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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
UNIFORM BILL — UB-04
APPROVED BY NATIONAL UNIFORM BILLING COMMITTEE (NUBC) · CMS-1450
CENTENE
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
03/14/26 through discharge
8b
Patient name
Vance, Oscar
12
Admission date
03/14/26
14
Admission type
1 — emergency
17
Patient discharge status
01 — discharged home
47
Total charges
$5,504.60
50
Payer
Centene
56
Billing provider NPI
1558903471
60
Insured's unique id
MBR-51730962
67
Principal diagnosis
N39.0 · POA Y
71
PPS / DRG code
690 — Kidney and urinary tract infections without MCC
76
Attending provider NPI
1558903471
71. PPS / DRG code
Billed DRG 690 — Kidney and urinary tract infections without MCC
Weight 0.8095 × base rate $6,800.00 = $5,504.60
67. Principal and secondary diagnoses
A. N39.0 Urinary tract infection, site not specified
42. Rev cd 45. Service date POS 44. HCPCS / DRG Modifier E. Dx ptr F. $ charges G. Units J. Rendering NPI
0101 03 14 26 — 03 14 26 21 DRG 690 — A $5,504.60 1 1558903471
47. Total charges $5,504.60
56. Billing provider St. Bernard Regional Medical Center · NPI 1558903471