Payment integrity
Source document
Centene · payment integrity
Source document
The claim as it was received
Availity clearinghouse · EDI 837P · received 27 Feb 2026 08:31 · 837P_20260227_391599.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.
FROM: BAYOU ONCOLOGY ASSOCIATES TO: CENTENE CLAIMS
27 Feb 2026 08:31 P.001
HEALTH INSURANCE CLAIM FORM
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
CENTENE
PO BOX 4000
FARMINGTON MO 63640
PO BOX 4000
FARMINGTON MO 63640
1a
Insured's ID number
MBR-30884201
2
Patient's name
Ferreira, Noor
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. C50.911
28
Total charge
$3,083.85
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.
C50.911
Malignant neoplasm of right female breast, unspecified site
| 24A. Date(s) of service | B. POS | D. CPT/HCPCS | Modifier | E. Dx ptr | F. $ charges | G. Units | J. Rendering NPI |
|---|---|---|---|---|---|---|---|
| 02 24 26 — 02 24 26 | 11 | J9355 | — | A | $3,083.85 | 42 | 1427809359 |
28. Total charge
$3,083.85
33. Billing provider
Bayou Oncology Associates · NPI 1427809359
A rendering of the same generated claim with fax artefacts applied — not an image of a real document. Nothing in this demo is scanned from anywhere.