Verdict Claims Explorer — Verdict Consulting Group

Claim Identification

Patient Name: LINCOLN, MARY
Service Date: 2024-02-12
DRG Code: 153.0
Claim ID: CLM-2024-97396
Service Line Number: 12
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: GREAT LAKES REGIONAL
Payer: LIBERTY BELL HEALTH

Patient Information

First Name: MARY
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: $55,560
Total Payment Amount: $40,706
Coverage Amount: $7,223
Line Charge Amount: $6,823
Line Paid Amount: $4,999
Line Allowed Amount: $1,407
Line Total Adjustment: $1,824
Underpayment: $0
Payment Rate: 73.26%
Patient Responsibility: $2,584
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-PATIENTGREAT LAKES REGIONAL (GLK-RGN)Claim #: 0000000000C00X

Patient

MARY 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	$55,560	$47,782	$7,223	$7,223	$0	$40,706

Messages / ReasonsE9

Contract Deductible / Copay$2,584

Provider Number0000000000

Total Deductions / Other Ineligible$2,584

Tax ID00-0000000

Patient's Share$2,584

Source Document

ZVAX_D000000_0000000_000.pdf

Pages: 17 - 0 · Extracted: 1/1/2026

PCS Record 2 of 2OUT-PATIENTGREAT LAKES REGIONAL (GLK-RGN)Claim #: 0000000000C00X

Patient

MARY 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	$23,335	$20,002	$3,334	$3,334	$0	$17,097

Messages / ReasonsE9

Contract Deductible / Copay$1,085

Provider Number0000000000

Total Deductions / Other Ineligible$1,085

Tax ID00-0000000

Patient's Share$1,085

Source Document

ZVAX_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

LIBERTY BELL HEALTH

Payer Contact

1-800-555-0182

Total Submitted Charges

$55,560

Net Total Paid

$40,706

Segments

Segment	Description
ISA00 00 ZZVERDICT ZZPAYER01	Interchange Control Header
GSHPVERDICTPAYER012025012914301023X005010X221A1	Functional Group Header
ST8350001	Transaction Set Header — Health Care Claim Payment/Advice
BPRI40706.00CACHCCP010000000000DA9876541512345678*010000000000DA987654	Financial Information
TRN100000040*0000000000	Reassociation Trace Number
DTM40520240212	Production Date
N1PRLIBERTY BELL HEALTH	Payer Identification
N1PESUMMIT POINT HOSPITALXX0000000000	Payee Identification
LX*1	Header Number
CLPCLM-2024-97396155560.0040706.002584.00HM00000011	Claim Payment Information
NM1QC1LINCOLNMARY	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

$55,560

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
NM1412GREAT LAKES REGIONAL***460000000000	Submitter Name
NM1402LIBERTY BELL HEALTH***46PAYER01	Receiver Name
HL1201	Billing Provider Hierarchical Level
NM1852SUMMIT POINT HOSPITAL***XX0000000000	Billing Provider Name
NM1IL1LINCOLNMARY****MIAAA000000000	Subscriber Name
CLMCLM-2024-9739655560.00**11:B:1YAY*Y	Claim Information
DTP434RD8*20240212-20240212	Date — Statement Dates
SE380001	Transaction Set Trailer

EOB / Claim Summary

Summary

Billed

$55,560

Allowed

$7,223

Paid

$40,706

Patient Responsibility

$2,584

Underpayment

Payment Rate

73.3%

Adjustment Reason Codes

F1Claim/service denied. Payment is included in the allowance for another service/procedure.
L3The benefit for this service is included in the payment/allowance for another service that has already been adjudicated.

All Service Lines for Claim CLM-2024-97396

12 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	$6,823	$1,407	$4,999	$1,824	$2,029	$0	PRIMARY
2	99284	Emergency department visit, problem of high severity	0450	Emergency Room - General	$6,777	$1,014	$4,965	$1,812	$2,646	$0	PRIMARY
3	70450	CT scan head/brain without contrast	0352	Diagnostic Radiology - CT Scan	$6,137	$1,385	$4,496	$1,641	$895	$0	PRIMARY
4	93005	Routine electrocardiogram with 12 leads	0730	EKG/ECG (electrocardiogram)	$6,057	$916	$4,438	$1,619	$1,811	$0	PRIMARY
5	J3010	Injection, fentanyl citrate, 0.1 mg	0250	Pharmacy - General	$5,357	$1,130	$3,925	$1,432	$649	$0	PRIMARY
6	84075	Phosphatase (enzyme) level	0300	Laboratory - General	$5,019	$1,415	$3,677	$1,342	$853	$0	PRIMARY
7	84484	Troponin (protein) analysis	0305	Laboratory - Hematology	$4,948	$1,475	$3,625	$1,323	$1,820	$0	PRIMARY
8	72125	CT cervical spine without contrast	0352	Diagnostic Radiology - CT Scan	$3,800	$741	$2,784	$1,016	$730	$0	PRIMARY
9	71046	Radiologic examination, chest; 2 views	0324	Radiology - Diagnostic	$3,690	$1,064	$2,704	$987	$1,303	$0	PRIMARY
10	J1170	Injection, hydromorphone, up to 4 mg	0250	Pharmacy - General	$2,854	$774	$2,091	$763	$1,243	$0	PRIMARY
11	J2765	Injection, metoclopramide HCl, up to 10 mg	0250	Pharmacy - General	$2,072	$550	$1,518	$554	$741	$0	PRIMARY
12	J1885	Injection, ketorolac tromethamine, per 15 mg	0250	Pharmacy - General	$2,026	$502	$1,484	$542	$779	$0	PRIMARY

Back to all claims View population context →

Verdict Consulting Group · All values shown are demo data · 12 service lines extracted