Verdict Claims Explorer — Verdict Consulting Group

Claim Identification

Patient Name: JOHNSON, LADY BIRD
Service Date: 2024-08-27
DRG Code: 153.0
Claim ID: CLM-2024-80152
Service Line Number: 9
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: LADY BIRD
Last Name: JOHNSON
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: $40,510
Total Payment Amount: $21,707
Coverage Amount: $5,266
Line Charge Amount: $8,833
Line Paid Amount: $4,733
Line Allowed Amount: $1,372
Line Total Adjustment: $4,100
Underpayment: $3,871
Payment Rate: 53.58%
Patient Responsibility: $1,274
Payment Date: 2024-09-22
Payment Method: ACH
Check / Ref Trace Number: C00000E00000000

Service Details

Service Date From: 2024-08-27
Service Date To: 2024-08-27

Statement Date From: 2024-08-27
Statement Date To: 2024-08-27

Production Date: 2024-09-20
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

LADY BIRD JOHNSON

Patient No

AA00000

Admit Date

N/A

From Date

2024-08-27

Group-Sub No

000000-ABC000000

End Date

2024-08-27

Claim Type

00/00/00

Days/TRT	DRG Code	Provider Charge	Other Payable / Withhold	Facility Allowable	Adjusted Prov Charge	Managed Care Deductions	Total Amount Paid
00001	153	$40,510	$34,839	$5,266	$5,266	$0	$21,707

Messages / ReasonsM6

Contract Deductible / Copay$1,274

Provider Number0000000000

Total Deductions / Other Ineligible$1,274

Tax ID00-0000000

Patient's Share$1,274

Source Document

FMVQ_D000000_0000000_000.pdf

Pages: 17 - 0 · Extracted: 1/1/2026

PCS Record 2 of 2OUT-PATIENTMOUNTAIN REGIONAL (MNT-RGN)Claim #: 0000000000C00X

Patient

LADY BIRD JOHNSON

Patient No

AA00000

Admit Date

N/A

From Date

2024-08-27

Group-Sub No

000000-ABC000000

End Date

2024-08-27

Claim Type

00/00/00

Days/TRT	DRG Code	Provider Charge	Other Payable / Withhold	Facility Allowable	Adjusted Prov Charge	Managed Care Deductions	Total Amount Paid
00001	153	$17,014	$14,584	$2,431	$2,431	$0	$9,117

Messages / ReasonsM6

Contract Deductible / Copay$535

Provider Number0000000000

Total Deductions / Other Ineligible$535

Tax ID00-0000000

Patient's Share$535

Source Document

FMVQ_D000000_0000000_000.pdf

Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI

Control Number

C00000E00000000

Payment Date

2024-09-22

Payment Method

ACH

Check / EFT

EFT000000

Payer

MERIDIAN HEALTH PLAN

Payer Contact

1-800-555-0182

Total Submitted Charges

$40,510

Net Total Paid

$21,707

Segments

Segment	Description
ISA00 00 ZZVERDICT ZZPAYER01	Interchange Control Header
GSHPVERDICTPAYER012025012914301023X005010X221A1	Functional Group Header
ST8350001	Transaction Set Header — Health Care Claim Payment/Advice
BPRI21707.00CACHCCP010000000000DA9876541512345678*010000000000DA987654	Financial Information
TRN100000040*0000000000	Reassociation Trace Number
DTM40520240827	Production Date
N1PRMERIDIAN HEALTH PLAN	Payer Identification
N1PEOAK RIDGE HEALTHXX0000000000	Payee Identification
LX*1	Header Number
CLPCLM-2024-80152140510.0021707.001274.00HM00000011	Claim Payment Information
NM1QC1JOHNSONLADY BIRD	Patient Name
SE420001	Transaction Set Trailer

837 Original Claim Submission

EDI

Control Number

S000000000A

Submission Date

2024-08-30

Billing Provider

OAK RIDGE HEALTH

Tax ID

00-0000000

Total Charges

$40,510

Filing Indicator

Frequency Type

Transaction Set

005010X222A1

Segments

Segment	Description
ISA00 00 ZZVERDICT ZZPAYER01	Interchange Control Header
GSHCVERDICTPAYER012025010409151023X005010X222A1	Functional Group Header
ST8370001*005010X222A1	Transaction Set Header — Health Care Claim: Professional
BHT001900000000202408270915CH	Beginning of Hierarchical Transaction
NM1412MOUNTAIN REGIONAL***460000000000	Submitter Name
NM1402MERIDIAN HEALTH PLAN***46PAYER01	Receiver Name
HL1201	Billing Provider Hierarchical Level
NM1852OAK RIDGE HEALTH***XX0000000000	Billing Provider Name
NM1IL1JOHNSONLADY BIRD****MIAAA000000000	Subscriber Name
CLMCLM-2024-8015240510.00**11:B:1YAY*Y	Claim Information
DTP434RD8*20240827-20240827	Date — Statement Dates
SE380001	Transaction Set Trailer

EOB / Claim Summary

Summary

Billed

$40,510

Allowed

$5,266

Paid

$21,707

Patient Responsibility

$1,274

Underpayment

$3,871

Payment Rate

53.6%

Adjustment Reason Codes

Y4Claim/service denied. Payment is included in the allowance for another service/procedure.
Y8The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2024-80152

9 service lines

Line #	Procedure Code	Procedure Description	Revenue Code	Revenue Description	Billed	Allowed	Paid	Underpaid	Benchmark	Benchmark Underpaid	Status
1	71046	Radiologic examination, chest; 2 views	0324	Radiology - Diagnostic	$8,833	$1,372	$4,733	$4,100	$3,411	$0	PRIMARY
2	84484	Troponin (protein) analysis	0305	Laboratory - Hematology	$6,340	$1,797	$3,397	$2,943	$1,391	$0	PRIMARY
3	82977	Glutamyltransferase (liver enzyme) level	0300	Laboratory - General	$5,426	$1,124	$2,908	$2,519	$310	$0	PRIMARY
4	82040	Albumin (protein) level	0300	Laboratory - General	$5,225	$1,183	$2,800	$2,425	$2,268	$0	PRIMARY
5	84155	Total protein level, blood	0300	Laboratory - General	$4,982	$857	$2,670	$2,313	$324	$0	PRIMARY
6	85025	Complete blood cell count, automated test	0305	Laboratory - Hematology	$3,535	$753	$1,894	$1,641	$338	$0	PRIMARY
7	84075	Phosphatase (enzyme) level	0300	Laboratory - General	$2,244	$626	$1,202	$1,041	$489	$0	PRIMARY
8	85379	Coagulation function measurement	0305	Laboratory - Hematology	$1,972	$299	$1,057	$915	$549	$0	PRIMARY
9	93005	Routine electrocardiogram with 12 leads	0730	EKG/ECG (electrocardiogram)	$1,954	$424	$1,047	$907	$167	$0	PRIMARY

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Verdict Consulting Group · All values shown are demo data · 9 service lines extracted