claim_id,member_id,claim_type,claim_status,submission_channel,submission_date,service_date_from,service_date_to,adjudication_date,adjudication_engine,adjudication_turnaround_days,rendering_provider_npi,billing_provider_npi,provider_taxonomy_code,provider_specialty,place_of_service_code,network_status,primary_diagnosis_code,secondary_diagnosis_codes,procedure_code,drg_code,formulary_tier,payer_type,plan_type,member_age,member_sex,risk_score_raf,denial_code,denial_category,billed_amount,allowed_amount,paid_amount,member_deductible_applied,member_copay_applied,member_coinsurance_applied,contractual_adjustment,cob_primary_paid,cob_secondary_paid,fraud_label,fraud_typology,fraud_risk_score,anomaly_flags,siu_referral,provider_fraud_risk_tier,high_cost_claimant_flag,readmission_30d_flag,preventable_admission_flag,mlr_contribution,leakage_flag,generic_substitution_flag,hedis_measure_triggered,value_based_contract_type
CLM0000000000,MBR00000096,Medical_Institutional,Denied,Electronic_EDI,2023-11-24,2023-11-24,2023-11-24,2023-11-26,Manual_Review,2,1356331863,1187669363,225100000X,Physical Therapist,32,In_Network,OTHER,Z00.00|E78.5|E13.9,revenue_code:0300,,0,Medicaid_MCO,MCO,62,M,0.7948,4,Authorization,3812.07,2854.36,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0113,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000000001,MBR00000054,Pharmacy,Paid,Electronic_EDI,2023-07-10,2023-07-10,2023-07-10,2023-07-24,Auto_Adjudicated,14,1539066691,1007652766,207RC0000X,Cardiovascular Disease,11,In_Network,R05.9,,00071012831,,2,Medicare_Advantage,MA_HMO,66,F,0.8625,,,144.19,105.92,83.39,0.68,1.0,20.85,38.27,0.0,0.0,0,,0.0399,none,0,1,0,0,0,8e-06,0,0,COA_Care_Transitions,FFS
CLM0000000002,MBR00000201,Pharmacy,Paid,Electronic_EDI,2023-06-12,2023-06-12,2023-06-12,2023-06-28,Manual_Review,16,1453331651,1587454801,101YP2500X,Psychologist Clinical,23,In_Network,E11.9,Z00.00,00006001954,,3,Medicare_Advantage,MA_PPO,74,M,1.1575,,,567.15,459.45,352.94,12.27,6.0,88.24,107.7,0.0,0.0,0,,0.0362,none,0,1,0,0,0,3.3e-05,0,0,,FFS
CLM0000000003,MBR00000008,Medical_Professional,Paid,Electronic_EDI,2023-05-21,2023-05-21,2023-05-21,2023-06-13,Auto_Adjudicated,23,1728728765,1391074619,2086S0122X,Orthopedic Surgery,22,In_Network,OTHER,Z00.00|E11.9,97140,,0,Medicaid_MCO,MCO,74,M,0.8375,,,631.82,243.85,242.85,0.0,1.0,0.0,387.97,0.0,0.0,0,,0.0571,none,0,1,0,0,0,2.2e-05,0,0,CBP_Controlling_BP,FFS
CLM0000000004,MBR00000051,Medical_Professional,Paid,Electronic_EDI,2023-03-20,2023-03-20,2023-03-20,2023-03-27,Auto_Adjudicated,7,1490172833,1977073565,207RN0300X,Nephrology,31,Out_of_Network,OTHER,Z00.00,17000,,0,Medicare_Advantage,MA_PPO,17,F,1.0695,,,551.47,314.73,205.18,44.25,14.0,51.3,236.74,0.0,0.0,0,,0.0723,temporal_clustering,0,1,0,0,0,1.9e-05,1,0,POD_Persistence_of_Beta_Blocker,Capitation
CLM0000000005,MBR00000273,Dental,Paid,Paper,2023-05-18,2023-05-18,2023-05-18,2023-06-01,Auto_Adjudicated,14,1983779639,1587454801,246ZN0300X,Neuropsychology,11,In_Network,N40.0,,D0120,,0,ACA_Marketplace,ACA_Bronze,4,M,1.3569,,,345.38,264.28,0.0,264.28,0.0,0.0,81.1,0.0,0.0,0,,0.0475,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000006,MBR00000300,Medical_Professional,Paid,Electronic_EDI,2023-10-14,2023-10-14,2023-10-14,2023-11-02,Manual_Review,19,1658382624,1252125670,207R00000X,Internal Medicine,22,In_Network,J06.9,Z12.11|E11.9,99214,,0,Commercial,PPO,64,F,1.0393,,,300.84,175.62,66.52,63.47,29.0,16.63,125.22,0.0,0.0,0,,0.1118,npi_mismatch,0,1,0,1,0,6e-06,0,0,COL_Colorectal_Cancer_Screening,Bundled_Payment
CLM0000000007,MBR00000151,Pharmacy,Paid,Electronic_EDI,2023-07-21,2023-07-21,2023-07-21,2023-08-10,Manual_Review,20,1086690796,1575884274,207Q00000X,Family Medicine,11,In_Network,F41.1,,59148001506,,1,Medicare_Advantage,MA_HMO,77,M,0.8709,,,202.11,94.14,69.39,1.41,6.0,17.35,107.97,50.71,10.51,0,,0.0122,none,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000000008,MBR00000154,Medical_Professional,Paid,Electronic_EDI,2023-05-22,2023-05-22,2023-05-22,2023-06-08,Auto_Adjudicated,17,1946657989,1804282800,207RG0100X,Gastroenterology,23,In_Network,J06.9,M54.5,99285,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,545.29,408.37,318.1,10.75,0.0,79.52,136.92,0.0,0.0,0,,0.1237,none,0,1,0,1,0,2.9e-05,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000000009,MBR00000228,Pharmacy,Paid,Paper,2023-02-08,2023-02-08,2023-02-08,2023-02-26,Auto_Adjudicated,18,1624242487,1694343357,207RG0100X,Gastroenterology,24,In_Network,OTHER,OTHER|K21.0,00310075090,,3,Commercial,PPO,55,F,0.7203,,,101.1,37.94,0.0,37.94,0.0,0.0,63.16,0.0,0.0,0,,0.0965,high_volume_same_code,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000000010,MBR00000012,Medical_Professional,Paid,Paper,2023-05-29,2023-05-29,2023-05-29,2023-06-03,Auto_Adjudicated,5,1331829614,1831337866,207R00000X,Internal Medicine,22,In_Network,M54.5,,74178,,0,Commercial,HMO,84,M,1.3904,,,562.43,298.63,209.9,8.26,28.0,52.47,263.8,0.0,0.0,0,,0.1202,none,0,1,0,0,0,1.9e-05,0,0,POD_Persistence_of_Beta_Blocker,Shared_Savings
