MemberSim - Claims and Payer Data Generation

For Claude

Use this skill when the user requests healthcare claims, payer data, or benefits administration scenarios. This is the primary skill for generating realistic synthetic claims and member data.

When to apply this skill:

• User mentions claims, billing, or reimbursement
• User requests 837P (professional) or 837I (facility) claims
• User specifies payer, insurance, or benefits scenarios
• User asks for X12 formatted output (834, 835, 837, 270/271)
• User needs member enrollment, eligibility, or prior authorization data

Key capabilities:

• Generate members with coverage and benefit plans
• Create professional and facility claims with proper coding
• Model claim adjudication with CARC codes and payment calculations
• Track accumulators (deductible, OOP, coinsurance)
• Handle prior authorization workflows
• Transform output to X12 formats (837, 835, 834, 270/271)

For specific claims scenarios, load the appropriate scenario skill from the table below.

Overview

MemberSim generates realistic synthetic claims and payer data for testing claims processing systems, payment integrity, and benefits administration. This includes:

• Member enrollment and eligibility
• Professional claims (837P)
• Institutional/facility claims (837I)
• Claim adjudication and payment
• Prior authorization workflows
• Accumulator tracking (deductible, OOP)

Quick Start

Simple Professional Claim

Request: "Generate a professional claim for an office visit"

{
  "claim": {
    "claim_id": "CLM20250115000001",
    "claim_type": "PROFESSIONAL",
    "member_id": "MEM001234",
    "provider_npi": "1234567890",
    "service_date": "2025-01-15",
    "place_of_service": "11",
    "principal_diagnosis": "I10",
    "claim_lines": [
      {
        "line_number": 1,
        "procedure_code": "99214",
        "charge_amount": 175.00,
        "units": 1
      }
    ]
  },
  "adjudication": {
    "status": "paid",
    "allowed_amount": 125.00,
    "paid_amount": 100.00,
    "copay": 25.00
  }
}

Facility Claim with DRG

Request: "Generate an inpatient claim for heart failure admission"

Claude loads facility-claims.md and produces a complete 837I-style claim with DRG assignment.

Scenario Skills

Load the appropriate scenario based on user request:

Scenario	Trigger Phrases	File
Plan & Benefits	plan, benefit plan, HMO, PPO, HDHP, copay, deductible structure	plan-benefits.md
Enrollment & Eligibility	enrollment, eligibility, 834, 270, 271, coverage	enrollment-eligibility.md
Professional Claims	office visit, 837P, physician claim, E&M	professional-claims.md
Facility Claims	hospital, inpatient, 837I, DRG, UB-04	facility-claims.md
Prior Authorization	prior auth, pre-cert, authorization, PA	prior-authorization.md
Accumulator Tracking	deductible, OOP, accumulator, cost sharing	accumulator-tracking.md
Value-Based Care	quality measures, VBC, HEDIS, risk adjustment, HCC, care gaps	value-based-care.md
Behavioral Health	mental health, psychiatry, psychotherapy, substance abuse, SUD	behavioral-health.md

Generation Parameters

Parameter	Type	Default	Description
claim_type	string	PROFESSIONAL	PROFESSIONAL, INSTITUTIONAL, DENTAL
claim_status	string	paid	paid, denied, pending, partial
network_status	string	in-network	in-network, out-of-network
member_age	int or range	18-65	Member age
plan_type	string	PPO	HMO, PPO, EPO, POS, HDHP

Output Entities

Member

Extends Person with coverage information:

• member_id, subscriber_id, relationship_code
• group_id, plan_code
• coverage_start, coverage_end
• PCP assignment (for HMO)

Claim

Claim header with:

• claim_id, claim_type
• member_id, provider_npi
• service dates, place of service
• diagnosis codes (principal + secondary)
• claim_lines array

ClaimLine

Individual service line:

• procedure_code (CPT/HCPCS)
• modifiers, units
• charge_amount
• revenue_code (for institutional)

Adjudication

Payment determination:

• status (paid, denied, pending)
• allowed_amount, paid_amount
• deductible, copay, coinsurance
• adjustment_reason_codes

Plan

Benefit plan configuration:

• plan_type (HMO, PPO, etc.)
• deductibles, OOP maximums
• copays, coinsurance rates
• network requirements

Accumulator

Year-to-date cost sharing:

• deductible_applied vs deductible_limit
• oop_applied vs oop_limit
• Family vs individual tracking

See ../../references/data-models.md for complete schemas.

