Payment integrity Source document
Centene · payment integrity
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

What was paid

Check / EFT EFT-20260325-4538
Payment date 25 Mar 2026
Payer Centene
Payee St. Bernard Regional Medical Center
Payee NPI 1558903471
Billed $5,504.60
Allowed $5,504.60
Paid $5,504.60
Patient responsibility $0.00
The remittance matches the allowable on file. No variance identified.

Line detail

CodeBilled AllowedPaid Should have allowed
DRG 690 $5,504.60 $5,504.60 $5,504.60 $5,504.60

835 segments

BPR*I*5504.60*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260325~
TRN*1*3505352284*1680000000~
DTM*405*20260325~
N1*PR*CENTENE~
N1*PE*ST. BERNARD REGIONAL MEDICAL CENTER*XX*1558903471~
LX*1~
CLP*CLM-0000017*1*5504.60*5504.60**CI*CCN-3113691360*11~