| Example 06: Not Covered/Not Authorized Inpatient Facility claim days X12 Admin Tue, 08/04/2026 - 09:18 Claim submitted for 5 day inpatient stay. Claim billed for 5 day stay Pre-Authorization was approved for 4 day Claim adjudication will approve and reimburse 4 days and Deny 1 Day as not authorized Per diem rate is $2000 – for total paid of $8000 $2000 denied not authorized Covered days shows 4 Transmission ISA *00 * *00 * *ZZ *ABCPAYER *ZZ *ABCPROVIDER *250827 *0212 *^ *00806 *191511902 *0 *P * |
~ GSHPABCDABCD202508271234567812345678X008060X322~ ST83510060875~ BPRI8000.00CCHK** |
