Payment integrity
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Centene · payment integrity
Eligibility and enrolment
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.
Current version
v6.1
in force since 2026-01-01 · as at 2026-04-02
Versions on file
2
back to 2025-06-01
Applies to
All lines of business
All states, with variations
Cited in this batch
25
claims tested against it
Where this sits
OwnerEnrolment Integrity
Lines of businessAll lines of business
StatesAll states, with variations
External basis45 CFR 156.270 (QHP grace period) · 42 CFR 435.916 (Medicaid redetermination) · CMS Medicare Managed Care Manual ch. 2
Variations by state and line of business
Marketplace QHP with advance premium tax credit: claims in months two and three of a grace period may be pended and, if the premium is not paid, recovered.
Texas Medicaid: coverage lost at redetermination terminates prospectively; a retroactive term is raised only for a determination of ineligibility.
Medicare Advantage: a retroactive disenrolment processed by CMS makes the plan not liable for the period concerned.
Version history
v6.1
2026-01-01 → current
In force now
Eligibility must be re-verified at audit as well as at adjudication, and both results recorded against the claim. A retroactive termination discovered at audit is itself a recovery reason.
Extracted from
CPP-080_eligibility-enrolment-retroactive-termination_v6.1.md
— 3 pages, indexed under
__live__,
so a finding on this version can quote it.
- Coverage is evaluated as at the date of service, not the date of payment or the date of audit.
- Both the enrolment status at adjudication and at re-verification are recorded, with the source and timestamp of each.
- A retroactive termination covering the date of service makes the full paid amount recoverable.
v6.0
2025-06-01 → 2025-12-31
Superseded
Baseline. Eligibility verified once, at adjudication.
No source document in the index. A finding on this version can
cite it by name but cannot quote a passage.
- Coverage is evaluated as at the date of service.
Claims in this batch tested against this policy
| Claim | Date of service | Version applied | Role | Paid | At risk |
|---|---|---|---|---|---|
| CLM-0000001 | 25 Mar 2026 | v6.1 | Supporting | $4,280.00 | $4,089.23 |
| CLM-0000004 | 11 Mar 2026 | v6.1 | Supporting | $135.42 | $67.71 |
| CLM-0000009 | 18 Mar 2026 | v6.1 | Supporting | $14.49 | $3.93 |
| CLM-0000002 | 04 Mar 2026 | v6.1 | Supporting | $94.22 | — |
| CLM-0000003 | 09 Mar 2026 | v6.1 | Supporting | $16.03 | — |
| CLM-0000005 | 27 Mar 2026 | v6.1 | Decisive | $133.60 | — |
| CLM-0000006 | 13 Mar 2026 | v6.1 | Supporting | $512.88 | — |
| CLM-0000007 | 06 Mar 2026 | v6.1 | Supporting | $7.77 | — |
| CLM-0000008 | 20 Mar 2026 | v6.1 | Supporting | $152.44 | — |
| CLM-0000010 | 02 Mar 2026 | v6.1 | Supporting | $67.71 | — |
| CLM-0000011 | 16 Mar 2026 | v6.1 | Decisive | $10.56 | — |
| CLM-0000012 | 30 Mar 2026 | v6.1 | Supporting | $304.88 | — |
| CLM-0000015 | 09 Mar 2026 | v6.1 | Supporting | $7,532.36 | — |
| CLM-0000016 | 03 Mar 2026 | v6.1 | Supporting | $13,791.64 | — |
| CLM-0000017 | 14 Mar 2026 | v6.1 | Supporting | $5,504.60 | — |
| CLM-0000018 | 07 Mar 2026 | v6.1 | Supporting | $7,012.01 | — |
| CLM-0000019 | 21 Mar 2026 | v6.1 | Supporting | $7,920.05 | — |
| CLM-0000020 | 26 Mar 2026 | v6.1 | Supporting | $5,787.93 | — |
| CLM-0000013 | 12 Mar 2026 | v6.1 | Supporting | $8,729.84 | $2,956.64 |
| CLM-0000014 | 05 Mar 2026 | v6.1 | Supporting | $13,888.88 | $6,572.28 |
| CLM-0000021 | 19 Mar 2026 | v6.1 | Supporting | $8,069.76 | $1,344.96 |
| CLM-0000022 | 10 Mar 2026 | v6.1 | Supporting | $316.97 | — |
| CLM-0000023 | 23 Mar 2026 | v6.1 | Supporting | $191.72 | — |
| CLM-0000024 | 24 Feb 2026 | v6.1 | Supporting | $3,083.85 | — |
| CLM-0000025 | 05 Mar 2026 | v6.1 | Supporting | $254.18 | $254.18 |
This policy is synthetic — an internal document written for this demo. The external basis it cites is real.