Payment integrity
Reasoning trace
Centene · payment integrity
Reasoning
How this claim reached its determination
Inpatient DRG validation v2.7, signed off 2025-12-04 — 12 nodes, 11 of them resolved without a model, 14 citations. Read top to bottom: eligibility before policy, policy before pricing, and the finding drafted only once everything above it has answered.
DRG-1
Rule
on match
Active on the date of service
Coverage ran 2026-01-01 to 2026-12-31; the service on 12 Mar 2026 falls inside it. Re-verified at audit with no retroactive change.
Read
$.eligibility.coverage_from$.eligibility.coverage_to$.service_date
DRG-2
Rule
on match
Covered under the plan
Inpatient admission — covered under Part A equivalent benefit. Wellcare Medicare Advantage HMO · Louisiana.
Read
$.eligibility.benefit$.eligibility.plan
DRG-3
Rule
on match
Primacy confirmed
This plan is primary. Other coverage: None on file.
Read
$.eligibility.primacy$.eligibility.other_coverage
DRG-4
Rule
on match
Approved and matched
PA-2026-208114 valid 2026-03-11 to 2026-03-20. Inpatient admission, heart failure, up to 4 days — billed as authorised.
Read
$.prior_auth.status$.prior_auth.required
DRG-5
Rule
on match
Resolved to v3.1
CPP-047 v3.1, effective 2026-01-01, was in force on 12 Mar 2026.
Read
$.policy_refs$.service_date
pass
[7]
CPP-047 v3.1
DRG-6
Lookup
on match
DRG 291 priced from the grouper
291 — Heart failure and shock with MCC. Relative weight 1.2838 at a base rate of $6,800.00.
Read
$.lines
pass
[8]
CMS MS-DRG Definitions Manual v43
DRG-7
Rule
on match
Present-on-admission indicators consistent
No secondary diagnosis driving the severity tier is reported POA = N or POA = U.
Read
$.findings
DRG-8
Needs a scoped call
on field missing
Requires the inpatient record
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. The agent is sent the claim, not the chart, so the rules cannot resolve this on the data available.
On the platform this node is a scoped model call over the retrieved record.
Not in the claim
$.record.inpatient.clinical_indicators
The branch taken is on field missing, which is a
different outcome from the check evaluating to false.
DRG-9
Formula
on no match
Regroups to DRG 292
Excluding the unsubstantiated condition, the admission groups to 292 — Heart failure and shock with CC — at relative weight 0.849.
Read
$.coding.supported
fail
[11]
CMS MS-DRG Definitions Manual v43
DRG-10
Formula
on no match
$2,956.64 recoverable
Weight difference 1.2838 − 0.849 = 0.4348, at a base rate of $6,800.00 = $2,956.64.
Read
$.lines
fail
DRG-11
Retrieval
on match
2 passages retrieved
Scoped to CPP-047 v3.1, the version in force on 12 Mar 2026. Best match on page 1.
On the platform this node is a scoped model call against the indexed policy.
Read
$.lines$.findings
DRG-12
Drafted
on no match
Finding and letter drafted for a reviewer
Separated into 3 layers — coding defect, clinical-evidence defect, payment consequence — with the policy citation and dispute rights already in the letter. Neither is sent by the agent.
On the platform this node is a scoped model call that writes the finding and the letter.
Terminal disposition
Route to a human — pend
ROUTE_TO_HUMAN_PEND
1 check could not be evaluated: the field it reads is not on the claim. 2 other checks did not pass, but the agent does not recommend on the merits while a material check is unresolved. $2,956.64 is at stake. The agent recommends holding for the missing information; a person decides.
The agent recommends holding for missing information. A check could not be evaluated, so no recommendation on the merits is offered.
12 nodes
11 deterministic
0 model calls
14 citations
94% of paths resolved