Payment integrity Source document
Centene · payment integrity
Audit queue/ CLM-0000014/ Source document
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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

What was paid

Check / EFT EFT-20260325-2534
Payment date 25 Mar 2026
Payer Centene
Payee Gulf Coast General Hospital
Payee NPI 1770448209
Billed $13,888.88
Allowed $13,888.88
Paid $13,888.88
Patient responsibility $0.00
The remittance shows the full $13,888.88 allowed with no adjustment taken. The audit identified $6,572.28 that should not have been paid.

Line detail

CodeBilled AllowedPaid Should have allowed
DRG 871 $13,888.88 $13,888.88 $13,888.88 $7,316.60

835 segments

BPR*I*13888.88*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260325~
TRN*1*6516304075*1680000000~
DTM*405*20260325~
N1*PR*CENTENE~
N1*PE*GULF COAST GENERAL HOSPITAL*XX*1770448209~
LX*1~
CLP*CLM-0000014*1*13888.88*13888.88**CI*CCN-3131452049*11~