Payment integrity Provider & member

Centene · payment integrity

CLM-0000013/Context

Context

St. Bernard Regional Medical Center

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

$2,956.64 identified

Flag rate, last 90 days

12.5%

1 of 8 · peer 8.0%

Specialty percentile

within Acute Care Hospital

Provider

Provider St. Bernard Regional Medical Center

NPI 1558903471

Specialty Acute Care Hospital

Network status In network

Contracted base rate $6,800.00 per weighted discharge

Claims last 90 days 8

Flag rate 12.5% (peer median 8.0%)

Prior denials 0

Specialty percentile 29th

Member

Member Grace Nakamura · 71

Member ID MBR-77031482

Plan Medicare Advantage · HMO

Eligibility on DOS Active, verified 12 Mar 2026

Other coverage None on file

Member liability $1,700 inpatient copay — unchanged by the downgrade

Open appeals None

Eligibility on the date of service

Active on the date of service

Evaluated as at 12 Mar 2026, the date of service — not as at the date of payment or the date of this audit.

Coverage

Plan Wellcare Medicare Advantage HMO

Product Medicare Advantage Part C

Line of business Medicare Advantage

State of coverage Louisiana (LA)

Member since 2023-01-01

Coverage span 2026-01-01 → 2026-12-31

Enrolment segment Continuous · no gap in coverage

Standing Part C enrolment confirmed against the CMS monthly membership report

Benefit and liability

Benefit on this service Inpatient admission — covered under Part A equivalent benefit

Accumulators Inpatient deductible applied at admission

Member liability $1,700 inpatient copay — unchanged by the downgrade — any recovery is provider-side, not the member's

Primacy This plan is primary

Other coverage None on file

Prior authorization Approved and matched

What was checked, when, and what it said

Enrolment system · 834 roster 12 Mar 2026 06:00 Active — coverage effective on the date of service As at date of service

Benefit configuration · plan build 12 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-047 Inpatient DRG validation — complications and comorbidities v3.1

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

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

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

This provider's claims in the current batch

Claim	DOS	Why selected	Paid	At risk	Status
CLM-0000015	09 Mar 2026	DRG severity tier review	$7,532.36	—	No finding
CLM-0000017	14 Mar 2026	Random control sample	$5,504.60	—	No finding
CLM-0000013	12 Mar 2026	DRG severity tier · single MCC	$8,729.84	$2,956.64	Finding open

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