Payment integrity Source document
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Audit queue/ CLM-0000017/ Source document
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Source document

The claim as it was received

Availity clearinghouse · EDI 837I · received 17 Mar 2026 07:21 · 837I_20260317_481293.edi

Received
17 Mar 2026 07:21
Source
Availity clearinghouse · EDI 837I
File
837I_20260317_481293.edi
Interchange control
121703464
Claim control
CCN-3113691360
Storage
az://centene-audit/claims/2026/03/CLM-0000017.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 *260317*0721*^*00501*121703464*0*P*:~ Interchange header — submitter, receiver, control number
GS*HC*AVAILITY*CENTENE*20260317*0721*511749*X*005010X223A2~ Functional group — health care claim, 837I version
ST*837*4450*005010X223A2~ Transaction set header
BHT*0019*00*631591*20260317*0721*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*ST. BERNARD REGIONAL MEDICAL CENTER*****XX*1558903471~ Billing provider — NPI 1558903471
N3*1 MEDICAL PLAZA~ Billing provider address
N4*HOUSTON*TX*77002~ Billing provider city / state / ZIP
REF*EI*759445292~ 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*VANCE*OSCAR****MI*MBR-51730962~ Subscriber — member id MBR-51730962
N3*100 MAIN STREET~ Subscriber address
N4*HOUSTON*TX*77002~ Subscriber city / state / ZIP
NM1*PR*2*CENTENE*****PI*68069~ Payer
CLM*CLM-0000017*5504.60***111:A:1*Y*A*Y*I~ Claim — total charge $5,504.60, type of bill 111 (inpatient)
HI*ABK:N390~ Diagnoses — ABK principal, ABF secondary, decimals removed
HI*DR:690~ DRG 690 — Kidney and urinary tract infections without MCC
LX*1~ Service line 1
SV2*0101*HC:DRG690*5504.60*UN*1~ DRG 690 — revenue code 0101, charged $5,504.60
DTP*472*D8*20260314~ Date of service 14 Mar 2026
SE*23*4450~ Transaction set trailer — segment count from ST to SE
GE*1*511749~ Functional group trailer
IEA*1*121703464~ Interchange trailer