Payment integrity
Provider & member
Centene · payment integrity
Context
Cypress Family Care Associates
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
$67.71 identified
Flag rate, last 90 days
4.2%
1 of 24
· peer 8.0%
Specialty percentile
22
within Family Medicine
Provider
Provider
Cypress Family Care Associates
NPI
1223887640
Specialty
Family Medicine
Network status
In network
Claims last 90 days
24
Flag rate
4.2% (peer median 8.0%)
Prior denials
0
Specialty percentile
22th
Member
Member
Rae Fontaine · 52
Member ID
MBR-42068817
Plan
Medicaid · TX STAR
Eligibility on DOS
Active, verified 09 Mar 2026
Other coverage
None on file
Member liability
$0 copay
Open appeals
None
Eligibility on the date of service
Coverage
Plan
Superior HealthPlan STAR
Product
Medicaid managed care
Line of business
Medicaid · TX STAR
State of coverage
Texas
(TX)
Member since
2023-03-01
Coverage span
2025-09-01 → 2026-08-31
Enrolment segment
Certification period 01 Sep 2025 – 31 Aug 2026
Standing
Redetermination not due before 31 Aug 2026
Benefit and liability
Benefit on this service
Covered under the state benefit plan
Accumulators
No member cost share on Medicaid
Member liability
$0 copay — any recovery is provider-side, not the member's
Primacy
This plan is payer of last resort
Other coverage
None on file
Prior authorization
Not required
What was checked, when, and what it said
Enrolment system · 834 roster
09 Mar 2026 06:00
Active — coverage effective on the date of service
As at date of service
Benefit configuration · plan build
09 Mar 2026 06:00
Service covered under the plan's benefit design
As at date of service
Coordination of benefits · TPL file
24 Mar 2026 09:00
No third party found — Medicaid paid correctly as last resort
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 CenterCoverage on the date of service
This provider's claims in the current batch
| Claim | DOS | Why selected | Paid | At risk | Status |
|---|---|---|---|---|---|
| CLM-0000004 | 11 Mar 2026 | Duplicate cluster · same date | $135.42 | $67.71 | Finding open |
| CLM-0000003 | 09 Mar 2026 | Random control sample | $16.03 | — | No finding |
| CLM-0000011 | 16 Mar 2026 | Component and panel scan | $10.56 | — | 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 |