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Audit queue/ CLM-0000019/ Source document
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Source document

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
UNIFORM BILL — UB-04
APPROVED BY NATIONAL UNIFORM BILLING COMMITTEE (NUBC) · CMS-1450
CENTENE
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
03/21/26 through discharge
8b
Patient name
Novak, Viktor
12
Admission date
03/21/26
14
Admission type
1 — emergency
17
Patient discharge status
01 — discharged home
47
Total charges
$7,920.05
50
Payer
Centene
56
Billing provider NPI
1770448209
60
Insured's unique id
MBR-29471085
67
Principal diagnosis
J44.1 · POA Y
71
PPS / DRG code
190 — Chronic obstructive pulmonary disease with MCC
76
Attending provider NPI
1770448209
71. PPS / DRG code
Billed DRG 190 — Chronic obstructive pulmonary disease with MCC
Weight 1.1077 × base rate $7,150.00 = $7,920.05
67. Principal and secondary diagnoses
A. J44.1 Chronic obstructive pulmonary disease with acute exacerbation
42. Rev cd 45. Service date POS 44. HCPCS / DRG Modifier E. Dx ptr F. $ charges G. Units J. Rendering NPI
0101 03 21 26 — 03 21 26 21 DRG 190 — A $7,920.05 1 1770448209
47. Total charges $7,920.05
56. Billing provider Gulf Coast General Hospital · NPI 1770448209