Payment integrity
Provider & member
Centene · payment integrity
Context
Dr. Jane Smith
Audit history, provider profile and the member's record — the systems an auditor would otherwise open one at a time.
In this batch
3
claims screened this period
Findings
1
$4,089.23 identified
Flag rate, last 90 days
25.0%
3 of 12
· peer 8.0%
Specialty percentile
78
within Internal Medicine
Provider
Provider
Dr. Jane Smith
NPI
1234567890
Specialty
Internal Medicine
Network status
In network
Claims last 90 days
12
Flag rate
25.0% (peer median 8.0%)
Prior denials
2
Specialty percentile
78th
Member
Member
Yves Baptiste · 44
Member ID
MBR-19477305
Plan
Marketplace · Silver 70
Eligibility on DOS
Active, verified 04 Mar 2026
Other coverage
None on file
Member liability
$25 copay, already applied
Open appeals
None
Eligibility on the date of service
Coverage
Plan
Ambetter Silver 70 HMO
Product
Marketplace QHP
Line of business
Marketplace
State of coverage
Texas
(TX)
Member since
2025-02-01
Coverage span
2026-01-01 → 2026-12-31
Enrolment segment
Continuous since 01 Feb 2025 · no gap in coverage
Standing
Premium paid through March 2026 · not in a grace period
Benefit and liability
Benefit on this service
Office visit, in network — covered, no member liability after deductible
Accumulators
Deductible met 04 Mar 2026
Member liability
$25 copay, already applied — any recovery is provider-side, not the member's
Primacy
This plan is primary
Other coverage
None on file
Prior authorization
Not required
What was checked, when, and what it said
Enrolment system · 834 roster
04 Mar 2026 06:00
Active — coverage effective on the date of service
As at date of service
Benefit configuration · plan build
04 Mar 2026 06:00
Service covered under the plan's benefit design
As at date of service
Coordination of benefits · TPL file
19 Mar 2026 09:00
No other coverage found — this plan paid correctly as primary
At adjudication
Re-verified for this audit
02 Apr 2026 18:01
No retroactive change to enrolment since payment
At audit
Both results are kept — the one at adjudication and the one at audit — because an audit months later can only defend a coverage decision if it can show what the record said at each point.
Policies this claim was tested against
Knowledge CenterThis provider's claims in the current batch
| Claim | DOS | Why selected | Paid | At risk | Status |
|---|---|---|---|---|---|
| CLM-0000001 | 25 Mar 2026 | E/M level · 94th percentile | $4,280.00 | $4,089.23 | Finding open |
| CLM-0000002 | 04 Mar 2026 | E/M level distribution | $94.22 | — | No finding |
| CLM-0000005 | 27 Mar 2026 | E/M level distribution | $133.60 | — | No finding |
Prior audits
| Audit | Period | Focus | Screened | Identified | Recovered | Outcome |
|---|---|---|---|---|---|---|
| AUD-2026-01-0004 | Jan 2026 | Evaluation and management levels | 9 | $612.40 | $612.40 | Closed |
| AUD-2025-10-0011 | Oct 2025 | Laboratory panel unbundling | 14 | $88.20 | $88.20 | Closed |
| AUD-2025-07-0008 | Jul 2025 | Duplicate professional services | 11 | $341.55 | $203.84 | Partly disputed |