Verdict Claims Explorer — Verdict Consulting Group

Claim Identification

Patient Name: KENNEDY, JACQUELINE
Service Date: 2023-05-29
DRG Code: 153.0
Claim ID: CLM-2023-79714
Service Line Number: 12
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: SOUTHERN REGIONAL
Payer: KEYSTONE NATIONAL

Patient Information

First Name: JACQUELINE
Last Name: KENNEDY
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: $53,940
Total Payment Amount: $10,581
Coverage Amount: $7,012
Line Charge Amount: $8,211
Line Paid Amount: $1,611
Line Allowed Amount: $1,210
Line Total Adjustment: $6,600
Underpayment: $23,873
Payment Rate: 19.62%
Patient Responsibility: $2,759
Payment Date: 2023-06-24
Payment Method: ACH
Check / Ref Trace Number: C00000E00000000

Service Details

Service Date From: 2023-05-29
Service Date To: 2023-05-29

Statement Date From: 2023-05-29
Statement Date To: 2023-05-29

Production Date: 2023-06-22
Filing Indicator: HM

Quantity: N/A
Line Unit Count: 1.0

PCS (Provider Claim Summary) Details

2 Records

PCS Record 1 of 2OUT-PATIENTSOUTHERN REGIONAL (SOU-RGN)Claim #: 0000000000C00X

Patient

JACQUELINE KENNEDY

Patient No

AA00000

Admit Date

N/A

From Date

2023-05-29

Group-Sub No

000000-ABC000000

End Date

2023-05-29

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	$53,940	$46,388	$7,012	$7,012	$0	$10,581

Messages / ReasonsU8

Contract Deductible / Copay$2,759

Provider Number0000000000

Total Deductions / Other Ineligible$2,759

Tax ID00-0000000

Patient's Share$2,759

Source Document

ADQU_D000000_0000000_000.pdf

Pages: 17 - 0 · Extracted: 1/1/2026

PCS Record 2 of 2OUT-PATIENTSOUTHERN REGIONAL (SOU-RGN)Claim #: 0000000000C00X

Patient

JACQUELINE KENNEDY

Patient No

AA00000

Admit Date

N/A

From Date

2023-05-29

Group-Sub No

000000-ABC000000

End Date

2023-05-29

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	$22,655	$19,418	$3,236	$3,236	$0	$4,444

Messages / ReasonsU8

Contract Deductible / Copay$1,159

Provider Number0000000000

Total Deductions / Other Ineligible$1,159

Tax ID00-0000000

Patient's Share$1,159

Source Document

ADQU_D000000_0000000_000.pdf

Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI

Control Number

C00000E00000000

Payment Date

2023-06-24

Payment Method

ACH

Check / EFT

EFT000000

Payer

KEYSTONE NATIONAL

Payer Contact

1-800-555-0182

Total Submitted Charges

$53,940

Net Total Paid

$10,581

Segments

Segment	Description
ISA00 00 ZZVERDICT ZZPAYER01	Interchange Control Header
GSHPVERDICTPAYER012025012914301023X005010X221A1	Functional Group Header
ST8350001	Transaction Set Header — Health Care Claim Payment/Advice
BPRI10581.00CACHCCP010000000000DA9876541512345678*010000000000DA987654	Financial Information
TRN100000040*0000000000	Reassociation Trace Number
DTM40520230529	Production Date
N1PRKEYSTONE NATIONAL	Payer Identification
N1PESUMMIT POINT HOSPITALXX0000000000	Payee Identification
LX*1	Header Number
CLPCLM-2023-79714153940.0010581.002759.00HM00000011	Claim Payment Information
NM1QC1KENNEDYJACQUELINE	Patient Name
SE420001	Transaction Set Trailer

837 Original Claim Submission

EDI

Control Number

S000000000A

Submission Date

2023-06-01

Billing Provider

SUMMIT POINT HOSPITAL

Tax ID

00-0000000

Total Charges

$53,940

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
BHT001900000000202305290915CH	Beginning of Hierarchical Transaction
NM1412SOUTHERN REGIONAL***460000000000	Submitter Name
NM1402KEYSTONE NATIONAL***46PAYER01	Receiver Name
HL1201	Billing Provider Hierarchical Level
NM1852SUMMIT POINT HOSPITAL***XX0000000000	Billing Provider Name
NM1IL1KENNEDYJACQUELINE****MIAAA000000000	Subscriber Name
CLMCLM-2023-7971453940.00**11:B:1YAY*Y	Claim Information
DTP434RD8*20230529-20230529	Date — Statement Dates
SE380001	Transaction Set Trailer

EOB / Claim Summary

Summary

Billed

$53,940

Allowed

$7,012

Paid

$10,581

Patient Responsibility

$2,759

Underpayment

$23,873

Payment Rate

19.6%

Adjustment Reason Codes

P4Claim/service denied. Payment is included in the allowance for another service/procedure.
I1The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2023-79714

12 service lines

Line #	Procedure Code	Procedure Description	Revenue Code	Revenue Description	Billed	Allowed	Paid	Underpaid	Benchmark	Benchmark Underpaid	Status
1	85025	Complete blood cell count, automated test	0305	Laboratory - Hematology	$8,211	$1,210	$1,611	$6,600	$3,632	$2,021	PRIMARY
2	82040	Albumin (protein) level	0300	Laboratory - General	$7,686	$1,769	$1,508	$6,178	$926	$0	PRIMARY
3	84155	Total protein level, blood	0300	Laboratory - General	$7,175	$1,132	$1,407	$5,768	$1,170	$0	PRIMARY
4	93005	Routine electrocardiogram with 12 leads	0730	EKG/ECG (electrocardiogram)	$6,711	$1,727	$1,317	$5,395	$1,946	$629	PRIMARY
5	82977	Glutamyltransferase (liver enzyme) level	0300	Laboratory - General	$6,207	$1,711	$1,218	$4,989	$1,737	$520	PRIMARY
6	72125	CT cervical spine without contrast	0352	Diagnostic Radiology - CT Scan	$5,577	$1,240	$1,094	$4,483	$387	$0	PRIMARY
7	84484	Troponin (protein) analysis	0305	Laboratory - Hematology	$3,359	$588	$659	$2,700	$1,334	$675	PRIMARY
8	71046	Radiologic examination, chest; 2 views	0324	Radiology - Diagnostic	$3,145	$726	$617	$2,528	$449	$0	PRIMARY
9	96368	Infusion into a vein, concurrent with another infusion	0260	IV Therapy - General	$2,958	$584	$580	$2,378	$1,096	$515	PRIMARY
10	J2765	Injection, metoclopramide HCl, up to 10 mg	0250	Pharmacy - General	$1,150	$196	$226	$924	$466	$240	PRIMARY
11	85379	Coagulation function measurement	0305	Laboratory - Hematology	$1,011	$163	$198	$813	$135	$0	PRIMARY
12	84075	Phosphatase (enzyme) level	0300	Laboratory - General	$751	$179	$147	$603	$278	$130	PRIMARY

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Verdict Consulting Group · All values shown are demo data · 12 service lines extracted