Payment integrity Claim audit
Centene · payment integrity
Audit queue/ AUD-2026-04-0001/ CLM-0000001
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Post-pay review · Dr. Jane Smith

Marketplace Member MBR-12345 DOS 25 Mar 2026 Paid 02 Apr 2026 · $4,280.00 Recovery window closes in 41 days
Eligibility: Active on the date of service Ambetter Silver 70 HMO · Texas Prior auth: Not required Professional service
Review determination letter

As paid vs. as it should have been

Overpaid $4,089.23
LnCodeDescription PaidShould be VarianceResult
1 99215 Office or other outpatient visit, established patient, high complexity
Z00.00 · Encounter for general adult medical examination without abnormal findings
 $4,280.00 $190.77 $4,089.23 Overpaid

Determination

3 of 3 layers

Separated so a provider can dispute the layer they disagree with, and so a reviewer can see which question was decided.

Coding defect Whether the code, level, units or sequencing follow the coding rule.
CDE
Billed 99215 · level 5, high complexity
The classic up-code: a higher level billed than the documentation carries. The payer's remedy is to down-code to the supported level, not to deny the visit.
Supporting Edit
Clinical-evidence defect Whether the record supports the condition or service that was coded.
LOS
Z00.00 does not support a level-5 visit
A routine adult examination without abnormal findings does not support the high-complexity medical decision making 99215 requires. The encounter reads as preventive, not problem-oriented.
Supporting Edit
Payment consequence What it costs, and how the recoverable amount is computed.
F-01
Paid $4,280.00 against a $190.77 allowable
The 2026 physician fee schedule allows $190.77 for 99215 in a non-facility setting in this locality. The paid amount is 22 times the allowable and is recoverable in full above it.
$4,089.23 Edit
Context, not part of the determination

These inform the reviewer. None of them is a reason the claim is wrong, and presenting them beside the defect is how an advisory becomes an allegation.

PAT
3 of this provider's last 12 claims were flagged
A 25% flag rate against an 8% peer group rate, 78th percentile for the specialty. Two prior denials already on file.
Advisory

How it was coded

Up-coded
Billed 99215 · level 5, high complexity
Supported by the record 99212 · level 2, on the record as submitted

Remedy: Reprice to the level the record supports, and recover the amount paid above the allowable

The classic up-code: a higher level billed than the documentation carries. The payer's remedy is to down-code to the supported level, not to deny the visit.

Prior authorization

Not required
Requirement Not required

No prior authorization requirement for this service on this plan.

Policy applied

Knowledge Center

Resolved as at the date of service, 25 Mar 2026 — not as at today.

CPP-014 Evaluation and management level selection Decisive

Sets what the record must contain to support a level-5 established-patient visit

In force on 25 Mar 2026: v4.2 effective 2026-01-01
From CPP-014 v4.2, retrieved for this claim
p2 CPP-014_em-level-selection_v4.2.md 0.278

wer level than the one billed, the claim is repriced to the level the record supports. It is not denied in full. The recoverable amount is the difference between the allowable for the billed level and the allowable for the supported level. This is the payer-side counterpart of up-coding: the remedy for a level billed…

p3 CPP-014_em-level-selection_v4.2.md 0.189

4. Recovery recovery = allowable(billed level) - allowable(supported level) Both allowables come from the fee schedule in effect for the locality on the date of service. Where the amount paid exceeded the allowable for the billed level, the excess above the allowable is recoverable in addition, and is a pricing…

v4.2 had been in force for 83 days when this service happened. Before it, v4.1 applied — “Annual refresh against the 2025 CPT revisions. No change to level-5 documentation requirements.”
CPP-080 Eligibility, enrolment and retroactive termination Supporting

Coverage on the date of service, and the re-verification at audit

In force on 25 Mar 2026: v6.1 effective 2026-01-01

v6.1 was extracted from CPP-080_eligibility-enrolment-retroactive-termination_v6.1.md. Passages are quoted only on the policy the finding rests on.

Source document

Open all four views
837P_20260328_592055.edi
Availity clearinghouse · EDI 837P · received 28 Mar 2026 13:46 · claim control CCN-0134662955
Claim form As received EDI Remittance

How this was decided

Open the full trace

Walked through Professional claims post-pay review v1.9, signed off 2026-01-14.

Procedure SOP-PRO-01 — Professional claims — office visits, procedures, laboratory, imaging
Nodes walked 12
Model calls 0 — every node that resolved did so on a rule, a lookup or arithmetic

Audit trail

Provider & member context
02 Apr 09:14 Claim paid, $4,280.00 released to provider Payment cycle
02 Apr 18:02 Selected for post-pay review, model score 0.94 Autonomize
02 Apr 18:03 Finding drafted with 4 evidence items Autonomize
03 Apr 08:41 Assigned to D. Mercer, professional claims audit Routing