Payment integrity
SOP reasoner
Centene · payment integrity
Reasoning
SOP reasoner
Every claim is walked node by node through the procedure that governs its type. Deterministic checks resolve first; a node only needs a scoped model call where the rules cannot answer on the data available. Every terminal decision traces to the node that produced it, and every node carries what it cited.
Claims walked
25
16 approved ·
9 routed to a human
Resolved deterministically
97%
292 of 302 nodes ·
0 model calls here.
On the platform 80%
of these nodes are deterministic —
the gap is retrieval and drafting, which are scoped calls there and
local code here.
Nodes that cite a source
79%
336 citations across the batch
Payload coverage
99%
435 of 438 claim paths
resolved · 3 nodes
took on_field_missing
How the batch terminated
Approve
APPROVE
16
Route to a human
ROUTE_TO_HUMAN
2
Route to a human — criteria not met
ROUTE_TO_HUMAN_CRITERIA_NOT_MET
4
Route to a human — pend
ROUTE_TO_HUMAN_PEND
3
Traversal trace
DRX-1
Rule
on match
Active on the date of service
Coverage ran 2026-01-01 to 2026-12-31; the service on 19 Mar 2026 falls inside it. Re-verified at audit with no retroactive change.
Read
$.eligibility.coverage_from$.eligibility.coverage_to$.service_date
DRX-2
Rule
on match
Covered under the plan
Physician-administered drug on the medical benefit — covered subject to prior authorization. Wellcare Medicare Advantage HMO · Louisiana.
Read
$.eligibility.benefit$.eligibility.plan
DRX-3
Rule
on match
Primacy confirmed
This plan is primary. Other coverage: None on file.
Read
$.eligibility.primacy$.eligibility.other_coverage
DRX-4
Rule
on no match
Authorization does not cover the claim as billed
PA-2026-219044 valid 2026-03-01 to 2026-05-31. Authorised: Nivolumab 200 mg per cycle, every two weeks, six cycles. Billed: 240 units on 19 Mar 2026 — 240 mg, 40 mg above the authorised dose.
Read
$.prior_auth.status$.prior_auth.required
DRX-5
Rule
on match
Resolved to v2.0
CPP-061 v2.0, effective 2026-03-01, was in force on 19 Mar 2026.
Read
$.policy_refs$.service_date
pass
[7]
CPP-061 v2.0
DRX-6
Lookup
on match
Codes valid on the date of service
J9299 against C34.90. Every code was billable on 19 Mar 2026.
Read
$.lines
pass
[8]
ICD-10-CM FY2026
[9]
HCPCS / CPT 2026
DRX-7
Lookup
on match
Per-unit rate matches the ASP file
J9299 is $33.62 per 1 mg in the file effective 2026-04-01 to 2026-06-30. 240 units billed = $8,069.76.
Read
$.lines
DRX-8
Rule
on match
Inside the unit ceiling — which is not validation
240 of J9299 against a published ceiling of 480. Derived from the maximum labelled dose over body surface area. The ceiling is a maximum, not an allowance: passing it validates nothing on its own.
Read
$.lines
DRX-9
Needs a scoped call
on field missing
Requires the medication administration record
The medication administration record for 19 March documents 200 mg administered. J9299 bills in 1 mg units, so 200 mg is 200 units. The 40 units above that are recoverable at the 2026 Q2 ASP rate of $33.624 per unit. The agent is sent the claim, not the administration record, so the rules cannot resolve this on the data available.
On the platform this node is a scoped model call over the retrieved record.
Not in the claim
$.record.medication_administration.administered_dose
The branch taken is on field missing, which is a
different outcome from the check evaluating to false.
DRX-10
Rule
on no match
Billed beyond the authorised dose
Authorised: Nivolumab 200 mg per cycle, every two weeks, six cycles. Billed: 240 units on 19 Mar 2026 — 240 mg, 40 mg above the authorised dose.
Read
$.prior_auth.authorized$.lines
DRX-11
Formula
on no match
$1,344.96 recoverable
40 units above the supported dose at $33.624 per unit = $1,344.96.
fail
DRX-12
Retrieval
on match
2 passages retrieved
Scoped to CPP-061 v2.0, the version in force on 19 Mar 2026. Best match on page 1.
On the platform this node is a scoped model call against the indexed policy.
Read
$.lines$.findings
DRX-13
Drafted
on no match
Finding and letter drafted for a reviewer
Separated into 3 layers — coding defect, 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 — pend
ROUTE_TO_HUMAN_PEND
1 check could not be evaluated: the field it reads is not on the claim. 2 other checks did not pass, but the agent does not recommend on the merits while a material check is unresolved. $1,344.96 is at stake. The agent recommends holding for the missing information; a person decides.
The agent recommends holding for missing information. A check could not be evaluated, so no recommendation on the merits is offered.
13 nodes
12 deterministic
0 model calls
18 citations
95% of paths resolved
Compiled procedures
Professional claims post-pay review
Live
signed off 2026-01-14
Inpatient DRG validation
Live
signed off 2025-12-04
Drug and biologic unit review
Live
signed off 2026-02-20
How nodes resolve
Rule
167
Lookup
42
Formula
33
Retrieval
25
Drafted
25
Needs a scoped call
10
Where a scoped call is genuinely needed
on field missing
Requires the inpatient record
Not in the claim
$.record.inpatient.clinical_indicators
mcc_substantiation · 2 claims: CLM-0000013, CLM-0000014
on field missing
Requires the medication administration record
Not in the claim
$.record.medication_administration.administered_dose
dose_reconciliation · 1 claim: CLM-0000021