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, 16 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 match
Active on the date of service
Coverage ran 2026-01-01 to 2026-12-31; the service on 13 Mar 2026 falls inside it. Re-verified at audit with no retroactive change.
Read
$.eligibility.coverage_from$.eligibility.coverage_to$.service_date
PRO-2
Rule
on match
Covered under the plan
Outpatient surgical procedure, in network — covered subject to prior authorization. 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 no match
Authorization does not cover the claim as billed
PA-2026-114907 valid 2026-01-10 to 2026-03-10. Authorised: Knee arthroscopy with meniscectomy, one session. Billed: One session performed 13 Mar 2026.
Read
$.prior_auth.status$.prior_auth.required
PRO-5
Rule
on match
Resolved to v3.4
CPP-085 v3.4, effective 2025-11-01, was in force on 13 Mar 2026.
Read
$.policy_refs$.service_date
pass
[7]
CPP-085 v3.4
PRO-6
Lookup
on match
Codes valid on the date of service
29881 against M23.221. Every code was billable on 13 Mar 2026.
Read
$.lines
pass
[8]
ICD-10-CM FY2026
[9]
HCPCS / CPT 2026
PRO-7
Lookup
on match
Allowable read from the fee schedule
29881 allows $512.88.
Read
$.lines
pass
[10]
CMS Physician Fee Schedule 2026 · TX locality 09
[11]
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
$512.88 paid against $512.88 allowable = $0.00.
pass
PRO-11
Retrieval
on match
2 passages retrieved
Scoped to CPP-085 v3.4, the version in force on 13 Mar 2026. Best match on page 2.
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
16 citations
100% of paths resolved