MemberSim - Claims and Payer Data Generation

For Claude

Use this skill when the user requests healthcare claims, payer data, or benefits administration cohorts. 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 cohorts
• 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 cohorts, load the appropriate cohort skill from the table below.

Safety Guardrails

• All data is synthetic. MemberSim generates fictional, simulated test data. No real patient or member data is used.
• No clinical advice. Never recommend treatments, prescriptions, or clinical decisions based on generated data. This is test data, not real medical records.
• Use valid medical code systems. Always reference recognized standards: ICD-10 for diagnoses, CPT/HCPCS for procedures, NPI for providers, NDC/RxNorm for drugs, LOINC for labs, SNOMED CT for clinical terms.
• Do NOT generate real SSNs, real member IDs from production systems, or data that could be confused with actual PHI.

Overview

MemberSim generates synthetic claims and payer data for testing claims processing, payment integrity, and benefits administration:

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:

{
  "claim": {
    "claim_type": "INSTITUTIONAL",
    "principal_diagnosis": "I50.9",
    "drg": { "ms_drg": "291", "description": "Heart failure & shock w/o CC/MCC" },
    "admit_date": "2025-01-10",
    "discharge_date": "2025-01-13",
    "claim_lines": [
      { "revenue_code": "0120", "description": "Room and board - semi-private", "per_diem": 1800.00, "units": 3 },
      { "revenue_code": "0250", "description": "Pharmacy", "charge_amount": 950.00 },
      { "revenue_code": "0300", "description": "Laboratory", "charge_amount": 1200.00 }
    ]
  }
}

Cohort Skills

Load the appropriate cohort based on user request:

Cohort	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

Entity	Key Fields
Member	member_id, subscriber_id, group_id, plan_code, coverage_start/end, PCP (HMO)
Claim	claim_id, claim_type, member_id, provider_npi, service dates, diagnosis codes, claim_lines[]
ClaimLine	procedure_code (CPT/HCPCS), modifiers, units, charge_amount, revenue_code (institutional)
Adjudication	status (paid/denied/pending), allowed_amount, paid_amount, deductible, copay, coinsurance, adjustment_reason_codes
Plan	plan_type (HMO/PPO/etc.), deductibles, OOP maximums, copays, coinsurance rates, network requirements
Accumulator	deductible_accumulated vs remaining, OOP/MOOP accumulated vs remaining, 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 (deductible accumulated/remaining, OOP/MOOP accumulated/remaining)

Common Denial Reasons

Code	Description	Cohort
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
  }
}

See claim-examples.md for additional examples: partial payment with deductible application, oncology infusion claims, OON emergency, and telehealth visits.

Related Skills

MemberSim Cohorts

• 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 Cohorts	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 Cohort 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)

PopulationSim provides real-world reference data (CDC PLACES, SVI, ADI) for actuarially realistic member generation. When geography is specified, look up actual prevalence rates and demographics to ground synthetic member panels.

Pattern: (1) Look up county/tract data by FIPS code, (2) apply prevalence rates to member generation, (3) include data provenance in output.

Source	Table	Use in MemberSim
CDC PLACES County	population.places_county (via healthsim_query_reference)	Utilization rates, risk adjustment
SVI County	population.svi_county (via healthsim_query_reference)	SDOH factors, plan selection
ADI Block Group	population.adi_blockgroup (via healthsim_query_reference)	Deprivation-based adherence

PopulationSim Skill	MemberSim Application
data-lookup.md	Prevalence rates for risk adjustment
county-profile.md	Service area demographics
svi-analysis.md	Social vulnerability → plan tier, adherence
adi-analysis.md	Area deprivation → utilization patterns

Key Principle: When geography is specified, always ground member generation in real PopulationSim data for actuarially realistic synthetic panels.

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

---

Generative Framework Integration

MemberSim integrates with the Generative Framework for specification-driven generation at scale.

Profile-Driven Generation

Use profile specifications to generate member populations:

"Use the commercial healthy profile to generate 500 members"

The Profile Executor will:

1. Sample demographics from profile distributions
2. Generate coverage attributes (plan type, benefits)
3. Create accumulator records
4. Link to NetworkSim providers for PCP assignment

Journey-Driven Generation

Attach journey specifications to create claims over time:

"Add the new member onboarding journey to each member"

The Journey Executor will:

1. Generate enrollment events
2. Create initial utilization claims
3. Track accumulator progression
4. Apply branching for engagement patterns

Cross-Domain Sync

When generating across products, MemberSim entities are automatically linked:

MemberSim Entity	Links To
Member	PatientSim Patient (via SSN)
Claim	PatientSim Encounter
Authorization	PatientSim Referral
Rx Claim	RxMemberSim Fill

See: ../generation/executors/cross-domain-sync.md