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, 10 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 14 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-2026-201700 valid 2026-03-01 to 2026-03-31. Inpatient admission, authorised length of stay — billed as authorised.
Read
$.prior_auth.status$.prior_auth.required
DRG-5
Rule
on match
No decisive policy
This claim is tested against supporting policies only.
Read
$.policy_refs$.service_date
info
DRG-6
Lookup
on match
DRG 690 priced from the grouper
690 — Kidney and urinary tract infections without MCC. Relative weight 0.8095 at a base rate of $6,800.00.
Read
$.lines
pass
[7]
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 match
Severity tier rests on more than one condition
No single complication carries this admission's tier, so removing any one of them does not reprice it.
On the platform this node is a scoped model call over the retrieved record.
Read
$.drg
DRG-9
Formula
on match
No regroup
The billed DRG stands.
Read
$.coding.supported
pass
DRG-10
Formula
on match
No repricing
Paid $5,504.60 as grouped.
Read
$.lines
pass
DRG-11
Retrieval
on match
Nothing to retrieve against
This claim rests on no single decisive policy, so there is no version to scope a retrieval to. The supporting policies are cited on the claim without being quoted.
On the platform this node is a scoped model call against the indexed policy.
Read
$.lines$.findings
DRG-12
Drafted
on match
Closing letter drafted
No variance to report. The letter states the claim was reviewed and closed with no finding.
On the platform this node is a scoped model call that writes the finding and the letter.
pass
Terminal disposition
Approve
APPROVE
Every node resolved and none found a variance. The claim was paid as the record and the fee schedule support. This is the only disposition the agent reaches on its own.
Every check resolved and none found a variance. This is the only disposition the agent decides on its own.
12 nodes
11 deterministic
0 model calls
10 citations
100% of paths resolved