The claim as it was received

Availity clearinghouse · EDI 837P · received 19 Mar 2026 10:35 · 837P_20260319_045583.edi

Received

19 Mar 2026 10:35

Source

Availity clearinghouse · EDI 837P

File

837P_20260319_045583.edi

Interchange control

224770140

Claim control

CCN-3640582125

Storage

az://centene-audit/claims/2026/03/CLM-0000011.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-20260330-2558

Payment date 30 Mar 2026

Payer Centene

Payee Cypress Family Care Associates

Payee NPI 1223887640

Billed $10.56

Allowed $10.56

Paid $10.56

Patient responsibility $0.00

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

Line detail

Code	Billed	Allowed	Paid	Should have allowed
80053	$10.56	$10.56	$10.56	$10.56

835 segments

BPR*I*10.56*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260330~

TRN*1*5058258500*1680000000~

DTM*405*20260330~

N1*PR*CENTENE~

N1*PE*CYPRESS FAMILY CARE ASSOCIATES*XX*1223887640~

LX*1~

CLP*CLM-0000011*1*10.56*10.56**CI*CCN-3640582125*11~