Adjudication Logic

Payment Calculation

1. Verify eligibility (coverage active on service date)
2. Check network status (in-network vs OON)
3. Determine allowed amount (fee schedule or % of charges)
4. Apply cost sharing:
   a. Deductible (if not met)
   b. Copay (fixed amount)
   c. Coinsurance (% of allowed after deductible)
5. Calculate paid amount = allowed - member responsibility
6. Update accumulators

Common Denial Reasons

Code	Description	Scenario
CO-4	Procedure code inconsistent with modifier	Invalid modifier
CO-45	Charge exceeds fee schedule	UCR violation
CO-50	Non-covered services	Benefit exclusion
CO-96	Non-covered charge(s)	Out of network, no OON benefit
CO-97	Benefit included in another service	Bundling
PR-1	Deductible amount	Member responsibility
PR-2	Coinsurance amount	Member responsibility
PR-3	Copay amount	Member responsibility

Output Formats

Format	Request	Use Case
JSON	default	API testing
X12 834	"as 834", "X12 enrollment"	Enrollment file
X12 270	"as 270", "eligibility inquiry"	Eligibility request
X12 271	"as 271", "eligibility response"	Eligibility response
X12 837P	"as 837P", "X12 professional"	Claims submission
X12 837I	"as 837I", "X12 institutional"	Facility claims
X12 835	"as 835", "remittance"	Payment posting
CSV	"as CSV"	Analytics
SQL	"as SQL"	Database loading

See ../../formats/ for transformation skills.

Examples

Example 1: Paid Office Visit

Request: "Generate a paid claim for a 99214 office visit for hypertension"

{
  "member": {
    "member_id": "MEM001234",
    "name": { "given_name": "Sarah", "family_name": "Johnson" },
    "birth_date": "1978-06-15",
    "gender": "F",
    "plan_code": "PPO-GOLD",
    "coverage_start": "2024-01-01"
  },
  "claim": {
    "claim_id": "CLM20250115000001",
    "claim_type": "PROFESSIONAL",
    "member_id": "MEM001234",
    "provider_npi": "1234567890",
    "service_date": "2025-01-15",
    "place_of_service": "11",
    "principal_diagnosis": "I10",
    "claim_lines": [
      {
        "line_number": 1,
        "procedure_code": "99214",
        "charge_amount": 175.00,
        "units": 1,
        "diagnosis_pointers": [1]
      }
    ]
  },
  "adjudication": {
    "status": "paid",
    "allowed_amount": 125.00,
    "deductible": 0.00,
    "copay": 25.00,
    "coinsurance": 0.00,
    "paid_amount": 100.00,
    "patient_responsibility": 25.00
  }
}

Example 2: Denied Claim (Prior Auth Required)

Request: "Generate a denied claim for MRI without prior authorization"

{
  "claim": {
    "claim_id": "CLM20250115000002",
    "claim_type": "PROFESSIONAL",
    "service_date": "2025-01-15",
    "place_of_service": "22",
    "principal_diagnosis": "M54.5",
    "claim_lines": [
      {
        "line_number": 1,
        "procedure_code": "72148",
        "charge_amount": 1500.00,
        "units": 1
      }
    ]
  },
  "adjudication": {
    "status": "denied",
    "denial_reason": "CO-15",
    "denial_message": "Prior authorization required",
    "allowed_amount": 0.00,
    "paid_amount": 0.00
  }
}

Example 3: Partial Payment (Deductible Applied)

Request: "Generate a claim where deductible applies"

{
  "accumulator_before": {
    "deductible_applied": 200.00,
    "deductible_limit": 500.00,
    "oop_applied": 200.00,
    "oop_limit": 3000.00
  },
  "claim": {
    "claim_id": "CLM20250115000003",
    "procedure_code": "99214",
    "charge_amount": 175.00
  },
  "adjudication": {
    "status": "paid",
    "allowed_amount": 125.00,
    "deductible": 125.00,
    "copay": 0.00,
    "paid_amount": 0.00,
    "patient_responsibility": 125.00
  },
  "accumulator_after": {
    "deductible_applied": 325.00,
    "deductible_limit": 500.00,
    "oop_applied": 325.00,
    "oop_limit": 3000.00
  }
}

Example 4: Oncology Infusion Claim

Request: "Generate a facility claim for chemotherapy infusion"

