Payment integrity Claim audit
Centene · payment integrity
Audit queue/ AUD-2026-04-0001/ CLM-0000003
Claim 5 of 25 Previous Next claim Back to queue

Post-pay review · Cypress Family Care

Medicaid · TX STAR Member MBR-42068817 DOS 09 Mar 2026 Paid 24 Mar 2026 · $16.03 Recovery window closes in 32 days
Eligibility: Active on the date of service Superior HealthPlan STAR · Texas Prior auth: Not required Professional service
Review closing letter

As paid vs. as it should have been

No variance
LnCodeDescription PaidShould be VarianceResult
1 93000 Electrocardiogram, routine, with interpretation and report
R00.2 · Palpitations
 $16.03 $16.03 — Correct

Determination

No defect in any layer

Reviewed with no variance. Every line was paid at the allowable on file.

How it was coded

Coded as documented
Billed As documented
Supported by the record As documented

Remedy: None — the claim was billed and priced as the record supports

Reviewed for level, severity and unit count. Nothing billed above what the record carries.

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, 09 Mar 2026 — not as at today.

CPP-080 Eligibility, enrolment and retroactive termination Supporting

Coverage on the date of service

In force on 09 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_20260312_710559.edi
Availity clearinghouse · EDI 837P · received 12 Mar 2026 10:07 · claim control CCN-3311605593
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
24 Mar 10:00 Claim paid, $16.03 released to provider Payment cycle
02 Apr 18:02 Selected for post-pay review Autonomize
07 Apr 09:30 Reviewed, no finding D. Mercer