Payment integrity
Source document
Centene · payment integrity
Source document
The claim as it was received
Availity clearinghouse · EDI 837I · received 10 Mar 2026 10:02 · 837I_20260310_471834.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.
FROM: GULF COAST GENERAL HOSPITAL TO: CENTENE CLAIMS
10 Mar 2026 10:02 P.001
UNIFORM BILL — UB-04
APPROVED BY NATIONAL UNIFORM BILLING COMMITTEE (NUBC) · CMS-1450
CENTENE
PO BOX 4000
FARMINGTON MO 63640
PO BOX 4000
FARMINGTON MO 63640
1
Billing provider
Gulf Coast General Hospital
4
Type of bill
111 — inpatient, admit through discharge
6
Statement covers period
03/07/26 through discharge
8b
Patient name
Marchetti, Lena
12
Admission date
03/07/26
14
Admission type
1 — emergency
17
Patient discharge status
01 — discharged home
47
Total charges
$7,012.01
50
Payer
Centene
56
Billing provider NPI
1770448209
60
Insured's unique id
MBR-38820174
67
Principal diagnosis
K92.2 · POA Y
71
PPS / DRG code
378 — Gastrointestinal haemorrhage with CC
76
Attending provider NPI
1770448209
71. PPS / DRG code
Billed
DRG 378
— Gastrointestinal haemorrhage with CC
Weight
0.9807
× base rate $7,150.00
= $7,012.01
67. Principal and secondary diagnoses
A.
K92.2
Gastrointestinal haemorrhage, unspecified
| 42. Rev cd | 45. Service date | POS | 44. HCPCS / DRG | Modifier | E. Dx ptr | F. $ charges | G. Units | J. Rendering NPI |
|---|---|---|---|---|---|---|---|---|
| 0101 | 03 07 26 — 03 07 26 | 21 | DRG 378 | — | A | $7,012.01 | 1 | 1770448209 |
47. Total charges
$7,012.01
56. Billing provider
Gulf Coast General Hospital · NPI 1770448209
A rendering of the same generated claim with fax artefacts applied — not an image of a real document. Nothing in this demo is scanned from anywhere.