Claims selected for review

25 claims in this batch, 7 findings still open. Sorted by dollars at risk, then days left in the recovery window.

Every claim here was drawn by a named clinical or cost criterion — advanced imaging, drug and biologic spend, DRG severity tier, a cost threshold, a bundling rule — or by the random control sample the others are measured against. The Why selected column says which.

Assigned to D. Mercer · 25

Clinical and cost

Cost threshold $500.00

Claim	Provider / LOB	Why selected	Paid	Suspected finding	At risk	Window	Source
CLM-0000001 Paid 02 Apr	Dr. Jane Smith Marketplace	E/M level · 94th percentile	$4,280.00	Overpayment of $4,089.23 on line 1 95% confidence	$4,089.23	41 d	Doc
CLM-0000004 Paid 27 Mar	Cypress Family Care Medicaid · TX STAR	Duplicate cluster · same date	$135.42	Duplicate payment of $67.71 98% confidence	$67.71	35 d	Doc
CLM-0000009 Paid 31 Mar	Northside Clinical Lab Medicaid · TX STAR	Component and panel scan	$14.49	Unbundled component of $3.93 92% confidence	$3.93	39 d	Doc
CLM-0000002 Paid 19 Mar	Dr. Jane Smith Marketplace	E/M level distribution	$94.22	No finding — paid correctly 88% confidence	—	27 d	Doc
CLM-0000003 Paid 24 Mar	Cypress Family Care Medicaid · TX STAR	Random control sample	$16.03	No finding — paid correctly 84% confidence	—	32 d	Doc
CLM-0000005 Paid 01 Apr	Dr. Jane Smith Marketplace	E/M level distribution	$133.60	No finding — paid correctly 81% confidence	—	47 d	Doc
CLM-0000006 Paid 28 Mar	Lakeview Surgical Marketplace	Paid above cost threshold	$512.88	No finding — paid correctly 79% confidence	—	36 d	Doc
CLM-0000007 Paid 20 Mar	Northside Clinical Lab Medicaid · TX STAR	Component and panel scan	$7.77	No finding — paid correctly 96% confidence	—	28 d	Doc
CLM-0000008 Paid 01 Apr	Meridian Counseling Behavioral health	Random control sample	$152.44	No finding — paid correctly 77% confidence	—	40 d	Doc
CLM-0000010 Paid 17 Mar	Lakeview Surgical Marketplace	Random control sample	$67.71	No finding — paid correctly 72% confidence	—	25 d	Doc
CLM-0000011 Paid 30 Mar	Cypress Family Care Medicaid · TX STAR	Component and panel scan	$10.56	No finding — paid correctly 86% confidence	—	38 d	Doc
CLM-0000012 Paid 02 Apr	Meridian Counseling Behavioral health	Repeat service cluster	$304.88	No finding — paid correctly 74% confidence	—	49 d	Doc
CLM-0000015 Paid 20 Mar	St. Bernard Regional Medicare Advantage	DRG severity tier review	$7,532.36	No finding — DRG correctly assigned 68% confidence	—	28 d	Doc
CLM-0000016 Paid 20 Mar	Gulf Coast General Medicare Advantage	Paid above cost threshold	$13,791.64	No finding — DRG correctly assigned 63% confidence	—	57 d	Doc
CLM-0000017 Paid 25 Mar	St. Bernard Regional Medicare Advantage	Random control sample	$5,504.60	No finding — DRG correctly assigned 59% confidence	—	33 d	Doc
CLM-0000018 Paid 01 Apr	Gulf Coast General Medicare Advantage	DRG severity tier review	$7,012.01	No finding — DRG correctly assigned 71% confidence	—	40 d	Doc
CLM-0000019 Paid 01 Apr	Gulf Coast General Medicare Advantage	Random control sample	$7,920.05	No finding — DRG correctly assigned 64% confidence	—	45 d	Doc
CLM-0000020 Paid 01 Apr	Gulf Coast General Medicare Advantage	Random control sample	$5,787.93	No finding — DRG correctly assigned 57% confidence	—	51 d	Doc
CLM-0000013 Paid 02 Apr	St. Bernard Regional Medicare Advantage	DRG severity tier · single MCC	$8,729.84	DRG downgrade — overpayment of $2,956.64 93% confidence	$2,956.64	41 d	Doc
CLM-0000014 Paid 25 Mar	Gulf Coast General Medicare Advantage	DRG severity tier · single MCC	$13,888.88	DRG downgrade — overpayment of $6,572.28 96% confidence	$6,572.28	33 d	Doc
CLM-0000021 Paid 31 Mar	Bayou Oncology Medicare Advantage	Drug spend · units vs. dose	$8,069.76	Overpayment of $1,344.96 on line 1 96% confidence	$1,344.96	44 d	Doc
CLM-0000022 Paid 24 Mar	Sunbelt Imaging Marketplace	Advanced imaging review	$316.97	No finding — paid correctly 88% confidence	—	33 d	Doc
CLM-0000023 Paid 01 Apr	Rio Grande Diagnostic Medicaid · TX STAR	Advanced imaging · repeat within 90 d	$191.72	No finding — paid correctly 90% confidence	—	47 d	Doc
CLM-0000024 Paid 10 Mar	Bayou Oncology Medicare Advantage	Drug and biologic spend	$3,083.85	No finding — paid correctly 92% confidence	—	39 d	Doc
CLM-0000025 Paid 19 Mar	Gulf Coast Imaging Medicaid	Advanced imaging review	$254.18	Not medically necessary — $254.18 recoverable 84% confidence	$254.18	31 d	Doc

25 of 25 claims shown. Open a row to review it, or tick several to act on them together. Enter opens the focused row, Space selects it.