Verdict Claims Explorer — Verdict Consulting Group

Claim Identification

Patient Name: ROOSEVELT, ELEANOR
Service Date: 2022-10-11
DRG Code: 153.0
Claim ID: CLM-2022-41780
Service Line Number: 6
Patient Control Number: AA00000
Payer Control Number: 0000000000C00X00
Line Control Number: 1

Claim Status Indicator Code: 1
Filing Indicator Code: HM
Frequency Type Code: 1
Transaction Type: 835
Transaction Control Number: C00000E00000000
PCS Claim Number: 0000000000C00X
Claim Origin: PACIFIC REGIONAL
Payer: KEYSTONE NATIONAL

Patient Information

First Name: ELEANOR
Last Name: ROOSEVELT
Middle Name: N/A
Patient Control Number: AA00000
Patient Identification Type: MEMBER_ID
Patient Identifier: AAA000000000
Corrected Patient ID Type: N/A
Corrected Patient Identifier: N/A

Financial Details

Total Claim Charges: $27,410
Total Payment Amount: $10,285
Coverage Amount: $3,563
Line Charge Amount: $6,476
Line Paid Amount: $2,430
Line Allowed Amount: $1,418
Line Total Adjustment: $4,046
Underpayment: $9,316
Payment Rate: 37.52%
Patient Responsibility: $861
Payment Date: 2022-11-06
Payment Method: ACH
Check / Ref Trace Number: C00000E00000000

Service Details

Service Date From: 2022-10-11
Service Date To: 2022-10-11

Statement Date From: 2022-10-11
Statement Date To: 2022-10-11

Production Date: 2022-11-04
Filing Indicator: HM

Quantity: N/A
Line Unit Count: 1.0

PCS (Provider Claim Summary) Details

2 Records

PCS Record 1 of 2OUT-PATIENTPACIFIC REGIONAL (PAC-RGN)Claim #: 0000000000C00X

Patient

ELEANOR ROOSEVELT

Patient No

AA00000

Admit Date

N/A

From Date

2022-10-11

Group-Sub No

000000-ABC000000

End Date

2022-10-11

Claim Type

00/00/00

Days/TRT	DRG Code	Provider Charge	Other Payable / Withhold	Facility Allowable	Adjusted Prov Charge	Managed Care Deductions	Total Amount Paid
00001	153	$27,410	$23,573	$3,563	$3,563	$0	$10,285

Messages / ReasonsL4

Contract Deductible / Copay$861

Provider Number0000000000

Total Deductions / Other Ineligible$861

Tax ID00-0000000

Patient's Share$861

Source Document

DTMU_D000000_0000000_000.pdf

Pages: 17 - 0 · Extracted: 1/1/2026

PCS Record 2 of 2OUT-PATIENTPACIFIC REGIONAL (PAC-RGN)Claim #: 0000000000C00X

Patient

ELEANOR ROOSEVELT

Patient No

AA00000

Admit Date

N/A

From Date

2022-10-11

Group-Sub No

000000-ABC000000

End Date

2022-10-11

Claim Type

00/00/00

Days/TRT	DRG Code	Provider Charge	Other Payable / Withhold	Facility Allowable	Adjusted Prov Charge	Managed Care Deductions	Total Amount Paid
00001	153	$11,512	$9,868	$1,645	$1,645	$0	$4,320

Messages / ReasonsL4

Contract Deductible / Copay$362

Provider Number0000000000

Total Deductions / Other Ineligible$362

Tax ID00-0000000

Patient's Share$362

Source Document

DTMU_D000000_0000000_000.pdf

Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI

Control Number

C00000E00000000

Payment Date

2022-11-06

Payment Method

ACH

Check / EFT

EFT000000

Payer

KEYSTONE NATIONAL

Payer Contact

1-800-555-0182

Total Submitted Charges

$27,410

Net Total Paid

$10,285

Segments

Segment	Description
ISA00 00 ZZVERDICT ZZPAYER01	Interchange Control Header
GSHPVERDICTPAYER012025012914301023X005010X221A1	Functional Group Header
ST8350001	Transaction Set Header — Health Care Claim Payment/Advice
BPRI10285.00CACHCCP010000000000DA9876541512345678*010000000000DA987654	Financial Information
TRN100000040*0000000000	Reassociation Trace Number
DTM40520221011	Production Date
N1PRKEYSTONE NATIONAL	Payer Identification
N1PELAKESIDE MEDICAL CENTERXX0000000000	Payee Identification
LX*1	Header Number
CLPCLM-2022-41780127410.0010285.00861.00HM00000011	Claim Payment Information
NM1QC1ROOSEVELTELEANOR	Patient Name
SE420001	Transaction Set Trailer

837 Original Claim Submission

EDI

Control Number

S000000000A

Submission Date

2022-10-14

Billing Provider

LAKESIDE MEDICAL CENTER

Tax ID

00-0000000

Total Charges

$27,410

Filing Indicator

Frequency Type

Transaction Set

005010X222A1

Segments

Segment	Description
ISA00 00 ZZVERDICT ZZPAYER01	Interchange Control Header
GSHCVERDICTPAYER012025010409151023X005010X222A1	Functional Group Header
ST8370001*005010X222A1	Transaction Set Header — Health Care Claim: Professional
BHT001900000000202210110915CH	Beginning of Hierarchical Transaction
NM1412PACIFIC REGIONAL***460000000000	Submitter Name
NM1402KEYSTONE NATIONAL***46PAYER01	Receiver Name
HL1201	Billing Provider Hierarchical Level
NM1852LAKESIDE MEDICAL CENTER***XX0000000000	Billing Provider Name
NM1IL1ROOSEVELTELEANOR****MIAAA000000000	Subscriber Name
CLMCLM-2022-4178027410.00**11:B:1YAY*Y	Claim Information
DTP434RD8*20221011-20221011	Date — Statement Dates
SE380001	Transaction Set Trailer

EOB / Claim Summary

Summary

Billed

$27,410

Allowed

$3,563

Paid

$10,285

Patient Responsibility

$861

Underpayment

$9,316

Payment Rate

37.5%

Adjustment Reason Codes

P5Claim/service denied. Payment is included in the allowance for another service/procedure.
C2The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2022-41780

6 service lines

Line #	Procedure Code	Procedure Description	Revenue Code	Revenue Description	Billed	Allowed	Paid	Underpaid	Benchmark	Benchmark Underpaid	Status
1	84155	Total protein level, blood	0300	Laboratory - General	$6,476	$1,418	$2,430	$4,046	$1,718	$0	PRIMARY
2	84484	Troponin (protein) analysis	0305	Laboratory - Hematology	$6,449	$1,150	$2,420	$4,029	$1,914	$0	PRIMARY
3	93005	Routine electrocardiogram with 12 leads	0730	EKG/ECG (electrocardiogram)	$6,262	$1,262	$2,350	$3,913	$1,044	$0	PRIMARY
4	85025	Complete blood cell count, automated test	0305	Laboratory - Hematology	$3,881	$993	$1,456	$2,425	$1,564	$108	PRIMARY
5	85379	Coagulation function measurement	0305	Laboratory - Hematology	$3,276	$464	$1,229	$2,047	$702	$0	PRIMARY
6	82040	Albumin (protein) level	0300	Laboratory - General	$1,066	$215	$400	$666	$83	$0	PRIMARY

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Verdict Consulting Group · All values shown are demo data · 6 service lines extracted