Payment integrity
Source document
Centene · payment integrity
Source document
The claim as it was received
Availity clearinghouse · EDI 837I · received 08 Mar 2026 10:10 · 837I_20260308_534426.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.
FROM: GULF COAST GENERAL HOSPITAL TO: CENTENE CLAIMS
08 Mar 2026 10:10 P.001
UNIFORM BILL — UB-04
APPROVED BY NATIONAL UNIFORM BILLING COMMITTEE (NUBC) · CMS-1450
CENTENE
PO BOX 4000
FARMINGTON MO 63640
PO BOX 4000
FARMINGTON MO 63640
1
Billing provider
Gulf Coast General Hospital
4
Type of bill
111 — inpatient, admit through discharge
6
Statement covers period
03/05/26 through discharge
8b
Patient name
Halloran, Rhys
12
Admission date
03/05/26
14
Admission type
1 — emergency
17
Patient discharge status
01 — discharged home
47
Total charges
$13,888.88
50
Payer
Centene
56
Billing provider NPI
1770448209
60
Insured's unique id
MBR-90248117
67
Principal diagnosis
A41.9 · POA Y
71
PPS / DRG code
871 — Septicemia or severe sepsis without MV >96 hours with MCC
76
Attending provider NPI
1770448209
71. PPS / DRG code
Billed
DRG 871
— Septicemia or severe sepsis without MV >96 hours with MCC
Weight
1.9425
× base rate $7,150.00
= $13,888.88
Should be
DRG 872
— Septicemia or severe sepsis without MV >96 hours without MCC ·
weight 1.0233
= $7,316.60
67. Principal and secondary diagnoses
A.
A41.9
Sepsis, unspecified organism
| 42. Rev cd | 45. Service date | POS | 44. HCPCS / DRG | Modifier | E. Dx ptr | F. $ charges | G. Units | J. Rendering NPI |
|---|---|---|---|---|---|---|---|---|
| 0101 | 03 05 26 — 03 05 26 | 21 | DRG 871 | — | A | $13,888.88 | 1 | 1770448209 |
47. Total charges
$13,888.88
56. Billing provider
Gulf Coast General Hospital · NPI 1770448209
A rendering of the same generated claim with fax artefacts applied — not an image of a real document. Nothing in this demo is scanned from anywhere.