Datasets:

Upstream-Intelligence
/

specialty-clinic-synthetic-claims

adjudication_date string	appeal_final_resolution_state string	appeal_outcome string	appeal_round_number int64	appeal_success_likelihood float64	appeal_turnaround_days int64	authorization_friction_score float64	benchmark_bucket string	cash_flow_pressure_score float64	claim_family string	claim_filing_indicator_code string	claim_form_type string	claim_frequency_code int64	claim_id string	denial_adjustment_group_code string	denial_carc_code float64	denial_probability float64	denial_rarc_code string	denial_reason_family string	denial_scope string	diagnosis_codes string	documentation_completeness_band string	documentation_risk_score float64	documentation_sensitivity string	economy_benefit_design_id string	economy_claim_intent_id string	economy_contract_id string	economy_expected_cash_impact_cents int64	economy_expected_denial_reason_family string	economy_expected_underpayment_risk float64	economy_policy_rule_id string	expected_payment_delay_days int64	facility_claim_indicator bool	follow_up_visit_indicator bool	line_count int64	member_id string	network_status string	out_of_network_leakage_score float64	pack_id string	payer_archetype string	payer_behavior_score float64	payer_id string	payer_region string	place_of_service string	preauth_required bool	primary_cpt_code int64	primary_cpt_family string	procedure_authorization_status string	provider_id string	provider_specialty string	provider_taxonomy_code string	reimbursement_delay_risk float64	scenario_label string	scenario_multiplier float64	service_end_date string	service_region string	service_start_date string	site_of_service_category string	specialty_service_line string	submission_date string	submission_month string	total_allowed_cents int64	total_billed_cents int64	total_paid_cents int64	type_of_bill_code float64	world_ar_pressure_score float64	world_auth_queue_depth int64	world_benefit_design_id string	world_contract_id string	world_contract_method string	world_employer_plan_id string	world_id string	world_member_profile_id string	world_operations_state_id string	world_payer_profile_id string	world_policy_action string	world_policy_rule_id string	world_provider_panel_id string	world_region_id string	world_underpayment_probability float64
2026-01-22	paid	not_applicable	0	0.26588	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:office_eval	0.5807	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000001	null	null	0.24015	null	null	null	G56.00	partial	0.6346	high	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000001	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	25,019	frequency_limit	0.1752	policy-specialty-clinic-payer-002-office_eval	30	false	true	1	specialty-clinic-member-000001	in_network	0.28	specialty-clinic	medicaid_like	0.672	specialty-clinic-payer-002	mid-atlantic	office	true	99,215	office_eval	expired	specialty-clinic-provider-00002	Multi-Specialty Clinic	207Q00000X	0.7333	baseline	1	2026-01-11	gulf-south	2026-01-10	office	dermatologic	2026-01-18	2026-01	92,020	127,805	92,020	null	0.718	22	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-002	world-specialty-clinic-2995344627	specialty-clinic-member-000001	ops-specialty-clinic-provider-00002-2026-01	specialty-clinic-payer-002	recoup_post_payment_review	policy-specialty-clinic-payer-002-office_eval	specialty-clinic-provider-00002	gulf-south	0.1752
2026-03-01	denied	upheld	0	0.294112	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:procedure	0.3777	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000002	CO	252	0.17075	N706	documentation	line	G43.909	missing	0.3284	medium	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000002	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	17,384	clean	0.0854	policy-specialty-clinic-payer-003-procedure	15	false	true	1	specialty-clinic-member-000002	in_network	0.28	specialty-clinic	medicare_like	0.4196	specialty-clinic-payer-003	gulf-south	ambulatory_surgery	true	64,483	procedure	expired	specialty-clinic-provider-00003	Multi-Specialty Clinic	207Q00000X	0.4	baseline	1	2026-02-11	north-texas	2026-02-10	asc	neurological	2026-02-22	2026-02	250,263	347,587	0	null	0.1353	10	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-003	world-specialty-clinic-2995344627	specialty-clinic-member-000002	ops-specialty-clinic-provider-00003-2026-01	specialty-clinic-payer-003	delay_pending_review	policy-specialty-clinic-payer-003-procedure	specialty-clinic-provider-00003	north-texas	0.0854
2026-03-26	paid	not_applicable	0	0.311695	0	0.74	specialty-clinic:baseline:bcbs_like:north-texas:diagnostic	0.4659	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000003	null	null	0.20425	null	null	null	K57.30	complete	0.1752	low	specialty-clinic-benefit-standard	intent:specialty-clinic:000003	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	24,250	clean	0.1684	policy-specialty-clinic-payer-001-diagnostic	22	false	false	2	specialty-clinic-member-000003	in_network	0.28	specialty-clinic	bcbs_like	0.5503	specialty-clinic-payer-001	mid-atlantic	office	true	73,721	diagnostic	not_required	specialty-clinic-provider-00006	Multi-Specialty Clinic	207Q00000X	0.5556	baseline	1	2026-03-14	north-texas	2026-03-13	office	gastrointestinal	2026-03-24	2026-03	593,330	824,070	593,330	null	0.6633	9	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-004	world-specialty-clinic-2995344627	specialty-clinic-member-000003	ops-specialty-clinic-provider-00006-2026-03	specialty-clinic-payer-001	delay_pending_review	policy-specialty-clinic-payer-001-diagnostic	specialty-clinic-provider-00006	north-texas	0.1684
2026-04-29	paid	not_applicable	0	0.309028	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:prior_auth_review	0.5515	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000004	null	null	0.22515	null	null	null	L30.9	complete	0.1837	high	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000004	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	26,982	documentation	0.1686	policy-specialty-clinic-payer-002-prior_auth_review	29	false	false	2	specialty-clinic-member-000004	in_network	0.28	specialty-clinic	medicaid_like	0.6664	specialty-clinic-payer-002	mid-atlantic	office	true	99,214	prior_auth_review	approved	specialty-clinic-provider-00009	Multi-Specialty Clinic	207Q00000X	0.7111	baseline	1	2026-04-14	gulf-south	2026-04-13	asc	neurological	2026-04-27	2026-04	308,798	428,886	308,798	null	0.86	18	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-005	world-specialty-clinic-2995344627	specialty-clinic-member-000004	ops-specialty-clinic-provider-00009-2026-04	specialty-clinic-payer-002	deny_missing_documentation	policy-specialty-clinic-payer-002-prior_auth_review	specialty-clinic-provider-00009	gulf-south	0.1686
2026-05-26	paid	not_applicable	0	0.294112	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:office_eval	0.3701	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000005	null	null	0.17075	null	null	null	K57.30	complete	0.3284	medium	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000005	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	21,781	frequency_limit	0.0602	policy-specialty-clinic-payer-003-office_eval	14	false	true	1	specialty-clinic-member-000005	in_network	0.28	specialty-clinic	medicare_like	0.414	specialty-clinic-payer-003	gulf-south	office	true	99,213	office_eval	missing	specialty-clinic-provider-00014	Multi-Specialty Clinic	207Q00000X	0.3778	baseline	1	2026-05-19	north-texas	2026-05-14	hospital_outpatient	dermatologic	2026-05-21	2026-05	291,801	405,279	291,801	null	0.4973	20	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-006	world-specialty-clinic-2995344627	specialty-clinic-member-000005	ops-specialty-clinic-provider-00014-2026-05	specialty-clinic-payer-003	downcode_frequency_exceeded	policy-specialty-clinic-payer-003-office_eval	specialty-clinic-provider-00014	north-texas	0.0602
2026-07-02	paid	not_applicable	0	0.303145	0	0.74	specialty-clinic:baseline:bcbs_like:mid-atlantic:procedure	0.4067	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000006	null	null	0.1955	null	null	null	G43.909	missing	0.3664	medium	specialty-clinic-benefit-standard	intent:specialty-clinic:000006	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	19,100	frequency_limit	0.0381	policy-specialty-clinic-payer-001-procedure	21	false	true	1	specialty-clinic-member-000006	in_network	0.12	specialty-clinic	bcbs_like	0.5281	specialty-clinic-payer-001	mid-atlantic	office	true	11,042	procedure	not_required	specialty-clinic-provider-00012	Multi-Specialty Clinic	207Q00000X	0.4667	baseline	1	2026-06-18	mid-atlantic	2026-06-14	asc	dermatologic	2026-06-30	2026-06	343,382	476,920	343,382	null	0.2432	13	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-001	world-specialty-clinic-2995344627	specialty-clinic-member-000006	ops-specialty-clinic-provider-00012-2026-05	specialty-clinic-payer-001	downcode_frequency_exceeded	policy-specialty-clinic-payer-001-procedure	specialty-clinic-provider-00012	mid-atlantic	0.0381
2026-07-30	paid	not_applicable	0	0.294308	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:diagnostic	0.5745	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000007	null	null	0.22515	null	null	null	G56.00	complete	0.3841	high	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000007	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	26,936	frequency_limit	0.2252	policy-specialty-clinic-payer-002-diagnostic	32	false	false	2	specialty-clinic-member-000001	in_network	0.28	specialty-clinic	medicaid_like	0.6831	specialty-clinic-payer-002	mid-atlantic	office	true	93,000	diagnostic	missing	specialty-clinic-provider-00002	Multi-Specialty Clinic	207Q00000X	0.7778	baseline	1	2026-07-19	gulf-south	2026-07-15	office	musculoskeletal	2026-07-23	2026-07	644,384	894,978	644,384	null	0.718	25	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-002	world-specialty-clinic-2995344627	specialty-clinic-member-000001	ops-specialty-clinic-provider-00002-2026-06	specialty-clinic-payer-002	request_attachment	policy-specialty-clinic-payer-002-diagnostic	specialty-clinic-provider-00002	gulf-south	0.1752