{
  "claim": {
    "claim_id": "CLM20250115000004",
    "claim_type": "INSTITUTIONAL",
    "member_id": "MEM005678",
    "provider_npi": "1234567890",
    "facility_type": "outpatient_hospital",
    "service_date": "2025-01-15",
    "principal_diagnosis": "C50.911",
    "diagnosis_description": "Malignant neoplasm of right female breast",
    "claim_lines": [
      {
        "line_number": 1,
        "revenue_code": "0335",
        "procedure_code": "96413",
        "hcpcs_code": "J9267",
        "description": "Paclitaxel injection, 1mg",
        "units": 175,
        "charge_amount": 3500.00
      },
      {
        "line_number": 2,
        "revenue_code": "0335",
        "procedure_code": "96415",
        "description": "Chemotherapy infusion, additional hour",
        "units": 2,
        "charge_amount": 400.00
      },
      {
        "line_number": 3,
        "revenue_code": "0250",
        "procedure_code": "96360",
        "hcpcs_code": "J2405",
        "description": "Ondansetron injection (antiemetic)",
        "units": 8,
        "charge_amount": 120.00
      }
    ]
  },
  "prior_auth": {
    "auth_number": "PA20250101-12345",
    "status": "approved",
    "approved_units": 6,
    "approved_through": "2025-06-30"
  },
  "adjudication": {
    "status": "paid",
    "allowed_amount": 3200.00,
    "deductible": 0.00,
    "coinsurance": 640.00,
    "paid_amount": 2560.00,
    "patient_responsibility": 640.00
  }
}

Key oncology claim elements:

• J-codes for injectable drugs (J9267 = paclitaxel)
• Revenue code 0335 (chemotherapy)
• Prior authorization reference
• Multi-line claim (drug + administration + supportive care)

Related Skills

MemberSim Scenarios

• plan-benefits.md - Plan configuration and benefit structure
• enrollment-eligibility.md - Enrollment and eligibility
• professional-claims.md - Professional claim details
• facility-claims.md - Institutional claim details
• prior-authorization.md - PA workflows (includes oncology PAs)
• accumulator-tracking.md - Cost sharing tracking
• value-based-care.md - VBC, HEDIS, risk adjustment

Cross-Product: PatientSim (Clinical)

MemberSim claims correspond to PatientSim clinical encounters:

MemberSim Skill	PatientSim Scenarios	Integration
professional-claims.md	Office visits, consults	Match E&M codes to encounter complexity
facility-claims.md	Inpatient, ED, surgery	Match DRG to admission diagnoses
prior-authorization.md	Elective procedures	PA approved → procedure scheduled
behavioral-health.md	Psychiatric care	Match visit types and diagnoses

PatientSim Scenario Links:

• ../patientsim/heart-failure.md - HF admission claims
• ../patientsim/diabetes-management.md - Diabetes office visit claims
• ../patientsim/elective-joint.md - Surgical episode claims
• ../patientsim/oncology/ - Oncology infusion claims
• ../patientsim/behavioral-health.md - Behavioral health claims

Integration Pattern: Generate clinical encounter in PatientSim first, then use MemberSim to create corresponding claims with matching service dates, diagnosis codes, and procedures.

Cross-Product: RxMemberSim (Pharmacy)

Medical and pharmacy benefits are often coordinated:

MemberSim Skill	RxMemberSim Skill	Integration
plan-benefits.md	formulary-management.md	Coordinated benefit design
accumulator-tracking.md	rx-accumulator.md	Combined deductible/OOP
prior-authorization.md	rx-prior-auth.md	Medical vs. pharmacy PA
enrollment-eligibility.md	rx-enrollment.md	Synchronized coverage

Integration Pattern: For integrated medical+Rx benefits, ensure accumulators are synchronized and coverage dates match. Some specialty drugs are covered under medical benefit (infused) vs. pharmacy benefit (oral).

Cross-Product: PopulationSim (Demographics & SDOH) - v2.0 Data Integration

PopulationSim v2.0 provides embedded real-world data for actuarially realistic member generation. When a geography is specified, MemberSim uses actual CDC PLACES, SVI, and ADI data to ground demographics, health patterns, and expected utilization.

Data-Driven Generation Pattern

Step 1: Look up real population data

# For Maricopa County, AZ (FIPS: 04013)
Read from: skills/populationsim/data/county/places_county_2024.csv
→ DIABETES_CrudePrev: 10.2%
→ OBESITY_CrudePrev: 29.8%
→ BPHIGH_CrudePrev: 29.1%
→ ACCESS2_CrudePrev: 12.8% (uninsured rate)

Read from: skills/populationsim/data/county/svi_county_2022.csv
→ RPL_THEMES (overall SVI): 0.52
→ EP_POV150: 18.1% (below 150% poverty)
→ EP_AGE65: 17.2% (65+ population)