CLM0000000011,MBR00000135,Medical_Institutional,Paid,Electronic_EDI,2023-03-19,2023-03-19,2023-03-20,2023-04-02,Auto_Adjudicated,14,1110312325,1356856197,225100000X,Physical Therapist,22,In_Network,E11.9,Z00.00|J20.9,revenue_code:0250,,0,Commercial,PPO,58,F,2.2702,,,13105.73,9085.46,7220.58,0.74,59.0,1805.14,4020.27,0.0,0.0,0,,0.1041,npi_mismatch,0,1,1,1,0,0.000668,0,0,BPD_BP_Declined,FFS
CLM0000000012,MBR00000029,Medical_Institutional,Paid,Electronic_EDI,2023-05-23,2023-05-23,2023-05-23,2023-06-09,Auto_Adjudicated,17,1469822310,1825450791,246ZN0300X,Neuropsychology,21,In_Network,E11.9,Z00.01|Z00.00,revenue_code:0360,291,0,Medicaid_MCO,MCO,13,F,0.9053,,,5321.56,2289.02,2286.02,0.0,3.0,0.0,3032.54,0.0,0.0,0,,0.1489,none,0,1,0,1,0,0.000212,0,0,,FFS
CLM0000000013,MBR00000128,Medical_Professional,Paid,Paper,2023-02-23,2023-02-23,2023-02-23,2023-02-26,Auto_Adjudicated,3,1196858674,1685903362,207RN0300X,Nephrology,23,In_Network,Z23,M54.5,99285,,0,Commercial,PPO,13,F,1.4203,,,223.95,172.31,90.89,45.7,13.0,22.72,51.64,0.0,0.0,0,,0.043,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000000014,MBR00000296,Medical_Institutional,Paid,Electronic_EDI,2023-12-07,2023-12-07,2023-12-09,2024-01-06,Auto_Adjudicated,30,1506426842,1616762819,2084P0800X,Psychiatry,65,In_Network,F33.0,,revenue_code:0200,,0,Commercial,HMO,83,F,1.4969,,,23919.34,13123.35,10314.77,186.89,43.0,2578.69,10795.99,0.0,0.0,0,,0.1395,none,0,1,1,0,0,0.000955,0,0,,FFS
CLM0000000015,MBR00000221,Dental,Paid,Electronic_EDI,2023-03-04,2023-03-04,2023-03-04,2023-03-23,Manual_Review,19,1666911728,1579331190,225100000X,Physical Therapist,23,In_Network,OTHER,E78.5|Z00.01,D7140,,0,Commercial,HDHP_HSA,28,M,1.6683,,,213.46,115.38,0.0,115.38,0.0,0.0,98.08,0.0,0.0,0,,0.0423,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000016,MBR00000296,Pharmacy,Paid,Electronic_EDI,2023-02-14,2023-02-14,2023-02-14,2023-03-08,Auto_Adjudicated,22,1528602428,1938465393,207R00000X,Internal Medicine,11,In_Network,OTHER,M54.5,00071015523,,1,Commercial,HMO,83,F,1.4969,,,1655.69,1365.22,976.93,113.06,31.0,244.23,290.47,0.0,0.0,0,,0.0386,none,0,1,0,0,0,9e-05,0,1,MMA_Medication_Management,Shared_Savings
CLM0000000017,MBR00000219,Behavioral_Health,Paid,Electronic_EDI,2023-08-24,2023-08-24,2023-08-24,2023-09-10,Auto_Adjudicated,17,1119160702,1650774392,207RN0300X,Nephrology,22,In_Network,Z00.00,F41.1,43239,,0,Medicare_Advantage,MA_HMO,84,M,0.9513,,,498.67,211.14,135.45,41.83,0.0,33.86,287.53,0.0,0.0,0,,0.1813,temporal_clustering|phantom_billing_indicator|high_oop_waiver,0,1,0,0,0,1.3e-05,0,0,CCS_Cervical_Cancer_Screening,Shared_Savings
CLM0000000018,MBR00000184,Pharmacy,Paid,Electronic_EDI,2023-05-04,2023-05-04,2023-05-04,2023-06-01,Auto_Adjudicated,28,1732726112,1402472115,246ZN0300X,Neuropsychology,24,Out_of_Network,Z00.00,,00003014960,,1,Medicaid_MCO,MLTSS,30,M,2.8302,,,207.37,117.82,115.82,0.0,2.0,0.0,89.55,0.0,0.0,0,,0.1471,none,0,1,0,0,0,1.1e-05,0,0,,Shared_Savings
CLM0000000019,MBR00000221,Medical_Institutional,Paid,Paper,2023-12-24,2023-12-24,2023-12-28,2023-12-25,Auto_Adjudicated,1,1201027197,1607833568,2086S0122X,Orthopedic Surgery,22,In_Network,J06.9,,revenue_code:0110,,0,Commercial,HDHP_HSA,28,M,1.6683,,,20145.27,12200.04,9593.64,208.0,0.0,2398.41,7945.23,0.0,0.0,0,,0.1412,none,0,1,1,0,0,0.000888,0,0,SPC_Statin_Therapy,P4P
CLM0000000020,MBR00000196,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-05-26,2023-05-26,2023-05-28,2023-06-24,Auto_Adjudicated,29,1508520529,1354265777,2084P0800X,Psychiatry,22,In_Network,OTHER,E78.5,revenue_code:0120,,0,Commercial,PPO,16,F,1.6015,256,Medical_Necessity,24008.08,9565.21,4278.15,147.08,36.0,1069.54,18477.31,0.0,0.0,0,,0.0839,none,0,1,0,0,0,0.000396,0,0,,P4P
CLM0000000021,MBR00000143,Vision,Paid,Provider_Portal,2023-08-22,2023-08-22,2023-08-22,2023-08-29,Auto_Adjudicated,7,1946657989,1650774392,2086S0122X,Orthopedic Surgery,65,In_Network,OTHER,Z00.00|OTHER,V2320,,0,Commercial,POS,85,M,1.6078,,,370.48,188.13,111.72,12.48,36.0,27.93,182.35,0.0,0.0,0,,0.0498,none,0,1,0,1,0,1e-05,0,0,,FFS