2026-09-03	paid	not_applicable	0	0.265096	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:prior_auth_review	0.4146	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000008	null	null	0.18575	null	null	null	L30.9	missing	0.5426	high	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000008	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	17,550	authorization	0.1354	policy-specialty-clinic-payer-003-prior_auth_review	17	false	false	2	specialty-clinic-member-000002	in_network	0.28	specialty-clinic	medicare_like	0.4307	specialty-clinic-payer-003	gulf-south	office	true	99,214	prior_auth_review	not_required	specialty-clinic-provider-00003	Multi-Specialty Clinic	207Q00000X	0.4444	baseline	1	2026-08-17	north-texas	2026-08-15	asc	dermatologic	2026-08-27	2026-08	552,894	767,908	552,894	null	0.1353	19	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-003	world-specialty-clinic-2995344627	specialty-clinic-member-000002	ops-specialty-clinic-provider-00003-2026-07	specialty-clinic-payer-003	require_authorization	policy-specialty-clinic-payer-003-prior_auth_review	specialty-clinic-provider-00003	north-texas	0.0854
2026-09-28	paid	not_applicable	0	0.311695	0	0.74	specialty-clinic:baseline:bcbs_like:north-texas:office_eval	0.4813	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000009	null	null	0.20425	null	null	null	K57.30	complete	0.1752	high	specialty-clinic-benefit-standard	intent:specialty-clinic:000009	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	27,125	documentation	0.2184	policy-specialty-clinic-payer-001-office_eval	24	false	true	2	specialty-clinic-member-000003	in_network	0.28	specialty-clinic	bcbs_like	0.5614	specialty-clinic-payer-001	mid-atlantic	office	true	99,214	office_eval	not_required	specialty-clinic-provider-00006	Multi-Specialty Clinic	207Q00000X	0.6	baseline	1	2026-09-16	north-texas	2026-09-15	asc	neurological	2026-09-26	2026-09	389,603	541,115	389,603	null	0.6633	13	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-004	world-specialty-clinic-2995344627	specialty-clinic-member-000003	ops-specialty-clinic-provider-00006-2026-08	specialty-clinic-payer-001	deny_missing_documentation	policy-specialty-clinic-payer-001-office_eval	specialty-clinic-provider-00006	north-texas	0.1684
2026-11-01	paid	not_applicable	0	0.309028	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:procedure	0.5668	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000010	null	null	0.22515	null	null	null	M54.50	complete	0.1837	low	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000010	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	29,108	frequency_limit	0.2186	policy-specialty-clinic-payer-002-procedure	31	false	true	3	specialty-clinic-member-000004	in_network	0.28	specialty-clinic	medicaid_like	0.6776	specialty-clinic-payer-002	mid-atlantic	hospital_outpatient	true	20,610	procedure	missing	specialty-clinic-provider-00009	Multi-Specialty Clinic	207Q00000X	0.7556	baseline	1	2026-10-18	gulf-south	2026-10-16	office	neurological	2026-10-27	2026-10	1,025,588	1,424,428	1,025,588	null	0.86	20	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-005	world-specialty-clinic-2995344627	specialty-clinic-member-000004	ops-specialty-clinic-provider-00009-2026-09	specialty-clinic-payer-002	require_authorization	policy-specialty-clinic-payer-002-procedure	specialty-clinic-provider-00009	gulf-south	0.1686
2026-11-30	paid	not_applicable	0	0.30836	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:diagnostic	0.3854	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000011	null	null	0.17075	null	null	null	M17.11	partial	0.1571	low	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000011	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	23,656	recoupment_risk	0.1102	policy-specialty-clinic-payer-003-diagnostic	16	false	true	2	specialty-clinic-member-000005	in_network	0.28	specialty-clinic	medicare_like	0.4251	specialty-clinic-payer-003	gulf-south	hospital_outpatient	true	76,942	diagnostic	missing	specialty-clinic-provider-00014	Multi-Specialty Clinic	207Q00000X	0.4222	baseline	1	2026-11-20	north-texas	2026-11-16	asc	neurological	2026-11-25	2026-11	404,929	562,402	404,929	null	0.4973	12	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-006	world-specialty-clinic-2995344627	specialty-clinic-member-000005	ops-specialty-clinic-provider-00014-2026-10	specialty-clinic-payer-003	recoup_post_payment_review	policy-specialty-clinic-payer-003-diagnostic	specialty-clinic-provider-00014	north-texas	0.0602
2026-12-25	paid	not_applicable	0	0.31768	0	0.74	specialty-clinic:baseline:bcbs_like:mid-atlantic:prior_auth_review	0.4143	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000012	null	null	0.1955	null	null	null	E03.9	missing	0.1752	low	specialty-clinic-benefit-standard	intent:specialty-clinic:000012	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	21,225	recoupment_risk	0.0881	policy-specialty-clinic-payer-001-prior_auth_review	22	false	true	2	specialty-clinic-member-000006	in_network	0.12	specialty-clinic	bcbs_like	0.5337	specialty-clinic-payer-001	mid-atlantic	hospital_outpatient	true	99,214	prior_auth_review	expired	specialty-clinic-provider-00012	Multi-Specialty Clinic	207Q00000X	0.4889	baseline	1	2026-12-05	mid-atlantic	2026-12-05	office	musculoskeletal	2026-12-18	2026-12	403,974	561,075	403,974	null	0.2432	8	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-001	world-specialty-clinic-2995344627	specialty-clinic-member-000006	ops-specialty-clinic-provider-00012-2026-11	specialty-clinic-payer-001	recoup_post_payment_review	policy-specialty-clinic-payer-001-prior_auth_review	specialty-clinic-provider-00012	mid-atlantic	0.0381
2026-01-23	paid	not_applicable	0	0.309028	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:office_eval	0.5592	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000013	null	null	0.22515	null	null	null	K57.30	partial	0.1837	low	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000013	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	25,019	frequency_limit	0.1752	policy-specialty-clinic-payer-002-office_eval	30	false	true	3	specialty-clinic-member-000001	in_network	0.28	specialty-clinic	medicaid_like	0.672	specialty-clinic-payer-002	mid-atlantic	office	true	99,215	office_eval	expired	specialty-clinic-provider-00002	Multi-Specialty Clinic	207Q00000X	0.7333	baseline	1	2026-01-16	gulf-south	2026-01-10	asc	dermatologic	2026-01-18	2026-01	543,938	755,470	543,938	null	0.718	22	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-002	world-specialty-clinic-2995344627	specialty-clinic-member-000001	ops-specialty-clinic-provider-00002-2026-01	specialty-clinic-payer-002	recoup_post_payment_review	policy-specialty-clinic-payer-002-office_eval	specialty-clinic-provider-00002	gulf-south	0.1752
2026-02-24	paid	not_applicable	0	0.265096	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:procedure	0.3993	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000014	null	null	0.18575	null	null	null	K21.9	missing	0.5426	high	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000014	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	17,384	clean	0.0854	policy-specialty-clinic-payer-003-procedure	15	false	false	3	specialty-clinic-member-000002	in_network	0.28	specialty-clinic	medicare_like	0.4196	specialty-clinic-payer-003	gulf-south	office	true	64,483	procedure	approved	specialty-clinic-provider-00003	Multi-Specialty Clinic	207Q00000X	0.4	baseline	1	2026-02-10	north-texas	2026-02-10	asc	gastrointestinal	2026-02-22	2026-02	816,998	1,134,720	816,998	null	0.1353	10	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-003	world-specialty-clinic-2995344627	specialty-clinic-member-000002	ops-specialty-clinic-provider-00003-2026-01	specialty-clinic-payer-003	delay_pending_review	policy-specialty-clinic-payer-003-procedure	specialty-clinic-provider-00003	north-texas	0.0854
2026-03-31	paid	not_applicable	0	0.311695	0	0.74	specialty-clinic:baseline:bcbs_like:north-texas:diagnostic	0.4659	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000015	null	null	0.20425	null	null	null	E11.9	missing	0.1752	low	specialty-clinic-benefit-standard	intent:specialty-clinic:000015	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	24,250	clean	0.1684	policy-specialty-clinic-payer-001-diagnostic	22	false	true	3	specialty-clinic-member-000003	in_network	0.28	specialty-clinic	bcbs_like	0.5503	specialty-clinic-payer-001	mid-atlantic	ambulatory_surgery	true	73,721	diagnostic	missing	specialty-clinic-provider-00006	Multi-Specialty Clinic	207Q00000X	0.5556	baseline	1	2026-03-14	north-texas	2026-03-13	asc	dermatologic	2026-03-24	2026-03	444,905	617,924	444,905	null	0.6633	9	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-004	world-specialty-clinic-2995344627	specialty-clinic-member-000003	ops-specialty-clinic-provider-00006-2026-03	specialty-clinic-payer-001	delay_pending_review	policy-specialty-clinic-payer-001-diagnostic	specialty-clinic-provider-00006	north-texas	0.1684
2026-05-02	paid	not_applicable	0	0.26588	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:prior_auth_review	0.5731	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000016	null	null	0.24015	null	null	null	K21.9	complete	0.6346	high	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000016	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	26,982	documentation	0.1686	policy-specialty-clinic-payer-002-prior_auth_review	29	false	true	2	specialty-clinic-member-000004	in_network	0.28	specialty-clinic	medicaid_like	0.6664	specialty-clinic-payer-002	mid-atlantic	hospital_outpatient	true	99,214	prior_auth_review	expired	specialty-clinic-provider-00009	Multi-Specialty Clinic	207Q00000X	0.7111	baseline	1	2026-04-15	gulf-south	2026-04-13	asc	gastrointestinal	2026-04-27	2026-04	685,323	951,838	685,323	null	0.86	18	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-005	world-specialty-clinic-2995344627	specialty-clinic-member-000004	ops-specialty-clinic-provider-00009-2026-04	specialty-clinic-payer-002	deny_missing_documentation	policy-specialty-clinic-payer-002-prior_auth_review	specialty-clinic-provider-00009	gulf-south	0.1686
