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Verdict Claims Explorer / Claim Details

Claim Details

CLM-2024-53476Correct

Claim Identification

Patient Name
TRUMAN, BESS
Service Date
2024-05-08
DRG Code
153.0
Claim ID
CLM-2024-53476
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
SOUTHERN REGIONAL
Payer
SUMMIT BENEFITS

Patient Information

First Name
BESS
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
$1,990
Total Payment Amount
$1,700
Coverage Amount
$259
Line Charge Amount
$645
Line Paid Amount
$551
Line Allowed Amount
$83
Line Total Adjustment
$94
Underpayment
$0
Payment Rate
85.43%
Patient Responsibility
$136
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-PATIENTSOUTHERN REGIONAL (SOU-RGN)Claim #: 0000000000C00X
Patient
BESS 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$1,990$1,711$259$259$0$1,700
Messages / ReasonsP1
Contract Deductible / Copay$136
Provider Number0000000000
Total Deductions / Other Ineligible$136
Tax ID00-0000000
Patient's Share$136
Source Document
LJMP_D000000_0000000_000.pdf
Pages: 17 - 0 · Extracted: 1/1/2026
PCS Record 2 of 2OUT-PATIENTSOUTHERN REGIONAL (SOU-RGN)Claim #: 0000000000C00X
Patient
BESS 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$836$716$119$119$0$714
Messages / ReasonsP1
Contract Deductible / Copay$57
Provider Number0000000000
Total Deductions / Other Ineligible$57
Tax ID00-0000000
Patient's Share$57
Source Document
LJMP_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
$1,990
Net Total Paid
$1,700
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*1700.00*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*LAKESIDE MEDICAL CENTER*XX*0000000000Payee Identification
LX*1Header Number
CLP*CLM-2024-53476*1*1990.00*1700.00*136.00*HM*000000*11Claim Payment Information
NM1*QC*1*TRUMAN*BESSPatient Name
SE*42*0001Transaction Set Trailer

837 Original Claim Submission

EDI
Control Number
S000000000A
Submission Date
2024-05-11
Billing Provider
LAKESIDE MEDICAL CENTER
Tax ID
00-0000000
Total Charges
$1,990
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*SOUTHERN REGIONAL*****46*0000000000Submitter Name
NM1*40*2*SUMMIT BENEFITS*****46*PAYER01Receiver Name
HL*1**20*1Billing Provider Hierarchical Level
NM1*85*2*LAKESIDE MEDICAL CENTER*****XX*0000000000Billing Provider Name
NM1*IL*1*TRUMAN*BESS*****MI*AAA000000000Subscriber Name
CLM*CLM-2024-53476*1990.00***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
$1,990
Allowed
$259
Paid
$1,700
Patient Responsibility
$136
Underpayment
$0
Payment Rate
85.4%
Adjustment Reason Codes
  • G6Claim/service denied. Payment is included in the allowance for another service/procedure.
  • A2The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2024-53476

5 service lines
Line #Procedure CodeProcedure DescriptionRevenue CodeRevenue DescriptionBilledAllowedPaidUnderpaidBenchmarkBenchmark UnderpaidStatus
196368Infusion into a vein, concurrent with another infusion0260IV Therapy - General$645$83$551$94$147$0PRIMARY
272125CT cervical spine without contrast0352Diagnostic Radiology - CT Scan$517$113$442$75$90$0PRIMARY
370450CT scan head/brain without contrast0352Diagnostic Radiology - CT Scan$429$64$367$63$30$0PRIMARY
484075Phosphatase (enzyme) level0300Laboratory - General$292$72$249$43$104$0PRIMARY
582977Glutamyltransferase (liver enzyme) level0300Laboratory - General$107$17$91$16$38$0PRIMARY
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Verdict Consulting Group · All values shown are demo data · 5 service lines extracted

Demo Data