CLM0000000022,MBR00000092,Medical_Institutional,Paid,Electronic_EDI,2023-10-27,2023-10-27,2023-10-30,2023-11-23,Auto_Adjudicated,27,1231231881,1847196500,207Q00000X,Family Medicine,32,In_Network,I10,R05.9,revenue_code:0100,,0,Medicaid_MCO,MLTSS,68,F,1.3217,,,13076.23,8057.92,8048.92,0.0,9.0,0.0,5018.31,0.0,0.0,0,,0.1146,none,0,1,1,0,0,0.000745,0,0,,FFS
CLM0000000023,MBR00000159,Medical_Institutional,Paid,Electronic_EDI,2023-12-20,2023-12-20,2023-12-24,2023-12-22,Auto_Adjudicated,2,1907932706,1220755708,207Q00000X,Family Medicine,11,In_Network,E78.5,,revenue_code:0370,,0,Commercial,PPO,70,F,1.2009,,,142819.18,115839.28,92588.88,32.18,71.0,23147.22,26979.9,0.0,0.0,0,,0.1246,outlier_billing_amount,0,1,1,0,0,0.00857,0,0,,FFS
CLM0000000024,MBR00000080,Pharmacy,Paid,Electronic_EDI,2023-10-18,2023-10-18,2023-10-18,2023-10-28,Auto_Adjudicated,10,1542851144,1827839595,2084P0800X,Psychiatry,22,In_Network,OTHER,C50.911|Z23|I25.10,00006001954,,2,Commercial,HDHP_HSA,74,M,0.5935,,,101.32,59.27,0.0,59.27,0.0,0.0,42.05,0.0,0.0,0,,0.0886,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000000025,MBR00000151,Vision,Paid,Electronic_EDI,2023-07-27,2023-07-27,2023-07-27,2023-08-14,Auto_Adjudicated,18,1513407277,1978943761,207Q00000X,Family Medicine,22,In_Network,I25.10,Z87.891,V2115,,0,Medicare_Advantage,MA_HMO,77,M,0.8709,,,230.74,145.21,109.87,1.87,6.0,27.47,85.53,0.0,0.0,0,,0.0094,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000000026,MBR00000046,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-10-20,2023-10-20,2023-10-24,2023-11-09,Auto_Adjudicated,20,1641660170,1330485436,207RP1001X,Pulmonary Disease,31,In_Network,Z23,,revenue_code:0370,,0,Commercial,HMO,76,F,0.9613,18,Medical_Necessity,12810.94,8808.78,4769.36,49.03,41.0,1192.34,6759.21,0.0,0.0,0,,0.0825,none,0,1,0,1,0,0.000441,0,0,AWV_Annual_Wellness_Visit,Bundled_Payment
CLM0000000027,MBR00000170,Medical_Professional,Paid,Electronic_EDI,2023-04-12,2023-04-12,2023-04-12,2023-04-13,Auto_Adjudicated,1,1864546991,1650774392,207RP1001X,Pulmonary Disease,11,In_Network,E11.9,J06.9|OTHER|E11.9,27447,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,28272.56,11955.56,9561.12,1.16,3.0,2390.28,16317.0,0.0,0.0,0,,0.0969,none,0,1,1,1,0,0.000885,0,0,FUM_Follow_Up_ED_Mental_Health,Bundled_Payment
CLM0000000028,MBR00000076,Medical_Institutional,Paid,Electronic_EDI,2023-11-09,2023-11-09,2023-11-12,2023-11-20,Auto_Adjudicated,11,1750232347,1694343357,246ZN0300X,Neuropsychology,11,In_Network,Z00.01,M54.5,revenue_code:0250,,0,Commercial,HMO,26,M,2.1785,,,73370.19,31076.71,24827.7,2.09,40.0,6206.92,42293.48,19627.6,2861.86,0,,0.1773,outlier_billing_amount|billing_spike_recent,0,1,1,0,0,0.002298,0,0,,P4P
CLM0000000029,MBR00000092,Pharmacy,Paid,Electronic_EDI,2023-11-10,2023-11-10,2023-11-10,2023-12-06,Auto_Adjudicated,26,1830816512,1461075342,207RN0300X,Nephrology,22,Out_of_Network,Z00.01,I10,00078043215,,3,Medicaid_MCO,MLTSS,68,F,1.3217,,,179.76,105.91,102.91,0.0,3.0,0.0,73.85,0.0,0.0,0,,0.1295,none,0,1,0,0,0,1e-05,1,1,SPC_Statin_Therapy,Capitation
CLM0000000030,MBR00000154,Medical_Professional,Paid,Electronic_EDI,2023-05-18,2023-05-18,2023-05-18,2023-05-24,Auto_Adjudicated,6,1826919173,1945682535,246ZN0300X,Neuropsychology,22,In_Network,I50.9,M17.11|OTHER,99284,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,373.93,247.58,192.89,6.46,0.0,48.22,126.35,0.0,0.0,0,,0.1448,none,0,1,0,0,0,1.8e-05,0,0,,Capitation
CLM0000000031,MBR00000052,Pharmacy,Partially_Paid,Electronic_EDI,2023-01-25,2023-01-25,2023-01-25,2023-02-23,Auto_Adjudicated,29,1133514780,1643673796,207RN0300X,Nephrology,11,In_Network,F10.10,,00310075090,,1,Commercial,PPO,0,F,1.325,97,Medical_Necessity,245.04,124.66,32.16,19.41,32.0,8.04,153.43,0.0,0.0,0,,0.0165,none,0,1,0,0,0,3e-06,0,0,CCS_Cervical_Cancer_Screening,Bundled_Payment
CLM0000000032,MBR00000292,Medical_Institutional,Denied,Electronic_EDI,2023-09-03,2023-09-03,2023-09-03,2023-09-25,Auto_Adjudicated,22,1267286378,1419347445,207V00000X,Obstetrics & Gynecology,71,In_Network,J06.9,E11.65,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,4,M,1.1779,22,Medical_Necessity,11139.56,4351.68,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0767,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000033,MBR00000139,Medical_Professional,Paid,Electronic_EDI,2023-02-06,2023-02-06,2023-02-06,2023-03-08,Manual_Review,30,1397401856,1540743888,246ZN0300X,Neuropsychology,21,Out_of_Network,N18.3,J06.9|Z23,99213,,0,Commercial,PPO,74,M,1.7701,,,520.96,379.11,18.2,335.36,21.0,4.55,141.85,0.0,0.0,0,,0.125,none,0,1,0,0,0,2e-06,0,0,COA_Care_Transitions,FFS