2026-05-25	paid	not_applicable	0	0.294112	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:office_eval	0.3701	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000017	null	null	0.17075	null	null	null	E11.9	partial	0.3284	medium	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000017	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	21,781	frequency_limit	0.0602	policy-specialty-clinic-payer-003-office_eval	14	false	false	3	specialty-clinic-member-000005	in_network	0.28	specialty-clinic	medicare_like	0.414	specialty-clinic-payer-003	gulf-south	office	true	99,213	office_eval	missing	specialty-clinic-provider-00014	Multi-Specialty Clinic	207Q00000X	0.3778	baseline	1	2026-05-17	north-texas	2026-05-14	asc	dermatologic	2026-05-21	2026-05	724,355	1,006,049	724,355	null	0.4973	20	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-006	world-specialty-clinic-2995344627	specialty-clinic-member-000005	ops-specialty-clinic-provider-00014-2026-05	specialty-clinic-payer-003	downcode_frequency_exceeded	policy-specialty-clinic-payer-003-office_eval	specialty-clinic-provider-00014	north-texas	0.0602
2026-07-07	paid	not_applicable	0	0.27474	0	0.74	specialty-clinic:baseline:bcbs_like:mid-atlantic:procedure	0.4283	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000018	null	null	0.2105	null	null	null	M54.50	missing	0.6053	high	specialty-clinic-benefit-standard	intent:specialty-clinic:000018	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	19,100	frequency_limit	0.0381	policy-specialty-clinic-payer-001-procedure	21	false	true	1	specialty-clinic-member-000006	in_network	0.12	specialty-clinic	bcbs_like	0.5281	specialty-clinic-payer-001	mid-atlantic	ambulatory_surgery	true	11,042	procedure	missing	specialty-clinic-provider-00012	Multi-Specialty Clinic	207Q00000X	0.4667	baseline	1	2026-06-20	mid-atlantic	2026-06-14	hospital_outpatient	gastrointestinal	2026-06-30	2026-06	141,150	196,042	141,150	null	0.2432	13	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-001	world-specialty-clinic-2995344627	specialty-clinic-member-000006	ops-specialty-clinic-provider-00012-2026-05	specialty-clinic-payer-001	downcode_frequency_exceeded	policy-specialty-clinic-payer-001-procedure	specialty-clinic-provider-00012	mid-atlantic	0.0381
2026-07-25	paid	not_applicable	0	0.309028	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:diagnostic	0.5745	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000019	null	null	0.22515	null	null	null	K57.30	partial	0.1837	high	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000019	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	26,936	frequency_limit	0.2252	policy-specialty-clinic-payer-002-diagnostic	32	false	true	2	specialty-clinic-member-000001	in_network	0.28	specialty-clinic	medicaid_like	0.6831	specialty-clinic-payer-002	mid-atlantic	office	true	93,000	diagnostic	expired	specialty-clinic-provider-00002	Multi-Specialty Clinic	207Q00000X	0.7778	baseline	1	2026-07-22	gulf-south	2026-07-15	hospital_outpatient	musculoskeletal	2026-07-23	2026-07	418,689	581,513	418,689	null	0.718	25	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-002	world-specialty-clinic-2995344627	specialty-clinic-member-000001	ops-specialty-clinic-provider-00002-2026-06	specialty-clinic-payer-002	request_attachment	policy-specialty-clinic-payer-002-diagnostic	specialty-clinic-provider-00002	gulf-south	0.1752
2026-09-01	paid	not_applicable	0	0.294112	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:prior_auth_review	0.393	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000020	null	null	0.17075	null	null	null	M54.50	complete	0.3284	medium	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000020	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	17,550	authorization	0.1354	policy-specialty-clinic-payer-003-prior_auth_review	17	false	false	1	specialty-clinic-member-000002	in_network	0.28	specialty-clinic	medicare_like	0.4307	specialty-clinic-payer-003	gulf-south	hospital_outpatient	true	99,214	prior_auth_review	not_required	specialty-clinic-provider-00003	Multi-Specialty Clinic	207Q00000X	0.4444	baseline	1	2026-08-21	north-texas	2026-08-15	office	dermatologic	2026-08-27	2026-08	409,530	568,791	409,530	null	0.1353	19	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-003	world-specialty-clinic-2995344627	specialty-clinic-member-000002	ops-specialty-clinic-provider-00003-2026-07	specialty-clinic-payer-003	require_authorization	policy-specialty-clinic-payer-003-prior_auth_review	specialty-clinic-provider-00003	north-texas	0.0854
2026-09-29	paid	not_applicable	0	0.268755	0	0.74	specialty-clinic:baseline:bcbs_like:north-texas:office_eval	0.5029	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000021	null	null	0.21925	null	null	null	M17.11	missing	0.6053	high	specialty-clinic-benefit-standard	intent:specialty-clinic:000021	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	27,125	documentation	0.2184	policy-specialty-clinic-payer-001-office_eval	24	false	false	1	specialty-clinic-member-000003	in_network	0.28	specialty-clinic	bcbs_like	0.5614	specialty-clinic-payer-001	mid-atlantic	hospital_outpatient	true	99,214	office_eval	missing	specialty-clinic-provider-00006	Multi-Specialty Clinic	207Q00000X	0.6	baseline	1	2026-09-22	north-texas	2026-09-15	office	neurological	2026-09-26	2026-09	69,811	96,960	69,811	null	0.6633	13	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-004	world-specialty-clinic-2995344627	specialty-clinic-member-000003	ops-specialty-clinic-provider-00006-2026-08	specialty-clinic-payer-001	deny_missing_documentation	policy-specialty-clinic-payer-001-office_eval	specialty-clinic-provider-00006	north-texas	0.1684
2026-10-29	paid	not_applicable	0	0.309028	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:procedure	0.5668	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000022	null	null	0.22515	null	null	null	M54.50	partial	0.1837	low	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000022	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	29,108	frequency_limit	0.2186	policy-specialty-clinic-payer-002-procedure	31	false	false	2	specialty-clinic-member-000004	in_network	0.28	specialty-clinic	medicaid_like	0.6776	specialty-clinic-payer-002	mid-atlantic	ambulatory_surgery	true	20,610	procedure	not_required	specialty-clinic-provider-00009	Multi-Specialty Clinic	207Q00000X	0.7556	baseline	1	2026-10-17	gulf-south	2026-10-16	asc	dermatologic	2026-10-27	2026-10	723,732	1,005,183	723,732	null	0.86	20	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-005	world-specialty-clinic-2995344627	specialty-clinic-member-000004	ops-specialty-clinic-provider-00009-2026-09	specialty-clinic-payer-002	require_authorization	policy-specialty-clinic-payer-002-procedure	specialty-clinic-provider-00009	gulf-south	0.1686
2026-11-29	paid	not_applicable	0	0.30836	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:diagnostic	0.3854	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000023	null	null	0.17075	null	null	null	G56.00	missing	0.1571	low	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000023	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	23,656	recoupment_risk	0.1102	policy-specialty-clinic-payer-003-diagnostic	16	false	true	2	specialty-clinic-member-000005	in_network	0.28	specialty-clinic	medicare_like	0.4251	specialty-clinic-payer-003	gulf-south	office	true	76,942	diagnostic	expired	specialty-clinic-provider-00014	Multi-Specialty Clinic	207Q00000X	0.4222	baseline	1	2026-11-18	north-texas	2026-11-16	hospital_outpatient	endocrine_metabolic	2026-11-25	2026-11	722,981	1,004,140	722,981	null	0.4973	12	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-006	world-specialty-clinic-2995344627	specialty-clinic-member-000005	ops-specialty-clinic-provider-00014-2026-10	specialty-clinic-payer-003	recoup_post_payment_review	policy-specialty-clinic-payer-003-diagnostic	specialty-clinic-provider-00014	north-texas	0.0602
2026-12-25	denied	upheld	0	0.31768	0	0.74	specialty-clinic:baseline:bcbs_like:mid-atlantic:prior_auth_review	0.4143	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000024	CO	11	0.1955	N30	coding	claim	K21.9	partial	0.1752	low	specialty-clinic-benefit-standard	intent:specialty-clinic:000024	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	21,225	recoupment_risk	0.0881	policy-specialty-clinic-payer-001-prior_auth_review	22	false	false	3	specialty-clinic-member-000006	in_network	0.12	specialty-clinic	bcbs_like	0.5337	specialty-clinic-payer-001	mid-atlantic	office	true	99,214	prior_auth_review	expired	specialty-clinic-provider-00012	Multi-Specialty Clinic	207Q00000X	0.4889	baseline	1	2026-12-07	mid-atlantic	2026-12-05	hospital_outpatient	endocrine_metabolic	2026-12-18	2026-12	944,081	1,311,224	0	null	0.2432	8	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-001	world-specialty-clinic-2995344627	specialty-clinic-member-000006	ops-specialty-clinic-provider-00012-2026-11	specialty-clinic-payer-001	recoup_post_payment_review	policy-specialty-clinic-payer-001-prior_auth_review	specialty-clinic-provider-00012	mid-atlantic	0.0381
