Payment integrity Source document
Centene · payment integrity
Audit queue/ CLM-0000022/ Source document
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Source document

The claim as it was received

Availity clearinghouse · EDI 837P · received 13 Mar 2026 11:45 · 837P_20260313_454373.edi

Received
13 Mar 2026 11:45
Source
Availity clearinghouse · EDI 837P
File
837P_20260313_454373.edi
Interchange control
055534300
Claim control
CCN-4820574827
Storage
az://centene-audit/claims/2026/03/CLM-0000022.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

What was paid

Check / EFT EFT-20260324-5101
Payment date 24 Mar 2026
Payer Centene
Payee Sunbelt Imaging Center
Payee NPI 1709942365
Billed $316.97
Allowed $316.97
Paid $316.97
Patient responsibility $0.00
The remittance matches the allowable on file. No variance identified.

Line detail

CodeBilled AllowedPaid Should have allowed
70553 $316.97 $316.97 $316.97 $316.97

835 segments

BPR*I*316.97*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260324~
TRN*1*5513526113*1680000000~
DTM*405*20260324~
N1*PR*CENTENE~
N1*PE*SUNBELT IMAGING CENTER*XX*1709942365~
LX*1~
CLP*CLM-0000022*1*316.97*316.97**CI*CCN-4820574827*11~