Verdict Claims Explorer — Verdict Consulting Group

Claim Identification

Patient Name: KENNEDY, JOHN
Service Date: 2023-05-29
DRG Code: 153.0
Claim ID: CLM-2023-89778
Service Line Number: 11
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: GREAT LAKES REGIONAL
Payer: LIBERTY BELL HEALTH

Patient Information

First Name: JOHN
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: $47,595
Total Payment Amount: $21,151
Coverage Amount: $6,187
Line Charge Amount: $6,238
Line Paid Amount: $2,772
Line Allowed Amount: $1,396
Line Total Adjustment: $3,466
Underpayment: $16,301
Payment Rate: 44.44%
Patient Responsibility: $2,525
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-PATIENTGREAT LAKES REGIONAL (GLK-RGN)Claim #: 0000000000C00X

Patient

JOHN 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	$47,595	$40,932	$6,187	$6,187	$0	$21,151

Messages / ReasonsP6

Contract Deductible / Copay$2,525

Provider Number0000000000

Total Deductions / Other Ineligible$2,525

Tax ID00-0000000

Patient's Share$2,525

Source Document

EUXL_D000000_0000000_000.pdf

Pages: 17 - 0 · Extracted: 1/1/2026

PCS Record 2 of 2OUT-PATIENTGREAT LAKES REGIONAL (GLK-RGN)Claim #: 0000000000C00X

Patient

JOHN 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	$19,990	$17,134	$2,856	$2,856	$0	$8,883

Messages / ReasonsP6

Contract Deductible / Copay$1,061

Provider Number0000000000

Total Deductions / Other Ineligible$1,061

Tax ID00-0000000

Patient's Share$1,061

Source Document

EUXL_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

LIBERTY BELL HEALTH

Payer Contact

1-800-555-0182

Total Submitted Charges

$47,595

Net Total Paid

$21,151

Segments

Segment	Description
ISA00 00 ZZVERDICT ZZPAYER01	Interchange Control Header
GSHPVERDICTPAYER012025012914301023X005010X221A1	Functional Group Header
ST8350001	Transaction Set Header — Health Care Claim Payment/Advice
BPRI21151.00CACHCCP010000000000DA9876541512345678*010000000000DA987654	Financial Information
TRN100000040*0000000000	Reassociation Trace Number
DTM40520230529	Production Date
N1PRLIBERTY BELL HEALTH	Payer Identification
N1PELAKESIDE MEDICAL CENTERXX0000000000	Payee Identification
LX*1	Header Number
CLPCLM-2023-89778147595.0021151.002525.00HM00000011	Claim Payment Information
NM1QC1KENNEDYJOHN	Patient Name
SE420001	Transaction Set Trailer

837 Original Claim Submission

EDI

Control Number

S000000000A

Submission Date

2023-06-01

Billing Provider

LAKESIDE MEDICAL CENTER

Tax ID

00-0000000

Total Charges

$47,595

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
NM1412GREAT LAKES REGIONAL***460000000000	Submitter Name
NM1402LIBERTY BELL HEALTH***46PAYER01	Receiver Name
HL1201	Billing Provider Hierarchical Level
NM1852LAKESIDE MEDICAL CENTER***XX0000000000	Billing Provider Name
NM1IL1KENNEDYJOHN****MIAAA000000000	Subscriber Name
CLMCLM-2023-8977847595.00**11:B:1YAY*Y	Claim Information
DTP434RD8*20230529-20230529	Date — Statement Dates
SE380001	Transaction Set Trailer

EOB / Claim Summary

Summary

Billed

$47,595

Allowed

$6,187

Paid

$21,151

Patient Responsibility

$2,525

Underpayment

$16,301

Payment Rate

44.4%

Adjustment Reason Codes

C2Claim/service denied. Payment is included in the allowance for another service/procedure.
P4The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2023-89778

11 service lines

Line #	Procedure Code	Procedure Description	Revenue Code	Revenue Description	Billed	Allowed	Paid	Underpaid	Benchmark	Benchmark Underpaid	Status
1	82040	Albumin (protein) level	0300	Laboratory - General	$6,238	$1,396	$2,772	$3,466	$591	$0	PRIMARY
2	96368	Infusion into a vein, concurrent with another infusion	0260	IV Therapy - General	$6,096	$882	$2,709	$3,387	$2,059	$0	PRIMARY
3	72125	CT cervical spine without contrast	0352	Diagnostic Radiology - CT Scan	$5,939	$1,180	$2,639	$3,300	$1,495	$0	PRIMARY
4	82977	Glutamyltransferase (liver enzyme) level	0300	Laboratory - General	$4,836	$992	$2,149	$2,687	$836	$0	PRIMARY
5	85379	Coagulation function measurement	0305	Laboratory - Hematology	$4,758	$863	$2,114	$2,643	$1,602	$0	PRIMARY
6	71046	Radiologic examination, chest; 2 views	0324	Radiology - Diagnostic	$4,334	$1,115	$1,926	$2,408	$1,722	$0	PRIMARY
7	84155	Total protein level, blood	0300	Laboratory - General	$4,285	$544	$1,904	$2,381	$788	$0	PRIMARY
8	93005	Routine electrocardiogram with 12 leads	0730	EKG/ECG (electrocardiogram)	$4,193	$892	$1,863	$2,330	$1,134	$0	PRIMARY
9	85025	Complete blood cell count, automated test	0305	Laboratory - Hematology	$3,361	$436	$1,494	$1,868	$453	$0	PRIMARY
10	84075	Phosphatase (enzyme) level	0300	Laboratory - General	$1,886	$430	$838	$1,048	$584	$0	PRIMARY
11	84484	Troponin (protein) analysis	0305	Laboratory - Hematology	$1,669	$273	$742	$927	$91	$0	PRIMARY

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Verdict Consulting Group · All values shown are demo data · 11 service lines extracted