2026-01-20	paid	not_applicable	0	0.294308	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:office_eval	0.5592	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000025	null	null	0.22515	null	null	null	K57.30	complete	0.3841	medium	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000025	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	25,019	frequency_limit	0.1752	policy-specialty-clinic-payer-002-office_eval	30	false	false	3	specialty-clinic-member-000001	in_network	0.28	specialty-clinic	medicaid_like	0.672	specialty-clinic-payer-002	mid-atlantic	office	true	99,215	office_eval	expired	specialty-clinic-provider-00002	Multi-Specialty Clinic	207Q00000X	0.7333	baseline	1	2026-01-16	gulf-south	2026-01-10	office	gastrointestinal	2026-01-18	2026-01	848,346	1,178,259	848,346	null	0.718	22	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-002	world-specialty-clinic-2995344627	specialty-clinic-member-000001	ops-specialty-clinic-provider-00002-2026-01	specialty-clinic-payer-002	recoup_post_payment_review	policy-specialty-clinic-payer-002-office_eval	specialty-clinic-provider-00002	gulf-south	0.1752
2026-03-01	paid	not_applicable	0	0.294112	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:procedure	0.3777	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000026	null	null	0.17075	null	null	null	K21.9	partial	0.3284	medium	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000026	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	17,384	clean	0.0854	policy-specialty-clinic-payer-003-procedure	15	false	true	2	specialty-clinic-member-000002	in_network	0.28	specialty-clinic	medicare_like	0.4196	specialty-clinic-payer-003	gulf-south	office	true	64,483	procedure	expired	specialty-clinic-provider-00003	Multi-Specialty Clinic	207Q00000X	0.4	baseline	1	2026-02-12	north-texas	2026-02-10	asc	neurological	2026-02-22	2026-02	541,490	752,069	541,490	null	0.1353	10	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-003	world-specialty-clinic-2995344627	specialty-clinic-member-000002	ops-specialty-clinic-provider-00003-2026-01	specialty-clinic-payer-003	delay_pending_review	policy-specialty-clinic-payer-003-procedure	specialty-clinic-provider-00003	north-texas	0.0854
2026-03-26	paid	not_applicable	0	0.29716	0	0.74	specialty-clinic:baseline:bcbs_like:north-texas:diagnostic	0.4659	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000027	null	null	0.20425	null	null	null	M17.11	partial	0.3664	medium	specialty-clinic-benefit-standard	intent:specialty-clinic:000027	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	24,250	clean	0.1684	policy-specialty-clinic-payer-001-diagnostic	22	false	false	1	specialty-clinic-member-000003	in_network	0.28	specialty-clinic	bcbs_like	0.5503	specialty-clinic-payer-001	mid-atlantic	hospital_outpatient	true	73,721	diagnostic	approved	specialty-clinic-provider-00006	Multi-Specialty Clinic	207Q00000X	0.5556	baseline	1	2026-03-16	north-texas	2026-03-13	hospital_outpatient	musculoskeletal	2026-03-24	2026-03	143,580	199,417	143,580	null	0.6633	9	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-004	world-specialty-clinic-2995344627	specialty-clinic-member-000003	ops-specialty-clinic-provider-00006-2026-03	specialty-clinic-payer-001	delay_pending_review	policy-specialty-clinic-payer-001-diagnostic	specialty-clinic-provider-00006	north-texas	0.1684
2026-04-29	paid	not_applicable	0	0.294308	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:prior_auth_review	0.5515	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000028	null	null	0.22515	null	null	null	E03.9	missing	0.3841	high	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000028	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	26,982	documentation	0.1686	policy-specialty-clinic-payer-002-prior_auth_review	29	false	true	2	specialty-clinic-member-000004	in_network	0.28	specialty-clinic	medicaid_like	0.6664	specialty-clinic-payer-002	mid-atlantic	ambulatory_surgery	true	99,214	prior_auth_review	missing	specialty-clinic-provider-00009	Multi-Specialty Clinic	207Q00000X	0.7111	baseline	1	2026-04-13	gulf-south	2026-04-13	asc	musculoskeletal	2026-04-27	2026-04	404,885	562,340	404,885	null	0.86	18	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-005	world-specialty-clinic-2995344627	specialty-clinic-member-000004	ops-specialty-clinic-provider-00009-2026-04	specialty-clinic-payer-002	deny_missing_documentation	policy-specialty-clinic-payer-002-prior_auth_review	specialty-clinic-provider-00009	gulf-south	0.1686
2026-05-27	paid	not_applicable	0	0.30836	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:office_eval	0.3701	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000029	null	null	0.17075	null	null	null	M17.11	missing	0.1571	low	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000029	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	21,781	frequency_limit	0.0602	policy-specialty-clinic-payer-003-office_eval	14	false	false	2	specialty-clinic-member-000005	in_network	0.28	specialty-clinic	medicare_like	0.414	specialty-clinic-payer-003	gulf-south	ambulatory_surgery	true	99,213	office_eval	approved	specialty-clinic-provider-00014	Multi-Specialty Clinic	207Q00000X	0.3778	baseline	1	2026-05-17	north-texas	2026-05-14	hospital_outpatient	neurological	2026-05-21	2026-05	829,436	1,151,994	829,436	null	0.4973	20	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-006	world-specialty-clinic-2995344627	specialty-clinic-member-000005	ops-specialty-clinic-provider-00014-2026-05	specialty-clinic-payer-003	downcode_frequency_exceeded	policy-specialty-clinic-payer-003-office_eval	specialty-clinic-provider-00014	north-texas	0.0602
2026-07-04	paid	not_applicable	0	0.31768	0	0.74	specialty-clinic:baseline:bcbs_like:mid-atlantic:procedure	0.4067	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000030	null	null	0.1955	null	null	null	K21.9	partial	0.1752	low	specialty-clinic-benefit-standard	intent:specialty-clinic:000030	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	19,100	frequency_limit	0.0381	policy-specialty-clinic-payer-001-procedure	21	false	true	2	specialty-clinic-member-000006	in_network	0.12	specialty-clinic	bcbs_like	0.5281	specialty-clinic-payer-001	mid-atlantic	office	true	11,042	procedure	approved	specialty-clinic-provider-00012	Multi-Specialty Clinic	207Q00000X	0.4667	baseline	1	2026-06-20	mid-atlantic	2026-06-14	asc	endocrine_metabolic	2026-06-30	2026-06	143,491	199,293	143,491	null	0.2432	13	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-001	world-specialty-clinic-2995344627	specialty-clinic-member-000006	ops-specialty-clinic-provider-00012-2026-05	specialty-clinic-payer-001	downcode_frequency_exceeded	policy-specialty-clinic-payer-001-procedure	specialty-clinic-provider-00012	mid-atlantic	0.0381
2026-07-30	paid	not_applicable	0	0.26588	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:diagnostic	0.5961	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000031	null	null	0.24015	null	null	null	D48.5	missing	0.6346	high	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000031	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	26,936	frequency_limit	0.2252	policy-specialty-clinic-payer-002-diagnostic	32	false	true	2	specialty-clinic-member-000001	in_network	0.28	specialty-clinic	medicaid_like	0.6831	specialty-clinic-payer-002	mid-atlantic	office	true	93,000	diagnostic	missing	specialty-clinic-provider-00002	Multi-Specialty Clinic	207Q00000X	0.7778	baseline	1	2026-07-15	gulf-south	2026-07-15	asc	neurological	2026-07-23	2026-07	164,357	228,273	164,357	null	0.718	25	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-002	world-specialty-clinic-2995344627	specialty-clinic-member-000001	ops-specialty-clinic-provider-00002-2026-06	specialty-clinic-payer-002	request_attachment	policy-specialty-clinic-payer-002-diagnostic	specialty-clinic-provider-00002	gulf-south	0.1752
2026-09-03	paid	not_applicable	0	0.30836	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:prior_auth_review	0.393	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000032	null	null	0.17075	null	null	null	M54.50	complete	0.1571	low	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000032	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	17,550	authorization	0.1354	policy-specialty-clinic-payer-003-prior_auth_review	17	false	true	1	specialty-clinic-member-000002	in_network	0.28	specialty-clinic	medicare_like	0.4307	specialty-clinic-payer-003	gulf-south	ambulatory_surgery	true	99,214	prior_auth_review	expired	specialty-clinic-provider-00003	Multi-Specialty Clinic	207Q00000X	0.4444	baseline	1	2026-08-16	north-texas	2026-08-15	hospital_outpatient	endocrine_metabolic	2026-08-27	2026-08	142,008	197,234	142,008	null	0.1353	19	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-003	world-specialty-clinic-2995344627	specialty-clinic-member-000002	ops-specialty-clinic-provider-00003-2026-07	specialty-clinic-payer-003	require_authorization	policy-specialty-clinic-payer-003-prior_auth_review	specialty-clinic-provider-00003	north-texas	0.0854
2026-10-03	paid	not_applicable	0	0.29716	0	0.74	specialty-clinic:baseline:bcbs_like:north-texas:office_eval	0.4813	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000033	null	null	0.20425	null	null	null	E11.9	complete	0.3664	high	specialty-clinic-benefit-standard	intent:specialty-clinic:000033	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	27,125	documentation	0.2184	policy-specialty-clinic-payer-001-office_eval	24	false	true	1	specialty-clinic-member-000003	in_network	0.28	specialty-clinic	bcbs_like	0.5614	specialty-clinic-payer-001	mid-atlantic	office	true	99,214	office_eval	not_required	specialty-clinic-provider-00006	Multi-Specialty Clinic	207Q00000X	0.6	baseline	1	2026-09-22	north-texas	2026-09-15	asc	neurological	2026-09-26	2026-09	217,042	301,447	217,042	null	0.6633	13	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-004	world-specialty-clinic-2995344627	specialty-clinic-member-000003	ops-specialty-clinic-provider-00006-2026-08	specialty-clinic-payer-001	deny_missing_documentation	policy-specialty-clinic-payer-001-office_eval	specialty-clinic-provider-00006	north-texas	0.1684
