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, 15 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 no match
Covered, with an open exposure
Coverage ran 2026-01-01 to 2026-12-31 and the service falls inside it. IN A GRACE PERIOD — March premium unpaid, month 2 of 3 — an eligibility exposure that is not a coding finding.
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 Gold 80 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
Resolved to v6.1
CPP-080 v6.1, effective 2026-01-01, was in force on 27 Mar 2026.
Read
$.policy_refs$.service_date
pass
[6]
CPP-080 v6.1
PRO-6
Lookup
on match
Codes valid on the date of service
99214 against E11.9. Every code was billable on 27 Mar 2026.
Read
$.lines
pass
[7]
ICD-10-CM FY2026
[8]
HCPCS / CPT 2026
PRO-7
Lookup
on match
Allowable read from the fee schedule
99214 allows $133.60.
Read
$.lines
pass
[9]
CMS Physician Fee Schedule 2026 · TX locality 09
[10]
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
$133.60 paid against $133.60 allowable = $0.00.
pass
PRO-11
Retrieval
on match
2 passages retrieved
Scoped to CPP-080 v6.1, the version in force on 27 Mar 2026. Best match on page 3.
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
Route to a human
ROUTE_TO_HUMAN
Every check passed, but the claim carries an exposure that is not a coding finding. The agent has no recommendation to make on it; a person decides.
The agent has no recommendation. Something on the claim needs a person's judgement and the rules do not reach it.
12 nodes
12 deterministic
0 model calls
15 citations
100% of paths resolved