Verdict Claims Explorer — Verdict Consulting Group

Claim Identification

Patient Name: LINCOLN, ABRAHAM
Service Date: 2024-02-12
DRG Code: 153.0
Claim ID: CLM-2024-87729
Service Line Number: 11
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: WESTERN REGIONAL
Payer: CASCADE MUTUAL

Patient Information

First Name: ABRAHAM
Last Name: LINCOLN
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: $47,840
Total Payment Amount: $39,190
Coverage Amount: $6,219
Line Charge Amount: $8,751
Line Paid Amount: $7,169
Line Allowed Amount: $1,892
Line Total Adjustment: $1,582
Underpayment: $0
Payment Rate: 81.92%
Patient Responsibility: $1,112
Payment Date: 2024-03-09
Payment Method: ACH
Check / Ref Trace Number: C00000E00000000

Service Details

Service Date From: 2024-02-12
Service Date To: 2024-02-12

Statement Date From: 2024-02-12
Statement Date To: 2024-02-12

Production Date: 2024-03-07
Filing Indicator: HM

Quantity: N/A
Line Unit Count: 1.0

PCS (Provider Claim Summary) Details

2 Records

PCS Record 1 of 2OUT-PATIENTWESTERN REGIONAL (WST-RGN)Claim #: 0000000000C00X

Patient

ABRAHAM LINCOLN

Patient No

AA00000

Admit Date

N/A

From Date

2024-02-12

Group-Sub No

000000-ABC000000

End Date

2024-02-12

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	$47,840	$41,142	$6,219	$6,219	$0	$39,190

Messages / ReasonsG9

Contract Deductible / Copay$1,112

Provider Number0000000000

Total Deductions / Other Ineligible$1,112

Tax ID00-0000000

Patient's Share$1,112

Source Document

UJTE_D000000_0000000_000.pdf

Pages: 17 - 0 · Extracted: 1/1/2026

PCS Record 2 of 2OUT-PATIENTWESTERN REGIONAL (WST-RGN)Claim #: 0000000000C00X

Patient

ABRAHAM LINCOLN

Patient No

AA00000

Admit Date

N/A

From Date

2024-02-12

Group-Sub No

000000-ABC000000

End Date

2024-02-12

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	$20,093	$17,222	$2,870	$2,870	$0	$16,460

Messages / ReasonsG9

Contract Deductible / Copay$467

Provider Number0000000000

Total Deductions / Other Ineligible$467

Tax ID00-0000000

Patient's Share$467

Source Document

UJTE_D000000_0000000_000.pdf

Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI

Control Number

C00000E00000000

Payment Date

2024-03-09

Payment Method

ACH

Check / EFT

EFT000000

Payer

CASCADE MUTUAL

Payer Contact

1-800-555-0182

Total Submitted Charges

$47,840

Net Total Paid

$39,190

Segments

Segment	Description
ISA00 00 ZZVERDICT ZZPAYER01	Interchange Control Header
GSHPVERDICTPAYER012025012914301023X005010X221A1	Functional Group Header
ST8350001	Transaction Set Header — Health Care Claim Payment/Advice
BPRI39190.00CACHCCP010000000000DA9876541512345678*010000000000DA987654	Financial Information
TRN100000040*0000000000	Reassociation Trace Number
DTM40520240212	Production Date
N1PRCASCADE MUTUAL	Payer Identification
N1PESUMMIT POINT HOSPITALXX0000000000	Payee Identification
LX*1	Header Number
CLPCLM-2024-87729147840.0039190.001112.00HM00000011	Claim Payment Information
NM1QC1LINCOLNABRAHAM	Patient Name
SE420001	Transaction Set Trailer

837 Original Claim Submission

EDI

Control Number

S000000000A

Submission Date

2024-02-15

Billing Provider

SUMMIT POINT HOSPITAL

Tax ID

00-0000000

Total Charges

$47,840

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
BHT001900000000202402120915CH	Beginning of Hierarchical Transaction
NM1412WESTERN REGIONAL***460000000000	Submitter Name
NM1402CASCADE MUTUAL***46PAYER01	Receiver Name
HL1201	Billing Provider Hierarchical Level
NM1852SUMMIT POINT HOSPITAL***XX0000000000	Billing Provider Name
NM1IL1LINCOLNABRAHAM****MIAAA000000000	Subscriber Name
CLMCLM-2024-8772947840.00**11:B:1YAY*Y	Claim Information
DTP434RD8*20240212-20240212	Date — Statement Dates
SE380001	Transaction Set Trailer

EOB / Claim Summary

Summary

Billed

$47,840

Allowed

$6,219

Paid

$39,190

Patient Responsibility

$1,112

Underpayment

Payment Rate

81.9%

Adjustment Reason Codes

X8Claim/service denied. Payment is included in the allowance for another service/procedure.
R5The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2024-87729

11 service lines

Line #	Procedure Code	Procedure Description	Revenue Code	Revenue Description	Billed	Allowed	Paid	Underpaid	Benchmark	Benchmark Underpaid	Status
1	96368	Infusion into a vein, concurrent with another infusion	0260	IV Therapy - General	$8,751	$1,892	$7,169	$1,582	$513	$0	PRIMARY
2	84155	Total protein level, blood	0300	Laboratory - General	$7,834	$1,605	$6,418	$1,416	$3,465	$0	PRIMARY
3	72125	CT cervical spine without contrast	0352	Diagnostic Radiology - CT Scan	$5,599	$783	$4,587	$1,012	$1,389	$0	PRIMARY
4	82040	Albumin (protein) level	0300	Laboratory - General	$5,379	$1,292	$4,407	$973	$459	$0	PRIMARY
5	84075	Phosphatase (enzyme) level	0300	Laboratory - General	$5,176	$1,181	$4,240	$936	$2,311	$0	PRIMARY
6	85025	Complete blood cell count, automated test	0305	Laboratory - Hematology	$4,727	$632	$3,872	$855	$368	$0	PRIMARY
7	85379	Coagulation function measurement	0305	Laboratory - Hematology	$3,180	$580	$2,605	$575	$485	$0	PRIMARY
8	J3010	Injection, fentanyl citrate, 0.1 mg	0250	Pharmacy - General	$2,431	$487	$1,992	$440	$959	$0	PRIMARY
9	82977	Glutamyltransferase (liver enzyme) level	0300	Laboratory - General	$2,314	$642	$1,895	$418	$536	$0	PRIMARY
10	70450	CT scan head/brain without contrast	0352	Diagnostic Radiology - CT Scan	$1,307	$326	$1,070	$236	$526	$0	PRIMARY
11	99284	Emergency department visit, problem of high severity	0450	Emergency Room - General	$1,142	$263	$936	$207	$388	$0	PRIMARY

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Verdict Consulting Group · All values shown are demo data · 11 service lines extracted