2026-10-31	paid	not_applicable	0	0.294308	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:procedure	0.5668	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000034	null	null	0.22515	null	null	null	M54.50	missing	0.3841	medium	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000034	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	29,108	frequency_limit	0.2186	policy-specialty-clinic-payer-002-procedure	31	false	true	2	specialty-clinic-member-000004	in_network	0.28	specialty-clinic	medicaid_like	0.6776	specialty-clinic-payer-002	mid-atlantic	office	true	20,610	procedure	approved	specialty-clinic-provider-00009	Multi-Specialty Clinic	207Q00000X	0.7556	baseline	1	2026-10-21	gulf-south	2026-10-16	asc	musculoskeletal	2026-10-27	2026-10	663,414	921,409	663,414	null	0.86	20	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-005	world-specialty-clinic-2995344627	specialty-clinic-member-000004	ops-specialty-clinic-provider-00009-2026-09	specialty-clinic-payer-002	require_authorization	policy-specialty-clinic-payer-002-procedure	specialty-clinic-provider-00009	gulf-south	0.1686
2026-11-30	paid	not_applicable	0	0.30836	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:diagnostic	0.3854	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000035	null	null	0.17075	null	null	null	M17.11	partial	0.1571	low	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000035	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	23,656	recoupment_risk	0.1102	policy-specialty-clinic-payer-003-diagnostic	16	false	false	2	specialty-clinic-member-000005	in_network	0.28	specialty-clinic	medicare_like	0.4251	specialty-clinic-payer-003	gulf-south	office	true	76,942	diagnostic	approved	specialty-clinic-provider-00014	Multi-Specialty Clinic	207Q00000X	0.4222	baseline	1	2026-11-21	north-texas	2026-11-16	office	endocrine_metabolic	2026-11-25	2026-11	248,363	344,949	248,363	null	0.4973	12	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-006	world-specialty-clinic-2995344627	specialty-clinic-member-000005	ops-specialty-clinic-provider-00014-2026-10	specialty-clinic-payer-003	recoup_post_payment_review	policy-specialty-clinic-payer-003-diagnostic	specialty-clinic-provider-00014	north-texas	0.0602
2026-12-20	paid	not_applicable	0	0.31768	0	0.74	specialty-clinic:baseline:bcbs_like:mid-atlantic:prior_auth_review	0.4143	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000036	null	null	0.1955	null	null	null	E03.9	complete	0.1752	low	specialty-clinic-benefit-standard	intent:specialty-clinic:000036	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	21,225	recoupment_risk	0.0881	policy-specialty-clinic-payer-001-prior_auth_review	22	false	true	2	specialty-clinic-member-000006	in_network	0.12	specialty-clinic	bcbs_like	0.5337	specialty-clinic-payer-001	mid-atlantic	ambulatory_surgery	true	99,214	prior_auth_review	not_required	specialty-clinic-provider-00012	Multi-Specialty Clinic	207Q00000X	0.4889	baseline	1	2026-12-10	mid-atlantic	2026-12-05	hospital_outpatient	gastrointestinal	2026-12-18	2026-12	493,625	685,590	493,625	null	0.2432	8	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-001	world-specialty-clinic-2995344627	specialty-clinic-member-000006	ops-specialty-clinic-provider-00012-2026-11	specialty-clinic-payer-001	recoup_post_payment_review	policy-specialty-clinic-payer-001-prior_auth_review	specialty-clinic-provider-00012	mid-atlantic	0.0381
2026-01-24	denied	upheld	0	0.309028	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:office_eval	0.5592	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000037	CO	252	0.22515	N706	documentation	line	K57.30	complete	0.1837	low	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000037	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	25,019	frequency_limit	0.1752	policy-specialty-clinic-payer-002-office_eval	30	false	false	3	specialty-clinic-member-000001	in_network	0.28	specialty-clinic	medicaid_like	0.672	specialty-clinic-payer-002	mid-atlantic	office	true	99,215	office_eval	approved	specialty-clinic-provider-00002	Multi-Specialty Clinic	207Q00000X	0.7333	baseline	1	2026-01-12	gulf-south	2026-01-10	asc	musculoskeletal	2026-01-18	2026-01	1,194,868	1,659,539	0	null	0.718	22	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-002	world-specialty-clinic-2995344627	specialty-clinic-member-000001	ops-specialty-clinic-provider-00002-2026-01	specialty-clinic-payer-002	recoup_post_payment_review	policy-specialty-clinic-payer-002-office_eval	specialty-clinic-provider-00002	gulf-south	0.1752
2026-02-24	paid	not_applicable	0	0.30836	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:procedure	0.3777	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000038	null	null	0.17075	null	null	null	G43.909	partial	0.1571	low	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000038	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	17,384	clean	0.0854	policy-specialty-clinic-payer-003-procedure	15	false	true	2	specialty-clinic-member-000002	in_network	0.28	specialty-clinic	medicare_like	0.4196	specialty-clinic-payer-003	gulf-south	ambulatory_surgery	true	64,483	procedure	approved	specialty-clinic-provider-00003	Multi-Specialty Clinic	207Q00000X	0.4	baseline	1	2026-02-10	north-texas	2026-02-10	office	endocrine_metabolic	2026-02-22	2026-02	304,559	422,999	304,559	null	0.1353	10	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-003	world-specialty-clinic-2995344627	specialty-clinic-member-000002	ops-specialty-clinic-provider-00003-2026-01	specialty-clinic-payer-003	delay_pending_review	policy-specialty-clinic-payer-003-procedure	specialty-clinic-provider-00003	north-texas	0.0854
2026-03-27	partially_paid	partially_overturned	1	0.29716	19	0.74	specialty-clinic:baseline:bcbs_like:north-texas:diagnostic	0.4659	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000039	CO	50	0.20425	N115	medical-necessity	claim	E11.9	partial	0.3664	medium	specialty-clinic-benefit-standard	intent:specialty-clinic:000039	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	24,250	clean	0.1684	policy-specialty-clinic-payer-001-diagnostic	22	false	true	2	specialty-clinic-member-000003	in_network	0.28	specialty-clinic	bcbs_like	0.5503	specialty-clinic-payer-001	mid-atlantic	office	true	73,721	diagnostic	missing	specialty-clinic-provider-00006	Multi-Specialty Clinic	207Q00000X	0.5556	baseline	1	2026-03-14	north-texas	2026-03-13	office	musculoskeletal	2026-03-24	2026-03	488,651	678,682	219,893	null	0.6633	9	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-004	world-specialty-clinic-2995344627	specialty-clinic-member-000003	ops-specialty-clinic-provider-00006-2026-03	specialty-clinic-payer-001	delay_pending_review	policy-specialty-clinic-payer-001-diagnostic	specialty-clinic-provider-00006	north-texas	0.1684
2026-05-01	paid	not_applicable	0	0.294308	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:prior_auth_review	0.5515	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000040	null	null	0.22515	null	null	null	E03.9	partial	0.3841	high	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000040	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	26,982	documentation	0.1686	policy-specialty-clinic-payer-002-prior_auth_review	29	false	true	2	specialty-clinic-member-000004	in_network	0.28	specialty-clinic	medicaid_like	0.6664	specialty-clinic-payer-002	mid-atlantic	office	true	99,214	prior_auth_review	expired	specialty-clinic-provider-00009	Multi-Specialty Clinic	207Q00000X	0.7111	baseline	1	2026-04-19	gulf-south	2026-04-13	asc	gastrointestinal	2026-04-27	2026-04	575,839	799,777	575,839	null	0.86	18	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-005	world-specialty-clinic-2995344627	specialty-clinic-member-000004	ops-specialty-clinic-provider-00009-2026-04	specialty-clinic-payer-002	deny_missing_documentation	policy-specialty-clinic-payer-002-prior_auth_review	specialty-clinic-provider-00009	gulf-south	0.1686
2026-05-26	paid	not_applicable	0	0.294112	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:office_eval	0.3701	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000041	null	null	0.17075	null	null	null	M17.11	complete	0.3284	medium	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000041	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	21,781	frequency_limit	0.0602	policy-specialty-clinic-payer-003-office_eval	14	false	false	1	specialty-clinic-member-000005	in_network	0.28	specialty-clinic	medicare_like	0.414	specialty-clinic-payer-003	gulf-south	office	true	99,213	office_eval	approved	specialty-clinic-provider-00014	Multi-Specialty Clinic	207Q00000X	0.3778	baseline	1	2026-05-20	north-texas	2026-05-14	asc	musculoskeletal	2026-05-21	2026-05	147,104	204,311	147,104	null	0.4973	20	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-006	world-specialty-clinic-2995344627	specialty-clinic-member-000005	ops-specialty-clinic-provider-00014-2026-05	specialty-clinic-payer-003	downcode_frequency_exceeded	policy-specialty-clinic-payer-003-office_eval	specialty-clinic-provider-00014	north-texas	0.0602
2026-07-02	paid	not_applicable	0	0.303145	0	0.74	specialty-clinic:baseline:bcbs_like:mid-atlantic:procedure	0.4067	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000042	null	null	0.1955	null	null	null	E03.9	missing	0.3664	medium	specialty-clinic-benefit-standard	intent:specialty-clinic:000042	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	19,100	frequency_limit	0.0381	policy-specialty-clinic-payer-001-procedure	21	false	true	2	specialty-clinic-member-000006	in_network	0.12	specialty-clinic	bcbs_like	0.5281	specialty-clinic-payer-001	mid-atlantic	ambulatory_surgery	true	11,042	procedure	missing	specialty-clinic-provider-00012	Multi-Specialty Clinic	207Q00000X	0.4667	baseline	1	2026-06-14	mid-atlantic	2026-06-14	hospital_outpatient	neurological	2026-06-30	2026-06	313,544	435,478	313,544	null	0.2432	13	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-001	world-specialty-clinic-2995344627	specialty-clinic-member-000006	ops-specialty-clinic-provider-00012-2026-05	specialty-clinic-payer-001	downcode_frequency_exceeded	policy-specialty-clinic-payer-001-procedure	specialty-clinic-provider-00012	mid-atlantic	0.0381
