Payment integrity Provider & member

Centene · payment integrity

CLM-0000014/Context

Context

Gulf Coast General Hospital

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

$6,572.28 identified

Flag rate, last 90 days

9.1%

1 of 11 · peer 8.0%

Specialty percentile

within Acute Care Hospital

Provider

Provider Gulf Coast General Hospital

NPI 1770448209

Specialty Acute Care Hospital

Network status In network

Contracted base rate $7,150.00 per weighted discharge

Claims last 90 days 11

Flag rate 9.1% (peer median 8.0%)

Prior denials 1

Specialty percentile 44th

Member

Member Rhys Halloran · 79

Member ID MBR-90248117

Plan Medicare Advantage · HMO

Eligibility on DOS Active, verified 05 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 05 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 Texas (TX)

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 05 Mar 2026 06:00 Active — coverage effective on the date of service As at date of service

Benefit configuration · plan build 05 Mar 2026 06:00 Service covered under the plan's benefit design As at date of service

Coordination of benefits · TPL file 25 Mar 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-052 Present on admission and hospital-acquired conditions v2.0

Governs a secondary diagnosis reported as not present on admission

CPP-047 Inpatient DRG validation — complications and comorbidities v3.1

Sets the clinical validation a reported MCC must meet

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-0000016	03 Mar 2026	Paid above cost threshold	$13,791.64	—	No finding
CLM-0000018	07 Mar 2026	DRG severity tier review	$7,012.01	—	No finding
CLM-0000019	21 Mar 2026	Random control sample	$7,920.05	—	No finding
CLM-0000020	26 Mar 2026	Random control sample	$5,787.93	—	No finding
CLM-0000014	05 Mar 2026	DRG severity tier · single MCC	$13,888.88	$6,572.28	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