Payment integrity Provider & member

Centene · payment integrity

CLM-0000006/Context

Context

Lakeview Surgical Group

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

$0.00 identified

Flag rate, last 90 days

5.6%

1 of 18 · peer 8.0%

Specialty percentile

within Orthopedic Surgery

Provider

Provider Lakeview Surgical Group

NPI 1902334815

Specialty Orthopedic Surgery

Network status In network

Claims last 90 days 18

Flag rate 5.6% (peer median 8.0%)

Prior denials 0

Specialty percentile 33th

Member

Member Grace Nakamura · 71

Member ID MBR-77031482

Plan Marketplace · Gold 80

Eligibility on DOS Active, verified 13 Mar 2026

Other coverage None on file

Member liability $150 coinsurance, already applied

Open appeals None

Eligibility on the date of service

Active on the date of service

Evaluated as at 13 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 2023-06-01

Coverage span 2026-01-01 → 2026-12-31

Enrolment segment Continuous since 01 Jun 2023 · no gap in coverage

Standing Premium paid through March 2026 · not in a grace period

Benefit and liability

Benefit on this service Outpatient surgical procedure, in network — covered subject to prior authorization

Accumulators Out-of-pocket maximum not reached

Member liability $150 coinsurance, already applied — any recovery is provider-side, not the member's

Primacy This plan is primary

Other coverage None on file

Prior authorization Expired before the date of service

What was checked, when, and what it said

Enrolment system · 834 roster 13 Mar 2026 06:00 Active — coverage effective on the date of service As at date of service

Benefit configuration · plan build 13 Mar 2026 06:00 Service covered under the plan's benefit design As at date of service

Coordination of benefits · TPL file 28 Mar 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-085 Prior authorization and post-service review v3.4

Whether the authorization on file covers the service billed

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

Coverage on the date of service

This provider's claims in the current batch

Claim	DOS	Why selected	Paid	At risk	Status
CLM-0000006	13 Mar 2026	Paid above cost threshold	$512.88	—	No finding
CLM-0000010	02 Mar 2026	Random control sample	$67.71	—	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