Payment integrity Knowledge Center

Centene · payment integrity

Policy

Knowledge Center

The internal policy library the findings in this batch are tested against. Every policy is versioned, and every version carries the dates it was in force — because an audit runs months after the service it is auditing.

10 policies · 20 versions · 6 categories · current as at 2026-04-02

Knowledge Base Search the index Extraction Upload a policy

The document index

Search it

Policy documents are ingested into a dataset, split into chunks, embedded, and written to a vector index scoped by organisation, project, dataset and policy version. A finding then quotes the passages that bear on it, from the version of the policy that was in force on the claim's date of service.

Documents ingested 7 across 18 pages

Chunks indexed 32 at 1000 characters, overlapping by 200

Embedding, here local-hashing-256 at 256d — a local deterministic hashing embedding, not a learned model

Embedding, on the platform text-embedding-3-small at 1536d via Azure OpenAI

Versions in the index __live__ v1.4

Payment integrity policy 7 documents · local-hashing-256 at 256d seeded

Which versions a finding can quote

7 of 20

A policy version with a source document in the index can be quoted on a finding — the passage, the page, the version. One without can only be cited by name. The gap is the useful number, so it is shown rather than hidden.

Versions with a source document 35%

CPP-014 Evaluation and management level selection CPP-014_em-level-selection_v4.2.md · 3 pages v4.2 CPP-021 Duplicate and repeat services CPP-021_duplicate-and-repeat-services_v2.3.md · 1 page v2.3 CPP-047 Inpatient DRG validation — complications and comorbidities CPP-047_inpatient-drg-validation_v3.1.md · 3 pages v3.1 CPP-061 Physician-administered drugs — dose, units and wastage CPP-061_physician-administered-drugs_v2.0.md · 3 pages v2.0 CPP-061 Physician-administered drugs — dose, units and wastage CPP-061_physician-administered-drugs_v1.4.md · 2 pages v1.4 CPP-080 Eligibility, enrolment and retroactive termination CPP-080_eligibility-enrolment-retroactive-termination_v6.1.md · 3 pages v6.1 CPP-085 Prior authorization and post-service review CPP-085_prior-authorization-post-service-review_v3.4.md · 3 pages v3.4

13 of 20 versions have no source document. Uploading one attaches it by the CPP-nnn and version in its filename or first page.

What the documents actually say

Criteria extracted 114 across 7 documents

By layer 29 coding · 29 clinical · 24 payment

Library criteria traced 20 of 21 · 1 not traced

The extractor is a deterministic parse, not a model — see Extraction for what that means and where it shows.

Policies in the library

20 versions across 6 categories

Cited by this batch

1 not reached by these claims

Carry a state variation

the same rule, different in different states

Governed by a superseded version

claims whose policy has changed since the service

Read against the version in force, not the current one

1 claim in this batch

The policy that governs a claim is the one that was in force on its date of service. For these, that is not the version the library shows today.

Claim	Date of service	Policy	Version that governs it	Version current today	Role
CLM-0000024	24 Feb 2026	CPP-061 Physician-administered drugs — dose, units and wastage	v1.4 effective 2024-07-01	v2.0 effective 2026-03-01	Decisive

Coding and documentation

1 policy

CPP-014 Evaluation and management level selection When the level billed for an office or outpatient visit is supported by the record, and what the record has to contain to support it. All lines of business · All states · 3 versions since 2023-10-01 · cited by 3 claims in this batch v4.2 since 2026-01-01

Claims editing

2 policies

CPP-021 Duplicate and repeat services When the same service billed more than once for one member on one date is a repeat service and when it is a duplicate payment. All lines of business · All states · 2 versions since 2024-04-01 · cited by 3 claims in this batch v2.3 since 2025-07-01 CPP-033 Laboratory panel and component billing How component laboratory tests billed alongside the panel that contains them are adjudicated. All lines of business · All states · 2 versions since 2024-01-01 · cited by 3 claims in this batch v5.0 since 2025-10-01

Facility and inpatient

2 policies

CPP-047 Inpatient DRG validation — complications and comorbidities What a secondary diagnosis has to be supported by before it is allowed to raise the severity tier, and therefore the payment, of an admission. Medicare Advantage · Medicaid · All states · 2 versions since 2025-01-01 · cited by 8 claims in this batch v3.1 since 2026-01-01 CPP-052 Present on admission and hospital-acquired conditions How the present-on-admission indicator is used, and why a condition acquired in hospital cannot raise the payment for that admission. Medicare Advantage · Medicaid · All states · 2 versions since 2024-02-01 · cited by 7 claims in this batch v2.0 since 2025-10-01

Drug and biologic spend

1 policy

CPP-061 Physician-administered drugs — dose, units and wastage How units billed for an infused or injected drug are reconciled against the dose the record says was given, and when discarded drug is payable. Medicare Advantage · Medicaid · Marketplace · All states · 2 versions since 2024-07-01 · cited by 2 claims in this batch v2.0 since 2026-03-01

Utilization and medical necessity

2 policies

CPP-070 Advanced imaging — medical necessity and site of service Coverage conditions for MRI, CT, PET and nuclear cardiology, and how the setting the study was performed in affects what is payable. All lines of business · All states, with variations · 2 versions since 2024-01-01 · cited by 3 claims in this batch v1.3 since 2025-04-01 CPP-085 Prior authorization and post-service review Prior authorization happens before the service; the claim is the downstream step. This policy governs what a post-service audit may and may not revisit once an authorization exists. All lines of business · All states, with variations · 2 versions since 2024-09-01 · cited by 6 claims in this batch v3.4 since 2025-11-01

Eligibility and enrolment

2 policies

CPP-080 Eligibility, enrolment and retroactive termination Whether the member was covered on the date of service, and what happens to a claim already paid when enrolment changes afterwards. All lines of business · All states, with variations · 2 versions since 2025-06-01 · cited by 25 claims in this batch v6.1 since 2026-01-01 CPP-092 Coordination of benefits and third-party liability Which payer is primary, and what is recoverable when this plan paid as primary and should not have. All lines of business · All states · 1 version since 2025-01-01 v4.0 since 2025-01-01

What the Context Graph supplied

9 sources

Every allowable, weight, edit and unit ceiling behind a finding in this batch was looked up rather than invented. These are the sources, and the vintage each was read at.

Source	Vintage read	What it answered
Physician Fee Schedule	2026 · TX locality 09 · conversion factor 33.4009	Allowables for professional service lines
Clinical Laboratory Fee Schedule	2026 Q2	Allowables for laboratory lines
Outpatient Prospective Payment System	2026	Outpatient rates and APC assignment for imaging
MS-DRG grouper and relative weights	v43	Inpatient pricing, and the arithmetic behind a severity downgrade
NCCI procedure-to-procedure edits	2026 Q2	Whether a component test bundles into the panel billed with it
Medically Unlikely Edits	2026 Q2	Unit ceilings per code and setting
Part B ASP pricing file	2026 Q2	Per-unit payment for physician-administered drugs
ICD-10-CM	FY2026	Diagnosis validity, and whether a diagnosis supports the service billed
Knowledge Center policy library	internal · versioned	The policy version in force on each date of service

Every policy here is synthetic — an internal document written for this demo. The external basis each one cites is real, and is what an internal policy at a payer this size sits on top of.