Verdict Claims Explorer — Verdict Consulting Group

Claim Identification

Patient Name: CARTER, JAMES
Service Date: 2024-10-01
DRG Code: 153.0
Claim ID: CLM-2024-25346
Service Line Number: 17
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: SUMMIT BENEFITS

Patient Information

First Name: JAMES
Last Name: CARTER
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: $76,040
Total Payment Amount: $16,106
Coverage Amount: $9,885
Line Charge Amount: $8,807
Line Paid Amount: $1,866
Line Allowed Amount: $1,568
Line Total Adjustment: $6,942
Underpayment: $42,640
Payment Rate: 21.18%
Patient Responsibility: $3,500
Payment Date: 2024-10-27
Payment Method: ACH
Check / Ref Trace Number: C00000E00000000

Service Details

Service Date From: 2024-10-01
Service Date To: 2024-10-01

Statement Date From: 2024-10-01
Statement Date To: 2024-10-01

Production Date: 2024-10-25
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

JAMES CARTER

Patient No

AA00000

Admit Date

N/A

From Date

2024-10-01

Group-Sub No

000000-ABC000000

End Date

2024-10-01

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	$76,040	$65,394	$9,885	$9,885	$0	$16,106

Messages / ReasonsO6

Contract Deductible / Copay$3,500

Provider Number0000000000

Total Deductions / Other Ineligible$3,500

Tax ID00-0000000

Patient's Share$3,500

Source Document

XBRX_D000000_0000000_000.pdf

Pages: 17 - 0 · Extracted: 1/1/2026

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

Patient

JAMES CARTER

Patient No

AA00000

Admit Date

N/A

From Date

2024-10-01

Group-Sub No

000000-ABC000000

End Date

2024-10-01

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	$31,937	$27,374	$4,562	$4,562	$0	$6,765

Messages / ReasonsO6

Contract Deductible / Copay$1,470

Provider Number0000000000

Total Deductions / Other Ineligible$1,470

Tax ID00-0000000

Patient's Share$1,470

Source Document

XBRX_D000000_0000000_000.pdf

Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI

Control Number

C00000E00000000

Payment Date

2024-10-27

Payment Method

ACH

Check / EFT

EFT000000

Payer

SUMMIT BENEFITS

Payer Contact

1-800-555-0182

Total Submitted Charges

$76,040

Net Total Paid

$16,106

Segments

Segment	Description
ISA00 00 ZZVERDICT ZZPAYER01	Interchange Control Header
GSHPVERDICTPAYER012025012914301023X005010X221A1	Functional Group Header
ST8350001	Transaction Set Header — Health Care Claim Payment/Advice
BPRI16106.00CACHCCP010000000000DA9876541512345678*010000000000DA987654	Financial Information
TRN100000040*0000000000	Reassociation Trace Number
DTM40520241001	Production Date
N1PRSUMMIT BENEFITS	Payer Identification
N1PEPACIFIC CREST ERXX0000000000	Payee Identification
LX*1	Header Number
CLPCLM-2024-25346176040.0016106.003500.00HM00000011	Claim Payment Information
NM1QC1CARTERJAMES	Patient Name
SE420001	Transaction Set Trailer

837 Original Claim Submission

EDI

Control Number

S000000000A

Submission Date

2024-10-04

Billing Provider

PACIFIC CREST ER

Tax ID

00-0000000

Total Charges

$76,040

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
BHT001900000000202410010915CH	Beginning of Hierarchical Transaction
NM1412SOUTHERN REGIONAL***460000000000	Submitter Name
NM1402SUMMIT BENEFITS***46PAYER01	Receiver Name
HL1201	Billing Provider Hierarchical Level
NM1852PACIFIC CREST ER***XX0000000000	Billing Provider Name
NM1IL1CARTERJAMES****MIAAA000000000	Subscriber Name
CLMCLM-2024-2534676040.00**11:B:1YAY*Y	Claim Information
DTP434RD8*20241001-20241001	Date — Statement Dates
SE380001	Transaction Set Trailer

EOB / Claim Summary

Summary

Billed

$76,040

Allowed

$9,885

Paid

$16,106

Patient Responsibility

$3,500

Underpayment

$42,640

Payment Rate

21.2%

Adjustment Reason Codes

V3Claim/service denied. Payment is included in the allowance for another service/procedure.
B3The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2024-25346

17 service lines

Line #	Procedure Code	Procedure Description	Revenue Code	Revenue Description	Billed	Allowed	Paid	Underpaid	Benchmark	Benchmark Underpaid	Status
1	72125	CT cervical spine without contrast	0352	Diagnostic Radiology - CT Scan	$8,807	$1,568	$1,866	$6,942	$2,657	$791	PRIMARY
2	82040	Albumin (protein) level	0300	Laboratory - General	$8,755	$2,561	$1,854	$6,901	$3,085	$1,230	PRIMARY
3	96368	Infusion into a vein, concurrent with another infusion	0260	IV Therapy - General	$8,724	$1,445	$1,848	$6,876	$1,429	$0	PRIMARY
4	J3010	Injection, fentanyl citrate, 0.1 mg	0250	Pharmacy - General	$8,212	$1,688	$1,739	$6,473	$3,500	$1,761	PRIMARY
5	85379	Coagulation function measurement	0305	Laboratory - Hematology	$6,374	$1,895	$1,350	$5,024	$1,436	$86	PRIMARY
6	85025	Complete blood cell count, automated test	0305	Laboratory - Hematology	$5,628	$1,056	$1,192	$4,436	$2,212	$1,020	PRIMARY
7	84155	Total protein level, blood	0300	Laboratory - General	$4,905	$1,069	$1,039	$3,866	$1,853	$815	PRIMARY
8	99284	Emergency department visit, problem of high severity	0450	Emergency Room - General	$4,470	$1,312	$947	$3,523	$1,162	$215	PRIMARY
9	J2765	Injection, metoclopramide HCl, up to 10 mg	0250	Pharmacy - General	$4,087	$1,191	$866	$3,222	$965	$99	PRIMARY
10	J1885	Injection, ketorolac tromethamine, per 15 mg	0250	Pharmacy - General	$3,659	$445	$775	$2,884	$829	$54	PRIMARY
11	71046	Radiologic examination, chest; 2 views	0324	Radiology - Diagnostic	$3,505	$983	$742	$2,763	$954	$212	PRIMARY
12	93005	Routine electrocardiogram with 12 leads	0730	EKG/ECG (electrocardiogram)	$2,219	$410	$470	$1,749	$684	$214	PRIMARY
13	70450	CT scan head/brain without contrast	0352	Diagnostic Radiology - CT Scan	$1,921	$464	$407	$1,514	$426	$19	PRIMARY
14	84075	Phosphatase (enzyme) level	0300	Laboratory - General	$1,802	$287	$382	$1,420	$704	$323	PRIMARY
15	84484	Troponin (protein) analysis	0305	Laboratory - Hematology	$1,347	$263	$285	$1,062	$536	$250	PRIMARY
16	82977	Glutamyltransferase (liver enzyme) level	0300	Laboratory - General	$960	$258	$203	$757	$380	$176	PRIMARY
17	J1170	Injection, hydromorphone, up to 4 mg	0250	Pharmacy - General	$664	$133	$141	$523	$234	$93	PRIMARY

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Verdict Consulting Group · All values shown are demo data · 17 service lines extracted