Verdict Claims Explorer — Verdict Consulting Group

Claim Identification

Patient Name: FORD, BETTY
Service Date: 2022-07-14
DRG Code: 153.0
Claim ID: CLM-2022-90771
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: KEYSTONE NATIONAL

Patient Information

First Name: BETTY
Last Name: FORD
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: $21,785
Total Payment Amount: $17,818
Coverage Amount: $2,832
Line Charge Amount: $6,828
Line Paid Amount: $5,585
Line Allowed Amount: $1,282
Line Total Adjustment: $1,243
Underpayment: $0
Payment Rate: 81.79%
Patient Responsibility: $808
Payment Date: 2022-08-09
Payment Method: ACH
Check / Ref Trace Number: C00000E00000000

Service Details

Service Date From: 2022-07-14
Service Date To: 2022-07-14

Statement Date From: 2022-07-14
Statement Date To: 2022-07-14

Production Date: 2022-08-07
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

BETTY FORD

Patient No

AA00000

Admit Date

N/A

From Date

2022-07-14

Group-Sub No

000000-ABC000000

End Date

2022-07-14

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	$21,785	$18,735	$2,832	$2,832	$0	$17,818

Messages / ReasonsB6

Contract Deductible / Copay$808

Provider Number0000000000

Total Deductions / Other Ineligible$808

Tax ID00-0000000

Patient's Share$808

Source Document

MVAP_D000000_0000000_000.pdf

Pages: 17 - 0 · Extracted: 1/1/2026

PCS Record 2 of 2OUT-PATIENTNORTHEAST REGIONAL (NEN-RGN)Claim #: 0000000000C00X

Patient

BETTY FORD

Patient No

AA00000

Admit Date

N/A

From Date

2022-07-14

Group-Sub No

000000-ABC000000

End Date

2022-07-14

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	$9,150	$7,843	$1,307	$1,307	$0	$7,484

Messages / ReasonsB6

Contract Deductible / Copay$339

Provider Number0000000000

Total Deductions / Other Ineligible$339

Tax ID00-0000000

Patient's Share$339

Source Document

MVAP_D000000_0000000_000.pdf

Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI

Control Number

C00000E00000000

Payment Date

2022-08-09

Payment Method

ACH

Check / EFT

EFT000000

Payer

KEYSTONE NATIONAL

Payer Contact

1-800-555-0182

Total Submitted Charges

$21,785

Net Total Paid

$17,818

Segments

Segment	Description
ISA00 00 ZZVERDICT ZZPAYER01	Interchange Control Header
GSHPVERDICTPAYER012025012914301023X005010X221A1	Functional Group Header
ST8350001	Transaction Set Header — Health Care Claim Payment/Advice
BPRI17818.00CACHCCP010000000000DA9876541512345678*010000000000DA987654	Financial Information
TRN100000040*0000000000	Reassociation Trace Number
DTM40520220714	Production Date
N1PRKEYSTONE NATIONAL	Payer Identification
N1PELAKESIDE MEDICAL CENTERXX0000000000	Payee Identification
LX*1	Header Number
CLPCLM-2022-90771121785.0017818.00808.00HM00000011	Claim Payment Information
NM1QC1FORDBETTY	Patient Name
SE420001	Transaction Set Trailer

837 Original Claim Submission

EDI

Control Number

S000000000A

Submission Date

2022-07-17

Billing Provider

LAKESIDE MEDICAL CENTER

Tax ID

00-0000000

Total Charges

$21,785

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
BHT001900000000202207140915CH	Beginning of Hierarchical Transaction
NM1412NORTHEAST REGIONAL***460000000000	Submitter Name
NM1402KEYSTONE NATIONAL***46PAYER01	Receiver Name
HL1201	Billing Provider Hierarchical Level
NM1852LAKESIDE MEDICAL CENTER***XX0000000000	Billing Provider Name
NM1IL1FORDBETTY****MIAAA000000000	Subscriber Name
CLMCLM-2022-9077121785.00**11:B:1YAY*Y	Claim Information
DTP434RD8*20220714-20220714	Date — Statement Dates
SE380001	Transaction Set Trailer

EOB / Claim Summary

Summary

Billed

$21,785

Allowed

$2,832

Paid

$17,818

Patient Responsibility

$808

Underpayment

Payment Rate

81.8%

Adjustment Reason Codes

V5Claim/service denied. Payment is included in the allowance for another service/procedure.
H1The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2022-90771

5 service lines

Line #	Procedure Code	Procedure Description	Revenue Code	Revenue Description	Billed	Allowed	Paid	Underpaid	Benchmark	Benchmark Underpaid	Status
1	84075	Phosphatase (enzyme) level	0300	Laboratory - General	$6,828	$1,282	$5,585	$1,243	$1,233	$0	PRIMARY
2	82040	Albumin (protein) level	0300	Laboratory - General	$5,145	$734	$4,208	$937	$654	$0	PRIMARY
3	84155	Total protein level, blood	0300	Laboratory - General	$4,462	$1,230	$3,650	$813	$1,426	$0	PRIMARY
4	96368	Infusion into a vein, concurrent with another infusion	0260	IV Therapy - General	$3,020	$829	$2,470	$550	$184	$0	PRIMARY
5	82977	Glutamyltransferase (liver enzyme) level	0300	Laboratory - General	$2,330	$577	$1,906	$424	$722	$0	PRIMARY

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