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, 13 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 04 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
No decisive policy
This claim is tested against supporting policies only.
Read
$.policy_refs$.service_date
info
PRO-6
Lookup
on match
Codes valid on the date of service
99213 against I10. Every code was billable on 04 Mar 2026.
Read
$.lines
pass
[6]
ICD-10-CM FY2026
[7]
HCPCS / CPT 2026
PRO-7
Lookup
on match
Allowable read from the fee schedule
99213 allows $94.22.
Read
$.lines
pass
[8]
CMS Physician Fee Schedule 2026 · TX locality 09
[9]
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 match
Paid at the allowable
$94.22 paid against $94.22 allowable = $0.00.
pass
PRO-11
Retrieval
on match
Nothing to retrieve against
This claim rests on no single decisive policy, so there is no version to scope a retrieval to. The supporting policies are cited on the claim without being quoted.
On the platform this node is a scoped model call against the indexed policy.
Read
$.lines$.findings
PRO-12
Drafted
on match
Closing letter drafted
No variance to report. The letter states the claim was reviewed and closed with no finding.
On the platform this node is a scoped model call that writes the finding and the letter.
pass
Terminal disposition
Approve
APPROVE
Every node resolved and none found a variance. The claim was paid as the record and the fee schedule support. This is the only disposition the agent reaches on its own.
Every check resolved and none found a variance. This is the only disposition the agent decides on its own.
12 nodes
12 deterministic
0 model calls
13 citations
100% of paths resolved