Payment integrity Source document
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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
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
03/26/26 through discharge
8b
Patient name
Thackeray, Colette
12
Admission date
03/26/26
14
Admission type
1 — emergency
17
Patient discharge status
01 — discharged home
47
Total charges
$5,787.93
50
Payer
Centene
56
Billing provider NPI
1770448209
60
Insured's unique id
MBR-77105293
67
Principal diagnosis
N39.0 · POA Y
71
PPS / DRG code
690 — Kidney and urinary tract infections without MCC
76
Attending provider NPI
1770448209
71. PPS / DRG code
Billed DRG 690 — Kidney and urinary tract infections without MCC
Weight 0.8095 × base rate $7,150.00 = $5,787.93
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 26 26 — 03 26 26 21 DRG 690 — A $5,787.93 1 1770448209
47. Total charges $5,787.93
56. Billing provider Gulf Coast General Hospital · NPI 1770448209