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

What was paid

Check / EFT EFT-20260320-2080

Payment date 20 Mar 2026

Payer Centene

Payee St. Bernard Regional Medical Center

Payee NPI 1558903471

Billed $7,532.36

Allowed $7,532.36

Paid $7,532.36

Patient responsibility $0.00

The remittance matches the allowable on file. No variance identified.

Line detail

Code	Billed	Allowed	Paid	Should have allowed
DRG 190	$7,532.36	$7,532.36	$7,532.36	$7,532.36

835 segments

BPR*I*7532.36*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260320~

TRN*1*3293720879*1680000000~

DTM*405*20260320~

N1*PR*CENTENE~

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

LX*1~

CLP*CLM-0000015*1*7532.36*7532.36**CI*CCN-0149229962*11~