Payment integrity Provider & member

Centene · payment integrity

CLM-0000011/Context

Context

Cypress Family Care Associates

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

$67.71 identified

Flag rate, last 90 days

4.2%

1 of 24 · peer 8.0%

Specialty percentile

within Family Medicine

Provider

Provider Cypress Family Care Associates

NPI 1223887640

Specialty Family Medicine

Network status In network

Claims last 90 days 24

Flag rate 4.2% (peer median 8.0%)

Prior denials 0

Specialty percentile 22th

Member

Member Tomas Barros · 61

Member ID MBR-55810322

Plan Medicaid · TX STAR

Eligibility on DOS Active, verified 16 Mar 2026

Other coverage None on file

Member liability $0 copay

Open appeals None

Eligibility on the date of service

Active on the date of service

Evaluated as at 16 Mar 2026, the date of service — not as at the date of payment or the date of this audit.

Coverage

Plan Superior HealthPlan STAR

Product Medicaid managed care

Line of business Medicaid · TX STAR

State of coverage Texas (TX)

Member since 2022-05-01

Coverage span 2025-09-01 → 2026-03-31

Enrolment segment Certification period 01 Sep 2025 – 31 Mar 2026

Standing Redetermination completed 24 Mar 2026 — coverage ended 31 Mar 2026, PROSPECTIVELY

Benefit and liability

Benefit on this service Laboratory panel — covered under the state benefit plan

Accumulators No member cost share on Medicaid

Member liability $0 copay — any recovery is provider-side, not the member's

Primacy This plan is payer of last resort

Other coverage None on file

Prior authorization Not required

Coverage ended after this date of service, not before it. A prospective termination creates no exposure on a claim already paid. It is recorded because CPP-080 v6.1 requires the re-verification result either way.

What was checked, when, and what it said

Enrolment system · 834 roster 16 Mar 2026 06:00 Active — coverage effective on the date of service As at date of service

Benefit configuration · plan build 16 Mar 2026 06:00 Service covered under the plan's benefit design As at date of service

Coordination of benefits · TPL file 30 Mar 2026 09:00 No third party found — Medicaid paid correctly as last resort 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-080 Eligibility, enrolment and retroactive termination v6.1

Coverage on the date of service, and the redetermination recorded against it

CPP-033 Laboratory panel and component billing v5.0

Component and panel billing for the tests on this claim

This provider's claims in the current batch

Claim	DOS	Why selected	Paid	At risk	Status
CLM-0000004	11 Mar 2026	Duplicate cluster · same date	$135.42	$67.71	Finding open
CLM-0000003	09 Mar 2026	Random control sample	$16.03	—	No finding
CLM-0000011	16 Mar 2026	Component and panel scan	$10.56	—	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