Payment integrity Claim audit
Centene · payment integrity
Audit queue/ AUD-2026-04-0001/ CLM-0000013
Claim 19 of 25 Previous Next claim Back to queue

Post-pay DRG review · St. Bernard Regional

Medicare Advantage Member MBR-77031482 DOS 12 Mar 2026 Paid 02 Apr 2026 · $8,729.84 Recovery window closes in 41 days
Eligibility: Active on the date of service Wellcare Medicare Advantage HMO · Louisiana Prior auth: Approved and matched Inpatient admission
Review determination letter

As paid vs. as it should have been

Overpaid $2,956.64
LnCodeDescription PaidShould be VarianceResult
1 DRG 291 Heart failure and shock with MCC
I50.23 · Acute on chronic systolic (congestive) heart failure
 $8,729.84 $5,773.20 $2,956.64 Overpaid

Determination

3 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.
CDE
Billed DRG 291 · heart failure with MCC
Severity up-coding. A single unsubstantiated MCC moved the admission up a severity tier and took the payment with it.
Supporting Edit
Clinical-evidence defect Whether the record supports the condition or service that was coded.
DRG
DRG 291 rests on an MCC the record does not support
N17.9 acute kidney failure was coded as the major complication that lifts this admission from DRG 292 to 291. Peak creatinine was 1.1 mg/dL against a 1.0 baseline with normal urine output — no KDIGO stage is met at any point of the stay. Without the MCC the admission groups to DRG 292.
$2,956.64 Edit
Payment consequence What it costs, and how the recoverable amount is computed.
CALC
Weight difference of 0.4348 at a $6,800.00 base rate
DRG 291 weight 1.2838 paid $8,729.84. DRG 292 weight 0.8490 pays $5,773.20. The recoverable difference is $2,956.64.
$2,956.64 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.

LOS
Length of stay is consistent with the lower tier
The 4-day stay sits near the DRG 292 arithmetic mean of 3.7 days and below the DRG 291 mean of 5.0, which supports the downgrade rather than contradicting it.
Supporting

How it was coded

Up-coded
Billed DRG 291 · heart failure with MCC
Supported by the record DRG 292 · heart failure with CC

Remedy: Reprice to DRG 292

Severity up-coding. A single unsubstantiated MCC moved the admission up a severity tier and took the payment with it.

Prior authorization

Approved and matched
Authorization PA-2026-208114
Approved 2026-03-11
Valid 2026-03-11 → 2026-03-20
What was authorised Inpatient admission, heart failure, up to 4 days
What was billed Admission 12 Mar 2026, 3 days

The admission itself was authorised, so CPP-085 v3.4 bars a post-service medical-necessity review of it. The finding is a DRG severity-tier correction, which is coding accuracy and remains reviewable.

Policy applied

Knowledge Center

Resolved as at the date of service, 12 Mar 2026 — not as at today.

CPP-047 Inpatient DRG validation — complications and comorbidities Decisive

Sets what a reported MCC must be supported by before it may raise the severity tier

In force on 12 Mar 2026: v3.1 effective 2026-01-01
From CPP-047 v3.1, retrieved for this claim
p1 CPP-047_inpatient-drg-validation_v3.1.md 0.223

CPP-047 — Inpatient DRG validation: complications and comorbidities Version 3.1 · Effective 1 January 2026 · Supersedes v3.0 Owner: Facility Audit Policy Applies to: Medicare Advantage · Medicaid — all states External basis: CMS MS-DRG Definitions Manual v43 · ICD-10-CM Official Guidelines for Coding and Reporting 1…

p3 CPP-047_inpatient-drg-validation_v3.1.md 0.187

4. Recovery The recoverable amount is the difference between the relative weight of the billed DRG and the relative weight of the corrected DRG, multiplied by the contracted base rate for the facility. recovery = (billed weight - corrected weight) x base rate Both weights come from the MS-DRG Definitions Manual…

v3.1 had been in force for 70 days when this service happened. Before it, v3.0 applied — “Baseline clinical-validation policy for the v42 grouper.”
CPP-080 Eligibility, enrolment and retroactive termination Supporting

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

In force on 12 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
837I_20260315_215209.edi
Availity clearinghouse · EDI 837I · received 15 Mar 2026 13:22 · claim control CCN-7008944956
Claim form As received EDI Remittance

How this was decided

Open the full trace

Walked through Inpatient DRG validation v2.7, signed off 2025-12-04.

Procedure SOP-DRG-01 — Institutional inpatient admissions priced by MS-DRG
Nodes walked 12
Model calls 0 — every node that resolved did so on a rule, a lookup or arithmetic

Audit trail

Provider & member context
02 Apr 09:20 Claim paid, $8,729.84 released to facility Payment cycle
02 Apr 18:02 Selected for DRG validation, model score 0.91 Autonomize
02 Apr 18:04 Finding drafted with 4 evidence items Autonomize
05 Apr 09:15 Assigned to D. Mercer, facility audit Routing