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, 15 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 2026-01-01 to 2026-12-31; the service on 05 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, in network — covered when the medical necessity criteria are met. Superior HealthPlan STAR+PLUS · Texas.
Read
$.eligibility.benefit$.eligibility.plan
PRO-3
Rule
on match
Primacy confirmed
This plan is primary. Other coverage: None on file.
Read
$.eligibility.primacy$.eligibility.other_coverage
PRO-4
Rule
on match
Not required
This is why the finding is reachable. Under CPP-085 v3.4 an approved authorization bars post-service medical-necessity review of the authorised service; with no authorization on file that bar does not apply, and the criterion in CPP-070 is reviewable after payment. Had the provider obtained one, this review would have been limited to coding and pricing — both of which are correct.
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 05 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 05 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 $0.00.
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 no match
$254.18 above the allowable
$254.18 paid against $0.00 allowable = $254.18.
fail
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 no match
Finding and letter drafted for a reviewer
Separated into 2 layers — clinical-evidence defect, payment consequence — with the policy citation and dispute rights already in the letter. Neither is sent by the agent.
On the platform this node is a scoped model call that writes the finding and the letter.
Terminal disposition
Route to a human — criteria not met
ROUTE_TO_HUMAN_CRITERIA_NOT_MET
1 check did not pass and every check that mattered could be evaluated. $254.18 is at risk. The agent recommends the criteria are not met — it does not deny, and a person confirms.
The agent recommends the claim does not meet the criteria. It does not deny — a person confirms.
12 nodes
12 deterministic
0 model calls
15 citations
100% of paths resolved