Payment integrity Source document
Centene · payment integrity
Audit queue/ CLM-0000020/ Source document
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Source document

The claim as it was received

Availity clearinghouse · EDI 837I · received 29 Mar 2026 12:05 · 837I_20260329_688841.edi

Received
29 Mar 2026 12:05
Source
Availity clearinghouse · EDI 837I
File
837I_20260329_688841.edi
Interchange control
023030101
Claim control
CCN-9705306276
Storage
az://centene-audit/claims/2026/03/CLM-0000020.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-20260401-3334
Payment date 01 Apr 2026
Payer Centene
Payee Gulf Coast General Hospital
Payee NPI 1770448209
Billed $5,787.93
Allowed $5,787.93
Paid $5,787.93
Patient responsibility $0.00
The remittance matches the allowable on file. No variance identified.

Line detail

CodeBilled AllowedPaid Should have allowed
DRG 690 $5,787.93 $5,787.93 $5,787.93 $5,787.93

835 segments

BPR*I*5787.93*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260401~
TRN*1*5850920647*1680000000~
DTM*405*20260401~
N1*PR*CENTENE~
N1*PE*GULF COAST GENERAL HOSPITAL*XX*1770448209~
LX*1~
CLP*CLM-0000020*1*5787.93*5787.93**CI*CCN-9705306276*11~