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Verdict Claims Explorer / Claim Details

Claim Details

CLM-2024-79359Correct

Claim Identification

Patient Name
JACKSON, ANDREW
Service Date
2024-03-15
DRG Code
153.0
Claim ID
CLM-2024-79359
Service Line Number
7
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
MIDWEST REGIONAL
Payer
HEARTLAND ASSURANCE

Patient Information

First Name
ANDREW
Last Name
JACKSON
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
$32,950
Total Payment Amount
$28,088
Coverage Amount
$4,284
Line Charge Amount
$5,923
Line Paid Amount
$5,049
Line Allowed Amount
$1,056
Line Total Adjustment
$874
Underpayment
$0
Payment Rate
85.24%
Patient Responsibility
$1,436
Payment Date
2024-04-10
Payment Method
ACH
Check / Ref Trace Number
C00000E00000000

Service Details

Service Date From
2024-03-15
Service Date To
2024-03-15
Statement Date From
2024-03-15
Statement Date To
2024-03-15
Production Date
2024-04-08
Filing Indicator
HM
Quantity
N/A
Line Unit Count
1.0

PCS (Provider Claim Summary) Details

2 Records
PCS Record 1 of 2OUT-PATIENTMIDWEST REGIONAL (MID-RGN)Claim #: 0000000000C00X
Patient
ANDREW JACKSON
Patient No
AA00000
Admit Date
N/A
From Date
2024-03-15
Group-Sub No
000000-ABC000000
End Date
2024-03-15
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$32,950$28,337$4,284$4,284$0$28,088
Messages / ReasonsY9
Contract Deductible / Copay$1,436
Provider Number0000000000
Total Deductions / Other Ineligible$1,436
Tax ID00-0000000
Patient's Share$1,436
Source Document
BJBS_D000000_0000000_000.pdf
Pages: 17 - 0 · Extracted: 1/1/2026
PCS Record 2 of 2OUT-PATIENTMIDWEST REGIONAL (MID-RGN)Claim #: 0000000000C00X
Patient
ANDREW JACKSON
Patient No
AA00000
Admit Date
N/A
From Date
2024-03-15
Group-Sub No
000000-ABC000000
End Date
2024-03-15
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$13,839$11,862$1,977$1,977$0$11,797
Messages / ReasonsY9
Contract Deductible / Copay$603
Provider Number0000000000
Total Deductions / Other Ineligible$603
Tax ID00-0000000
Patient's Share$603
Source Document
BJBS_D000000_0000000_000.pdf
Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI
Control Number
C00000E00000000
Payment Date
2024-04-10
Payment Method
ACH
Check / EFT
EFT000000
Payer
HEARTLAND ASSURANCE
Payer Contact
1-800-555-0182
Total Submitted Charges
$32,950
Net Total Paid
$28,088
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*28088.00*C*ACH*CCP*01*0000000000*DA*987654*1512345678**01*0000000000*DA*987654Financial Information
TRN*1*00000040*0000000000Reassociation Trace Number
DTM*405*20240315Production Date
N1*PR*HEARTLAND ASSURANCEPayer Identification
N1*PE*NORTHGATE SURGICAL*XX*0000000000Payee Identification
LX*1Header Number
CLP*CLM-2024-79359*1*32950.00*28088.00*1436.00*HM*000000*11Claim Payment Information
NM1*QC*1*JACKSON*ANDREWPatient Name
SE*42*0001Transaction Set Trailer

837 Original Claim Submission

EDI
Control Number
S000000000A
Submission Date
2024-03-18
Billing Provider
NORTHGATE SURGICAL
Tax ID
00-0000000
Total Charges
$32,950
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*20240315*0915*CHBeginning of Hierarchical Transaction
NM1*41*2*MIDWEST REGIONAL*****46*0000000000Submitter Name
NM1*40*2*HEARTLAND ASSURANCE*****46*PAYER01Receiver Name
HL*1**20*1Billing Provider Hierarchical Level
NM1*85*2*NORTHGATE SURGICAL*****XX*0000000000Billing Provider Name
NM1*IL*1*JACKSON*ANDREW*****MI*AAA000000000Subscriber Name
CLM*CLM-2024-79359*32950.00***11:B:1*Y*A*Y*YClaim Information
DTP*434*RD8*20240315-20240315Date — Statement Dates
SE*38*0001Transaction Set Trailer

EOB / Claim Summary

Summary
Billed
$32,950
Allowed
$4,284
Paid
$28,088
Patient Responsibility
$1,436
Underpayment
$0
Payment Rate
85.2%
Adjustment Reason Codes
  • W9Claim/service denied. Payment is included in the allowance for another service/procedure.
  • G7The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2024-79359

7 service lines
Line #Procedure CodeProcedure DescriptionRevenue CodeRevenue DescriptionBilledAllowedPaidUnderpaidBenchmarkBenchmark UnderpaidStatus
1J1885Injection, ketorolac tromethamine, per 15 mg0250Pharmacy - General$5,923$1,056$5,049$874$364$0PRIMARY
2J3010Injection, fentanyl citrate, 0.1 mg0250Pharmacy - General$5,838$933$4,976$861$1,912$0PRIMARY
3J1170Injection, hydromorphone, up to 4 mg0250Pharmacy - General$5,506$1,450$4,693$812$1,618$0PRIMARY
4J2765Injection, metoclopramide HCl, up to 10 mg0250Pharmacy - General$5,384$1,503$4,590$794$2,378$0PRIMARY
571046Radiologic examination, chest; 2 views0324Radiology - Diagnostic$3,459$567$2,949$510$1,526$0PRIMARY
693005Routine electrocardiogram with 12 leads0730EKG/ECG (electrocardiogram)$3,427$508$2,922$506$1,034$0PRIMARY
784484Troponin (protein) analysis0305Laboratory - Hematology$3,412$672$2,909$504$1,126$0PRIMARY
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Verdict Consulting Group · All values shown are demo data · 7 service lines extracted

Demo Data