Payment integrity Provider & member

Centene · payment integrity

CLM-0000021/Context

Context

Bayou Oncology Associates

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

$1,344.96 identified

Flag rate, last 90 days

12.5%

2 of 16 · peer 8.0%

Specialty percentile

within Medical Oncology

Provider

Provider Bayou Oncology Associates

NPI 1427809359

Specialty Medical Oncology

Network status In network

Claims last 90 days 16

Flag rate 12.5% (peer median 8.0%)

Prior denials 1

Specialty percentile 61st

Member

Member Rowan Castellanos · 69

Member ID MBR-30772614

Plan Medicare Advantage · HMO

Eligibility on DOS Active, verified 19 Mar 2026

Other coverage None on file

Member liability $0 — recovery is provider-side

Open appeals None

Eligibility on the date of service

Active on the date of service

Evaluated as at 19 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 Louisiana (LA)

Member since 2022-01-01

Coverage span 2026-01-01 → 2026-12-31

Enrolment segment Continuous since 01 Jan 2022 · no gap in coverage

Standing Part C enrolment confirmed against the CMS monthly membership report

Benefit and liability

Benefit on this service Physician-administered drug on the medical benefit — covered subject to prior authorization

Accumulators Part B coinsurance applied at 20%

Member liability $0 member liability — any recovery is provider-side

Primacy This plan is primary

Other coverage None on file

Prior authorization Approved — claim exceeds what was authorised

What was checked, when, and what it said

Enrolment system · 834 roster 19 Mar 2026 06:00 Active — coverage effective on the date of service As at date of service

CMS monthly membership report 19 Mar 2026 06:00 Enrolled in this contract and plan benefit package for March 2026 As at date of service

Coordination of benefits · TPL file 31 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-061 Physician-administered drugs — dose, units and wastage v2.0

Governs how billed units are reconciled against the dose recorded in the infusion record, and says in terms that passing the MUE is not validation

CPP-080 Eligibility, enrolment and retroactive termination v6.1

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

CPP-085 Prior authorization and post-service review v3.4

Makes units billed beyond those authorised reviewable and recoverable even where the therapy itself was approved

This provider's claims in the current batch

Claim	DOS	Why selected	Paid	At risk	Status
CLM-0000021	19 Mar 2026	Drug spend · units vs. dose	$8,069.76	$1,344.96	Finding open
CLM-0000024	24 Feb 2026	Drug and biologic spend	$3,083.85	—	No finding

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