Payment integrity Source document
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Audit queue/ CLM-0000016/ Source document
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Source document

The claim as it was received

Availity clearinghouse · EDI 837I · received 06 Mar 2026 09:55 · 837I_20260306_095164.edi

Received
06 Mar 2026 09:55
Source
Availity clearinghouse · EDI 837I
File
837I_20260306_095164.edi
Interchange control
550015650
Claim control
CCN-2094625727
Storage
az://centene-audit/claims/2026/03/CLM-0000016.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

837P transaction, as received

ISA*00* *00* *ZZ*AVAILITY *ZZ*CENTENE *260306*0955*^*00501*550015650*0*P*:~ Interchange header — submitter, receiver, control number
GS*HC*AVAILITY*CENTENE*20260306*0955*625421*X*005010X223A2~ Functional group — health care claim, 837I version
ST*837*3344*005010X223A2~ Transaction set header
BHT*0019*00*051037*20260306*0955*CH~ Beginning of hierarchical transaction — CH = chargeable
NM1*41*2*AVAILITY LLC*****46*AV01~ Submitter
NM1*40*2*CENTENE*****46*68069~ Receiver
HL*1**20*1~ Billing provider hierarchical level
NM1*85*2*GULF COAST GENERAL HOSPITAL*****XX*1770448209~ Billing provider — NPI 1770448209
N3*1 MEDICAL PLAZA~ Billing provider address
N4*HOUSTON*TX*77002~ Billing provider city / state / ZIP
REF*EI*803782904~ Employer identification number
PRV*BI*PXC*207R00000X~ Taxonomy — Acute Care Hospital
HL*2*1*22*0~ Subscriber hierarchical level
SBR*P*18*******CI~ Subscriber — primary, self, commercial insurance
NM1*IL*1*ACHEBE*NADIA****MI*MBR-62094418~ Subscriber — member id MBR-62094418
N3*100 MAIN STREET~ Subscriber address
N4*HOUSTON*TX*77002~ Subscriber city / state / ZIP
NM1*PR*2*CENTENE*****PI*68069~ Payer
CLM*CLM-0000016*13791.64***111:A:1*Y*A*Y*I~ Claim — total charge $13,791.64, type of bill 111 (inpatient)
HI*ABK:M1611~ Diagnoses — ABK principal, ABF secondary, decimals removed
HI*DR:470~ DRG 470 — Major hip and knee joint replacement without MCC
LX*1~ Service line 1
SV2*0101*HC:DRG470*13791.64*UN*1~ DRG 470 — revenue code 0101, charged $13,791.64
DTP*472*D8*20260303~ Date of service 03 Mar 2026
SE*23*3344~ Transaction set trailer — segment count from ST to SE
GE*1*625421~ Functional group trailer
IEA*1*550015650~ Interchange trailer