Payment integrity
Source document
Centene · payment integrity
Source document
The claim as it was received
Availity clearinghouse · EDI 837P · received 08 Mar 2026 11:24 · 837P_20260308_495425.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.
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-64220518
2
Patient's name
Okafor, Nnamdi
3
Patient's birth date / sex
—— (not disclosed on this demo)
4
Insured's name
Same as patient
11
Insured's policy group
Medicaid
12
Patient's signature
Signature on file
17
Referring provider
—
21
Diagnosis or nature of illness
A. M54.50
28
Total charge
$254.18
29
Amount paid
$0.00
31
Signature of physician
Gulf Coast Diagnostic Imaging
32
Service facility
Gulf Coast Diagnostic Imaging
33
Billing provider
Gulf Coast Diagnostic Imaging · NPI 1558830274
21. Diagnosis or nature of illness or injury
A.
M54.50
Low back pain, unspecified
| 24A. Date(s) of service | B. POS | D. CPT/HCPCS | Modifier | E. Dx ptr | F. $ charges | G. Units | J. Rendering NPI |
|---|---|---|---|---|---|---|---|
| 03 05 26 — 03 05 26 | 11 | 72148 | — | A | $254.18 | 1 | 1558830274 |
28. Total charge
$254.18
33. Billing provider
Gulf Coast Diagnostic Imaging · NPI 1558830274