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Verdict Claims Explorer / Claim Details

Claim Details

CLM-2022-83630Correct

Claim Identification

Patient Name
NIXON, RICHARD
Service Date
2022-01-09
DRG Code
153.0
Claim ID
CLM-2022-83630
Service Line Number
17
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
CASCADE MUTUAL

Patient Information

First Name
RICHARD
Last Name
NIXON
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
$77,790
Total Payment Amount
$58,958
Coverage Amount
$10,113
Line Charge Amount
$9,055
Line Paid Amount
$6,863
Line Allowed Amount
$1,920
Line Total Adjustment
$2,192
Underpayment
$0
Payment Rate
75.79%
Patient Responsibility
$4,849
Payment Date
2022-02-04
Payment Method
ACH
Check / Ref Trace Number
C00000E00000000

Service Details

Service Date From
2022-01-09
Service Date To
2022-01-09
Statement Date From
2022-01-09
Statement Date To
2022-01-09
Production Date
2022-02-02
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
RICHARD NIXON
Patient No
AA00000
Admit Date
N/A
From Date
2022-01-09
Group-Sub No
000000-ABC000000
End Date
2022-01-09
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$77,790$66,899$10,113$10,113$0$58,958
Messages / ReasonsH4
Contract Deductible / Copay$4,849
Provider Number0000000000
Total Deductions / Other Ineligible$4,849
Tax ID00-0000000
Patient's Share$4,849
Source Document
HEQT_D000000_0000000_000.pdf
Pages: 17 - 0 · Extracted: 1/1/2026
PCS Record 2 of 2OUT-PATIENTNORTHEAST REGIONAL (NEN-RGN)Claim #: 0000000000C00X
Patient
RICHARD NIXON
Patient No
AA00000
Admit Date
N/A
From Date
2022-01-09
Group-Sub No
000000-ABC000000
End Date
2022-01-09
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$32,672$28,004$4,667$4,667$0$24,762
Messages / ReasonsH4
Contract Deductible / Copay$2,037
Provider Number0000000000
Total Deductions / Other Ineligible$2,037
Tax ID00-0000000
Patient's Share$2,037
Source Document
HEQT_D000000_0000000_000.pdf
Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI
Control Number
C00000E00000000
Payment Date
2022-02-04
Payment Method
ACH
Check / EFT
EFT000000
Payer
CASCADE MUTUAL
Payer Contact
1-800-555-0182
Total Submitted Charges
$77,790
Net Total Paid
$58,958
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*58958.00*C*ACH*CCP*01*0000000000*DA*987654*1512345678**01*0000000000*DA*987654Financial Information
TRN*1*00000040*0000000000Reassociation Trace Number
DTM*405*20220109Production Date
N1*PR*CASCADE MUTUALPayer Identification
N1*PE*WESTFIELD SURGICAL*XX*0000000000Payee Identification
LX*1Header Number
CLP*CLM-2022-83630*1*77790.00*58958.00*4849.00*HM*000000*11Claim Payment Information
NM1*QC*1*NIXON*RICHARDPatient Name
SE*42*0001Transaction Set Trailer

837 Original Claim Submission

EDI
Control Number
S000000000A
Submission Date
2022-01-12
Billing Provider
WESTFIELD SURGICAL
Tax ID
00-0000000
Total Charges
$77,790
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*20220109*0915*CHBeginning of Hierarchical Transaction
NM1*41*2*NORTHEAST REGIONAL*****46*0000000000Submitter Name
NM1*40*2*CASCADE MUTUAL*****46*PAYER01Receiver Name
HL*1**20*1Billing Provider Hierarchical Level
NM1*85*2*WESTFIELD SURGICAL*****XX*0000000000Billing Provider Name
NM1*IL*1*NIXON*RICHARD*****MI*AAA000000000Subscriber Name
CLM*CLM-2022-83630*77790.00***11:B:1*Y*A*Y*YClaim Information
DTP*434*RD8*20220109-20220109Date — Statement Dates
SE*38*0001Transaction Set Trailer

EOB / Claim Summary

Summary
Billed
$77,790
Allowed
$10,113
Paid
$58,958
Patient Responsibility
$4,849
Underpayment
$0
Payment Rate
75.8%
Adjustment Reason Codes
  • A1Claim/service denied. Payment is included in the allowance for another service/procedure.
  • U2The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2022-83630

17 service lines
Line #Procedure CodeProcedure DescriptionRevenue CodeRevenue DescriptionBilledAllowedPaidUnderpaidBenchmarkBenchmark UnderpaidStatus
185025Complete blood cell count, automated test0305Laboratory - Hematology$9,055$1,920$6,863$2,192$2,497$0PRIMARY
2J2765Injection, metoclopramide HCl, up to 10 mg0250Pharmacy - General$8,539$2,250$6,471$2,067$2,932$0PRIMARY
370450CT scan head/brain without contrast0352Diagnostic Radiology - CT Scan$7,797$1,987$5,910$1,888$390$0PRIMARY
485379Coagulation function measurement0305Laboratory - Hematology$7,722$1,548$5,852$1,869$585$0PRIMARY
596368Infusion into a vein, concurrent with another infusion0260IV Therapy - General$7,317$2,019$5,546$1,771$2,821$0PRIMARY
672125CT cervical spine without contrast0352Diagnostic Radiology - CT Scan$6,718$1,073$5,092$1,626$2,424$0PRIMARY
7J1170Injection, hydromorphone, up to 4 mg0250Pharmacy - General$5,303$1,154$4,019$1,284$2,347$0PRIMARY
882040Albumin (protein) level0300Laboratory - General$4,652$1,019$3,526$1,126$358$0PRIMARY
984075Phosphatase (enzyme) level0300Laboratory - General$4,355$962$3,301$1,054$1,333$0PRIMARY
1084484Troponin (protein) analysis0305Laboratory - Hematology$3,662$773$2,775$886$574$0PRIMARY
1193005Routine electrocardiogram with 12 leads0730EKG/ECG (electrocardiogram)$2,685$391$2,035$650$969$0PRIMARY
1299284Emergency department visit, problem of high severity0450Emergency Room - General$2,645$339$2,005$640$671$0PRIMARY
1382977Glutamyltransferase (liver enzyme) level0300Laboratory - General$2,642$467$2,002$640$141$0PRIMARY
1471046Radiologic examination, chest; 2 views0324Radiology - Diagnostic$2,263$634$1,715$548$261$0PRIMARY
15J1885Injection, ketorolac tromethamine, per 15 mg0250Pharmacy - General$1,037$164$786$251$341$0PRIMARY
16J3010Injection, fentanyl citrate, 0.1 mg0250Pharmacy - General$883$225$669$214$308$0PRIMARY
1784155Total protein level, blood0300Laboratory - General$516$112$391$125$29$0PRIMARY
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Verdict Consulting Group · All values shown are demo data · 17 service lines extracted

Demo Data