V
VerdictConsulting Group
Logout
Verdict Claims Explorer / Claim Details

Claim Details

CLM-2022-72571Disputed

Claim Identification

Patient Name
EISENHOWER, MAMIE
Service Date
2022-10-14
DRG Code
153.0
Claim ID
CLM-2022-72571
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
NORTHEAST REGIONAL
Payer
LIBERTY BELL HEALTH

Patient Information

First Name
MAMIE
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
$20,710
Total Payment Amount
$7,637
Coverage Amount
$2,692
Line Charge Amount
$5,919
Line Paid Amount
$2,183
Line Allowed Amount
$1,697
Line Total Adjustment
$3,736
Underpayment
$8,804
Payment Rate
36.88%
Patient Responsibility
$485
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-PATIENTNORTHEAST REGIONAL (NEN-RGN)Claim #: 0000000000C00X
Patient
MAMIE 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$20,710$17,811$2,692$2,692$0$7,637
Messages / ReasonsI5
Contract Deductible / Copay$485
Provider Number0000000000
Total Deductions / Other Ineligible$485
Tax ID00-0000000
Patient's Share$485
Source Document
ZCXZ_D000000_0000000_000.pdf
Pages: 17 - 0 · Extracted: 1/1/2026
PCS Record 2 of 2OUT-PATIENTNORTHEAST REGIONAL (NEN-RGN)Claim #: 0000000000C00X
Patient
MAMIE 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$8,698$7,456$1,243$1,243$0$3,208
Messages / ReasonsI5
Contract Deductible / Copay$204
Provider Number0000000000
Total Deductions / Other Ineligible$204
Tax ID00-0000000
Patient's Share$204
Source Document
ZCXZ_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
LIBERTY BELL HEALTH
Payer Contact
1-800-555-0182
Total Submitted Charges
$20,710
Net Total Paid
$7,637
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*7637.00*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*LIBERTY BELL HEALTHPayer Identification
N1*PE*WESTFIELD SURGICAL*XX*0000000000Payee Identification
LX*1Header Number
CLP*CLM-2022-72571*1*20710.00*7637.00*485.00*HM*000000*11Claim Payment Information
NM1*QC*1*EISENHOWER*MAMIEPatient Name
SE*42*0001Transaction Set Trailer

837 Original Claim Submission

EDI
Control Number
S000000000A
Submission Date
2022-10-17
Billing Provider
WESTFIELD SURGICAL
Tax ID
00-0000000
Total Charges
$20,710
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*NORTHEAST REGIONAL*****46*0000000000Submitter Name
NM1*40*2*LIBERTY BELL HEALTH*****46*PAYER01Receiver Name
HL*1**20*1Billing Provider Hierarchical Level
NM1*85*2*WESTFIELD SURGICAL*****XX*0000000000Billing Provider Name
NM1*IL*1*EISENHOWER*MAMIE*****MI*AAA000000000Subscriber Name
CLM*CLM-2022-72571*20710.00***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
$20,710
Allowed
$2,692
Paid
$7,637
Patient Responsibility
$485
Underpayment
$8,804
Payment Rate
36.9%
Adjustment Reason Codes
  • Y2Claim/service denied. Payment is included in the allowance for another service/procedure.
  • O8The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2022-72571

5 service lines
Line #Procedure CodeProcedure DescriptionRevenue CodeRevenue DescriptionBilledAllowedPaidUnderpaidBenchmarkBenchmark UnderpaidStatus
1J1170Injection, hydromorphone, up to 4 mg0250Pharmacy - General$5,919$1,697$2,183$3,736$1,254$0PRIMARY
284484Troponin (protein) analysis0305Laboratory - Hematology$5,108$830$1,884$3,225$2,276$392PRIMARY
371046Radiologic examination, chest; 2 views0324Radiology - Diagnostic$4,553$797$1,679$2,874$634$0PRIMARY
493005Routine electrocardiogram with 12 leads0730EKG/ECG (electrocardiogram)$3,047$559$1,124$1,923$478$0PRIMARY
5J2765Injection, metoclopramide HCl, up to 10 mg0250Pharmacy - General$2,083$319$768$1,315$644$0PRIMARY
Back to all claimsView population context →

Verdict Consulting Group · All values shown are demo data · 5 service lines extracted

Demo Data