The claim as it was received

Availity clearinghouse · EDI 837I · received 24 Mar 2026 09:42 · 837I_20260324_083334.edi

Received

24 Mar 2026 09:42

Source

Availity clearinghouse · EDI 837I

File

837I_20260324_083334.edi

Interchange control

404219429

Claim control

CCN-8482925002

Storage

az://centene-audit/claims/2026/03/CLM-0000019.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-20260401-3163

Payment date 01 Apr 2026

Payer Centene

Payee Gulf Coast General Hospital

Payee NPI 1770448209

Billed $7,920.05

Allowed $7,920.05

Paid $7,920.05

Patient responsibility $0.00

The remittance matches the allowable on file. No variance identified.

Line detail

Code	Billed	Allowed	Paid	Should have allowed
DRG 190	$7,920.05	$7,920.05	$7,920.05	$7,920.05

835 segments

BPR*I*7920.05*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260401~

TRN*1*0743680128*1680000000~

DTM*405*20260401~

N1*PR*CENTENE~

N1*PE*GULF COAST GENERAL HOSPITAL*XX*1770448209~

LX*1~

CLP*CLM-0000019*1*7920.05*7920.05**CI*CCN-8482925002*11~