Payment integrity Provider & member

Centene · payment integrity

CLM-0000024/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 Noor Ferreira · 63

Member ID MBR-30884201

Plan Medicare Advantage · HMO

Eligibility on DOS Active, verified 24 Feb 2026

Other coverage None on file

Member liability 20% Part B coinsurance

Open appeals None

Eligibility on the date of service

Active on the date of service

Evaluated as at 24 Feb 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 2021-01-01

Coverage span 2026-01-01 → 2026-12-31

Enrolment segment Continuous since 01 Jan 2021 · 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 20% Part B coinsurance — any recovery is provider-side, not the member's

Primacy This plan is primary

Other coverage None on file

Prior authorization Approved and matched

What was checked, when, and what it said

Enrolment system · 834 roster 24 Feb 2026 06:00 Active — coverage effective on the date of service As at date of service

CMS monthly membership report 24 Feb 2026 06:00 Enrolled in this contract and plan benefit package for February 2026 As at date of service

Coordination of benefits · TPL file 10 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 v1.4 now v2.0

Governs how billed units are reconciled against the documented dose. Resolves to v1.4 here, not the v2.0 an auditor would find today

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-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