Payment integrity Provider & member

Centene · payment integrity

CLM-0000022/Context

Context

Sunbelt Imaging Center

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

$0.00 identified

Flag rate, last 90 days

6.7%

2 of 30 · peer 8.0%

Specialty percentile

within Diagnostic Radiology

Provider

Provider Sunbelt Imaging Center

NPI 1709942365

Specialty Diagnostic Radiology

Network status In network

Claims last 90 days 30

Flag rate 6.7% (peer median 8.0%)

Prior denials 0

Specialty percentile 44th

Member

Member Imani Delacroix · 46

Member ID MBR-50913377

Plan Marketplace · Silver 70

Eligibility on DOS Active, verified 10 Mar 2026

Other coverage None on file

Member liability $0 after deductible

Open appeals None

Eligibility on the date of service

Active on the date of service

Evaluated as at 10 Mar 2026, the date of service — not as at the date of payment or the date of this audit.

Coverage

Plan Ambetter Silver 70 HMO

Product Marketplace QHP

Line of business Marketplace

State of coverage Florida (FL)

Member since 2023-01-01

Coverage span 2026-01-01 → 2026-12-31

Enrolment segment Continuous since 01 Jan 2023 · no gap in coverage

Standing Premium paid through March 2026 · not in a grace period

Benefit and liability

Benefit on this service Advanced imaging, in network — covered subject to prior authorization

Accumulators Deductible met 02 Mar 2026

Member liability $0 after deductible — any recovery is provider-side, not the member's

Primacy This plan is primary

Other coverage None on file

Prior authorization Approved and matched

A Florida marketplace member on the same product family as the Texas marketplace claims in this batch. The benefit design is the same; the imaging policy that applies to it is not, because CPP-070 carries a state variation. Multi-state is where policy volume comes from.

What was checked, when, and what it said

Enrolment system · 834 roster 10 Mar 2026 06:00 Active — coverage effective on the date of service As at date of service

Benefit configuration · plan build 10 Mar 2026 06:00 Advanced imaging covered under the plan's benefit design As at date of service

Coordination of benefits · TPL file 24 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-070 Advanced imaging — medical necessity and site of service v1.3

Coverage conditions for advanced imaging, and the Florida variation that applies to this member

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

The authorization on file, and what it closes off from post-service review

This provider's claims in the current batch

Claim	DOS	Why selected	Paid	At risk	Status
CLM-0000022	10 Mar 2026	Advanced imaging review	$316.97	—	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