CLM0000000034,MBR00000111,Medical_Institutional,Denied,Electronic_EDI,2023-01-07,2023-01-07,2023-01-10,2023-02-04,Manual_Review,28,1396168768,1297948643,2084P0800X,Psychiatry,11,In_Network,I10,,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,44,M,0.7462,3,Eligibility,17645.52,12346.53,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0829,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000035,MBR00000010,Medical_Professional,Paid,Electronic_EDI,2023-12-07,2023-12-07,2023-12-07,2023-12-14,Auto_Adjudicated,7,1901547390,1061113875,207R00000X,Internal Medicine,11,Out_of_Network,Z00.00,M47.816|M17.11,20610,,0,Medicare_Advantage,MA_HMO,44,F,1.4631,,,1298.57,1044.27,824.41,9.75,4.0,206.1,254.3,0.0,0.0,0,,0.0613,none,0,1,0,0,0,7.6e-05,1,0,,P4P
CLM0000000036,MBR00000252,Pharmacy,Denied,Electronic_EDI,2023-07-23,2023-07-23,2023-07-23,2023-08-21,Manual_Review,29,1756856314,1297948643,246ZN0300X,Neuropsychology,11,In_Network,Z00.01,,50458085930,,1,Medicare_Advantage,MA_HMO,80,M,0.7173,170,Coding_Error,142.38,106.19,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2026,benford_violation,0,2,0,0,0,0.0,0,1,,Bundled_Payment
CLM0000000037,MBR00000186,Medical_Professional,Paid,Electronic_EDI,2023-08-22,2023-08-22,2023-08-22,2023-09-06,Manual_Review,15,1797494973,1509799493,207RN0300X,Nephrology,11,In_Network,Z00.01,J20.9|N18.3,99205,,0,Commercial,PPO,65,M,1.6983,,,213.67,153.91,56.59,71.18,12.0,14.15,59.76,0.0,0.0,0,,0.1254,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000000038,MBR00000132,Pharmacy,Paid,Paper,2023-11-13,2023-11-13,2023-11-13,2023-11-21,Auto_Adjudicated,8,1956215244,1007652766,207RE0101X,Endocrinology,21,In_Network,OTHER,K29.70,59148001506,,3,Medicare_Advantage,MA_PPO,84,F,1.3018,,,136.79,83.64,61.99,0.16,6.0,15.5,53.15,0.0,0.0,0,,0.0033,none,0,1,0,0,0,6e-06,0,0,,Capitation
CLM0000000039,MBR00000076,Medical_Professional,Paid,Electronic_EDI,2023-11-30,2023-11-30,2023-11-30,2023-12-27,Auto_Adjudicated,27,1891821845,1461075342,207RG0100X,Gastroenterology,11,In_Network,E11.9,F33.0,99233,,0,Commercial,HMO,26,M,2.1785,,,325.14,266.28,169.1,22.9,32.0,42.28,58.86,0.0,0.0,0,,0.0905,none,0,1,0,0,0,1.6e-05,0,0,AWV_Annual_Wellness_Visit,P4P
CLM0000000040,MBR00000218,Vision,Paid,Electronic_EDI,2023-12-10,2023-12-10,2023-12-10,2023-12-25,Auto_Adjudicated,15,1700802848,1197700958,207V00000X,Obstetrics & Gynecology,22,In_Network,I10,E13.9,92004,,0,Commercial,HDHP_HSA,11,F,0.4964,,,489.62,339.85,0.0,339.85,0.0,0.0,149.77,0.0,0.0,0,,0.0771,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000041,MBR00000286,Pharmacy,Partially_Paid,Electronic_EDI,2023-02-17,2023-02-17,2023-02-17,2023-03-10,Auto_Adjudicated,21,1879212418,1554490060,207Q00000X,Family Medicine,21,In_Network,OTHER,,00085163102,,4,Medicare_Advantage,PFFS,40,F,1.2751,3,Medical_Necessity,963.25,390.9,191.39,11.37,3.0,47.85,709.64,0.0,0.0,0,,0.0888,none,0,1,0,1,0,1.8e-05,0,0,POD_Persistence_of_Beta_Blocker,Shared_Savings
CLM0000000042,MBR00000121,Medical_Professional,Paid,Electronic_EDI,2023-04-27,2023-04-27,2023-04-27,2023-05-16,Auto_Adjudicated,19,1292994726,1477113725,225100000X,Physical Therapist,22,In_Network,J06.9,,97140,,0,Medicare_Advantage,MA_PPO,58,M,1.226,,,734.7,542.78,414.35,6.84,18.0,103.59,191.92,0.0,0.0,0,,0.1861,npi_mismatch,0,1,0,0,0,3.8e-05,0,0,,FFS
CLM0000000043,MBR00000042,Behavioral_Health,Paid,Electronic_EDI,2023-10-03,2023-10-03,2023-10-03,2023-10-12,Auto_Adjudicated,9,1014482814,1788579687,2086S0122X,Orthopedic Surgery,81,Emergency,E11.9,G47.33|OTHER,99202,,0,Commercial,HMO,78,F,1.1448,,,558.51,258.3,170.88,24.7,20.0,42.72,300.21,0.0,0.0,0,,0.1614,npi_mismatch,0,1,0,0,0,1.6e-05,0,0,SPC_Statin_Therapy,FFS
CLM0000000044,MBR00000034,Medical_Institutional,Paid,Electronic_EDI,2023-01-11,2023-01-11,2023-01-14,2023-02-10,Auto_Adjudicated,30,1836409547,1228356980,207RN0300X,Nephrology,81,In_Network,E11.9,H52.4|J20.9,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,35,M,0.7712,,,21083.66,15892.57,12677.83,1.28,44.0,3169.46,5191.09,0.0,0.0,0,,0.0965,none,0,1,1,0,0,0.001173,0,0,KED_ESRD_Patients,FFS
