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Post-pay review · Rio Grande Diagnostic Imaging

Medicaid · TX STAR Member MBR-41220863 DOS 23 Mar 2026 Paid 01 Apr 2026 · $191.72 Recovery window closes in 47 days
Eligibility: Active on the date of service Superior HealthPlan STAR · Texas Prior auth: Not required — provider is gold-carded Advanced imaging
Review closing letter

As paid vs. as it should have been

No variance
LnCodeDescription PaidShould be VarianceResult
1 72148 MRI, lumbar spine, without contrast material
M54.50 · Low back pain, unspecified
$191.72 $191.72 Correct

Determination

No defect in any layer

Reviewed with no variance. Every line was paid at the allowable on file.

How it was coded

Coded as documented
Billed 72148 · MRI lumbar spine without contrast
Supported by the record 72148 · MRI lumbar spine without contrast

Remedy: None — the claim was billed and priced as the record supports

A repeat study of the same region inside 90 days, which is what put it in the batch. CPP-070 v1.3 allows it where the record documents a change in clinical status, and the record does.

Prior authorization

Not required — provider is gold-carded
Requirement Not required — provider is gold-carded

Texas HB 3459 exempts a provider whose prior-authorization requests were approved at or above the statutory rate from having to obtain them for the qualifying service. This provider holds that exemption for advanced imaging, so the absence of an authorization is not an authorization gap. CPP-085 carries the state variation; the same claim in Florida would have needed one.

Policy applied

Knowledge Center

Resolved as at the date of service, 23 Mar 2026 — not as at today.

CPP-070 Advanced imaging — medical necessity and site of service Decisive

Sets the condition a repeat study of the same region within 90 days has to meet, and carries the Texas variation on site of service

In force on 23 Mar 2026: v1.3 effective 2025-04-01

No source document for v1.3 is in the index, so this policy can be cited here but not quoted. Upload it.

CPP-080 Eligibility, enrolment and retroactive termination Supporting

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

In force on 23 Mar 2026: v6.1 effective 2026-01-01

v6.1 was extracted from CPP-080_eligibility-enrolment-retroactive-termination_v6.1.md. Passages are quoted only on the policy the finding rests on.

CPP-085 Prior authorization and post-service review Supporting

Carries the Texas gold-carding exemption that makes the missing authorization a non-issue

In force on 23 Mar 2026: v3.4 effective 2025-11-01

v3.4 was extracted from CPP-085_prior-authorization-post-service-review_v3.4.md. Passages are quoted only on the policy the finding rests on.

Source document

Open all four views
837P_20260326_041179.edi
Availity clearinghouse · EDI 837P · received 26 Mar 2026 12:27 · claim control CCN-2355554142
Claim form As received EDI Remittance

How this was decided

Open the full trace

Walked through Professional claims post-pay review v1.9, signed off 2026-01-14.

Procedure SOP-PRO-01 — Professional claims — office visits, procedures, laboratory, imaging
Nodes walked 12
Model calls 0 — every node that resolved did so on a rule, a lookup or arithmetic
01 Apr 09:15 Claim paid, $191.72 released to provider Payment cycle
02 Apr 18:02 Selected as a repeat study within 90 days Autonomize
02 Apr 18:03 CPP-070 resolved to v1.3, the version in force on 23 Mar 2026 Autonomize
07 Apr 09:30 Reviewed, no finding D. Mercer