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Verdict Claims Explorer / Claim Details

Claim Details

CLM-2022-92949Underpaid

Claim Identification

Patient Name
WASHINGTON, MARTHA
Service Date
2022-02-22
DRG Code
153.0
Claim ID
CLM-2022-92949
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
WESTERN REGIONAL
Payer
SUMMIT BENEFITS

Patient Information

First Name
MARTHA
Last Name
WASHINGTON
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
$6,460
Total Payment Amount
$3,242
Coverage Amount
$840
Line Charge Amount
$2,441
Line Paid Amount
$1,225
Line Allowed Amount
$515
Line Total Adjustment
$1,216
Underpayment
$1,763
Payment Rate
50.19%
Patient Responsibility
$275
Payment Date
2022-03-20
Payment Method
ACH
Check / Ref Trace Number
C00000E00000000

Service Details

Service Date From
2022-02-22
Service Date To
2022-02-22
Statement Date From
2022-02-22
Statement Date To
2022-02-22
Production Date
2022-03-18
Filing Indicator
HM
Quantity
N/A
Line Unit Count
1.0

PCS (Provider Claim Summary) Details

2 Records
PCS Record 1 of 2OUT-PATIENTWESTERN REGIONAL (WST-RGN)Claim #: 0000000000C00X
Patient
MARTHA WASHINGTON
Patient No
AA00000
Admit Date
N/A
From Date
2022-02-22
Group-Sub No
000000-ABC000000
End Date
2022-02-22
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$6,460$5,556$840$840$0$3,242
Messages / ReasonsR7
Contract Deductible / Copay$275
Provider Number0000000000
Total Deductions / Other Ineligible$275
Tax ID00-0000000
Patient's Share$275
Source Document
RPQR_D000000_0000000_000.pdf
Pages: 17 - 0 · Extracted: 1/1/2026
PCS Record 2 of 2OUT-PATIENTWESTERN REGIONAL (WST-RGN)Claim #: 0000000000C00X
Patient
MARTHA WASHINGTON
Patient No
AA00000
Admit Date
N/A
From Date
2022-02-22
Group-Sub No
000000-ABC000000
End Date
2022-02-22
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$2,713$2,326$388$388$0$1,362
Messages / ReasonsR7
Contract Deductible / Copay$116
Provider Number0000000000
Total Deductions / Other Ineligible$116
Tax ID00-0000000
Patient's Share$116
Source Document
RPQR_D000000_0000000_000.pdf
Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI
Control Number
C00000E00000000
Payment Date
2022-03-20
Payment Method
ACH
Check / EFT
EFT000000
Payer
SUMMIT BENEFITS
Payer Contact
1-800-555-0182
Total Submitted Charges
$6,460
Net Total Paid
$3,242
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*3242.00*C*ACH*CCP*01*0000000000*DA*987654*1512345678**01*0000000000*DA*987654Financial Information
TRN*1*00000040*0000000000Reassociation Trace Number
DTM*405*20220222Production Date
N1*PR*SUMMIT BENEFITSPayer Identification
N1*PE*WESTFIELD SURGICAL*XX*0000000000Payee Identification
LX*1Header Number
CLP*CLM-2022-92949*1*6460.00*3242.00*275.00*HM*000000*11Claim Payment Information
NM1*QC*1*WASHINGTON*MARTHAPatient Name
SE*42*0001Transaction Set Trailer

837 Original Claim Submission

EDI
Control Number
S000000000A
Submission Date
2022-02-25
Billing Provider
WESTFIELD SURGICAL
Tax ID
00-0000000
Total Charges
$6,460
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*20220222*0915*CHBeginning of Hierarchical Transaction
NM1*41*2*WESTERN REGIONAL*****46*0000000000Submitter Name
NM1*40*2*SUMMIT BENEFITS*****46*PAYER01Receiver Name
HL*1**20*1Billing Provider Hierarchical Level
NM1*85*2*WESTFIELD SURGICAL*****XX*0000000000Billing Provider Name
NM1*IL*1*WASHINGTON*MARTHA*****MI*AAA000000000Subscriber Name
CLM*CLM-2022-92949*6460.00***11:B:1*Y*A*Y*YClaim Information
DTP*434*RD8*20220222-20220222Date — Statement Dates
SE*38*0001Transaction Set Trailer

EOB / Claim Summary

Summary
Billed
$6,460
Allowed
$840
Paid
$3,242
Patient Responsibility
$275
Underpayment
$1,763
Payment Rate
50.2%
Adjustment Reason Codes
  • C4Claim/service denied. Payment is included in the allowance for another service/procedure.
  • W1The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2022-92949

5 service lines
Line #Procedure CodeProcedure DescriptionRevenue CodeRevenue DescriptionBilledAllowedPaidUnderpaidBenchmarkBenchmark UnderpaidStatus
184155Total protein level, blood0300Laboratory - General$2,441$515$1,225$1,216$824$0PRIMARY
282040Albumin (protein) level0300Laboratory - General$1,569$224$787$782$577$0PRIMARY
385379Coagulation function measurement0305Laboratory - Hematology$1,468$375$737$731$630$0PRIMARY
482977Glutamyltransferase (liver enzyme) level0300Laboratory - General$718$173$360$358$133$0PRIMARY
585025Complete blood cell count, automated test0305Laboratory - Hematology$264$67$132$131$116$0PRIMARY
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Verdict Consulting Group · All values shown are demo data · 5 service lines extracted

Demo Data