The claim as it was received

Availity clearinghouse · EDI 837P · received 08 Mar 2026 11:24 · 837P_20260308_495425.edi

Received

08 Mar 2026 11:24

Source

Availity clearinghouse · EDI 837P

File

837P_20260308_495425.edi

Interchange control

938380411

Claim control

CCN-7610575933

Storage

az://centene-audit/claims/2026/03/CLM-0000025.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-20260319-8642

Payment date 19 Mar 2026

Payer Centene

Payee Gulf Coast Diagnostic Imaging

Payee NPI 1558830274

Billed $254.18

Allowed $254.18

Paid $254.18

Patient responsibility $0.00

The remittance shows the full $254.18 allowed with no adjustment taken. The audit identified $254.18 that should not have been paid.

Line detail

Code	Billed	Allowed	Paid	Should have allowed
72148	$254.18	$254.18	$254.18	$0.00

835 segments

BPR*I*254.18*C*ACH*CCP*01*061000104*DA*0000*1234567890**01*021000021*DA*9876543210*20260319~

TRN*1*1150023518*1680000000~

DTM*405*20260319~

N1*PR*CENTENE~

N1*PE*GULF COAST DIAGNOSTIC IMAGING*XX*1558830274~

LX*1~

CLP*CLM-0000025*1*254.18*254.18**CI*CCN-7610575933*11~