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Verdict Claims Explorer / Claim Details

Claim Details

CLM-2024-46971Underpaid

Claim Identification

Patient Name
WASHINGTON, GEORGE
Service Date
2024-02-22
DRG Code
153.0
Claim ID
CLM-2024-46971
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
WESTERN REGIONAL
Payer
COASTLINE PPO

Patient Information

First Name
GEORGE
Last Name
WASHINGTON
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
$40,650
Total Payment Amount
$22,152
Coverage Amount
$5,285
Line Charge Amount
$8,792
Line Paid Amount
$4,791
Line Allowed Amount
$2,225
Line Total Adjustment
$4,001
Underpayment
$3,754
Payment Rate
54.49%
Patient Responsibility
$1,644
Payment Date
2024-03-19
Payment Method
ACH
Check / Ref Trace Number
C00000E00000000

Service Details

Service Date From
2024-02-22
Service Date To
2024-02-22
Statement Date From
2024-02-22
Statement Date To
2024-02-22
Production Date
2024-03-17
Filing Indicator
HM
Quantity
N/A
Line Unit Count
1.0

PCS (Provider Claim Summary) Details

2 Records
PCS Record 1 of 2OUT-PATIENTWESTERN REGIONAL (WST-RGN)Claim #: 0000000000C00X
Patient
GEORGE WASHINGTON
Patient No
AA00000
Admit Date
N/A
From Date
2024-02-22
Group-Sub No
000000-ABC000000
End Date
2024-02-22
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$40,650$34,959$5,285$5,285$0$22,152
Messages / ReasonsE2
Contract Deductible / Copay$1,644
Provider Number0000000000
Total Deductions / Other Ineligible$1,644
Tax ID00-0000000
Patient's Share$1,644
Source Document
DHXB_D000000_0000000_000.pdf
Pages: 17 - 0 · Extracted: 1/1/2026
PCS Record 2 of 2OUT-PATIENTWESTERN REGIONAL (WST-RGN)Claim #: 0000000000C00X
Patient
GEORGE WASHINGTON
Patient No
AA00000
Admit Date
N/A
From Date
2024-02-22
Group-Sub No
000000-ABC000000
End Date
2024-02-22
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$17,073$14,634$2,439$2,439$0$9,304
Messages / ReasonsE2
Contract Deductible / Copay$690
Provider Number0000000000
Total Deductions / Other Ineligible$690
Tax ID00-0000000
Patient's Share$690
Source Document
DHXB_D000000_0000000_000.pdf
Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI
Control Number
C00000E00000000
Payment Date
2024-03-19
Payment Method
ACH
Check / EFT
EFT000000
Payer
COASTLINE PPO
Payer Contact
1-800-555-0182
Total Submitted Charges
$40,650
Net Total Paid
$22,152
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*22152.00*C*ACH*CCP*01*0000000000*DA*987654*1512345678**01*0000000000*DA*987654Financial Information
TRN*1*00000040*0000000000Reassociation Trace Number
DTM*405*20240222Production Date
N1*PR*COASTLINE PPOPayer Identification
N1*PE*CEDAR VALLEY MEDICAL*XX*0000000000Payee Identification
LX*1Header Number
CLP*CLM-2024-46971*1*40650.00*22152.00*1644.00*HM*000000*11Claim Payment Information
NM1*QC*1*WASHINGTON*GEORGEPatient Name
SE*42*0001Transaction Set Trailer

837 Original Claim Submission

EDI
Control Number
S000000000A
Submission Date
2024-02-25
Billing Provider
CEDAR VALLEY MEDICAL
Tax ID
00-0000000
Total Charges
$40,650
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*20240222*0915*CHBeginning of Hierarchical Transaction
NM1*41*2*WESTERN REGIONAL*****46*0000000000Submitter Name
NM1*40*2*COASTLINE PPO*****46*PAYER01Receiver Name
HL*1**20*1Billing Provider Hierarchical Level
NM1*85*2*CEDAR VALLEY MEDICAL*****XX*0000000000Billing Provider Name
NM1*IL*1*WASHINGTON*GEORGE*****MI*AAA000000000Subscriber Name
CLM*CLM-2024-46971*40650.00***11:B:1*Y*A*Y*YClaim Information
DTP*434*RD8*20240222-20240222Date — Statement Dates
SE*38*0001Transaction Set Trailer

EOB / Claim Summary

Summary
Billed
$40,650
Allowed
$5,285
Paid
$22,152
Patient Responsibility
$1,644
Underpayment
$3,754
Payment Rate
54.5%
Adjustment Reason Codes
  • L1Claim/service denied. Payment is included in the allowance for another service/procedure.
  • Z2The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2024-46971

9 service lines
Line #Procedure CodeProcedure DescriptionRevenue CodeRevenue DescriptionBilledAllowedPaidUnderpaidBenchmarkBenchmark UnderpaidStatus
185379Coagulation function measurement0305Laboratory - Hematology$8,792$2,225$4,791$4,001$1,279$0PRIMARY
293005Routine electrocardiogram with 12 leads0730EKG/ECG (electrocardiogram)$7,140$1,452$3,891$3,249$1,250$0PRIMARY
384484Troponin (protein) analysis0305Laboratory - Hematology$5,992$1,415$3,265$2,727$1,391$0PRIMARY
471046Radiologic examination, chest; 2 views0324Radiology - Diagnostic$5,412$1,355$2,949$2,463$1,092$0PRIMARY
5J2765Injection, metoclopramide HCl, up to 10 mg0250Pharmacy - General$4,594$947$2,503$2,091$2,000$0PRIMARY
6J1170Injection, hydromorphone, up to 4 mg0250Pharmacy - General$3,166$610$1,725$1,441$865$0PRIMARY
7J1885Injection, ketorolac tromethamine, per 15 mg0250Pharmacy - General$2,260$511$1,232$1,028$976$0PRIMARY
884155Total protein level, blood0300Laboratory - General$2,147$310$1,170$977$245$0PRIMARY
985025Complete blood cell count, automated test0305Laboratory - Hematology$1,147$198$625$522$84$0PRIMARY
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Verdict Consulting Group · All values shown are demo data · 9 service lines extracted

Demo Data