The claim as it was received

Availity clearinghouse · EDI 837P · received 26 Mar 2026 12:27 · 837P_20260326_041179.edi

Received

26 Mar 2026 12:27

Source

Availity clearinghouse · EDI 837P

File

837P_20260326_041179.edi

Interchange control

215351309

Claim control

CCN-2355554142

Storage

az://centene-audit/claims/2026/03/CLM-0000023.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-20260401-5475

Payment date 01 Apr 2026

Payer Centene

Payee Rio Grande Diagnostic Imaging

Payee NPI 1288556172

Billed $191.72

Allowed $191.72

Paid $191.72

Patient responsibility $0.00

The remittance matches the allowable on file. No variance identified.

Line detail

Code	Billed	Allowed	Paid	Should have allowed
72148	$191.72	$191.72	$191.72	$191.72

835 segments

BPR*I*191.72*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260401~

TRN*1*5302055152*1680000000~

DTM*405*20260401~

N1*PR*CENTENE~

N1*PE*RIO GRANDE DIAGNOSTIC IMAGING*XX*1288556172~

LX*1~

CLP*CLM-0000023*1*191.72*191.72**CI*CCN-2355554142*11~