Payment integrity Source document
Centene · payment integrity
Audit queue/ CLM-0000012/ Source document
Back to the audit
Source document

The claim as it was received

Availity clearinghouse · EDI 837P · received 02 Apr 2026 10:23 · 837P_20260402_194514.edi

Received
02 Apr 2026 10:23
Source
Availity clearinghouse · EDI 837P
File
837P_20260402_194514.edi
Interchange control
382383062
Claim control
CCN-3422575697
Storage
az://centene-audit/claims/2026/04/CLM-0000012.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
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-71904288
2
Patient's name
Halloran, Neve
3
Patient's birth date / sex
—— (not disclosed on this demo)
4
Insured's name
Same as patient
11
Insured's policy group
Behavioral health
12
Patient's signature
Signature on file
17
Referring provider
—
21
Diagnosis or nature of illness
A. F33.1
28
Total charge
$304.88
29
Amount paid
$0.00
31
Signature of physician
Meridian Counseling Services
32
Service facility
Meridian Counseling Services
33
Billing provider
Meridian Counseling Services · NPI 1660271934
21. Diagnosis or nature of illness or injury
A. F33.1 Major depressive disorder, recurrent, moderate
24A. Date(s) of service B. POS D. CPT/HCPCS Modifier E. Dx ptr F. $ charges G. Units J. Rendering NPI
03 30 26 — 03 30 26 11 90837 — A $304.88 2 1660271934
28. Total charge $304.88
33. Billing provider Meridian Counseling Services · NPI 1660271934