Payment integrity Source document
Centene · payment integrity
Audit queue/ CLM-0000014/ Source document
Back to the audit
Source document

The claim as it was received

Availity clearinghouse · EDI 837I · received 08 Mar 2026 10:10 · 837I_20260308_534426.edi

Received
08 Mar 2026 10:10
Source
Availity clearinghouse · EDI 837I
File
837I_20260308_534426.edi
Interchange control
304180815
Claim control
CCN-3131452049
Storage
az://centene-audit/claims/2026/03/CLM-0000014.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

837P transaction, as received

ISA*00* *00* *ZZ*AVAILITY *ZZ*CENTENE *260308*1010*^*00501*304180815*0*P*:~ Interchange header — submitter, receiver, control number
GS*HC*AVAILITY*CENTENE*20260308*1010*449345*X*005010X223A2~ Functional group — health care claim, 837I version
ST*837*5182*005010X223A2~ Transaction set header
BHT*0019*00*349081*20260308*1010*CH~ Beginning of hierarchical transaction — CH = chargeable
NM1*41*2*AVAILITY LLC*****46*AV01~ Submitter
NM1*40*2*CENTENE*****46*68069~ Receiver
HL*1**20*1~ Billing provider hierarchical level
NM1*85*2*GULF COAST GENERAL HOSPITAL*****XX*1770448209~ Billing provider — NPI 1770448209
N3*1 MEDICAL PLAZA~ Billing provider address
N4*HOUSTON*TX*77002~ Billing provider city / state / ZIP
REF*EI*541391235~ Employer identification number
PRV*BI*PXC*207R00000X~ Taxonomy — Acute Care Hospital
HL*2*1*22*0~ Subscriber hierarchical level
SBR*P*18*******CI~ Subscriber — primary, self, commercial insurance
NM1*IL*1*HALLORAN*RHYS****MI*MBR-90248117~ Subscriber — member id MBR-90248117
N3*100 MAIN STREET~ Subscriber address
N4*HOUSTON*TX*77002~ Subscriber city / state / ZIP
NM1*PR*2*CENTENE*****PI*68069~ Payer
CLM*CLM-0000014*13888.88***111:A:1*Y*A*Y*I~ Claim — total charge $13,888.88, type of bill 111 (inpatient)
HI*ABK:A419~ Diagnoses — ABK principal, ABF secondary, decimals removed
HI*DR:871~ DRG 871 — Septicemia or severe sepsis without MV >96 hours with MCC
LX*1~ Service line 1
SV2*0101*HC:DRG871*13888.88*UN*1~ DRG 871 — revenue code 0101, charged $13,888.88
DTP*472*D8*20260305~ Date of service 05 Mar 2026
SE*23*5182~ Transaction set trailer — segment count from ST to SE
GE*1*449345~ Functional group trailer
IEA*1*304180815~ Interchange trailer