As paid vs. as it should have been
| Ln | Code | Description | Paid | Should be | Variance | Result |
|---|---|---|---|---|---|---|
| 1 | 80053 |
Comprehensive metabolic panel
E11.9 · Type 2 diabetes mellitus without complications
|
$10.56 | $10.56 | — | Correct |
Determination
Reviewed with no variance. Every line was paid at the allowable on file.
How it was coded
Remedy: None — the claim was billed and priced as the record supports
Reviewed for level, severity and unit count. Nothing billed above what the record carries.
Prior authorization
No prior authorization requirement for this service on this plan.
Policy applied
Knowledge CenterCoverage on the date of service, and the redetermination recorded against it
3. Criteria 3.1 The date that governs Coverage is evaluated as at the date of service. Not the date of payment, and not the date of the audit. A member covered on the date of service whose coverage later ends prospectively creates no exposure on a claim already paid. 3.2 Recording the checks Both the enrolment status…
CPP-080 — Eligibility, enrolment and retroactive termination Version 6.1 · Effective 1 January 2026 · Supersedes v6.0 Owner: Enrolment Integrity Applies to: All lines of business — all states, with variations External basis: 45 CFR 156.270 (QHP grace period) · 42 CFR 435.916 (Medicaid redetermination) · CMS Medicare…