Payment integrity Source document
Centene · payment integrity
Audit queue/ CLM-0000015/ Source document
Back to the audit
Source document

The claim as it was received

Availity clearinghouse · EDI 837I · received 12 Mar 2026 07:27 · 837I_20260312_308047.edi

Received
12 Mar 2026 07:27
Source
Availity clearinghouse · EDI 837I
File
837I_20260312_308047.edi
Interchange control
383163573
Claim control
CCN-0149229962
Storage
az://centene-audit/claims/2026/03/CLM-0000015.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
UNIFORM BILL — UB-04
APPROVED BY NATIONAL UNIFORM BILLING COMMITTEE (NUBC) · CMS-1450
CENTENE
PO BOX 4000
FARMINGTON MO 63640
1
Billing provider
St. Bernard Regional Medical Center
4
Type of bill
111 — inpatient, admit through discharge
6
Statement covers period
03/09/26 through discharge
8b
Patient name
Sepulveda, Elias
12
Admission date
03/09/26
14
Admission type
1 — emergency
17
Patient discharge status
01 — discharged home
47
Total charges
$7,532.36
50
Payer
Centene
56
Billing provider NPI
1558903471
60
Insured's unique id
MBR-40118273
67
Principal diagnosis
J44.1 · POA Y
71
PPS / DRG code
190 — Chronic obstructive pulmonary disease with MCC
76
Attending provider NPI
1558903471
71. PPS / DRG code
Billed DRG 190 — Chronic obstructive pulmonary disease with MCC
Weight 1.1077 × base rate $6,800.00 = $7,532.36
67. Principal and secondary diagnoses
A. J44.1 Chronic obstructive pulmonary disease with acute exacerbation
42. Rev cd 45. Service date POS 44. HCPCS / DRG Modifier E. Dx ptr F. $ charges G. Units J. Rendering NPI
0101 03 09 26 — 03 09 26 21 DRG 190 — A $7,532.36 1 1558903471
47. Total charges $7,532.36
56. Billing provider St. Bernard Regional Medical Center · NPI 1558903471