CLM0000000045,MBR00000003,Medical_Institutional,Paid,Electronic_EDI,2023-03-26,2023-03-26,2023-03-27,2023-04-21,Auto_Adjudicated,26,1881358103,1020312030,207R00000X,Internal Medicine,21,In_Network,I10,,revenue_code:0300,682,0,Commercial,PPO,79,F,1.3879,,,6575.46,5556.79,4397.1,10.41,50.0,1099.28,1018.67,0.0,0.0,0,,0.056,none,0,1,0,1,0,0.000407,0,0,,Bundled_Payment
CLM0000000046,MBR00000218,Dental,Denied,Electronic_EDI,2023-07-04,2023-07-04,2023-07-04,2023-07-20,Auto_Adjudicated,16,1597245892,1432077493,207RG0100X,Gastroenterology,21,In_Network,Z00.00,OTHER|E78.5,D1110,,0,Commercial,HDHP_HSA,11,F,0.4964,3,COB,375.88,156.02,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0856,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000047,MBR00000296,Dental,Paid,Electronic_EDI,2023-05-04,2023-05-04,2023-05-04,2023-05-22,Auto_Adjudicated,18,1485543430,1461075342,207RN0300X,Nephrology,23,In_Network,K57.30,OTHER,D4341,,0,Commercial,HMO,83,F,1.4969,,,555.29,216.68,56.16,115.48,31.0,14.04,338.61,0.0,0.0,0,,0.1348,unbundling_pattern,0,1,0,0,0,5e-06,0,0,,Capitation
CLM0000000048,MBR00000298,Pharmacy,Paid,Electronic_EDI,2023-03-04,2023-03-04,2023-03-04,2023-03-07,Auto_Adjudicated,3,1145887050,1209882852,207RN0300X,Nephrology,21,In_Network,K21.0,OTHER,00069420020,,1,Medicaid_MCO,MCO,75,M,0.8324,,,354.34,262.34,262.34,0.0,0.0,0.0,92.0,0.0,0.0,0,,0.0969,phantom_billing_indicator,0,1,0,0,0,2.4e-05,0,0,,Bundled_Payment
CLM0000000049,MBR00000232,Behavioral_Health,Paid,Electronic_EDI,2023-11-19,2023-11-19,2023-11-19,2023-12-11,Auto_Adjudicated,22,1963647323,1903401648,207RP1001X,Pulmonary Disease,24,In_Network,I10,E11.9,99396,,0,Medicaid_MCO,MCO,40,M,1.1083,,,173.09,129.68,127.68,0.0,2.0,0.0,43.41,0.0,0.0,0,,0.0737,none,0,1,0,0,0,1.2e-05,0,0,,P4P
CLM0000000050,MBR00000051,Medical_Professional,Denied,Electronic_EDI,2023-06-10,2023-06-10,2023-06-10,2023-07-08,Auto_Adjudicated,28,1611521069,1007652766,225100000X,Physical Therapist,22,In_Network,OTHER,Z12.11|Z23,80053,,0,Medicare_Advantage,MA_PPO,17,F,1.0695,CO-45,Network,990.74,680.65,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Identity Theft,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|benford_violation|impossible_service_combo|duplicate_claim_indicator|phantom_billing_indicator|diagnosis_procedure_mismatch,1,5,0,0,0,0.0,0,0,,FFS
CLM0000000051,MBR00000294,Medical_Professional,Paid,Electronic_EDI,2023-05-28,2023-05-28,2023-05-28,2023-06-27,Auto_Adjudicated,30,1141106555,1391074619,207RP1001X,Pulmonary Disease,11,Out_of_Network,Z00.00,N18.3,70553,,0,Medicare_Advantage,MA_HMO,8,M,0.6878,,,566.02,329.86,241.6,9.87,18.0,60.4,236.16,0.0,0.0,0,,0.0511,none,0,1,0,0,0,2.2e-05,1,0,DDE_Diabetes_Short_Term_Complications,Shared_Savings
CLM0000000052,MBR00000104,Medical_Professional,Paid,Electronic_EDI,2023-08-25,2023-08-25,2023-08-25,2023-09-11,Clinical_Review,17,1034110592,1643673796,207RE0101X,Endocrinology,21,Out_of_Network,K21.0,,99283,,0,Medicaid_MCO,MCO,87,F,1.2297,,,326.19,254.09,254.09,0.0,0.0,0.0,72.1,0.0,0.0,0,,0.1394,benford_violation,0,1,0,1,0,2.4e-05,0,0,,Capitation
CLM0000000053,MBR00000105,Medical_Professional,Paid,Electronic_EDI,2023-08-29,2023-08-29,2023-08-29,2023-09-28,Manual_Review,30,1181941909,1831337866,207RE0101X,Endocrinology,31,In_Network,I10,,90834,,0,Commercial,HMO,74,M,1.1834,,,2437.24,1660.46,917.25,498.9,15.0,229.31,776.78,576.86,242.61,0,,0.0662,none,0,1,0,0,0,8.5e-05,0,0,,P4P
CLM0000000054,MBR00000205,Medical_Institutional,Paid,Electronic_EDI,2023-06-26,2023-06-26,2023-06-26,2023-07-20,Auto_Adjudicated,24,1864546991,1880530717,2084P0800X,Psychiatry,22,Out_of_Network,Z00.00,OTHER,revenue_code:0450,,0,Medicaid_MCO,MCO,1,F,0.9425,,,8214.19,6424.21,6416.21,0.0,8.0,0.0,1789.98,4809.66,1346.35,0,,0.0932,phantom_billing_indicator,0,1,1,0,0,0.000594,1,0,CDC_HbA1c_Poor_Control,FFS
CLM0000000055,MBR00000014,Medical_Professional,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-12-01,Manual_Review,16,1264432433,1591405274,207RG0100X,Gastroenterology,23,In_Network,J20.9,M54.5,99284,,0,Commercial,HMO,77,M,2.8513,,,123.35,63.81,0.0,63.81,0.0,0.0,59.54,0.0,0.0,0,,0.0935,none,0,1,0,0,0,0.0,0,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000000056,MBR00000247,Medical_Institutional,Paid,Electronic_EDI,2023-04-17,2023-04-17,2023-04-17,2023-05-12,Auto_Adjudicated,25,1175448241,1685903362,207Q00000X,Family Medicine,23,In_Network,I10,,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,2589.23,1347.95,1030.8,7.46,52.0,257.7,1241.28,0.0,0.0,0,,0.0937,none,0,1,0,1,0,9.5e-05,0,0,W30_Well_Child_Visit,FFS
