MemberSim - Claims and Payer Data Generation Skill

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:

Sample demographics from profile distributions
Generate coverage attributes (plan type, benefits)
Create accumulator records
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:

Generate enrollment events
Create initial utilization claims
Track accumulator progression
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

Agent Skills: MemberSim - Claims and Payer Data Generation

Install this agent skill to your local

Skill Files