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Audit queue/ CLM-0000010/ Source document
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Source document

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
FROM: LAKEVIEW SURGICAL GROUP   TO: CENTENE CLAIMS   05 Mar 2026 12:32   P.001
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-30112447
2
Patient's name
Lindqvist, Maren
3
Patient's birth date / sex
—— (not disclosed on this demo)
4
Insured's name
Same as patient
11
Insured's policy group
Marketplace
12
Patient's signature
Signature on file
17
Referring provider
—
21
Diagnosis or nature of illness
A. M17.11
28
Total charge
$67.71
29
Amount paid
$0.00
31
Signature of physician
Lakeview Surgical Group
32
Service facility
Lakeview Surgical Group
33
Billing provider
Lakeview Surgical Group · NPI 1902334815
21. Diagnosis or nature of illness or injury
A. M17.11 Unilateral primary osteoarthritis, right knee
24A. Date(s) of service B. POS D. CPT/HCPCS Modifier E. Dx ptr F. $ charges G. Units J. Rendering NPI
03 02 26 — 03 02 26 11 20610 — A $67.71 1 1902334815
28. Total charge $67.71
33. Billing provider Lakeview Surgical Group · NPI 1902334815

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.