CLM0000000057,MBR00000300,Medical_Professional,Paid,Electronic_EDI,2023-11-09,2023-11-09,2023-11-09,2023-11-14,Auto_Adjudicated,5,1461820376,1575884274,207RN0300X,Nephrology,22,In_Network,Z00.00,Z00.121,90847,,0,Commercial,PPO,64,F,1.0393,,,1592.9,1043.53,773.95,47.09,29.0,193.49,549.37,0.0,0.0,1,Provider Impersonation,0.9458,outlier_billing_amount|benford_violation|impossible_service_combo|service_date_weekend|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,1,0,7.2e-05,0,0,BCS_Breast_Cancer_Screening,Shared_Savings
CLM0000000058,MBR00000228,Medical_Professional,Paid,Provider_Portal,2023-11-08,2023-11-08,2023-11-08,2023-11-29,Auto_Adjudicated,21,1741980770,1903401648,208600000X,Surgery General,11,In_Network,F41.1,,97110,,0,Commercial,PPO,55,F,0.7203,,,785.02,544.62,0.0,544.62,0.0,0.0,240.4,0.0,0.0,0,,0.1227,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000059,MBR00000231,Pharmacy,Paid,Electronic_EDI,2023-01-04,2023-01-04,2023-01-04,2023-01-23,Auto_Adjudicated,19,1111846258,1196833348,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,OTHER,00071012831,,1,ACA_Marketplace,ACA_Silver,12,M,0.6456,,,102.2,42.61,0.0,42.61,0.0,0.0,59.59,0.0,0.0,0,,0.0449,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000000060,MBR00000125,Medical_Professional,Paid,Electronic_EDI,2023-09-28,2023-09-28,2023-09-28,2023-10-13,Manual_Review,15,1731980913,1469642907,207RC0000X,Cardiovascular Disease,11,In_Network,F41.1,M47.816,99213,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,260.0,111.65,76.7,4.77,11.0,19.18,148.35,0.0,0.0,0,,0.1109,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000000061,MBR00000020,Pharmacy,Paid,Paper,2023-02-26,2023-02-26,2023-02-26,2023-03-18,Auto_Adjudicated,20,1167433253,1691162131,207R00000X,Internal Medicine,22,Emergency,Z00.00,J44.1|I25.10|E78.5,00071015523,,1,Medicare_Advantage,MA_PPO,63,F,0.7119,,,138.78,106.37,79.61,0.86,6.0,19.9,32.41,0.0,0.0,0,,0.107,duplicate_claim_indicator,0,1,0,0,0,7e-06,0,0,ACR_Urine_Protein,FFS
CLM0000000062,MBR00000235,Pharmacy,Paid,Paper,2023-06-24,2023-06-24,2023-06-24,2023-07-20,Manual_Review,26,1214787184,1860951128,225100000X,Physical Therapist,11,In_Network,M54.5,,59148001506,,1,Commercial,HDHP_HSA,85,F,1.4308,,,103.91,66.21,0.0,66.21,0.0,0.0,37.7,0.0,0.0,0,,0.1286,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000000063,MBR00000180,Medical_Institutional,Paid,Electronic_EDI,2023-11-26,2023-11-26,2023-11-27,2023-12-14,Auto_Adjudicated,18,1014482814,1662516615,207R00000X,Internal Medicine,65,In_Network,K21.0,,revenue_code:0100,,0,Medicare_Advantage,MA_PPO,72,F,1.1909,,,36511.75,16959.99,13524.97,2.77,51.0,3381.24,19551.76,0.0,0.0,0,,0.1707,temporal_clustering,0,1,1,0,0,0.001252,0,0,,FFS
CLM0000000064,MBR00000274,Dental,Paid,Electronic_EDI,2023-03-12,2023-03-12,2023-03-12,2023-03-24,Auto_Adjudicated,12,1636337876,1829216053,207R00000X,Internal Medicine,24,In_Network,E78.5,I10,D0150,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,768.06,396.83,299.55,22.39,0.0,74.89,371.23,0.0,0.0,0,,0.0954,none,0,1,0,0,0,2.8e-05,0,0,,Bundled_Payment
CLM0000000065,MBR00000036,Vision,Paid,Electronic_EDI,2023-07-21,2023-07-21,2023-07-21,2023-08-03,Auto_Adjudicated,13,1719850506,1831337866,207RC0000X,Cardiovascular Disease,11,In_Network,J06.9,J06.9,92014,,0,Commercial,EPO,17,M,2.0136,,,385.56,292.55,120.89,108.44,33.0,30.22,93.01,0.0,0.0,0,,0.0797,none,0,1,0,0,0,1.1e-05,0,0,DAE_Drug_Alcohol_Dependence,Shared_Savings
CLM0000000066,MBR00000097,Medical_Professional,Paid,Electronic_EDI,2023-10-07,2023-10-07,2023-10-07,2023-10-25,Auto_Adjudicated,18,1119160702,1144950506,2084P0800X,Psychiatry,24,In_Network,M17.11,E11.9,90847,,0,Commercial,EPO,34,M,1.3765,,,2718.06,1239.21,544.54,534.54,24.0,136.13,1478.85,0.0,0.0,0,,0.1462,none,0,1,0,0,0,5e-05,0,0,,FFS
CLM0000000067,MBR00000114,Pharmacy,Paid,Electronic_EDI,2023-06-22,2023-06-22,2023-06-22,2023-07-10,Auto_Adjudicated,18,1313587359,1007652766,207RE0101X,Endocrinology,23,Out_of_Network,OTHER,R05.9,00078043215,,3,Medicare_Advantage,MA_PPO,57,F,1.0712,,,62.83,41.0,0.0,32.83,8.17,0.0,21.83,0.0,0.0,0,,0.1432,none,0,1,0,1,0,0.0,1,0,,Shared_Savings
CLM0000000068,MBR00000204,Medical_Professional,Paid,Electronic_EDI,2023-01-29,2023-01-29,2023-01-29,2023-02-08,Auto_Adjudicated,10,1007414142,1694343357,246ZN0300X,Neuropsychology,23,In_Network,OTHER,,12001,,0,Commercial,HMO,12,M,0.8716,,,560.76,338.85,95.92,186.95,32.0,23.98,221.91,0.0,0.0,0,,0.1922,service_date_weekend,0,1,0,0,0,9e-06,0,0,,Shared_Savings
