Verdict Claims Explorer — Verdict Consulting Group

Claim Identification

Patient Name: ADAMS, ABIGAIL
Service Date: 2024-10-30
DRG Code: 153.0
Claim ID: CLM-2024-26942
Service Line Number: 9
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: NORTHEAST REGIONAL
Payer: SUMMIT BENEFITS

Patient Information

First Name: ABIGAIL
Last Name: ADAMS
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: $39,345
Total Payment Amount: $22,009
Coverage Amount: $5,115
Line Charge Amount: $8,018
Line Paid Amount: $4,485
Line Allowed Amount: $1,240
Line Total Adjustment: $3,533
Underpayment: $6,457
Payment Rate: 55.94%
Patient Responsibility: $1,080
Payment Date: 2024-11-25
Payment Method: ACH
Check / Ref Trace Number: C00000E00000000

Service Details

Service Date From: 2024-10-30
Service Date To: 2024-10-30

Statement Date From: 2024-10-30
Statement Date To: 2024-10-30

Production Date: 2024-11-23
Filing Indicator: HM

Quantity: N/A
Line Unit Count: 1.0

PCS (Provider Claim Summary) Details

2 Records

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

Patient

ABIGAIL ADAMS

Patient No

AA00000

Admit Date

N/A

From Date

2024-10-30

Group-Sub No

000000-ABC000000

End Date

2024-10-30

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	$39,345	$33,837	$5,115	$5,115	$0	$22,009

Messages / ReasonsA9

Contract Deductible / Copay$1,080

Provider Number0000000000

Total Deductions / Other Ineligible$1,080

Tax ID00-0000000

Patient's Share$1,080

Source Document

YHMC_D000000_0000000_000.pdf

Pages: 17 - 0 · Extracted: 1/1/2026

PCS Record 2 of 2OUT-PATIENTNORTHEAST REGIONAL (NEN-RGN)Claim #: 0000000000C00X

Patient

ABIGAIL ADAMS

Patient No

AA00000

Admit Date

N/A

From Date

2024-10-30

Group-Sub No

000000-ABC000000

End Date

2024-10-30

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	$16,525	$14,164	$2,361	$2,361	$0	$9,244

Messages / ReasonsA9

Contract Deductible / Copay$454

Provider Number0000000000

Total Deductions / Other Ineligible$454

Tax ID00-0000000

Patient's Share$454

Source Document

YHMC_D000000_0000000_000.pdf

Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI

Control Number

C00000E00000000

Payment Date

2024-11-25

Payment Method

ACH

Check / EFT

EFT000000

Payer

SUMMIT BENEFITS

Payer Contact

1-800-555-0182

Total Submitted Charges

$39,345

Net Total Paid

$22,009

Segments

Segment	Description
ISA00 00 ZZVERDICT ZZPAYER01	Interchange Control Header
GSHPVERDICTPAYER012025012914301023X005010X221A1	Functional Group Header
ST8350001	Transaction Set Header — Health Care Claim Payment/Advice
BPRI22009.00CACHCCP010000000000DA9876541512345678*010000000000DA987654	Financial Information
TRN100000040*0000000000	Reassociation Trace Number
DTM40520241030	Production Date
N1PRSUMMIT BENEFITS	Payer Identification
N1PESUMMIT POINT HOSPITALXX0000000000	Payee Identification
LX*1	Header Number
CLPCLM-2024-26942139345.0022009.001080.00HM00000011	Claim Payment Information
NM1QC1ADAMSABIGAIL	Patient Name
SE420001	Transaction Set Trailer

837 Original Claim Submission

EDI

Control Number

S000000000A

Submission Date

2024-11-02

Billing Provider

SUMMIT POINT HOSPITAL

Tax ID

00-0000000

Total Charges

$39,345

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
BHT001900000000202410300915CH	Beginning of Hierarchical Transaction
NM1412NORTHEAST REGIONAL***460000000000	Submitter Name
NM1402SUMMIT BENEFITS***46PAYER01	Receiver Name
HL1201	Billing Provider Hierarchical Level
NM1852SUMMIT POINT HOSPITAL***XX0000000000	Billing Provider Name
NM1IL1ADAMSABIGAIL****MIAAA000000000	Subscriber Name
CLMCLM-2024-2694239345.00**11:B:1YAY*Y	Claim Information
DTP434RD8*20241030-20241030	Date — Statement Dates
SE380001	Transaction Set Trailer

EOB / Claim Summary

Summary

Billed

$39,345

Allowed

$5,115

Paid

$22,009

Patient Responsibility

$1,080

Underpayment

$6,457

Payment Rate

55.9%

Adjustment Reason Codes

I4Claim/service denied. Payment is included in the allowance for another service/procedure.
Q9The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2024-26942

9 service lines

Line #	Procedure Code	Procedure Description	Revenue Code	Revenue Description	Billed	Allowed	Paid	Underpaid	Benchmark	Benchmark Underpaid	Status
1	84155	Total protein level, blood	0300	Laboratory - General	$8,018	$1,240	$4,485	$3,533	$1,520	$0	PRIMARY
2	84484	Troponin (protein) analysis	0305	Laboratory - Hematology	$6,925	$1,870	$3,874	$3,051	$2,237	$0	PRIMARY
3	82977	Glutamyltransferase (liver enzyme) level	0300	Laboratory - General	$5,943	$836	$3,324	$2,619	$2,660	$0	PRIMARY
4	84075	Phosphatase (enzyme) level	0300	Laboratory - General	$5,761	$1,370	$3,223	$2,538	$1,071	$0	PRIMARY
5	93005	Routine electrocardiogram with 12 leads	0730	EKG/ECG (electrocardiogram)	$4,002	$1,141	$2,239	$1,763	$374	$0	PRIMARY
6	85025	Complete blood cell count, automated test	0305	Laboratory - Hematology	$3,199	$907	$1,789	$1,409	$1,013	$0	PRIMARY
7	82040	Albumin (protein) level	0300	Laboratory - General	$2,846	$604	$1,592	$1,254	$1,216	$0	PRIMARY
8	85379	Coagulation function measurement	0305	Laboratory - Hematology	$2,156	$362	$1,206	$950	$477	$0	PRIMARY
9	71046	Radiologic examination, chest; 2 views	0324	Radiology - Diagnostic	$495	$61	$277	$218	$182	$0	PRIMARY

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Verdict Consulting Group · All values shown are demo data · 9 service lines extracted