2026-07-27	paid	not_applicable	0	0.309028	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:diagnostic	0.5745	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000043	null	null	0.22515	null	null	null	G56.00	partial	0.1837	high	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000043	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	26,936	frequency_limit	0.2252	policy-specialty-clinic-payer-002-diagnostic	32	false	false	2	specialty-clinic-member-000001	in_network	0.28	specialty-clinic	medicaid_like	0.6831	specialty-clinic-payer-002	mid-atlantic	office	true	93,000	diagnostic	expired	specialty-clinic-provider-00002	Multi-Specialty Clinic	207Q00000X	0.7778	baseline	1	2026-07-15	gulf-south	2026-07-15	office	dermatologic	2026-07-23	2026-07	383,705	532,923	383,705	null	0.718	25	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-002	world-specialty-clinic-2995344627	specialty-clinic-member-000001	ops-specialty-clinic-provider-00002-2026-06	specialty-clinic-payer-002	request_attachment	policy-specialty-clinic-payer-002-diagnostic	specialty-clinic-provider-00002	gulf-south	0.1752
2026-09-01	paid	not_applicable	0	0.30836	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:prior_auth_review	0.393	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000044	null	null	0.17075	null	null	null	M54.50	partial	0.1571	low	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000044	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	17,550	authorization	0.1354	policy-specialty-clinic-payer-003-prior_auth_review	17	false	true	3	specialty-clinic-member-000002	in_network	0.28	specialty-clinic	medicare_like	0.4307	specialty-clinic-payer-003	gulf-south	office	true	99,214	prior_auth_review	missing	specialty-clinic-provider-00003	Multi-Specialty Clinic	207Q00000X	0.4444	baseline	1	2026-08-21	north-texas	2026-08-15	office	neurological	2026-08-27	2026-08	642,458	892,303	642,458	null	0.1353	19	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-003	world-specialty-clinic-2995344627	specialty-clinic-member-000002	ops-specialty-clinic-provider-00003-2026-07	specialty-clinic-payer-003	require_authorization	policy-specialty-clinic-payer-003-prior_auth_review	specialty-clinic-provider-00003	north-texas	0.0854
2026-09-28	paid	not_applicable	0	0.29716	0	0.74	specialty-clinic:baseline:bcbs_like:north-texas:office_eval	0.4813	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000045	null	null	0.20425	null	null	null	M17.11	partial	0.3664	high	specialty-clinic-benefit-standard	intent:specialty-clinic:000045	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	27,125	documentation	0.2184	policy-specialty-clinic-payer-001-office_eval	24	false	true	1	specialty-clinic-member-000003	in_network	0.28	specialty-clinic	bcbs_like	0.5614	specialty-clinic-payer-001	mid-atlantic	ambulatory_surgery	true	99,214	office_eval	approved	specialty-clinic-provider-00006	Multi-Specialty Clinic	207Q00000X	0.6	baseline	1	2026-09-20	north-texas	2026-09-15	asc	musculoskeletal	2026-09-26	2026-09	239,933	333,240	239,933	null	0.6633	13	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-004	world-specialty-clinic-2995344627	specialty-clinic-member-000003	ops-specialty-clinic-provider-00006-2026-08	specialty-clinic-payer-001	deny_missing_documentation	policy-specialty-clinic-payer-001-office_eval	specialty-clinic-provider-00006	north-texas	0.1684
2026-11-02	paid	not_applicable	0	0.309028	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:procedure	0.5668	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000046	null	null	0.22515	null	null	null	E03.9	missing	0.1837	low	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000046	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	29,108	frequency_limit	0.2186	policy-specialty-clinic-payer-002-procedure	31	false	false	2	specialty-clinic-member-000004	in_network	0.28	specialty-clinic	medicaid_like	0.6776	specialty-clinic-payer-002	mid-atlantic	hospital_outpatient	true	20,610	procedure	missing	specialty-clinic-provider-00009	Multi-Specialty Clinic	207Q00000X	0.7556	baseline	1	2026-10-18	gulf-south	2026-10-16	hospital_outpatient	gastrointestinal	2026-10-27	2026-10	458,765	637,174	458,765	null	0.86	20	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-005	world-specialty-clinic-2995344627	specialty-clinic-member-000004	ops-specialty-clinic-provider-00009-2026-09	specialty-clinic-payer-002	require_authorization	policy-specialty-clinic-payer-002-procedure	specialty-clinic-provider-00009	gulf-south	0.1686
2026-12-01	paid	not_applicable	0	0.294112	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:diagnostic	0.3854	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000047	null	null	0.17075	null	null	null	E11.9	complete	0.3284	medium	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000047	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	23,656	recoupment_risk	0.1102	policy-specialty-clinic-payer-003-diagnostic	16	false	false	2	specialty-clinic-member-000005	in_network	0.28	specialty-clinic	medicare_like	0.4251	specialty-clinic-payer-003	gulf-south	ambulatory_surgery	true	76,942	diagnostic	not_required	specialty-clinic-provider-00014	Multi-Specialty Clinic	207Q00000X	0.4222	baseline	1	2026-11-23	north-texas	2026-11-16	hospital_outpatient	gastrointestinal	2026-11-25	2026-11	676,291	939,293	676,291	null	0.4973	12	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-006	world-specialty-clinic-2995344627	specialty-clinic-member-000005	ops-specialty-clinic-provider-00014-2026-10	specialty-clinic-payer-003	recoup_post_payment_review	policy-specialty-clinic-payer-003-diagnostic	specialty-clinic-provider-00014	north-texas	0.0602
2026-12-24	paid	not_applicable	0	0.31768	0	0.74	specialty-clinic:baseline:bcbs_like:mid-atlantic:prior_auth_review	0.4143	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000048	null	null	0.1955	null	null	null	M54.50	partial	0.1752	low	specialty-clinic-benefit-standard	intent:specialty-clinic:000048	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	21,225	recoupment_risk	0.0881	policy-specialty-clinic-payer-001-prior_auth_review	22	false	true	1	specialty-clinic-member-000006	in_network	0.12	specialty-clinic	bcbs_like	0.5337	specialty-clinic-payer-001	mid-atlantic	ambulatory_surgery	true	99,214	prior_auth_review	expired	specialty-clinic-provider-00012	Multi-Specialty Clinic	207Q00000X	0.4889	baseline	1	2026-12-06	mid-atlantic	2026-12-05	asc	neurological	2026-12-18	2026-12	258,255	358,687	258,255	null	0.2432	8	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-001	world-specialty-clinic-2995344627	specialty-clinic-member-000006	ops-specialty-clinic-provider-00012-2026-11	specialty-clinic-payer-001	recoup_post_payment_review	policy-specialty-clinic-payer-001-prior_auth_review	specialty-clinic-provider-00012	mid-atlantic	0.0381
2026-01-20	paid	not_applicable	0	0.26588	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:office_eval	0.5807	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000049	null	null	0.24015	null	null	null	G56.00	missing	0.6346	high	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000049	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	25,019	frequency_limit	0.1752	policy-specialty-clinic-payer-002-office_eval	30	false	false	1	specialty-clinic-member-000001	in_network	0.28	specialty-clinic	medicaid_like	0.672	specialty-clinic-payer-002	mid-atlantic	office	true	99,215	office_eval	expired	specialty-clinic-provider-00002	Multi-Specialty Clinic	207Q00000X	0.7333	baseline	1	2026-01-14	gulf-south	2026-01-10	hospital_outpatient	musculoskeletal	2026-01-18	2026-01	106,352	147,711	106,352	null	0.718	22	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-002	world-specialty-clinic-2995344627	specialty-clinic-member-000001	ops-specialty-clinic-provider-00002-2026-01	specialty-clinic-payer-002	recoup_post_payment_review	policy-specialty-clinic-payer-002-office_eval	specialty-clinic-provider-00002	gulf-south	0.1752
2026-02-26	paid	not_applicable	0	0.265096	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:procedure	0.3993	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000050	null	null	0.18575	null	null	null	M54.50	partial	0.5426	high	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000050	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	17,384	clean	0.0854	policy-specialty-clinic-payer-003-procedure	15	false	true	3	specialty-clinic-member-000002	in_network	0.28	specialty-clinic	medicare_like	0.4196	specialty-clinic-payer-003	gulf-south	office	true	64,483	procedure	approved	specialty-clinic-provider-00003	Multi-Specialty Clinic	207Q00000X	0.4	baseline	1	2026-02-11	north-texas	2026-02-10	asc	neurological	2026-02-22	2026-02	478,316	664,328	478,316	null	0.1353	10	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-003	world-specialty-clinic-2995344627	specialty-clinic-member-000002	ops-specialty-clinic-provider-00003-2026-01	specialty-clinic-payer-003	delay_pending_review	policy-specialty-clinic-payer-003-procedure	specialty-clinic-provider-00003	north-texas	0.0854
2026-03-28	paid	not_applicable	0	0.311695	0	0.74	specialty-clinic:baseline:bcbs_like:north-texas:diagnostic	0.4659	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000051	null	null	0.20425	null	null	null	D48.5	missing	0.1752	low	specialty-clinic-benefit-standard	intent:specialty-clinic:000051	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	24,250	clean	0.1684	policy-specialty-clinic-payer-001-diagnostic	22	false	true	2	specialty-clinic-member-000003	in_network	0.28	specialty-clinic	bcbs_like	0.5503	specialty-clinic-payer-001	mid-atlantic	office	true	73,721	diagnostic	not_required	specialty-clinic-provider-00006	Multi-Specialty Clinic	207Q00000X	0.5556	baseline	1	2026-03-14	north-texas	2026-03-13	hospital_outpatient	gastrointestinal	2026-03-24	2026-03	347,905	483,202	347,905	null	0.6633	9	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-004	world-specialty-clinic-2995344627	specialty-clinic-member-000003	ops-specialty-clinic-provider-00006-2026-03	specialty-clinic-payer-001	delay_pending_review	policy-specialty-clinic-payer-001-diagnostic	specialty-clinic-provider-00006	north-texas	0.1684
