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Verdict Claims Explorer / Claim Details

Claim Details

CLM-2024-93273Underpaid

Claim Identification

Patient Name
MADISON, DOLLEY
Service Date
2024-03-16
DRG Code
153.0
Claim ID
CLM-2024-93273
Service Line Number
13
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
SOUTHERN REGIONAL
Payer
SUMMIT BENEFITS

Patient Information

First Name
DOLLEY
Last Name
MADISON
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
$57,990
Total Payment Amount
$33,066
Coverage Amount
$7,539
Line Charge Amount
$9,582
Line Paid Amount
$5,464
Line Allowed Amount
$1,205
Line Total Adjustment
$4,118
Underpayment
$5,105
Payment Rate
57.02%
Patient Responsibility
$3,169
Payment Date
2024-04-11
Payment Method
ACH
Check / Ref Trace Number
C00000E00000000

Service Details

Service Date From
2024-03-16
Service Date To
2024-03-16
Statement Date From
2024-03-16
Statement Date To
2024-03-16
Production Date
2024-04-09
Filing Indicator
HM
Quantity
N/A
Line Unit Count
1.0

PCS (Provider Claim Summary) Details

2 Records
PCS Record 1 of 2OUT-PATIENTSOUTHERN REGIONAL (SOU-RGN)Claim #: 0000000000C00X
Patient
DOLLEY MADISON
Patient No
AA00000
Admit Date
N/A
From Date
2024-03-16
Group-Sub No
000000-ABC000000
End Date
2024-03-16
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$57,990$49,871$7,539$7,539$0$33,066
Messages / ReasonsR6
Contract Deductible / Copay$3,169
Provider Number0000000000
Total Deductions / Other Ineligible$3,169
Tax ID00-0000000
Patient's Share$3,169
Source Document
BHFE_D000000_0000000_000.pdf
Pages: 17 - 0 · Extracted: 1/1/2026
PCS Record 2 of 2OUT-PATIENTSOUTHERN REGIONAL (SOU-RGN)Claim #: 0000000000C00X
Patient
DOLLEY MADISON
Patient No
AA00000
Admit Date
N/A
From Date
2024-03-16
Group-Sub No
000000-ABC000000
End Date
2024-03-16
Claim Type
00/00/00
Days/TRTDRG CodeProvider ChargeOther Payable / WithholdFacility AllowableAdjusted Prov ChargeManaged Care DeductionsTotal Amount Paid
00001153$24,356$20,876$3,479$3,479$0$13,888
Messages / ReasonsR6
Contract Deductible / Copay$1,331
Provider Number0000000000
Total Deductions / Other Ineligible$1,331
Tax ID00-0000000
Patient's Share$1,331
Source Document
BHFE_D000000_0000000_000.pdf
Pages: 9 - 0 · Extracted: 1/1/2026

835 Remittance Advice

EDI
Control Number
C00000E00000000
Payment Date
2024-04-11
Payment Method
ACH
Check / EFT
EFT000000
Payer
SUMMIT BENEFITS
Payer Contact
1-800-555-0182
Total Submitted Charges
$57,990
Net Total Paid
$33,066
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*33066.00*C*ACH*CCP*01*0000000000*DA*987654*1512345678**01*0000000000*DA*987654Financial Information
TRN*1*00000040*0000000000Reassociation Trace Number
DTM*405*20240316Production Date
N1*PR*SUMMIT BENEFITSPayer Identification
N1*PE*NORTHGATE SURGICAL*XX*0000000000Payee Identification
LX*1Header Number
CLP*CLM-2024-93273*1*57990.00*33066.00*3169.00*HM*000000*11Claim Payment Information
NM1*QC*1*MADISON*DOLLEYPatient Name
SE*42*0001Transaction Set Trailer

837 Original Claim Submission

EDI
Control Number
S000000000A
Submission Date
2024-03-19
Billing Provider
NORTHGATE SURGICAL
Tax ID
00-0000000
Total Charges
$57,990
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*20240316*0915*CHBeginning of Hierarchical Transaction
NM1*41*2*SOUTHERN REGIONAL*****46*0000000000Submitter Name
NM1*40*2*SUMMIT BENEFITS*****46*PAYER01Receiver Name
HL*1**20*1Billing Provider Hierarchical Level
NM1*85*2*NORTHGATE SURGICAL*****XX*0000000000Billing Provider Name
NM1*IL*1*MADISON*DOLLEY*****MI*AAA000000000Subscriber Name
CLM*CLM-2024-93273*57990.00***11:B:1*Y*A*Y*YClaim Information
DTP*434*RD8*20240316-20240316Date — Statement Dates
SE*38*0001Transaction Set Trailer

EOB / Claim Summary

Summary
Billed
$57,990
Allowed
$7,539
Paid
$33,066
Patient Responsibility
$3,169
Underpayment
$5,105
Payment Rate
57.0%
Adjustment Reason Codes
  • M9Claim/service denied. Payment is included in the allowance for another service/procedure.
  • G2The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2024-93273

13 service lines
Line #Procedure CodeProcedure DescriptionRevenue CodeRevenue DescriptionBilledAllowedPaidUnderpaidBenchmarkBenchmark UnderpaidStatus
182977Glutamyltransferase (liver enzyme) level0300Laboratory - General$9,582$1,205$5,464$4,118$1,743$0PRIMARY
293005Routine electrocardiogram with 12 leads0730EKG/ECG (electrocardiogram)$7,666$1,360$4,371$3,295$1,642$0PRIMARY
384484Troponin (protein) analysis0305Laboratory - Hematology$7,102$1,942$4,050$3,052$1,940$0PRIMARY
484075Phosphatase (enzyme) level0300Laboratory - General$7,014$1,032$3,999$3,015$2,504$0PRIMARY
596368Infusion into a vein, concurrent with another infusion0260IV Therapy - General$5,280$1,077$3,010$2,269$2,103$0PRIMARY
684155Total protein level, blood0300Laboratory - General$3,954$993$2,255$1,699$1,165$0PRIMARY
772125CT cervical spine without contrast0352Diagnostic Radiology - CT Scan$3,889$495$2,217$1,671$1,401$0PRIMARY
882040Albumin (protein) level0300Laboratory - General$3,784$461$2,158$1,626$1,613$0PRIMARY
985025Complete blood cell count, automated test0305Laboratory - Hematology$3,314$406$1,890$1,424$1,178$0PRIMARY
1070450CT scan head/brain without contrast0352Diagnostic Radiology - CT Scan$3,044$796$1,736$1,308$994$0PRIMARY
11J2765Injection, metoclopramide HCl, up to 10 mg0250Pharmacy - General$1,663$456$948$715$708$0PRIMARY
1285379Coagulation function measurement0305Laboratory - Hematology$970$289$553$417$307$0PRIMARY
1371046Radiologic examination, chest; 2 views0324Radiology - Diagnostic$729$184$416$313$149$0PRIMARY
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Verdict Consulting Group · All values shown are demo data · 13 service lines extracted

Demo Data