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, 13 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 05 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 · Texas.
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-2026-201880 valid 2026-03-04 to 2026-03-18. Inpatient admission, sepsis, up to 6 days — billed as authorised.
Read
$.prior_auth.status$.prior_auth.required
DRG-5
Rule
on match
Resolved to v2.0
CPP-052 v2.0, effective 2025-10-01, was in force on 05 Mar 2026.
Read
$.policy_refs$.service_date
pass
[7]
CPP-052 v2.0
DRG-6
Lookup
on match
DRG 871 priced from the grouper
871 — Septicemia or severe sepsis without MV >96 hours with MCC. Relative weight 1.9425 at a base rate of $7,150.00.
Read
$.lines
pass
[8]
CMS MS-DRG Definitions Manual v43
DRG-7
Rule
on no match
MCC reported as not present on admission
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.
Read
$.findings
DRG-8
Needs a scoped call
on field missing
Requires the inpatient record
The reported MCC has to be checked against clinical indicators in the record. 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 872
Excluding the unsubstantiated condition, the admission groups to 872 — Septicemia or severe sepsis without MV >96 hours without MCC — at relative weight 1.0233.
Read
$.coding.supported
fail
[11]
CMS MS-DRG Definitions Manual v43
DRG-10
Formula
on no match
$6,572.28 recoverable
Weight difference 1.9425 − 1.0233 = 0.9192, at a base rate of $7,150.00 = $6,572.28.
Read
$.lines
fail
DRG-11
Retrieval
on match
No source document indexed
CPP-052 v2.0 can be cited on this claim but not quoted — no document for that version is in the index.
On the platform this node is a scoped model call against the indexed policy.
Read
$.lines$.findings
info
[12]
Upload a policy
DRG-12
Drafted
on no match
Finding and letter drafted for a reviewer
Separated into 2 layers — coding 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. 3 other checks did not pass, but the agent does not recommend on the merits while a material check is unresolved. $6,572.28 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
13 citations
94% of paths resolved