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Audit queue/ CLM-0000021/ Source document
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Source document

The claim as it was received

Availity clearinghouse · EDI 837P · received 22 Mar 2026 11:31 · 837P_20260322_476306.edi

Received
22 Mar 2026 11:31
Source
Availity clearinghouse · EDI 837P
File
837P_20260322_476306.edi
Interchange control
594212022
Claim control
CCN-0387126116
Storage
az://centene-audit/claims/2026/03/CLM-0000021.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 CMS-1500 (02/12) As received Fax image, 200 dpi EDI 837P 005010X222A1 Remittance EDI 835
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
CENTENE
PO BOX 4000
FARMINGTON MO 63640
1a
Insured's ID number
MBR-30772614
2
Patient's name
Castellanos, Rowan
3
Patient's birth date / sex
—— (not disclosed on this demo)
4
Insured's name
Same as patient
11
Insured's policy group
Medicare Advantage
12
Patient's signature
Signature on file
17
Referring provider
—
21
Diagnosis or nature of illness
A. C34.90
28
Total charge
$8,069.76
29
Amount paid
$0.00
31
Signature of physician
Bayou Oncology Associates
32
Service facility
Bayou Oncology Associates
33
Billing provider
Bayou Oncology Associates · NPI 1427809359
21. Diagnosis or nature of illness or injury
A. C34.90 Malignant neoplasm of bronchus or lung, unspecified
24A. Date(s) of service B. POS D. CPT/HCPCS Modifier E. Dx ptr F. $ charges G. Units J. Rendering NPI
03 19 26 — 03 19 26 11 J9299 — A $8,069.76 240 1427809359
28. Total charge $8,069.76
33. Billing provider Bayou Oncology Associates · NPI 1427809359