Payment integrity
Reasoning trace
Centene · payment integrity
Reasoning
How this claim reached its determination
Drug and biologic unit review v1.2, signed off 2026-02-20 — 13 nodes, 12 of them resolved without a model, 17 citations. Read top to bottom: eligibility before policy, policy before pricing, and the finding drafted only once everything above it has answered.
DRX-1
Rule
on match
Active on the date of service
Coverage ran 2026-01-01 to 2026-12-31; the service on 24 Feb 2026 falls inside it. Re-verified at audit with no retroactive change.
Read
$.eligibility.coverage_from$.eligibility.coverage_to$.service_date
DRX-2
Rule
on match
Covered under the plan
Physician-administered drug on the medical benefit — covered subject to prior authorization. Wellcare Medicare Advantage HMO · Louisiana.
Read
$.eligibility.benefit$.eligibility.plan
DRX-3
Rule
on match
Primacy confirmed
This plan is primary. Other coverage: None on file.
Read
$.eligibility.primacy$.eligibility.other_coverage
DRX-4
Rule
on match
Approved and matched
PA-2026-211730 valid 2026-02-10 to 2026-05-10. Trastuzumab 420 mg per cycle, every three weeks — billed as authorised.
Read
$.prior_auth.status$.prior_auth.required
DRX-5
Rule
on match
Resolved to v1.4 — not the current version
CPP-061 v1.4 was in force on 24 Feb 2026. v2.0 took effect on 2026-03-01 and is what the library shows today.
Read
$.policy_refs$.service_date
pass
[7]
CPP-061 v1.4
DRX-6
Lookup
on match
Codes valid on the date of service
J9355 against C50.911. Every code was billable on 24 Feb 2026.
Read
$.lines
pass
[8]
ICD-10-CM FY2026
[9]
HCPCS / CPT 2026
DRX-7
Lookup
on match
Per-unit rate matches the ASP file
J9355 is $73.425 per 10 mg in the file effective 2026-04-01 to 2026-06-30. 42 units billed = $3,083.85.
Read
$.lines
DRX-8
Rule
on match
Inside the unit ceiling — which is not validation
42 of J9355 against a published ceiling of 240. Derived from the maximum labelled dose over body surface area. The ceiling is a maximum, not an allowance: passing it validates nothing on its own.
Read
$.lines
DRX-9
Needs a scoped call
on match
Units reconcile to the documented dose
J9355 × 42 units — 420 mg, per the medication administration record — the claim, the record and the authorization agree.
On the platform this node is a scoped model call over the retrieved record.
Read
$.lines$.prior_auth.authorized
DRX-10
Rule
on match
Within the authorisation
42 units on 24 Feb 2026 — 420 mg, exactly as authorised.
Read
$.prior_auth.authorized$.lines
DRX-11
Formula
on match
No unit variance
42 units billed and supported.
pass
DRX-12
Retrieval
on match
2 passages retrieved
Scoped to CPP-061 v1.4, the version in force on 24 Feb 2026. Best match on page 1.
On the platform this node is a scoped model call against the indexed policy.
Read
$.lines$.findings
DRX-13
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.
13 nodes
12 deterministic
0 model calls
17 citations
100% of paths resolved