Verdict Claims Explorer — Verdict Consulting Group

Claim Identification

Patient Name: NIXON, PATRICIA
Service Date: 2024-01-09
DRG Code: 153.0
Claim ID: CLM-2024-85195
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: SUMMIT BENEFITS

Patient Information

First Name: PATRICIA
Last Name: NIXON
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: $42,175
Total Payment Amount: $30,055
Coverage Amount: $5,483
Line Charge Amount: $8,391
Line Paid Amount: $5,979
Line Allowed Amount: $2,331
Line Total Adjustment: $2,411
Underpayment: $0
Payment Rate: 71.26%
Patient Responsibility: $2,523
Payment Date: 2024-02-04
Payment Method: ACH
Check / Ref Trace Number: C00000E00000000

Service Details

Service Date From: 2024-01-09
Service Date To: 2024-01-09

Statement Date From: 2024-01-09
Statement Date To: 2024-01-09

Production Date: 2024-02-02
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

PATRICIA NIXON

Patient No

AA00000

Admit Date

N/A

From Date

2024-01-09

Group-Sub No

000000-ABC000000

End Date

2024-01-09

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	$42,175	$36,271	$5,483	$5,483	$0	$30,055

Messages / ReasonsE4

Contract Deductible / Copay$2,523

Provider Number0000000000

Total Deductions / Other Ineligible$2,523

Tax ID00-0000000

Patient's Share$2,523

Source Document

EDTD_D000000_0000000_000.pdf

Pages: 17 - 0 · Extracted: 1/1/2026

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

Patient

PATRICIA NIXON

Patient No

AA00000

Admit Date

N/A

From Date

2024-01-09

Group-Sub No

000000-ABC000000

End Date

2024-01-09

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	$17,714	$15,183	$2,531	$2,531	$0	$12,623

Messages / ReasonsE4

Contract Deductible / Copay$1,060

Provider Number0000000000

Total Deductions / Other Ineligible$1,060

Tax ID00-0000000

Patient's Share$1,060

Source Document

EDTD_D000000_0000000_000.pdf

Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI

Control Number

C00000E00000000

Payment Date

2024-02-04

Payment Method

ACH

Check / EFT

EFT000000

Payer

SUMMIT BENEFITS

Payer Contact

1-800-555-0182

Total Submitted Charges

$42,175

Net Total Paid

$30,055

Segments

Segment	Description
ISA00 00 ZZVERDICT ZZPAYER01	Interchange Control Header
GSHPVERDICTPAYER012025012914301023X005010X221A1	Functional Group Header
ST8350001	Transaction Set Header — Health Care Claim Payment/Advice
BPRI30055.00CACHCCP010000000000DA9876541512345678*010000000000DA987654	Financial Information
TRN100000040*0000000000	Reassociation Trace Number
DTM40520240109	Production Date
N1PRSUMMIT BENEFITS	Payer Identification
N1PEWESTFIELD SURGICALXX0000000000	Payee Identification
LX*1	Header Number
CLPCLM-2024-85195142175.0030055.002523.00HM00000011	Claim Payment Information
NM1QC1NIXONPATRICIA	Patient Name
SE420001	Transaction Set Trailer

837 Original Claim Submission

EDI

Control Number

S000000000A

Submission Date

2024-01-12

Billing Provider

WESTFIELD SURGICAL

Tax ID

00-0000000

Total Charges

$42,175

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
BHT001900000000202401090915CH	Beginning of Hierarchical Transaction
NM1412MOUNTAIN REGIONAL***460000000000	Submitter Name
NM1402SUMMIT BENEFITS***46PAYER01	Receiver Name
HL1201	Billing Provider Hierarchical Level
NM1852WESTFIELD SURGICAL***XX0000000000	Billing Provider Name
NM1IL1NIXONPATRICIA****MIAAA000000000	Subscriber Name
CLMCLM-2024-8519542175.00**11:B:1YAY*Y	Claim Information
DTP434RD8*20240109-20240109	Date — Statement Dates
SE380001	Transaction Set Trailer

EOB / Claim Summary

Summary

Billed

$42,175

Allowed

$5,483

Paid

$30,055

Patient Responsibility

$2,523

Underpayment

Payment Rate

71.3%

Adjustment Reason Codes

J8Claim/service denied. Payment is included in the allowance for another service/procedure.
Y9The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2024-85195

9 service lines

Line #	Procedure Code	Procedure Description	Revenue Code	Revenue Description	Billed	Allowed	Paid	Underpaid	Benchmark	Benchmark Underpaid	Status
1	82977	Glutamyltransferase (liver enzyme) level	0300	Laboratory - General	$8,391	$2,331	$5,979	$2,411	$1,255	$0	PRIMARY
2	J3010	Injection, fentanyl citrate, 0.1 mg	0250	Pharmacy - General	$8,253	$1,481	$5,882	$2,372	$3,047	$0	PRIMARY
3	70450	CT scan head/brain without contrast	0352	Diagnostic Radiology - CT Scan	$6,860	$872	$4,889	$1,971	$2,832	$0	PRIMARY
4	84075	Phosphatase (enzyme) level	0300	Laboratory - General	$5,378	$1,466	$3,832	$1,545	$1,905	$0	PRIMARY
5	82040	Albumin (protein) level	0300	Laboratory - General	$4,315	$1,211	$3,075	$1,240	$804	$0	PRIMARY
6	99284	Emergency department visit, problem of high severity	0450	Emergency Room - General	$2,480	$455	$1,767	$713	$425	$0	PRIMARY
7	96368	Infusion into a vein, concurrent with another infusion	0260	IV Therapy - General	$2,308	$514	$1,645	$663	$263	$0	PRIMARY
8	J1885	Injection, ketorolac tromethamine, per 15 mg	0250	Pharmacy - General	$2,213	$309	$1,577	$636	$543	$0	PRIMARY
9	72125	CT cervical spine without contrast	0352	Diagnostic Radiology - CT Scan	$1,978	$513	$1,410	$569	$297	$0	PRIMARY

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