CLM0000000069,MBR00000233,Medical_Institutional,Paid,Electronic_EDI,2023-01-24,2023-01-24,2023-01-27,2023-02-10,Auto_Adjudicated,17,1295273693,1625992541,207R00000X,Internal Medicine,21,In_Network,E11.9,OTHER|I10|G47.33,revenue_code:0360,683,0,Medicare_Advantage,MA_PPO,87,M,0.8034,,,8764.08,7254.04,5760.22,5.77,48.0,1440.05,1510.04,0.0,0.0,0,,0.0684,none,0,1,1,0,0,0.000533,0,0,,Bundled_Payment
CLM0000000070,MBR00000291,Medical_Institutional,Denied,Electronic_EDI,2023-07-05,2023-07-05,2023-07-09,2023-07-14,Auto_Adjudicated,9,1164721841,1144950506,207RC0000X,Cardiovascular Disease,22,In_Network,OTHER,I10,revenue_code:0250,,0,Commercial,PPO,78,M,1.4773,170,Medical_Necessity,57863.1,42301.89,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Prescription Drug Diversion,0.9327,outlier_billing_amount|benford_violation|impossible_service_combo|duplicate_claim_indicator|unbundling_pattern|npi_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,1,0,0.0,0,0,,FFS
CLM0000000071,MBR00000092,Pharmacy,Denied,Electronic_EDI,2023-01-09,2023-01-09,2023-01-09,2023-02-07,Clinical_Review,29,1461820376,1825450791,207R00000X,Internal Medicine,22,In_Network,Z12.11,Z12.11|I10,00085163102,,5,Medicaid_MCO,MLTSS,68,F,1.3217,4,Duplicate,307.02,217.45,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1396,temporal_clustering,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000072,MBR00000153,Pharmacy,Paid,Electronic_EDI,2023-01-06,2023-01-06,2023-01-06,2023-01-23,Auto_Adjudicated,17,1154652946,1867389043,207RP1001X,Pulmonary Disease,21,In_Network,OTHER,M54.5,00085163102,,2,Commercial,POS,12,F,0.6525,,,56.75,41.23,0.0,41.23,0.0,0.0,15.52,0.0,0.0,0,,0.0685,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000000073,MBR00000010,Pharmacy,Paid,Electronic_EDI,2023-12-09,2023-12-09,2023-12-09,2024-01-04,Auto_Adjudicated,26,1453331651,1452088018,225100000X,Physical Therapist,22,In_Network,F33.0,OTHER|Z23,00071012831,,1,Medicare_Advantage,MA_HMO,44,F,1.4631,,,327.42,269.67,195.55,21.23,4.0,48.89,57.75,0.0,0.0,0,,0.0158,none,0,1,0,0,0,1.8e-05,0,0,,Capitation
CLM0000000074,MBR00000078,Pharmacy,Paid,Electronic_EDI,2023-07-11,2023-07-11,2023-07-11,2023-07-23,Auto_Adjudicated,12,1866366547,1228356980,207RC0000X,Cardiovascular Disease,11,In_Network,K57.30,Z00.01|E11.9,00078043215,,1,Commercial,EPO,65,F,1.3174,,,453.45,216.81,2.48,176.71,37.0,0.62,236.64,0.0,0.0,0,,0.2191,geographic_mismatch|high_oop_waiver,0,2,0,0,0,0.0,0,1,SPD_Spirometry_Testing,Bundled_Payment
CLM0000000075,MBR00000118,Medical_Institutional,Denied,Electronic_EDI,2023-06-20,2023-06-20,2023-06-20,2023-07-02,Auto_Adjudicated,12,1375680589,1804282800,207V00000X,Obstetrics & Gynecology,32,In_Network,J06.9,,revenue_code:0120,,0,Medicaid_MCO,MCO,69,M,1.2773,CO-45,COB,4332.63,1591.25,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1643,geographic_mismatch|duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000076,MBR00000179,Medical_Professional,Paid,Electronic_EDI,2023-02-06,2023-02-06,2023-02-06,2023-02-15,Auto_Adjudicated,9,1133514780,1432077493,2084P0800X,Psychiatry,81,Out_of_Network,N40.0,,81001,,0,Medicare_Advantage,SNP,82,F,0.5266,,,502.68,248.8,176.45,11.24,17.0,44.11,253.88,0.0,0.0,0,,0.085,none,0,1,0,1,0,1.6e-05,0,0,,FFS
CLM0000000077,MBR00000144,Medical_Professional,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-10,2023-10-28,Auto_Adjudicated,18,1374458552,1579331190,207RP1001X,Pulmonary Disease,21,In_Network,E11.65,,99386,,0,Commercial,HDHP_HSA,56,F,2.5926,,,507.71,409.26,140.63,233.47,0.0,35.16,98.45,0.0,0.0,0,,0.1234,none,0,1,0,0,0,1.3e-05,0,0,CBP_Controlling_BP,FFS
CLM0000000078,MBR00000115,Medical_Institutional,Paid,Electronic_EDI,2023-07-03,2023-07-03,2023-07-05,2023-07-22,Auto_Adjudicated,19,1344162462,1388050552,207RP1001X,Pulmonary Disease,21,In_Network,F33.0,OTHER|Z23,revenue_code:0110,194,0,Commercial,PPO,15,F,0.7398,,,41997.02,29378.46,23121.77,429.25,47.0,5780.44,12618.56,14944.79,6981.3,0,,0.0496,none,0,1,1,0,0,0.00214,0,0,,FFS
CLM0000000079,MBR00000186,Pharmacy,Paid,Electronic_EDI,2023-03-20,2023-03-20,2023-03-20,2023-04-06,Clinical_Review,17,1718336220,1951488764,207RN0300X,Nephrology,11,Out_of_Network,J20.9,,59148001506,,1,Commercial,PPO,65,M,1.6983,,,112.58,48.18,0.0,48.18,0.0,0.0,64.4,0.0,0.0,1,Provider Impersonation,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|temporal_clustering|high_volume_same_code|impossible_service_combo|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,0.0,0,0,SPC_Statin_Therapy,FFS