Step 2: Apply rates to member generation

{
  "cohort_parameters": {
    "geography": { "county_fips": "04013", "name": "Maricopa County, AZ" },
    "expected_prevalence": {
      "diabetes": 0.102,
      "obesity": 0.298,
      "hypertension": 0.291
    },
    "demographic_context": {
      "age_65_plus": 0.172,
      "poverty_rate": 0.181
    },
    "data_provenance": {
      "source": "CDC_PLACES_2024",
      "data_year": 2022
    }
  }
}

Step 3: Generate members matching real rates

• Age distribution mirrors county demographics
• Expected chronic conditions match PLACES prevalence
• Risk scores (HCC) calibrated to population health
• Plan tier selection reflects income distribution

Embedded Data Sources

Source	File	Use in MemberSim
CDC PLACES County	populationsim/data/county/places_county_2024.csv	Expected utilization rates, risk adjustment
CDC PLACES Tract	populationsim/data/tract/places_tract_2024.csv	Neighborhood-level health patterns
SVI County	populationsim/data/county/svi_county_2022.csv	SDOH factors, plan selection patterns
SVI Tract	populationsim/data/tract/svi_tract_2022.csv	Tract-level vulnerability
ADI Block Group	populationsim/data/block_group/adi_blockgroup_2023.csv	Deprivation-based adherence modeling

PopulationSim Integration Skills

PopulationSim Skill	MemberSim Application
data-lookup.md	Exact prevalence rates for risk adjustment
county-profile.md	Service area demographics, health patterns
svi-analysis.md	Social vulnerability → plan tier, adherence
adi-analysis.md	Area deprivation → utilization patterns
cohort-specification.md	Data-driven member panel definition

Example: Data-Grounded Medicare Advantage Panel

Request: "Generate 1,000 members for a Medicare Advantage plan in Maricopa County, AZ"

Data Lookup:

From places_county_2024.csv (FIPS 04013):
  DIABETES_CrudePrev: 10.2%
  CHD_CrudePrev: 6.1%
  COPD_CrudePrev: 6.8%
  KIDNEY_CrudePrev: 2.9%

From svi_county_2022.csv (FIPS 04013):
  RPL_THEMES: 0.52 (moderate vulnerability)
  EP_AGE65: 17.2%
  EP_DISABL: 13.1%

Applied to Generation:

• ~17% of members are 65+ (matches county rate)
• ~10% have diabetes diagnosis (expected chronic conditions)
• ~6% have CHD (drives HCC scoring)
• SVI 0.52 → moderate plan selection diversity
• Output includes provenance tracking

Output with Provenance:

{
  "member_panel": {
    "total_members": 1000,
    "geography": "Maricopa County, AZ (04013)",
    "generation_context": {
      "data_sources": ["CDC_PLACES_2024", "CDC_SVI_2022"],
      "rates_applied": {
        "diabetes": 0.102,
        "chd": 0.061,
        "age_65_plus": 0.172
      }
    }
  }
}

Key Principle: When geography is specified, always ground member generation in real PopulationSim data. This enables actuarially realistic synthetic member panels for testing claims systems, risk adjustment, and care management.

Cross-Product: NetworkSim (Provider Networks)

NetworkSim provides network context for claims processing:

MemberSim Need	NetworkSim Skill	Integration
Provider network status	network-for-member.md	In-network vs OON determination
Benefit cost sharing	benefit-for-claim.md	Copay, coinsurance, deductible
Network configuration	synthetic-network.md	HMO/PPO/tiered structure

Integration Pattern: Use NetworkSim to determine network status before adjudicating claims. Network type (HMO/PPO) affects whether out-of-network claims are covered and at what cost share.

Cross-Product: TrialSim (Clinical Trials)

Members may participate in clinical trials with claims integration:

MemberSim Context	TrialSim Integration	Claims Impact
Specialty drug coverage	Trial drug provided free	Reduced Rx claims during trial
Standard of care	SOC claims continue	Normal claim adjudication
Trial-related AEs	May generate medical claims	AE → ED/inpatient claims

Integration Pattern: When a member enrolls in a trial, standard of care claims continue through MemberSim while trial-specific treatments are tracked in TrialSim. Trial-related adverse events may generate claims.

Output Formats

• ../../formats/x12-834.md - X12 enrollment format
• ../../formats/x12-270-271.md - X12 eligibility format
• ../../formats/x12-837.md - X12 claim format
• ../../formats/x12-835.md - Remittance format
• ../../formats/csv.md - CSV export
• ../../formats/sql.md - SQL export

Reference Data

• ../../references/data-models.md - Entity schemas
• ../../references/oncology/ - Oncology codes, medications, regimens