Payment integrity
Source document
Centene · payment integrity
Source document
The claim as it was received
Availity clearinghouse · EDI 837I · received 12 Mar 2026 07:27 · 837I_20260312_308047.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: ST. BERNARD REGIONAL MEDICAL CENTER TO: CENTENE CLAIMS
12 Mar 2026 07:27 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
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
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.