Payment integrity
Reasoning trace
Centene · payment integrity
Reasoning
How this claim reached its determination
Professional claims post-pay review v1.9, signed off 2026-01-14 — 12 nodes, 12 of them resolved without a model, 16 citations. Read top to bottom: eligibility before policy, policy before pricing, and the finding drafted only once everything above it has answered.
PRO-1
Rule
on match
Active on the date of service
Coverage ran 2026-01-01 to 2026-12-31; the service on 25 Mar 2026 falls inside it. Re-verified at audit with no retroactive change.
Read
$.eligibility.coverage_from$.eligibility.coverage_to$.service_date
PRO-2
Rule
on match
Covered under the plan
Office visit, in network — covered, no member liability after deductible. Ambetter Silver 70 HMO · Texas.
Read
$.eligibility.benefit$.eligibility.plan
PRO-3
Rule
on match
Primacy confirmed
This plan is primary. Other coverage: None on file.
Read
$.eligibility.primacy$.eligibility.other_coverage
PRO-4
Rule
on match
Not required
No prior authorization requirement for this service on this plan.
Read
$.prior_auth.status$.prior_auth.required
PRO-5
Rule
on match
Resolved to v4.2
CPP-014 v4.2, effective 2026-01-01, was in force on 25 Mar 2026.
Read
$.policy_refs$.service_date
pass
[6]
CPP-014 v4.2
PRO-6
Lookup
on match
Codes valid on the date of service
99215 against Z00.00. Every code was billable on 25 Mar 2026.
Read
$.lines
pass
[7]
ICD-10-CM FY2026
[8]
HCPCS / CPT 2026
PRO-7
Lookup
on match
Allowable read from the fee schedule
99215 allows $190.77.
Read
$.lines
pass
[9]
CMS Physician Fee Schedule 2026 · TX locality 09
[10]
CMS Clinical Laboratory Fee Schedule 2026 Q2
PRO-8
Rule
on match
No bundling edit applies
No code on this claim is listed in the code-group table as a component of another code billed alongside it.
Read
$.lines
PRO-9
Rule
on match
Units and modifiers consistent
Every line bills a single unit.
Read
$.lines
PRO-10
Formula
on no match
$4,089.23 above the allowable
$4,280.00 paid against $190.77 allowable = $4,089.23.
fail
PRO-11
Retrieval
on match
2 passages retrieved
Scoped to CPP-014 v4.2, the version in force on 25 Mar 2026. Best match on page 2.
On the platform this node is a scoped model call against the indexed policy.
Read
$.lines$.findings
PRO-12
Drafted
on no match
Finding and letter drafted for a reviewer
Separated into 3 layers — coding defect, clinical-evidence defect, payment consequence — with the policy citation and dispute rights already in the letter. Neither is sent by the agent.
On the platform this node is a scoped model call that writes the finding and the letter.
Terminal disposition
Route to a human — criteria not met
ROUTE_TO_HUMAN_CRITERIA_NOT_MET
1 check did not pass and every check that mattered could be evaluated. $4,089.23 is at risk. The agent recommends the criteria are not met — it does not deny, and a person confirms.
The agent recommends the claim does not meet the criteria. It does not deny — a person confirms.
12 nodes
12 deterministic
0 model calls
16 citations
100% of paths resolved