2026-04-30	paid	not_applicable	0	0.309028	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:prior_auth_review	0.5515	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000052	null	null	0.22515	null	null	null	K21.9	complete	0.1837	high	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000052	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	26,982	documentation	0.1686	policy-specialty-clinic-payer-002-prior_auth_review	29	false	true	1	specialty-clinic-member-000004	in_network	0.28	specialty-clinic	medicaid_like	0.6664	specialty-clinic-payer-002	mid-atlantic	office	true	99,214	prior_auth_review	missing	specialty-clinic-provider-00009	Multi-Specialty Clinic	207Q00000X	0.7111	baseline	1	2026-04-16	gulf-south	2026-04-13	office	musculoskeletal	2026-04-27	2026-04	35,225	48,923	35,225	null	0.86	18	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-005	world-specialty-clinic-2995344627	specialty-clinic-member-000004	ops-specialty-clinic-provider-00009-2026-04	specialty-clinic-payer-002	deny_missing_documentation	policy-specialty-clinic-payer-002-prior_auth_review	specialty-clinic-provider-00009	gulf-south	0.1686
2026-05-23	paid	not_applicable	0	0.294112	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:office_eval	0.3701	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000053	null	null	0.17075	null	null	null	M17.11	missing	0.3284	medium	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000053	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	21,781	frequency_limit	0.0602	policy-specialty-clinic-payer-003-office_eval	14	false	false	1	specialty-clinic-member-000005	in_network	0.28	specialty-clinic	medicare_like	0.414	specialty-clinic-payer-003	gulf-south	office	true	99,213	office_eval	not_required	specialty-clinic-provider-00014	Multi-Specialty Clinic	207Q00000X	0.3778	baseline	1	2026-05-15	north-texas	2026-05-14	hospital_outpatient	dermatologic	2026-05-21	2026-05	15,565	21,618	15,565	null	0.4973	20	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-006	world-specialty-clinic-2995344627	specialty-clinic-member-000005	ops-specialty-clinic-provider-00014-2026-05	specialty-clinic-payer-003	downcode_frequency_exceeded	policy-specialty-clinic-payer-003-office_eval	specialty-clinic-provider-00014	north-texas	0.0602
2026-07-06	paid	not_applicable	0	0.31768	0	0.74	specialty-clinic:baseline:bcbs_like:mid-atlantic:procedure	0.4067	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000054	null	null	0.1955	null	null	null	K21.9	complete	0.1752	low	specialty-clinic-benefit-standard	intent:specialty-clinic:000054	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	19,100	frequency_limit	0.0381	policy-specialty-clinic-payer-001-procedure	21	false	false	2	specialty-clinic-member-000006	in_network	0.12	specialty-clinic	bcbs_like	0.5281	specialty-clinic-payer-001	mid-atlantic	office	true	11,042	procedure	approved	specialty-clinic-provider-00012	Multi-Specialty Clinic	207Q00000X	0.4667	baseline	1	2026-06-19	mid-atlantic	2026-06-14	office	musculoskeletal	2026-06-30	2026-06	623,727	866,288	623,727	null	0.2432	13	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00012-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-001	world-specialty-clinic-2995344627	specialty-clinic-member-000006	ops-specialty-clinic-provider-00012-2026-05	specialty-clinic-payer-001	downcode_frequency_exceeded	policy-specialty-clinic-payer-001-procedure	specialty-clinic-provider-00012	mid-atlantic	0.0381
2026-07-29	paid	not_applicable	0	0.294308	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:diagnostic	0.5745	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000055	null	null	0.22515	null	null	null	M17.11	complete	0.3841	high	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000055	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	26,936	frequency_limit	0.2252	policy-specialty-clinic-payer-002-diagnostic	32	false	true	1	specialty-clinic-member-000001	in_network	0.28	specialty-clinic	medicaid_like	0.6831	specialty-clinic-payer-002	mid-atlantic	ambulatory_surgery	true	93,000	diagnostic	approved	specialty-clinic-provider-00002	Multi-Specialty Clinic	207Q00000X	0.7778	baseline	1	2026-07-20	gulf-south	2026-07-15	hospital_outpatient	endocrine_metabolic	2026-07-23	2026-07	93,548	129,928	93,548	null	0.718	25	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00002-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-002	world-specialty-clinic-2995344627	specialty-clinic-member-000001	ops-specialty-clinic-provider-00002-2026-06	specialty-clinic-payer-002	request_attachment	policy-specialty-clinic-payer-002-diagnostic	specialty-clinic-provider-00002	gulf-south	0.1752
2026-09-03	paid	not_applicable	0	0.265096	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:prior_auth_review	0.4146	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000056	null	null	0.18575	null	null	null	G43.909	missing	0.5426	high	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000056	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	17,550	authorization	0.1354	policy-specialty-clinic-payer-003-prior_auth_review	17	false	false	3	specialty-clinic-member-000002	in_network	0.28	specialty-clinic	medicare_like	0.4307	specialty-clinic-payer-003	gulf-south	ambulatory_surgery	true	99,214	prior_auth_review	missing	specialty-clinic-provider-00003	Multi-Specialty Clinic	207Q00000X	0.4444	baseline	1	2026-08-15	north-texas	2026-08-15	asc	endocrine_metabolic	2026-08-27	2026-08	449,247	623,954	449,247	null	0.1353	19	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00003-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-003	world-specialty-clinic-2995344627	specialty-clinic-member-000002	ops-specialty-clinic-provider-00003-2026-07	specialty-clinic-payer-003	require_authorization	policy-specialty-clinic-payer-003-prior_auth_review	specialty-clinic-provider-00003	north-texas	0.0854
2026-09-29	paid	overturned	1	0.29716	23	0.74	specialty-clinic:baseline:bcbs_like:north-texas:office_eval	0.4813	specialty_clinic_procedure	CI	837P_like	1	specialty-clinic-claim-00000057	CO	197	0.20425	N130	authorization	claim	D48.5	complete	0.3664	high	specialty-clinic-benefit-standard	intent:specialty-clinic:000057	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	27,125	documentation	0.2184	policy-specialty-clinic-payer-001-office_eval	24	false	false	1	specialty-clinic-member-000003	in_network	0.28	specialty-clinic	bcbs_like	0.5614	specialty-clinic-payer-001	mid-atlantic	office	true	99,214	office_eval	approved	specialty-clinic-provider-00006	Multi-Specialty Clinic	207Q00000X	0.6	baseline	1	2026-09-18	north-texas	2026-09-15	hospital_outpatient	endocrine_metabolic	2026-09-26	2026-09	295,415	410,298	295,415	null	0.6633	13	specialty-clinic-benefit-standard	contract-specialty-clinic-provider-00006-specialty-clinic-payer-001	medicare_indexed	specialty-clinic-plan-004	world-specialty-clinic-2995344627	specialty-clinic-member-000003	ops-specialty-clinic-provider-00006-2026-08	specialty-clinic-payer-001	deny_missing_documentation	policy-specialty-clinic-payer-001-office_eval	specialty-clinic-provider-00006	north-texas	0.1684
2026-10-30	paid	not_applicable	0	0.309028	0	0.74	specialty-clinic:baseline:medicaid_like:gulf-south:procedure	0.5668	specialty_clinic_procedure	MC	837P_like	1	specialty-clinic-claim-00000058	null	null	0.22515	null	null	null	G43.909	partial	0.1837	low	specialty-clinic-benefit-tight-auth	intent:specialty-clinic:000058	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	29,108	frequency_limit	0.2186	policy-specialty-clinic-payer-002-procedure	31	false	false	3	specialty-clinic-member-000004	in_network	0.28	specialty-clinic	medicaid_like	0.6776	specialty-clinic-payer-002	mid-atlantic	office	true	20,610	procedure	expired	specialty-clinic-provider-00009	Multi-Specialty Clinic	207Q00000X	0.7556	baseline	1	2026-10-18	gulf-south	2026-10-16	hospital_outpatient	neurological	2026-10-27	2026-10	626,668	870,372	626,668	null	0.86	20	specialty-clinic-benefit-tight-auth	contract-specialty-clinic-provider-00009-specialty-clinic-payer-002	medicare_indexed	specialty-clinic-plan-005	world-specialty-clinic-2995344627	specialty-clinic-member-000004	ops-specialty-clinic-provider-00009-2026-09	specialty-clinic-payer-002	require_authorization	policy-specialty-clinic-payer-002-procedure	specialty-clinic-provider-00009	gulf-south	0.1686
2026-11-30	paid	not_applicable	0	0.30836	0	0.74	specialty-clinic:baseline:medicare_like:north-texas:diagnostic	0.3854	specialty_clinic_procedure	MB	837P_like	1	specialty-clinic-claim-00000059	null	null	0.17075	null	null	null	G56.00	partial	0.1571	low	specialty-clinic-benefit-cob-heavy	intent:specialty-clinic:000059	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	23,656	recoupment_risk	0.1102	policy-specialty-clinic-payer-003-diagnostic	16	false	true	2	specialty-clinic-member-000005	in_network	0.28	specialty-clinic	medicare_like	0.4251	specialty-clinic-payer-003	gulf-south	office	true	76,942	diagnostic	expired	specialty-clinic-provider-00014	Multi-Specialty Clinic	207Q00000X	0.4222	baseline	1	2026-11-20	north-texas	2026-11-16	office	endocrine_metabolic	2026-11-25	2026-11	566,353	786,602	566,353	null	0.4973	12	specialty-clinic-benefit-cob-heavy	contract-specialty-clinic-provider-00014-specialty-clinic-payer-003	medicare_indexed	specialty-clinic-plan-006	world-specialty-clinic-2995344627	specialty-clinic-member-000005	ops-specialty-clinic-provider-00014-2026-10	specialty-clinic-payer-003	recoup_post_payment_review	policy-specialty-clinic-payer-003-diagnostic	specialty-clinic-provider-00014	north-texas	0.0602

