Payment integrity Provider & member

Centene · payment integrity

CLM-0000005/Context

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

claims screened this period

Findings

$4,089.23 identified

Flag rate, last 90 days

25.0%

3 of 12 · peer 8.0%

Specialty percentile

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 Sergei Ivanov · 34

Member ID MBR-88109443

Plan Marketplace · Gold 80

Eligibility on DOS Active, verified 27 Mar 2026

Other coverage None on file

Member liability $30 copay, already applied

Open appeals None

Eligibility on the date of service

Active on the date of service Coverage at risk

Evaluated as at 27 Mar 2026, the date of service — not as at the date of payment or the date of this audit.

Coverage

Plan Ambetter Gold 80 HMO

Product Marketplace QHP

Line of business Marketplace

State of coverage Texas (TX)

Member since 2025-01-01

Coverage span 2026-01-01 → 2026-12-31

Enrolment segment Continuous since 01 Jan 2025 · no gap in coverage

Standing IN A GRACE PERIOD — March premium unpaid, month 2 of 3

Benefit and liability

Benefit on this service Office visit, in network — covered, no member liability after deductible

Accumulators Deductible met 20 Jan 2026

Member liability $30 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

This member is in month 2 of an advance-premium-tax-credit grace period. The claim was paid, and under CPP-080 it becomes recoverable in full if the March premium is not paid by 30 April 2026. This is an eligibility exposure, not a coding finding — the service itself was billed and priced correctly.

What was checked, when, and what it said

Enrolment system · 834 roster 27 Mar 2026 06:00 Active — coverage effective on the date of service As at date of service

Benefit configuration · plan build 27 Mar 2026 06:00 Service covered under the plan's benefit design As at date of service

Coordination of benefits · TPL file 01 Apr 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 Center

CPP-080 Eligibility, enrolment and retroactive termination v6.1

Coverage on the date of service, and the grace-period rule that applies to it

CPP-014 Evaluation and management level selection v4.2

Level selection for the visit billed

This 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