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Verdict Claims Explorer / Claim Details

Claim Details

CLM-2024-43471Underpaid

Claim Identification

Patient Name
TRUMAN, HARRY
Service Date
2024-05-08
DRG Code
153.0
Claim ID
CLM-2024-43471
Service Line Number
7
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
HARRY
Last Name
TRUMAN
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
$29,395
Total Payment Amount
$21,401
Coverage Amount
$3,821
Line Charge Amount
$7,373
Line Paid Amount
$5,368
Line Allowed Amount
$1,928
Line Total Adjustment
$2,005
Underpayment
$4,804
Payment Rate
72.80%
Patient Responsibility
$1,019
Payment Date
2024-06-03
Payment Method
ACH
Check / Ref Trace Number
C00000E00000000

Service Details

Service Date From
2024-05-08
Service Date To
2024-05-08
Statement Date From
2024-05-08
Statement Date To
2024-05-08
Production Date
2024-06-01
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
HARRY TRUMAN
Patient No
AA00000
Admit Date
N/A
From Date
2024-05-08
Group-Sub No
000000-ABC000000
End Date
2024-05-08
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$29,395$25,280$3,821$3,821$0$21,401
Messages / ReasonsE8
Contract Deductible / Copay$1,019
Provider Number0000000000
Total Deductions / Other Ineligible$1,019
Tax ID00-0000000
Patient's Share$1,019
Source Document
WTSZ_D000000_0000000_000.pdf
Pages: 17 - 0 · Extracted: 1/1/2026
PCS Record 2 of 2OUT-PATIENTNORTHEAST REGIONAL (NEN-RGN)Claim #: 0000000000C00X
Patient
HARRY TRUMAN
Patient No
AA00000
Admit Date
N/A
From Date
2024-05-08
Group-Sub No
000000-ABC000000
End Date
2024-05-08
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$12,346$10,582$1,764$1,764$0$8,988
Messages / ReasonsE8
Contract Deductible / Copay$428
Provider Number0000000000
Total Deductions / Other Ineligible$428
Tax ID00-0000000
Patient's Share$428
Source Document
WTSZ_D000000_0000000_000.pdf
Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI
Control Number
C00000E00000000
Payment Date
2024-06-03
Payment Method
ACH
Check / EFT
EFT000000
Payer
SUMMIT BENEFITS
Payer Contact
1-800-555-0182
Total Submitted Charges
$29,395
Net Total Paid
$21,401
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*21401.00*C*ACH*CCP*01*0000000000*DA*987654*1512345678**01*0000000000*DA*987654Financial Information
TRN*1*00000040*0000000000Reassociation Trace Number
DTM*405*20240508Production Date
N1*PR*SUMMIT BENEFITSPayer Identification
N1*PE*RIVERSIDE REGIONAL*XX*0000000000Payee Identification
LX*1Header Number
CLP*CLM-2024-43471*1*29395.00*21401.00*1019.00*HM*000000*11Claim Payment Information
NM1*QC*1*TRUMAN*HARRYPatient Name
SE*42*0001Transaction Set Trailer

837 Original Claim Submission

EDI
Control Number
S000000000A
Submission Date
2024-05-11
Billing Provider
RIVERSIDE REGIONAL
Tax ID
00-0000000
Total Charges
$29,395
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*20240508*0915*CHBeginning of Hierarchical Transaction
NM1*41*2*NORTHEAST REGIONAL*****46*0000000000Submitter Name
NM1*40*2*SUMMIT BENEFITS*****46*PAYER01Receiver Name
HL*1**20*1Billing Provider Hierarchical Level
NM1*85*2*RIVERSIDE REGIONAL*****XX*0000000000Billing Provider Name
NM1*IL*1*TRUMAN*HARRY*****MI*AAA000000000Subscriber Name
CLM*CLM-2024-43471*29395.00***11:B:1*Y*A*Y*YClaim Information
DTP*434*RD8*20240508-20240508Date — Statement Dates
SE*38*0001Transaction Set Trailer

EOB / Claim Summary

Summary
Billed
$29,395
Allowed
$3,821
Paid
$21,401
Patient Responsibility
$1,019
Underpayment
$4,804
Payment Rate
72.8%
Adjustment Reason Codes
  • C8Claim/service denied. Payment is included in the allowance for another service/procedure.
  • O9The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2024-43471

7 service lines
Line #Procedure CodeProcedure DescriptionRevenue CodeRevenue DescriptionBilledAllowedPaidUnderpaidBenchmarkBenchmark UnderpaidStatus
1J2765Injection, metoclopramide HCl, up to 10 mg0250Pharmacy - General$7,373$1,928$5,368$2,005$1,506$0PRIMARY
2J1885Injection, ketorolac tromethamine, per 15 mg0250Pharmacy - General$6,173$1,012$4,494$1,679$1,978$0PRIMARY
385379Coagulation function measurement0305Laboratory - Hematology$5,520$1,454$4,019$1,501$2,136$0PRIMARY
493005Routine electrocardiogram with 12 leads0730EKG/ECG (electrocardiogram)$5,025$840$3,658$1,367$1,626$0PRIMARY
584484Troponin (protein) analysis0305Laboratory - Hematology$3,540$511$2,578$963$996$0PRIMARY
6J1170Injection, hydromorphone, up to 4 mg0250Pharmacy - General$1,107$285$806$301$436$0PRIMARY
771046Radiologic examination, chest; 2 views0324Radiology - Diagnostic$656$154$478$178$233$0PRIMARY
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Verdict Consulting Group · All values shown are demo data · 7 service lines extracted

Demo Data