Payment integrity Provider & member
Centene · payment integrity
CLM-0000012/Context
Context

Meridian Counseling Services

Audit history, provider profile and the member's record — the systems an auditor would otherwise open one at a time.

In this batch
2
claims screened this period
Findings
0
$0.00 identified
Flag rate, last 90 days
6.2%
1 of 16 · peer 8.0%
Specialty percentile
38
within Behavioral Health

Provider

Provider Meridian Counseling Services
NPI 1660271934
Specialty Behavioral Health
Network status In network
Claims last 90 days 16
Flag rate 6.2% (peer median 8.0%)
Prior denials 0
Specialty percentile 38th

Member

Member Neve Halloran · 41
Member ID MBR-71904288
Plan Behavioral health carve-in
Eligibility on DOS Active, verified 30 Mar 2026
Other coverage None on file
Member liability $50 copay, already applied
Open appeals None

Eligibility on the date of service

Active on the date of service

Evaluated as at 30 Mar 2026, the date of service — not as at the date of payment or the date of this audit.

Coverage
Plan Behavioral health carve-in
Product Carve-in behavioural benefit
Line of business Behavioral health
State of coverage Texas (TX)
Member since 2024-04-01
Coverage span 2026-01-01 → 2026-12-31
Enrolment segment Continuous · no gap in coverage
Standing Benefit active · no visit limit reached
Benefit and liability
Benefit on this service Outpatient psychotherapy — covered, no authorization required
Accumulators No visit limit on this benefit
Member liability $50 copay, already applied — any recovery is provider-side, not the member's
Primacy This plan is primary
Other coverage None on file
Prior authorization Not required
What was checked, when, and what it said
Enrolment system · 834 roster 30 Mar 2026 06:00 Active — coverage effective on the date of service As at date of service
Benefit configuration · plan build 30 Mar 2026 06:00 Service covered under the plan's benefit design As at date of service
Coordination of benefits · TPL file 02 Apr 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-021 Duplicate and repeat services v2.3

Repeat and duplicate service rules

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

Coverage on the date of service

This provider's claims in the current batch

ClaimDOSWhy selected PaidAt riskStatus
CLM-0000008 20 Mar 2026 Random control sample $152.44 — No finding
CLM-0000012 30 Mar 2026 Repeat service cluster $304.88 — No finding

Prior audits

AuditPeriodFocus ScreenedIdentified RecoveredOutcome
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