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Verdict Claims Explorer / Claim Details

Claim Details

CLM-2022-78966Disputed

Claim Identification

Patient Name
JOHNSON, LYNDON
Service Date
2022-08-27
DRG Code
153.0
Claim ID
CLM-2022-78966
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
SOUTHERN REGIONAL
Payer
LIBERTY BELL HEALTH

Patient Information

First Name
LYNDON
Last Name
JOHNSON
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
$23,790
Total Payment Amount
$6,610
Coverage Amount
$3,093
Line Charge Amount
$11,159
Line Paid Amount
$3,100
Line Allowed Amount
$3,118
Line Total Adjustment
$8,058
Underpayment
$8,961
Payment Rate
27.78%
Patient Responsibility
$615
Payment Date
2022-09-22
Payment Method
ACH
Check / Ref Trace Number
C00000E00000000

Service Details

Service Date From
2022-08-27
Service Date To
2022-08-27
Statement Date From
2022-08-27
Statement Date To
2022-08-27
Production Date
2022-09-20
Filing Indicator
HM
Quantity
N/A
Line Unit Count
1.0

PCS (Provider Claim Summary) Details

2 Records
PCS Record 1 of 2OUT-PATIENTSOUTHERN REGIONAL (SOU-RGN)Claim #: 0000000000C00X
Patient
LYNDON JOHNSON
Patient No
AA00000
Admit Date
N/A
From Date
2022-08-27
Group-Sub No
000000-ABC000000
End Date
2022-08-27
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$23,790$20,459$3,093$3,093$0$6,610
Messages / ReasonsY6
Contract Deductible / Copay$615
Provider Number0000000000
Total Deductions / Other Ineligible$615
Tax ID00-0000000
Patient's Share$615
Source Document
MGHT_D000000_0000000_000.pdf
Pages: 17 - 0 · Extracted: 1/1/2026
PCS Record 2 of 2OUT-PATIENTSOUTHERN REGIONAL (SOU-RGN)Claim #: 0000000000C00X
Patient
LYNDON JOHNSON
Patient No
AA00000
Admit Date
N/A
From Date
2022-08-27
Group-Sub No
000000-ABC000000
End Date
2022-08-27
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$9,992$8,564$1,427$1,427$0$2,776
Messages / ReasonsY6
Contract Deductible / Copay$258
Provider Number0000000000
Total Deductions / Other Ineligible$258
Tax ID00-0000000
Patient's Share$258
Source Document
MGHT_D000000_0000000_000.pdf
Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI
Control Number
C00000E00000000
Payment Date
2022-09-22
Payment Method
ACH
Check / EFT
EFT000000
Payer
LIBERTY BELL HEALTH
Payer Contact
1-800-555-0182
Total Submitted Charges
$23,790
Net Total Paid
$6,610
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*6610.00*C*ACH*CCP*01*0000000000*DA*987654*1512345678**01*0000000000*DA*987654Financial Information
TRN*1*00000040*0000000000Reassociation Trace Number
DTM*405*20220827Production Date
N1*PR*LIBERTY BELL HEALTHPayer Identification
N1*PE*WESTFIELD SURGICAL*XX*0000000000Payee Identification
LX*1Header Number
CLP*CLM-2022-78966*1*23790.00*6610.00*615.00*HM*000000*11Claim Payment Information
NM1*QC*1*JOHNSON*LYNDONPatient Name
SE*42*0001Transaction Set Trailer

837 Original Claim Submission

EDI
Control Number
S000000000A
Submission Date
2022-08-30
Billing Provider
WESTFIELD SURGICAL
Tax ID
00-0000000
Total Charges
$23,790
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*20220827*0915*CHBeginning of Hierarchical Transaction
NM1*41*2*SOUTHERN 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*JOHNSON*LYNDON*****MI*AAA000000000Subscriber Name
CLM*CLM-2022-78966*23790.00***11:B:1*Y*A*Y*YClaim Information
DTP*434*RD8*20220827-20220827Date — Statement Dates
SE*38*0001Transaction Set Trailer

EOB / Claim Summary

Summary
Billed
$23,790
Allowed
$3,093
Paid
$6,610
Patient Responsibility
$615
Underpayment
$8,961
Payment Rate
27.8%
Adjustment Reason Codes
  • K4Claim/service denied. Payment is included in the allowance for another service/procedure.
  • J1The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2022-78966

5 service lines
Line #Procedure CodeProcedure DescriptionRevenue CodeRevenue DescriptionBilledAllowedPaidUnderpaidBenchmarkBenchmark UnderpaidStatus
1J2765Injection, metoclopramide HCl, up to 10 mg0250Pharmacy - General$11,159$3,118$3,100$8,058$2,250$0PRIMARY
2J3010Injection, fentanyl citrate, 0.1 mg0250Pharmacy - General$5,898$1,663$1,639$4,259$847$0PRIMARY
399284Emergency department visit, problem of high severity0450Emergency Room - General$2,974$474$826$2,148$1,273$447PRIMARY
4J1885Injection, ketorolac tromethamine, per 15 mg0250Pharmacy - General$1,926$299$535$1,391$337$0PRIMARY
5J1170Injection, hydromorphone, up to 4 mg0250Pharmacy - General$1,833$472$509$1,324$106$0PRIMARY
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Verdict Consulting Group · All values shown are demo data · 5 service lines extracted

Demo Data