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Verdict Claims Explorer / Claim Details

Claim Details

CLM-2023-47376Correct

Claim Identification

Patient Name
MONROE, JAMES
Service Date
2023-04-28
DRG Code
153.0
Claim ID
CLM-2023-47376
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
COASTLINE PPO

Patient Information

First Name
JAMES
Last Name
MONROE
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
$22,070
Total Payment Amount
$16,850
Coverage Amount
$2,869
Line Charge Amount
$9,205
Line Paid Amount
$7,028
Line Allowed Amount
$1,186
Line Total Adjustment
$2,177
Underpayment
$0
Payment Rate
76.35%
Patient Responsibility
$1,379
Payment Date
2023-05-24
Payment Method
ACH
Check / Ref Trace Number
C00000E00000000

Service Details

Service Date From
2023-04-28
Service Date To
2023-04-28
Statement Date From
2023-04-28
Statement Date To
2023-04-28
Production Date
2023-05-22
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
JAMES MONROE
Patient No
AA00000
Admit Date
N/A
From Date
2023-04-28
Group-Sub No
000000-ABC000000
End Date
2023-04-28
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$22,070$18,980$2,869$2,869$0$16,850
Messages / ReasonsP9
Contract Deductible / Copay$1,379
Provider Number0000000000
Total Deductions / Other Ineligible$1,379
Tax ID00-0000000
Patient's Share$1,379
Source Document
SZBM_D000000_0000000_000.pdf
Pages: 17 - 0 · Extracted: 1/1/2026
PCS Record 2 of 2OUT-PATIENTWESTERN REGIONAL (WST-RGN)Claim #: 0000000000C00X
Patient
JAMES MONROE
Patient No
AA00000
Admit Date
N/A
From Date
2023-04-28
Group-Sub No
000000-ABC000000
End Date
2023-04-28
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$9,269$7,945$1,324$1,324$0$7,077
Messages / ReasonsP9
Contract Deductible / Copay$579
Provider Number0000000000
Total Deductions / Other Ineligible$579
Tax ID00-0000000
Patient's Share$579
Source Document
SZBM_D000000_0000000_000.pdf
Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI
Control Number
C00000E00000000
Payment Date
2023-05-24
Payment Method
ACH
Check / EFT
EFT000000
Payer
COASTLINE PPO
Payer Contact
1-800-555-0182
Total Submitted Charges
$22,070
Net Total Paid
$16,850
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*16850.00*C*ACH*CCP*01*0000000000*DA*987654*1512345678**01*0000000000*DA*987654Financial Information
TRN*1*00000040*0000000000Reassociation Trace Number
DTM*405*20230428Production Date
N1*PR*COASTLINE PPOPayer Identification
N1*PE*RIVERSIDE REGIONAL*XX*0000000000Payee Identification
LX*1Header Number
CLP*CLM-2023-47376*1*22070.00*16850.00*1379.00*HM*000000*11Claim Payment Information
NM1*QC*1*MONROE*JAMESPatient Name
SE*42*0001Transaction Set Trailer

837 Original Claim Submission

EDI
Control Number
S000000000A
Submission Date
2023-05-01
Billing Provider
RIVERSIDE REGIONAL
Tax ID
00-0000000
Total Charges
$22,070
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*20230428*0915*CHBeginning of Hierarchical Transaction
NM1*41*2*WESTERN REGIONAL*****46*0000000000Submitter Name
NM1*40*2*COASTLINE PPO*****46*PAYER01Receiver Name
HL*1**20*1Billing Provider Hierarchical Level
NM1*85*2*RIVERSIDE REGIONAL*****XX*0000000000Billing Provider Name
NM1*IL*1*MONROE*JAMES*****MI*AAA000000000Subscriber Name
CLM*CLM-2023-47376*22070.00***11:B:1*Y*A*Y*YClaim Information
DTP*434*RD8*20230428-20230428Date — Statement Dates
SE*38*0001Transaction Set Trailer

EOB / Claim Summary

Summary
Billed
$22,070
Allowed
$2,869
Paid
$16,850
Patient Responsibility
$1,379
Underpayment
$0
Payment Rate
76.3%
Adjustment Reason Codes
  • Q6Claim/service denied. Payment is included in the allowance for another service/procedure.
  • D6The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2023-47376

5 service lines
Line #Procedure CodeProcedure DescriptionRevenue CodeRevenue DescriptionBilledAllowedPaidUnderpaidBenchmarkBenchmark UnderpaidStatus
1J3010Injection, fentanyl citrate, 0.1 mg0250Pharmacy - General$9,205$1,186$7,028$2,177$502$0PRIMARY
2J1885Injection, ketorolac tromethamine, per 15 mg0250Pharmacy - General$4,334$980$3,309$1,025$1,822$0PRIMARY
399284Emergency department visit, problem of high severity0450Emergency Room - General$3,559$958$2,717$842$226$0PRIMARY
470450CT scan head/brain without contrast0352Diagnostic Radiology - CT Scan$3,487$985$2,662$825$648$0PRIMARY
572125CT cervical spine without contrast0352Diagnostic Radiology - CT Scan$1,486$294$1,134$351$479$0PRIMARY
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Verdict Consulting Group · All values shown are demo data · 5 service lines extracted

Demo Data