Payment integrity Claim audit
Centene · payment integrity
Audit queue/ AUD-2026-04-0001/ CLM-0000009
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Post-pay review · Northside Clinical Lab

Medicaid · TX STAR Member MBR-51902264 DOS 18 Mar 2026 Paid 31 Mar 2026 · $14.49 Recovery window closes in 39 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 $3.93
LnCodeDescription PaidShould be VarianceResult
1 80053 Comprehensive metabolic panel
E11.9 · Type 2 diabetes mellitus without complications
 $10.56 $10.56 — Correct
2 82947 Glucose, quantitative, blood
E11.9 · Type 2 diabetes mellitus without complications
 $3.93 $0.00 $3.93 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
82947 is a component of 80053
An active NCCI procedure-to-procedure edit bundles 82947 into 80053 with the rationale "Laboratory panel". No bypass modifier is present, so the component is not separately payable.
$3.93 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
$3.93 recoverable
Recover the component line
$3.93 Edit
Context, not part of the determination

These inform the reviewer. None of them is a reason the claim is wrong, and presenting them beside the defect is how an advisory becomes an allegation.

OBS
The panel itself was paid correctly
80053 was paid $10.56, matching the clinical laboratory fee schedule. The error is the additional component line, not the panel price.
Supporting

How it was coded

Unbundled
Billed 80053 panel + 82947 component
Supported by the record 80053 panel only

Remedy: Recover the component line

Unbundling, not up-coding — the level billed is correct on each line, but one of the lines should not be there at all.

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, 18 Mar 2026 — not as at today.

CPP-033 Laboratory panel and component billing Decisive

Governs a component test billed alongside the panel that contains it

In force on 18 Mar 2026: v5.0 effective 2025-10-01

No source document for v5.0 is in the index, so this policy can be cited here but not quoted. Upload it.

CPP-080 Eligibility, enrolment and retroactive termination Supporting

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

In force on 18 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_20260321_435639.edi
Availity clearinghouse · EDI 837P · received 21 Mar 2026 06:32 · claim control CCN-5362471102
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
31 Mar 11:20 Claim paid, $14.49 released to provider Payment cycle
02 Apr 18:02 Selected for post-pay review, model score 0.71 Autonomize
02 Apr 18:03 Finding drafted with 3 evidence items Autonomize