305_419779.edi

Received

05 Mar 2026 12:32

Source

Availity clearinghouse · EDI 837P

File

837P_20260305_419779.edi

Interchange control

230770141

Claim control

CCN-1750151357

Storage

az://centene-audit/claims/2026/03/CLM-0000010.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-20260317-0205

Payment date 17 Mar 2026

Payer Centene

Payee Lakeview Surgical Group

Payee NPI 1902334815

Billed $67.71

Allowed $67.71

Paid $67.71

Patient responsibility $0.00

The remittance matches the allowable on file. No variance identified.

Line detail

Code	Billed	Allowed	Paid	Should have allowed
20610	$67.71	$67.71	$67.71	$67.71

835 segments

BPR*I*67.71*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260317~

TRN*1*5502842750*1680000000~

DTM*405*20260317~

N1*PR*CENTENE~

N1*PE*LAKEVIEW SURGICAL GROUP*XX*1902334815~

LX*1~

CLP*CLM-0000010*1*67.71*67.71**CI*CCN-1750151357*11~