Payment integrity Claim audit

Centene · payment integrity

Audit queue/ AUD-2026-04-0001/ CLM-0000014

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Post-pay DRG review · Gulf Coast General

Medicare Advantage Member MBR-90248117 DOS 05 Mar 2026 Paid 25 Mar 2026 · $13,888.88 Recovery window closes in 33 days

Eligibility: Active on the date of service Wellcare Medicare Advantage HMO · Texas Prior auth: Approved and matched Inpatient admission

Review determination letter

As paid vs. as it should have been

Overpaid $6,572.28

Ln	Code	Description	Paid	Should be	Variance	Result
1	DRG 871	Septicemia or severe sepsis without MV >96 hours with MCC A41.9 · Sepsis, unspecified organism	$13,888.88	$7,316.60	$6,572.28	Overpaid

Determination

2 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.

HAC

The MCC carries a present-on-admission indicator of N

Stage 3 pressure ulcer L89.153 was coded as the major complication and reported POA = N, meaning it developed during the stay. A hospital-acquired condition cannot be used to assign a higher-paying DRG.

$6,572.28 Edit

Clinical-evidence defect Whether the record supports the condition or service that was coded.

No clinical-evidence defect. The record supports the service as documented; what is wrong is how it was coded or priced.

Payment consequence What it costs, and how the recoverable amount is computed.

CALC

Weight difference of 0.9192 at a $7,150.00 base rate

DRG 871 weight 1.9425 paid $13,888.88. DRG 872 weight 1.0233 pays $7,316.60. The recoverable difference is $6,572.28.

$6,572.28 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.

PAT

Second pressure-ulcer HAC at this facility in six months

One prior claim was flagged for the same pattern. Candidate for a targeted review of the facility's POA reporting rather than a one-off recovery.

Advisory

How it was coded

Up-coded

Billed DRG 871 · sepsis with MCC

Supported by the record DRG 872 · sepsis without MCC

Remedy: Reprice to DRG 872

Severity up-coding by a condition the hospital acquired. Present-on-admission reporting is what separates the two.

Prior authorization

Approved and matched

Authorization PA-2026-201880

Approved 2026-03-04

Valid 2026-03-04 → 2026-03-18

What was authorised Inpatient admission, sepsis, up to 6 days

What was billed Admission 05 Mar 2026, 5 days

Authorised admission. The finding concerns how the admission was coded, not whether it should have happened.

Policy applied

Knowledge Center

Resolved as at the date of service, 05 Mar 2026 — not as at today.

CPP-052 Present on admission and hospital-acquired conditions Decisive

Governs a secondary diagnosis reported as not present on admission

In force on 05 Mar 2026: v2.0 effective 2025-10-01

No source document for v2.0 is in the index, so this policy can be cited here but not quoted. Upload it.

CPP-047 Inpatient DRG validation — complications and comorbidities Supporting

Sets the clinical validation a reported MCC must meet

In force on 05 Mar 2026: v3.1 effective 2026-01-01

v3.1 was extracted from CPP-047_inpatient-drg-validation_v3.1.md. Passages are quoted only on the policy the finding rests on.

CPP-080 Eligibility, enrolment and retroactive termination Supporting

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

In force on 05 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_20260308_534426.edi

Availity clearinghouse · EDI 837I · received 08 Mar 2026 10:10 · claim control CCN-3131452049

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

25 Mar 14:05 Claim paid, $13,888.88 released to facility Payment cycle

02 Apr 18:02 Selected by provider watchlist rule Autonomize

02 Apr 18:05 Finding drafted with 4 evidence items Autonomize

05 Apr 11:40 Assigned to D. Mercer, facility audit Routing

Autonomize finding

DRG downgrade — overpayment of $6,572.28

MCC was not present on admission · DRG 871 should be 872

Tested against CPP-052 v2.0, in force on 05 Mar 2026

96% confidence

Evidence

Stage 3 pressure ulcer L89.153 is reported with present-on-admission indicator N on the claim.

[1] Claim CLM-0000014, diagnosis segment

A condition acquired during the stay may not be used to assign a higher-severity DRG under the hospital-acquired condition payment provision.

[2] CMS HAC payment provision, Deficit Reduction Act §5001(c)

MS-DRG 871 carries a relative weight of 1.9425 and MS-DRG 872 a weight of 1.0233, a difference of 0.9192.

[3] CMS MS-DRG v43

At the facility's contracted base rate of $7,150.00 per weighted discharge, that difference is $6,572.28.

[4] Gulf Coast facility agreement 2022-119

Or no finding, refer to SIU, or dismiss.

Run the agent

DRG Validation Agent

Set AI_STUDIO_API_KEY and the workflow ID in .env to call the agent from this screen.

Every finding keeps its evidence, the rule version it was tested against, and the auditor who dispositioned it.