Payment integrity Provider & member

Centene · payment integrity

CLM-0000025/Context

Context

Gulf Coast 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

$254.18 identified

Flag rate, last 90 days

9.8%

4 of 41 · peer 8.0%

Specialty percentile

within Diagnostic Radiology

Provider

Provider Gulf Coast Diagnostic Imaging

NPI 1558830274

Specialty Diagnostic Radiology

Network status In network

Claims last 90 days 41

Flag rate 9.8% (peer median 8.0%)

Prior denials 1

Specialty percentile 63rd

Member

Member Nnamdi Okafor · 52

Member ID MBR-64220518

Plan Medicaid · STAR+PLUS

Eligibility on DOS Active, verified 05 Mar 2026

Other coverage None on file

Member liability $0 — not balance billed

Open appeals None

Eligibility on the date of service

Active on the date of service

Evaluated as at 05 Mar 2026, the date of service — not as at the date of payment or the date of this audit.

Coverage

Plan Superior HealthPlan STAR+PLUS

Product Medicaid managed care

Line of business Medicaid

State of coverage Texas (TX)

Member since 2021-06-01

Coverage span 2026-01-01 → 2026-12-31

Enrolment segment Continuous since 01 Jun 2021 · no gap in coverage

Standing Medicaid eligibility redetermined 01 Jan 2026 · no action pending

Benefit and liability

Benefit on this service Advanced imaging, in network — covered when the medical necessity criteria are met

Accumulators No deductible under this Medicaid product

Member liability $0 — Medicaid members are not balance billed, so any recovery is provider-side

Primacy This plan is primary

Other coverage None on file

Prior authorization Not required for this study under the state plan

Eligibility is not the issue on this claim and the review says so. The member was covered, the benefit covers advanced imaging, and the plan paid as primary. What fails is the clinical criterion, which is a different question and is answered in its own section.

What was checked, when, and what it said

Enrolment system · 834 roster 05 Mar 2026 06:00 Active — coverage effective on the date of service As at date of service

Benefit configuration · plan build 05 Mar 2026 06:00 Advanced imaging covered subject to medical necessity criteria As at date of service

Coordination of benefits · TPL file 19 Mar 2026 09:00 No other coverage found — this plan paid correctly as primary At adjudication

Re-verified for this audit 02 Apr 2026 18:03 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

The repeat-imaging criterion that this study fails, in the version in force on the date 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

Why a post-service medical-necessity review is open here — there is no authorization on file to close it

This provider's claims in the current batch

Claim	DOS	Why selected	Paid	At risk	Status
CLM-0000025	05 Mar 2026	Advanced imaging review	$254.18	$254.18	Finding open

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