Payment integrity Source document
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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
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-50913377
2
Patient's name
Delacroix, Imani
3
Patient's birth date / sex
—— (not disclosed on this demo)
4
Insured's name
Same as patient
11
Insured's policy group
Marketplace
12
Patient's signature
Signature on file
17
Referring provider
—
21
Diagnosis or nature of illness
A. G43.109
28
Total charge
$316.97
29
Amount paid
$0.00
31
Signature of physician
Sunbelt Imaging Center
32
Service facility
Sunbelt Imaging Center
33
Billing provider
Sunbelt Imaging Center · NPI 1709942365
21. Diagnosis or nature of illness or injury
A. G43.109 Migraine with aura, intractable, without status migrainosus
24A. Date(s) of service B. POS D. CPT/HCPCS Modifier E. Dx ptr F. $ charges G. Units J. Rendering NPI
03 10 26 — 03 10 26 11 70553 — A $316.97 1 1709942365
28. Total charge $316.97
33. Billing provider Sunbelt Imaging Center · NPI 1709942365