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Verdict Claims Explorer / Claim Details

Claim Details

CLM-2022-53468Underpaid

Claim Identification

Patient Name
EISENHOWER, DWIGHT
Service Date
2022-10-14
DRG Code
153.0
Claim ID
CLM-2022-53468
Service Line Number
5
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
GREAT LAKES REGIONAL
Payer
HEARTLAND ASSURANCE

Patient Information

First Name
DWIGHT
Last Name
EISENHOWER
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
$24,355
Total Payment Amount
$7,822
Coverage Amount
$3,166
Line Charge Amount
$7,370
Line Paid Amount
$2,367
Line Allowed Amount
$1,037
Line Total Adjustment
$5,003
Underpayment
$7,588
Payment Rate
32.12%
Patient Responsibility
$1,929
Payment Date
2022-11-09
Payment Method
ACH
Check / Ref Trace Number
C00000E00000000

Service Details

Service Date From
2022-10-14
Service Date To
2022-10-14
Statement Date From
2022-10-14
Statement Date To
2022-10-14
Production Date
2022-11-07
Filing Indicator
HM
Quantity
N/A
Line Unit Count
1.0

PCS (Provider Claim Summary) Details

2 Records
PCS Record 1 of 2OUT-PATIENTGREAT LAKES REGIONAL (GLK-RGN)Claim #: 0000000000C00X
Patient
DWIGHT EISENHOWER
Patient No
AA00000
Admit Date
N/A
From Date
2022-10-14
Group-Sub No
000000-ABC000000
End Date
2022-10-14
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$24,355$20,945$3,166$3,166$0$7,822
Messages / ReasonsP6
Contract Deductible / Copay$1,929
Provider Number0000000000
Total Deductions / Other Ineligible$1,929
Tax ID00-0000000
Patient's Share$1,929
Source Document
CVBR_D000000_0000000_000.pdf
Pages: 17 - 0 · Extracted: 1/1/2026
PCS Record 2 of 2OUT-PATIENTGREAT LAKES REGIONAL (GLK-RGN)Claim #: 0000000000C00X
Patient
DWIGHT EISENHOWER
Patient No
AA00000
Admit Date
N/A
From Date
2022-10-14
Group-Sub No
000000-ABC000000
End Date
2022-10-14
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$10,229$8,768$1,461$1,461$0$3,285
Messages / ReasonsP6
Contract Deductible / Copay$810
Provider Number0000000000
Total Deductions / Other Ineligible$810
Tax ID00-0000000
Patient's Share$810
Source Document
CVBR_D000000_0000000_000.pdf
Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI
Control Number
C00000E00000000
Payment Date
2022-11-09
Payment Method
ACH
Check / EFT
EFT000000
Payer
HEARTLAND ASSURANCE
Payer Contact
1-800-555-0182
Total Submitted Charges
$24,355
Net Total Paid
$7,822
Segments
SegmentDescription
ISA*00* *00* *ZZ*VERDICT *ZZ*PAYER01 Interchange Control Header
GS*HP*VERDICT*PAYER01*20250129*1430*1023*X*005010X221A1Functional Group Header
ST*835*0001Transaction Set Header — Health Care Claim Payment/Advice
BPR*I*7822.00*C*ACH*CCP*01*0000000000*DA*987654*1512345678**01*0000000000*DA*987654Financial Information
TRN*1*00000040*0000000000Reassociation Trace Number
DTM*405*20221014Production Date
N1*PR*HEARTLAND ASSURANCEPayer Identification
N1*PE*NORTHGATE SURGICAL*XX*0000000000Payee Identification
LX*1Header Number
CLP*CLM-2022-53468*1*24355.00*7822.00*1929.00*HM*000000*11Claim Payment Information
NM1*QC*1*EISENHOWER*DWIGHTPatient Name
SE*42*0001Transaction Set Trailer

837 Original Claim Submission

EDI
Control Number
S000000000A
Submission Date
2022-10-17
Billing Provider
NORTHGATE SURGICAL
Tax ID
00-0000000
Total Charges
$24,355
Filing Indicator
HM
Frequency Type
1
Transaction Set
005010X222A1
Segments
SegmentDescription
ISA*00* *00* *ZZ*VERDICT *ZZ*PAYER01 Interchange Control Header
GS*HC*VERDICT*PAYER01*20250104*0915*1023*X*005010X222A1Functional Group Header
ST*837*0001*005010X222A1Transaction Set Header — Health Care Claim: Professional
BHT*0019*00*000000*20221014*0915*CHBeginning of Hierarchical Transaction
NM1*41*2*GREAT LAKES REGIONAL*****46*0000000000Submitter Name
NM1*40*2*HEARTLAND ASSURANCE*****46*PAYER01Receiver Name
HL*1**20*1Billing Provider Hierarchical Level
NM1*85*2*NORTHGATE SURGICAL*****XX*0000000000Billing Provider Name
NM1*IL*1*EISENHOWER*DWIGHT*****MI*AAA000000000Subscriber Name
CLM*CLM-2022-53468*24355.00***11:B:1*Y*A*Y*YClaim Information
DTP*434*RD8*20221014-20221014Date — Statement Dates
SE*38*0001Transaction Set Trailer

EOB / Claim Summary

Summary
Billed
$24,355
Allowed
$3,166
Paid
$7,822
Patient Responsibility
$1,929
Underpayment
$7,588
Payment Rate
32.1%
Adjustment Reason Codes
  • L2Claim/service denied. Payment is included in the allowance for another service/procedure.
  • U5The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2022-53468

5 service lines
Line #Procedure CodeProcedure DescriptionRevenue CodeRevenue DescriptionBilledAllowedPaidUnderpaidBenchmarkBenchmark UnderpaidStatus
172125CT cervical spine without contrast0352Diagnostic Radiology - CT Scan$7,370$1,037$2,367$5,003$872$0PRIMARY
299284Emergency department visit, problem of high severity0450Emergency Room - General$7,258$1,075$2,331$4,927$2,719$388PRIMARY
370450CT scan head/brain without contrast0352Diagnostic Radiology - CT Scan$7,012$1,224$2,252$4,760$2,993$741PRIMARY
4J1885Injection, ketorolac tromethamine, per 15 mg0250Pharmacy - General$1,675$345$538$1,137$219$0PRIMARY
5J3010Injection, fentanyl citrate, 0.1 mg0250Pharmacy - General$1,040$277$334$706$417$83PRIMARY
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Verdict Consulting Group · All values shown are demo data · 5 service lines extracted

Demo Data