Payment integrity
Reasoning trace
Centene · payment integrity
Reasoning
How this claim reached its determination
Professional claims post-pay review v1.9, signed off 2026-01-14 — 12 nodes, 12 of them resolved without a model, 14 citations. Read top to bottom: eligibility before policy, policy before pricing, and the finding drafted only once everything above it has answered.
PRO-1
Rule
on match
Active on the date of service
Coverage ran 2025-10-01 to 2026-09-30; the service on 23 Mar 2026 falls inside it. Re-verified at audit with no retroactive change.
Read
$.eligibility.coverage_from$.eligibility.coverage_to$.service_date
PRO-2
Rule
on match
Covered under the plan
Advanced imaging — covered under the state benefit plan. Superior HealthPlan STAR · Texas.
Read
$.eligibility.benefit$.eligibility.plan
PRO-3
Rule
on match
Primacy confirmed
This plan is payer of last resort. Other coverage: None on file.
Read
$.eligibility.primacy$.eligibility.other_coverage
PRO-4
Rule
on match
Not required
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.
Read
$.prior_auth.status$.prior_auth.required
PRO-5
Rule
on match
Resolved to v1.3
CPP-070 v1.3, effective 2025-04-01, was in force on 23 Mar 2026.
Read
$.policy_refs$.service_date
pass
[6]
CPP-070 v1.3
PRO-6
Lookup
on match
Codes valid on the date of service
72148 against M54.50. Every code was billable on 23 Mar 2026.
Read
$.lines
pass
[7]
ICD-10-CM FY2026
[8]
HCPCS / CPT 2026
PRO-7
Lookup
on match
Allowable read from the fee schedule
72148 allows $191.72.
Read
$.lines
pass
[9]
CMS Physician Fee Schedule 2026 · TX locality 09
[10]
CMS Clinical Laboratory Fee Schedule 2026 Q2
PRO-8
Rule
on match
No bundling edit applies
No code on this claim is listed in the code-group table as a component of another code billed alongside it.
Read
$.lines
PRO-9
Rule
on match
Units and modifiers consistent
Every line bills a single unit.
Read
$.lines
PRO-10
Formula
on match
Paid at the allowable
$191.72 paid against $191.72 allowable = $0.00.
pass
PRO-11
Retrieval
on match
No source document indexed
CPP-070 v1.3 can be cited on this claim but not quoted — no document for that version is in the index.
On the platform this node is a scoped model call against the indexed policy.
Read
$.lines$.findings
info
[14]
Upload a policy
PRO-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
12 deterministic
0 model calls
14 citations
100% of paths resolved