Payment integrity Source document
Centene · payment integrity
Audit queue/ CLM-0000016/ Source document
Back to the audit
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

What was paid

Check / EFT EFT-20260320-9672
Payment date 20 Mar 2026
Payer Centene
Payee Gulf Coast General Hospital
Payee NPI 1770448209
Billed $13,791.64
Allowed $13,791.64
Paid $13,791.64
Patient responsibility $0.00
The remittance matches the allowable on file. No variance identified.

Line detail

CodeBilled AllowedPaid Should have allowed
DRG 470 $13,791.64 $13,791.64 $13,791.64 $13,791.64

835 segments

BPR*I*13791.64*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260320~
TRN*1*2894543819*1680000000~
DTM*405*20260320~
N1*PR*CENTENE~
N1*PE*GULF COAST GENERAL HOSPITAL*XX*1770448209~
LX*1~
CLP*CLM-0000016*1*13791.64*13791.64**CI*CCN-2094625727*11~