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Verdict Claims Explorer / Claim Details

Claim Details

CLM-2024-49633Underpaid

Claim Identification

Patient Name
ROOSEVELT, FRANKLIN
Service Date
2024-01-30
DRG Code
153.0
Claim ID
CLM-2024-49633
Service Line Number
5
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
PACIFIC REGIONAL
Payer
LIBERTY BELL HEALTH

Patient Information

First Name
FRANKLIN
Last Name
ROOSEVELT
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
$13,390
Total Payment Amount
$4,909
Coverage Amount
$1,741
Line Charge Amount
$4,432
Line Paid Amount
$1,625
Line Allowed Amount
$659
Line Total Adjustment
$2,807
Underpayment
$5,150
Payment Rate
36.66%
Patient Responsibility
$377
Payment Date
2024-02-25
Payment Method
ACH
Check / Ref Trace Number
C00000E00000000

Service Details

Service Date From
2024-01-30
Service Date To
2024-01-30
Statement Date From
2024-01-30
Statement Date To
2024-01-30
Production Date
2024-02-23
Filing Indicator
HM
Quantity
N/A
Line Unit Count
1.0

PCS (Provider Claim Summary) Details

2 Records
PCS Record 1 of 2OUT-PATIENTPACIFIC REGIONAL (PAC-RGN)Claim #: 0000000000C00X
Patient
FRANKLIN ROOSEVELT
Patient No
AA00000
Admit Date
N/A
From Date
2024-01-30
Group-Sub No
000000-ABC000000
End Date
2024-01-30
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$13,390$11,515$1,741$1,741$0$4,909
Messages / ReasonsB9
Contract Deductible / Copay$377
Provider Number0000000000
Total Deductions / Other Ineligible$377
Tax ID00-0000000
Patient's Share$377
Source Document
TKLJ_D000000_0000000_000.pdf
Pages: 17 - 0 · Extracted: 1/1/2026
PCS Record 2 of 2OUT-PATIENTPACIFIC REGIONAL (PAC-RGN)Claim #: 0000000000C00X
Patient
FRANKLIN ROOSEVELT
Patient No
AA00000
Admit Date
N/A
From Date
2024-01-30
Group-Sub No
000000-ABC000000
End Date
2024-01-30
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$5,624$4,820$803$803$0$2,062
Messages / ReasonsB9
Contract Deductible / Copay$158
Provider Number0000000000
Total Deductions / Other Ineligible$158
Tax ID00-0000000
Patient's Share$158
Source Document
TKLJ_D000000_0000000_000.pdf
Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI
Control Number
C00000E00000000
Payment Date
2024-02-25
Payment Method
ACH
Check / EFT
EFT000000
Payer
LIBERTY BELL HEALTH
Payer Contact
1-800-555-0182
Total Submitted Charges
$13,390
Net Total Paid
$4,909
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*4909.00*C*ACH*CCP*01*0000000000*DA*987654*1512345678**01*0000000000*DA*987654Financial Information
TRN*1*00000040*0000000000Reassociation Trace Number
DTM*405*20240130Production Date
N1*PR*LIBERTY BELL HEALTHPayer Identification
N1*PE*LAKESIDE MEDICAL CENTER*XX*0000000000Payee Identification
LX*1Header Number
CLP*CLM-2024-49633*1*13390.00*4909.00*377.00*HM*000000*11Claim Payment Information
NM1*QC*1*ROOSEVELT*FRANKLINPatient Name
SE*42*0001Transaction Set Trailer

837 Original Claim Submission

EDI
Control Number
S000000000A
Submission Date
2024-02-02
Billing Provider
LAKESIDE MEDICAL CENTER
Tax ID
00-0000000
Total Charges
$13,390
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*20240130*0915*CHBeginning of Hierarchical Transaction
NM1*41*2*PACIFIC REGIONAL*****46*0000000000Submitter Name
NM1*40*2*LIBERTY BELL HEALTH*****46*PAYER01Receiver Name
HL*1**20*1Billing Provider Hierarchical Level
NM1*85*2*LAKESIDE MEDICAL CENTER*****XX*0000000000Billing Provider Name
NM1*IL*1*ROOSEVELT*FRANKLIN*****MI*AAA000000000Subscriber Name
CLM*CLM-2024-49633*13390.00***11:B:1*Y*A*Y*YClaim Information
DTP*434*RD8*20240130-20240130Date — Statement Dates
SE*38*0001Transaction Set Trailer

EOB / Claim Summary

Summary
Billed
$13,390
Allowed
$1,741
Paid
$4,909
Patient Responsibility
$377
Underpayment
$5,150
Payment Rate
36.7%
Adjustment Reason Codes
  • A8Claim/service denied. Payment is included in the allowance for another service/procedure.
  • E3The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2024-49633

5 service lines
Line #Procedure CodeProcedure DescriptionRevenue CodeRevenue DescriptionBilledAllowedPaidUnderpaidBenchmarkBenchmark UnderpaidStatus
184075Phosphatase (enzyme) level0300Laboratory - General$4,432$659$1,625$2,807$646$0PRIMARY
272125CT cervical spine without contrast0352Diagnostic Radiology - CT Scan$4,230$675$1,551$2,679$1,379$0PRIMARY
399284Emergency department visit, problem of high severity0450Emergency Room - General$2,333$697$855$1,478$900$45PRIMARY
470450CT scan head/brain without contrast0352Diagnostic Radiology - CT Scan$1,987$356$729$1,259$448$0PRIMARY
596368Infusion into a vein, concurrent with another infusion0260IV Therapy - General$408$77$149$258$113$0PRIMARY
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Verdict Consulting Group · All values shown are demo data · 5 service lines extracted

Demo Data