The claim as it was received

Availity clearinghouse · EDI 837I · received 15 Mar 2026 13:22 · 837I_20260315_215209.edi

Received

15 Mar 2026 13:22

Source

Availity clearinghouse · EDI 837I

File

837I_20260315_215209.edi

Interchange control

424524031

Claim control

CCN-7008944956

Storage

az://centene-audit/claims/2026/03/CLM-0000013.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 UB-04 (CMS-1450) As received Fax image, 200 dpi EDI 837I 005010X223A2 Remittance EDI 835

What was paid

Check / EFT EFT-20260402-1934

Payment date 02 Apr 2026

Payer Centene

Payee St. Bernard Regional Medical Center

Payee NPI 1558903471

Billed $8,729.84

Allowed $8,729.84

Paid $8,729.84

Patient responsibility $0.00

The remittance shows the full $8,729.84 allowed with no adjustment taken. The audit identified $2,956.64 that should not have been paid.

Line detail

Code	Billed	Allowed	Paid	Should have allowed
DRG 291	$8,729.84	$8,729.84	$8,729.84	$5,773.20

835 segments

BPR*I*8729.84*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260402~

TRN*1*6030277589*1680000000~

DTM*405*20260402~

N1*PR*CENTENE~

N1*PE*ST. BERNARD REGIONAL MEDICAL CENTER*XX*1558903471~

LX*1~

CLP*CLM-0000013*1*8729.84*8729.84**CI*CCN-7008944956*11~