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Verdict Claims Explorer / Claim Details

Claim Details

CLM-2024-68891Resolved

Claim Identification

Patient Name
FORD, GERALD
Service Date
2024-07-14
DRG Code
153.0
Claim ID
CLM-2024-68891
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
HEARTLAND ASSURANCE

Patient Information

First Name
GERALD
Last Name
FORD
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
$10,570
Total Payment Amount
$5,854
Coverage Amount
$1,374
Line Charge Amount
$3,527
Line Paid Amount
$1,953
Line Allowed Amount
$839
Line Total Adjustment
$1,573
Underpayment
$888
Payment Rate
55.38%
Patient Responsibility
$252
Payment Date
2024-08-09
Payment Method
ACH
Check / Ref Trace Number
C00000E00000000

Service Details

Service Date From
2024-07-14
Service Date To
2024-07-14
Statement Date From
2024-07-14
Statement Date To
2024-07-14
Production Date
2024-08-07
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
GERALD FORD
Patient No
AA00000
Admit Date
N/A
From Date
2024-07-14
Group-Sub No
000000-ABC000000
End Date
2024-07-14
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$10,570$9,090$1,374$1,374$0$5,854
Messages / ReasonsT2
Contract Deductible / Copay$252
Provider Number0000000000
Total Deductions / Other Ineligible$252
Tax ID00-0000000
Patient's Share$252
Source Document
PCTL_D000000_0000000_000.pdf
Pages: 17 - 0 · Extracted: 1/1/2026
PCS Record 2 of 2OUT-PATIENTPACIFIC REGIONAL (PAC-RGN)Claim #: 0000000000C00X
Patient
GERALD FORD
Patient No
AA00000
Admit Date
N/A
From Date
2024-07-14
Group-Sub No
000000-ABC000000
End Date
2024-07-14
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$4,439$3,805$634$634$0$2,459
Messages / ReasonsT2
Contract Deductible / Copay$106
Provider Number0000000000
Total Deductions / Other Ineligible$106
Tax ID00-0000000
Patient's Share$106
Source Document
PCTL_D000000_0000000_000.pdf
Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI
Control Number
C00000E00000000
Payment Date
2024-08-09
Payment Method
ACH
Check / EFT
EFT000000
Payer
HEARTLAND ASSURANCE
Payer Contact
1-800-555-0182
Total Submitted Charges
$10,570
Net Total Paid
$5,854
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*5854.00*C*ACH*CCP*01*0000000000*DA*987654*1512345678**01*0000000000*DA*987654Financial Information
TRN*1*00000040*0000000000Reassociation Trace Number
DTM*405*20240714Production Date
N1*PR*HEARTLAND ASSURANCEPayer Identification
N1*PE*WESTFIELD SURGICAL*XX*0000000000Payee Identification
LX*1Header Number
CLP*CLM-2024-68891*1*10570.00*5854.00*252.00*HM*000000*11Claim Payment Information
NM1*QC*1*FORD*GERALDPatient Name
SE*42*0001Transaction Set Trailer

837 Original Claim Submission

EDI
Control Number
S000000000A
Submission Date
2024-07-17
Billing Provider
WESTFIELD SURGICAL
Tax ID
00-0000000
Total Charges
$10,570
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*20240714*0915*CHBeginning of Hierarchical Transaction
NM1*41*2*PACIFIC REGIONAL*****46*0000000000Submitter Name
NM1*40*2*HEARTLAND ASSURANCE*****46*PAYER01Receiver Name
HL*1**20*1Billing Provider Hierarchical Level
NM1*85*2*WESTFIELD SURGICAL*****XX*0000000000Billing Provider Name
NM1*IL*1*FORD*GERALD*****MI*AAA000000000Subscriber Name
CLM*CLM-2024-68891*10570.00***11:B:1*Y*A*Y*YClaim Information
DTP*434*RD8*20240714-20240714Date — Statement Dates
SE*38*0001Transaction Set Trailer

EOB / Claim Summary

Summary
Billed
$10,570
Allowed
$1,374
Paid
$5,854
Patient Responsibility
$252
Underpayment
$888
Payment Rate
55.4%
Adjustment Reason Codes
  • I7Claim/service denied. Payment is included in the allowance for another service/procedure.
  • X9The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2024-68891

5 service lines
Line #Procedure CodeProcedure DescriptionRevenue CodeRevenue DescriptionBilledAllowedPaidUnderpaidBenchmarkBenchmark UnderpaidStatus
199284Emergency department visit, problem of high severity0450Emergency Room - General$3,527$839$1,953$1,573$484$0PRIMARY
2J3010Injection, fentanyl citrate, 0.1 mg0250Pharmacy - General$3,398$762$1,882$1,516$930$0PRIMARY
370450CT scan head/brain without contrast0352Diagnostic Radiology - CT Scan$2,012$283$1,115$898$865$0PRIMARY
4J1885Injection, ketorolac tromethamine, per 15 mg0250Pharmacy - General$930$196$515$415$170$0PRIMARY
5J1170Injection, hydromorphone, up to 4 mg0250Pharmacy - General$703$155$389$314$213$0PRIMARY
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Verdict Consulting Group · All values shown are demo data · 5 service lines extracted

Demo Data