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Audit queue/ AUD-2026-04-0001/ CLM-0000004
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Post-pay review · Cypress Family Care

Medicaid · TX STAR Member MBR-30558129 DOS 11 Mar 2026 Paid 27 Mar 2026 · $135.42 Recovery window closes in 35 days
Eligibility: Active on the date of service Superior HealthPlan STAR · Texas Prior auth: Not required Professional service
Review determination letter

As paid vs. as it should have been

Overpaid $67.71
LnCodeDescription PaidShould be VarianceResult
1 20610 Arthrocentesis, aspiration or injection, major joint or bursa
M17.11 · Unilateral primary osteoarthritis, right knee
 $135.42 $67.71 $67.71 Overpaid

Determination

2 of 3 layers

Separated so a provider can dispute the layer they disagree with, and so a reviewer can see which question was decided.

Coding defect Whether the code, level, units or sequencing follow the coding rule.
F-01
20610 paid for two units on a single encounter
The record documents one injection. The second unit carries no anatomical or distinct-procedure modifier, so it is not separately payable.
$67.71 Edit
OBS
No RT, LT or modifier 59 on the line
A bilateral or distinct-site injection would carry one of these. None is present.
Supporting Edit
Clinical-evidence defect Whether the record supports the condition or service that was coded.

No clinical-evidence defect. The record supports the service as documented; what is wrong is how it was coded or priced.

Payment consequence What it costs, and how the recoverable amount is computed.
AMT
$67.71 recoverable
Recover the second unit
$67.71 Edit

How it was coded

Up-coded
Billed 20610 × 2 units
Supported by the record 20610 × 1 unit

Remedy: Recover the second unit

Up-coding by unit count rather than by level. The service is right; the quantity is not.

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, 11 Mar 2026 — not as at today.

CPP-021 Duplicate and repeat services Decisive

Governs when a second unit of a single-site procedure is separately payable

In force on 11 Mar 2026: v2.3 effective 2025-07-01
From CPP-021 v2.3, retrieved for this claim
p1 CPP-021_duplicate-and-repeat-services_v2.3.md 0.248

ingle-site procedure must now carry an anatomical modifier or modifier 59 on the claim line itself. Under version 2.2 a modifier documented in the record was accepted even where it was absent from the line. That is withdrawn: the claim is what is adjudicated, and an edit cannot read a chart. Criteria A second unit of…

p1 CPP-021_duplicate-and-repeat-services_v2.3.md 0.178

CPP-021 DUPLICATE AND REPEAT SERVICES Version 2.3, in force from 1 July 2025 Claims Editing Governance This document is deliberately NOT formatted like the other seeded policies. It has no numbered sections, no "## N." headings and no bulleted criteria list. It is here to test the extractor against a shape it was not…

CPP-080 Eligibility, enrolment and retroactive termination Supporting

Coverage on the date of service, and the re-verification at audit

In force on 11 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_20260314_602993.edi
Availity clearinghouse · EDI 837P · received 14 Mar 2026 11:16 · claim control CCN-3910990557
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
27 Mar 09:02 Claim paid, $135.42 released to provider Payment cycle
02 Apr 18:02 Selected by duplicate cluster rule Autonomize
02 Apr 18:03 Finding drafted with 3 evidence items Autonomize