Payment integrity Provider & member

Centene · payment integrity

CLM-0000023/Context

Context

Rio Grande Diagnostic Imaging

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

5.6%

1 of 18 · peer 8.0%

Specialty percentile

within Diagnostic Radiology

Provider

Provider Rio Grande Diagnostic Imaging

NPI 1288556172

Specialty Diagnostic Radiology

Network status In network

Claims last 90 days 18

Flag rate 5.6% (peer median 8.0%)

Prior denials 0

Specialty percentile 31st

Member

Member Priya Okonkwo · 55

Member ID MBR-41220863

Plan Medicaid · TX STAR

Eligibility on DOS Active, verified 23 Mar 2026

Other coverage None on file

Member liability $0 copay

Open appeals None

Eligibility on the date of service

Active on the date of service

Evaluated as at 23 Mar 2026, the date of service — not as at the date of payment or the date of this audit.

Coverage

Plan Superior HealthPlan STAR

Product Medicaid managed care

Line of business Medicaid · TX STAR

State of coverage Texas (TX)

Member since 2021-11-01

Coverage span 2025-10-01 → 2026-09-30

Enrolment segment Certification period 01 Oct 2025 – 30 Sep 2026

Standing Redetermination not due before 30 Sep 2026

Benefit and liability

Benefit on this service Advanced imaging — covered under the state benefit plan

Accumulators No member cost share on Medicaid

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

Primacy This plan is payer of last resort

Other coverage None on file

Prior authorization Not required — provider is gold-carded

What was checked, when, and what it said

Enrolment system · 834 roster 23 Mar 2026 06:00 Active — coverage effective on the date of service As at date of service

State eligibility file · TX HHSC 23 Mar 2026 06:00 Certified for the period covering the date of service As at date of service

Coordination of benefits · TPL file 01 Apr 2026 09:00 No third party found — Medicaid paid correctly as last resort 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

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

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

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

This provider's claims in the current batch

Claim	DOS	Why selected	Paid	At risk	Status
CLM-0000023	23 Mar 2026	Advanced imaging · repeat within 90 d	$191.72	—	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