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Claim Details

CLM-2024-58719Disputed

Claim Identification

Patient Name
ROOSEVELT, THEODORE
Service Date
2024-10-27
DRG Code
153.0
Claim ID
CLM-2024-58719
Service Line Number
17
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
MOUNTAIN REGIONAL
Payer
MERIDIAN HEALTH PLAN

Patient Information

First Name
THEODORE
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
$82,740
Total Payment Amount
$35,814
Coverage Amount
$10,756
Line Charge Amount
$8,304
Line Paid Amount
$3,595
Line Allowed Amount
$2,101
Line Total Adjustment
$4,710
Underpayment
$18,948
Payment Rate
43.28%
Patient Responsibility
$4,791
Payment Date
2024-11-22
Payment Method
ACH
Check / Ref Trace Number
C00000E00000000

Service Details

Service Date From
2024-10-27
Service Date To
2024-10-27
Statement Date From
2024-10-27
Statement Date To
2024-10-27
Production Date
2024-11-20
Filing Indicator
HM
Quantity
N/A
Line Unit Count
1.0

PCS (Provider Claim Summary) Details

2 Records
PCS Record 1 of 2OUT-PATIENTMOUNTAIN REGIONAL (MNT-RGN)Claim #: 0000000000C00X
Patient
THEODORE ROOSEVELT
Patient No
AA00000
Admit Date
N/A
From Date
2024-10-27
Group-Sub No
000000-ABC000000
End Date
2024-10-27
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$82,740$71,156$10,756$10,756$0$35,814
Messages / ReasonsI4
Contract Deductible / Copay$4,791
Provider Number0000000000
Total Deductions / Other Ineligible$4,791
Tax ID00-0000000
Patient's Share$4,791
Source Document
FEXZ_D000000_0000000_000.pdf
Pages: 17 - 0 · Extracted: 1/1/2026
PCS Record 2 of 2OUT-PATIENTMOUNTAIN REGIONAL (MNT-RGN)Claim #: 0000000000C00X
Patient
THEODORE ROOSEVELT
Patient No
AA00000
Admit Date
N/A
From Date
2024-10-27
Group-Sub No
000000-ABC000000
End Date
2024-10-27
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$34,751$29,786$4,964$4,964$0$15,042
Messages / ReasonsI4
Contract Deductible / Copay$2,012
Provider Number0000000000
Total Deductions / Other Ineligible$2,012
Tax ID00-0000000
Patient's Share$2,012
Source Document
FEXZ_D000000_0000000_000.pdf
Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI
Control Number
C00000E00000000
Payment Date
2024-11-22
Payment Method
ACH
Check / EFT
EFT000000
Payer
MERIDIAN HEALTH PLAN
Payer Contact
1-800-555-0182
Total Submitted Charges
$82,740
Net Total Paid
$35,814
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*35814.00*C*ACH*CCP*01*0000000000*DA*987654*1512345678**01*0000000000*DA*987654Financial Information
TRN*1*00000040*0000000000Reassociation Trace Number
DTM*405*20241027Production Date
N1*PR*MERIDIAN HEALTH PLANPayer Identification
N1*PE*RIVERSIDE REGIONAL*XX*0000000000Payee Identification
LX*1Header Number
CLP*CLM-2024-58719*1*82740.00*35814.00*4791.00*HM*000000*11Claim Payment Information
NM1*QC*1*ROOSEVELT*THEODOREPatient Name
SE*42*0001Transaction Set Trailer

837 Original Claim Submission

EDI
Control Number
S000000000A
Submission Date
2024-10-30
Billing Provider
RIVERSIDE REGIONAL
Tax ID
00-0000000
Total Charges
$82,740
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*20241027*0915*CHBeginning of Hierarchical Transaction
NM1*41*2*MOUNTAIN REGIONAL*****46*0000000000Submitter Name
NM1*40*2*MERIDIAN HEALTH PLAN*****46*PAYER01Receiver Name
HL*1**20*1Billing Provider Hierarchical Level
NM1*85*2*RIVERSIDE REGIONAL*****XX*0000000000Billing Provider Name
NM1*IL*1*ROOSEVELT*THEODORE*****MI*AAA000000000Subscriber Name
CLM*CLM-2024-58719*82740.00***11:B:1*Y*A*Y*YClaim Information
DTP*434*RD8*20241027-20241027Date — Statement Dates
SE*38*0001Transaction Set Trailer

EOB / Claim Summary

Summary
Billed
$82,740
Allowed
$10,756
Paid
$35,814
Patient Responsibility
$4,791
Underpayment
$18,948
Payment Rate
43.3%
Adjustment Reason Codes
  • Q8Claim/service denied. Payment is included in the allowance for another service/procedure.
  • S4The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2024-58719

17 service lines
Line #Procedure CodeProcedure DescriptionRevenue CodeRevenue DescriptionBilledAllowedPaidUnderpaidBenchmarkBenchmark UnderpaidStatus
1J1170Injection, hydromorphone, up to 4 mg0250Pharmacy - General$8,304$2,101$3,595$4,710$2,597$0PRIMARY
2J2765Injection, metoclopramide HCl, up to 10 mg0250Pharmacy - General$8,014$2,094$3,469$4,545$2,646$0PRIMARY
384484Troponin (protein) analysis0305Laboratory - Hematology$7,079$1,956$3,064$4,015$663$0PRIMARY
4J1885Injection, ketorolac tromethamine, per 15 mg0250Pharmacy - General$6,807$1,574$2,947$3,861$561$0PRIMARY
584155Total protein level, blood0300Laboratory - General$6,475$861$2,803$3,672$332$0PRIMARY
693005Routine electrocardiogram with 12 leads0730EKG/ECG (electrocardiogram)$6,458$1,605$2,795$3,663$1,170$0PRIMARY
7J3010Injection, fentanyl citrate, 0.1 mg0250Pharmacy - General$6,405$1,183$2,772$3,633$2,467$0PRIMARY
899284Emergency department visit, problem of high severity0450Emergency Room - General$6,000$1,655$2,597$3,403$1,043$0PRIMARY
972125CT cervical spine without contrast0352Diagnostic Radiology - CT Scan$5,695$1,631$2,465$3,230$2,233$0PRIMARY
1085025Complete blood cell count, automated test0305Laboratory - Hematology$5,281$1,069$2,286$2,995$2,355$69PRIMARY
1185379Coagulation function measurement0305Laboratory - Hematology$3,261$744$1,411$1,849$421$0PRIMARY
1296368Infusion into a vein, concurrent with another infusion0260IV Therapy - General$2,988$589$1,293$1,695$891$0PRIMARY
1371046Radiologic examination, chest; 2 views0324Radiology - Diagnostic$2,748$661$1,190$1,559$601$0PRIMARY
1482040Albumin (protein) level0300Laboratory - General$2,712$695$1,174$1,538$1,135$0PRIMARY
1570450CT scan head/brain without contrast0352Diagnostic Radiology - CT Scan$2,354$612$1,019$1,335$597$0PRIMARY
1684075Phosphatase (enzyme) level0300Laboratory - General$1,096$227$474$621$72$0PRIMARY
1782977Glutamyltransferase (liver enzyme) level0300Laboratory - General$1,063$283$460$603$89$0PRIMARY
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Verdict Consulting Group · All values shown are demo data · 17 service lines extracted

Demo Data