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Verdict Claims Explorer / Claim Details

Claim Details

CLM-2023-28962Underpaid

Claim Identification

Patient Name
MADISON, JAMES
Service Date
2023-03-16
DRG Code
153.0
Claim ID
CLM-2023-28962
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
ATLANTIC REGIONAL
Payer
COASTLINE PPO

Patient Information

First Name
JAMES
Last Name
MADISON
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
$10,720
Total Payment Amount
$2,375
Coverage Amount
$1,394
Line Charge Amount
$3,768
Line Paid Amount
$835
Line Allowed Amount
$1,013
Line Total Adjustment
$2,933
Underpayment
$4,676
Payment Rate
22.15%
Patient Responsibility
$503
Payment Date
2023-04-11
Payment Method
ACH
Check / Ref Trace Number
C00000E00000000

Service Details

Service Date From
2023-03-16
Service Date To
2023-03-16
Statement Date From
2023-03-16
Statement Date To
2023-03-16
Production Date
2023-04-09
Filing Indicator
HM
Quantity
N/A
Line Unit Count
1.0

PCS (Provider Claim Summary) Details

2 Records
PCS Record 1 of 2OUT-PATIENTATLANTIC REGIONAL (ATL-RGN)Claim #: 0000000000C00X
Patient
JAMES MADISON
Patient No
AA00000
Admit Date
N/A
From Date
2023-03-16
Group-Sub No
000000-ABC000000
End Date
2023-03-16
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$10,720$9,219$1,394$1,394$0$2,375
Messages / ReasonsT9
Contract Deductible / Copay$503
Provider Number0000000000
Total Deductions / Other Ineligible$503
Tax ID00-0000000
Patient's Share$503
Source Document
XESQ_D000000_0000000_000.pdf
Pages: 17 - 0 · Extracted: 1/1/2026
PCS Record 2 of 2OUT-PATIENTATLANTIC REGIONAL (ATL-RGN)Claim #: 0000000000C00X
Patient
JAMES MADISON
Patient No
AA00000
Admit Date
N/A
From Date
2023-03-16
Group-Sub No
000000-ABC000000
End Date
2023-03-16
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$4,502$3,859$643$643$0$998
Messages / ReasonsT9
Contract Deductible / Copay$211
Provider Number0000000000
Total Deductions / Other Ineligible$211
Tax ID00-0000000
Patient's Share$211
Source Document
XESQ_D000000_0000000_000.pdf
Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI
Control Number
C00000E00000000
Payment Date
2023-04-11
Payment Method
ACH
Check / EFT
EFT000000
Payer
COASTLINE PPO
Payer Contact
1-800-555-0182
Total Submitted Charges
$10,720
Net Total Paid
$2,375
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*2375.00*C*ACH*CCP*01*0000000000*DA*987654*1512345678**01*0000000000*DA*987654Financial Information
TRN*1*00000040*0000000000Reassociation Trace Number
DTM*405*20230316Production Date
N1*PR*COASTLINE PPOPayer Identification
N1*PE*LAKESIDE MEDICAL CENTER*XX*0000000000Payee Identification
LX*1Header Number
CLP*CLM-2023-28962*1*10720.00*2375.00*503.00*HM*000000*11Claim Payment Information
NM1*QC*1*MADISON*JAMESPatient Name
SE*42*0001Transaction Set Trailer

837 Original Claim Submission

EDI
Control Number
S000000000A
Submission Date
2023-03-19
Billing Provider
LAKESIDE MEDICAL CENTER
Tax ID
00-0000000
Total Charges
$10,720
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*20230316*0915*CHBeginning of Hierarchical Transaction
NM1*41*2*ATLANTIC REGIONAL*****46*0000000000Submitter Name
NM1*40*2*COASTLINE PPO*****46*PAYER01Receiver Name
HL*1**20*1Billing Provider Hierarchical Level
NM1*85*2*LAKESIDE MEDICAL CENTER*****XX*0000000000Billing Provider Name
NM1*IL*1*MADISON*JAMES*****MI*AAA000000000Subscriber Name
CLM*CLM-2023-28962*10720.00***11:B:1*Y*A*Y*YClaim Information
DTP*434*RD8*20230316-20230316Date — Statement Dates
SE*38*0001Transaction Set Trailer

EOB / Claim Summary

Summary
Billed
$10,720
Allowed
$1,394
Paid
$2,375
Patient Responsibility
$503
Underpayment
$4,676
Payment Rate
22.2%
Adjustment Reason Codes
  • P8Claim/service denied. Payment is included in the allowance for another service/procedure.
  • A2The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2023-28962

5 service lines
Line #Procedure CodeProcedure DescriptionRevenue CodeRevenue DescriptionBilledAllowedPaidUnderpaidBenchmarkBenchmark UnderpaidStatus
1J3010Injection, fentanyl citrate, 0.1 mg0250Pharmacy - General$3,768$1,013$835$2,933$1,159$324PRIMARY
2J1885Injection, ketorolac tromethamine, per 15 mg0250Pharmacy - General$3,417$814$757$2,660$1,533$776PRIMARY
3J1170Injection, hydromorphone, up to 4 mg0250Pharmacy - General$1,721$292$381$1,340$581$200PRIMARY
4J2765Injection, metoclopramide HCl, up to 10 mg0250Pharmacy - General$1,144$245$253$890$83$0PRIMARY
571046Radiologic examination, chest; 2 views0324Radiology - Diagnostic$671$132$149$522$212$64PRIMARY
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Verdict Consulting Group · All values shown are demo data · 5 service lines extracted

Demo Data