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Specialty Clinic Synthetic Claims Sample

This sample contains 1000 generated-from-scratch synthetic healthcare claim rows.

Use case: Model specialty clinic procedure authorization, documentation, and payer coverage friction across multi-specialty outpatient settings.

Synthetic-Only Boundary

No PHI.
No customer data.
No patient-level source records.
Generated from public healthcare references, explicit modeling assumptions, and deterministic synthesis code.

Dataset Files

Sample data: specialty-clinic.csv
Manifest: public_sample_manifest.json
Public source manifest: public_source_manifest.json
Synthetic-only attestation: synthetic_only_attestation.json

Schema

Schema version: 0.4.0
Total columns: 58
Specialty context columns: specialty_service_line, procedure_authorization_status, documentation_completeness_band, site_of_service_category, follow_up_visit_indicator

Source Coverage

Public sources: 56
Source stewards: 18
Source categories: Appeals, Authorization, Claims Standard, Coding Edit, Coverage Policy, Enrollment Demographics, Fee Schedule, Interoperability

Public Sample Artifacts

specialty-clinic.csv
public_sample_manifest.json
public_source_manifest.json
synthetic_only_attestation.json
LICENSE.md

Paywalled Delivery Artifacts

The following artifacts exist in paid delivery bundles and are intentionally omitted from public sample publication:

validation_report.json
benchmark_report.json
payer_behavior_report.json
cash_flow_forecast.json
scenario_report.json
training_corpus.jsonl
claim_realism_report.json
claim_edit_simulation_report.json
adjudication_trace.jsonl
adjudication_trace_summary.json
claim_envelopes.jsonl
remittance_advices.jsonl
transaction_bundle_manifest.json
transaction_validation_report.json
synthetic_edi_transactions.jsonl
claim_status_276_277.jsonl
attachment_275_workflows.jsonl
fhir_claim_eob_bundle.jsonl
transaction_surface_manifest.json
transaction_surface_validation_report.json
world_entities.jsonl
payer_policy_rules.jsonl
contract_terms.jsonl
operations_states.jsonl
world_model_manifest.json
world_validation_report.json
economy_operating_timeline.jsonl
economy_claim_intents.jsonl
economy_impact_report.json
economy_kernel_manifest.json
economy_kernel_validation.json
payer_policy_decisions.jsonl
payer_policy_decision_summary.json
contract_fee_schedule_lines.jsonl
contract_fee_schedule_manifest.json
contract_fee_schedule_report.json
payer_contract_simulator_config.json
payer_contract_simulation_manifest.json
payer_contract_simulation_report.json
revenue_cycle_events.jsonl
agent_evaluation_tasks.jsonl
event_simulation_manifest.json
event_validation_report.json
episode_journeys.jsonl
episode_manifest.json
episode_validation_report.json
operating_timeline.jsonl
synthetic_documents.jsonl
artifact_trace_graph.jsonl
operating_artifact_graph_manifest.json
operating_artifact_graph_validation.json
workflow_replays.jsonl
workflow_replay_public_index.json
workflow_replay_engine_manifest.json
workflow_replay_engine_validation.json
evaluation_suite_manifest.json
evaluation_harness_report.json
population_control_report.json
synthetic_twin_aggregate_config.json
synthetic_twin_calibration_report.json
synthetic_twin_reproducibility_packet.json
dataset.lock.json
release_ledger.jsonl

Limitations

Synthetic datasets are for software testing, model training, workflow benchmarking, and scenario planning.
The data should not be treated as observed payer behavior, reimbursement truth, or legal billing advice.
Public sources support structure, constraints, and calibration targets; they do not expose proprietary payer distributions.
Code presence is authoritative, but frequency and payer-specific usage are not provided.
Explains remittance context but does not expose payer frequency distributions.

License

Dataset usage is governed by upstream-data-synthetic-dataset-eula-v0. Review terms before production use.

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