CLM0000000080,MBR00000247,Medical_Professional,Paid,Electronic_EDI,2023-09-28,2023-09-28,2023-09-28,2023-10-24,Auto_Adjudicated,26,1466478716,1579331190,207RP1001X,Pulmonary Disease,32,In_Network,Z00.00,OTHER,17000,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,1027.12,533.96,417.56,7.01,5.0,104.39,493.16,0.0,0.0,0,,0.202,duplicate_claim_indicator,0,2,0,0,0,3.9e-05,0,0,TRC_Transition_of_Care,Capitation
CLM0000000081,MBR00000076,Medical_Institutional,Paid,Electronic_EDI,2023-03-27,2023-03-27,2023-03-31,2023-04-12,Manual_Review,16,1727787144,1804282800,207Q00000X,Family Medicine,11,In_Network,F32.9,E11.65,revenue_code:0370,,0,Commercial,HMO,26,M,2.1785,,,11900.51,7741.48,6155.52,7.07,40.0,1538.88,4159.03,0.0,0.0,0,,0.1335,none,0,1,1,0,0,0.00057,0,0,DAE_Drug_Alcohol_Dependence,Bundled_Payment
CLM0000000082,MBR00000107,Medical_Professional,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-25,Auto_Adjudicated,25,1901547390,1007652766,2086S0122X,Orthopedic Surgery,24,In_Network,Z00.00,M17.11|F32.9,99213,,0,Medicare_Advantage,MA_PPO,44,M,1.0439,,,574.11,247.72,180.99,13.49,8.0,45.25,326.39,0.0,0.0,0,,0.0041,none,0,1,0,0,0,1.7e-05,0,0,AWV_Annual_Wellness_Visit,FFS
CLM0000000083,MBR00000208,Medical_Institutional,Denied,Electronic_EDI,2023-07-21,2023-07-21,2023-07-21,2023-07-23,Auto_Adjudicated,2,1176378924,1132693989,101YP2500X,Psychologist Clinical,31,In_Network,I10,OTHER,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,PR-1,Authorization,7335.05,4763.29,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2431,unusual_service_frequency|service_date_weekend,0,2,0,0,0,0.0,0,0,POD_Persistence_of_Beta_Blocker,Shared_Savings
CLM0000000084,MBR00000229,Medical_Professional,Paid,Electronic_EDI,2023-04-11,2023-04-11,2023-04-11,2023-04-22,Auto_Adjudicated,11,1577859682,1034732777,225100000X,Physical Therapist,21,In_Network,F32.9,OTHER,99385,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,564.51,218.48,139.42,30.2,14.0,34.86,346.03,0.0,0.0,1,Medically Unnecessary Services,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|service_date_weekend|billing_spike_recent|upcoding_pattern|npi_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,1.3e-05,0,0,,FFS
CLM0000000085,MBR00000247,Medical_Professional,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-12-03,Auto_Adjudicated,22,1528834564,1354265777,207Q00000X,Family Medicine,24,In_Network,Z23,I10,99396,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,316.58,225.86,166.6,12.61,5.0,41.65,90.72,0.0,0.0,0,,0.0003,none,0,1,0,1,0,1.5e-05,0,0,DAE_Drug_Alcohol_Dependence,FFS
CLM0000000086,MBR00000064,Medical_Professional,Paid,Electronic_EDI,2023-09-10,2023-09-10,2023-09-10,2023-09-22,Manual_Review,12,1893886964,1688513262,207Q00000X,Family Medicine,22,In_Network,Z00.00,,80053,,0,Medicare_Advantage,SNP,73,M,1.0644,,,538.58,269.41,207.48,0.06,10.0,51.87,269.17,0.0,0.0,0,,0.0474,none,0,1,0,1,0,1.9e-05,0,0,IET_Initiation_Substance_Use,FFS
CLM0000000087,MBR00000164,Medical_Professional,Paid,Electronic_EDI,2023-04-14,2023-04-14,2023-04-14,2023-05-06,Auto_Adjudicated,22,1007414142,1461075342,246ZN0300X,Neuropsychology,21,In_Network,I10,,99384,,0,ACA_Marketplace,ACA_Silver,3,F,0.7155,,,837.94,472.33,133.0,243.34,39.0,57.0,365.61,0.0,0.0,1,Provider Impersonation,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|benford_violation|impossible_service_combo|billing_spike_recent|upcoding_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,1.2e-05,0,0,,Capitation
CLM0000000088,MBR00000273,Medical_Institutional,Paid,Electronic_EDI,2023-02-26,2023-02-26,2023-03-02,2023-03-16,Auto_Adjudicated,18,1788188920,1179350099,207RE0101X,Endocrinology,32,In_Network,F32.9,Z23|E78.5,revenue_code:0250,,0,ACA_Marketplace,ACA_Bronze,4,M,1.3569,,,10336.71,3690.23,1993.39,367.92,0.0,1328.92,6646.48,1724.11,184.86,0,,0.0971,benford_violation,0,1,0,0,0,0.000185,0,0,,Shared_Savings
CLM0000000089,MBR00000125,Vision,Paid,Paper,2023-04-29,2023-04-29,2023-04-29,2023-05-14,Auto_Adjudicated,15,1901054209,1942423230,207RP1001X,Pulmonary Disease,22,In_Network,OTHER,OTHER|H52.4|E78.5,V2115,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,317.73,213.62,154.56,9.42,11.0,38.64,104.11,126.27,14.47,0,,0.0956,none,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000000090,MBR00000135,Medical_Professional,Paid,Provider_Portal,2023-06-17,2023-06-17,2023-06-17,2023-07-04,Clinical_Review,17,1213747973,1767402068,207V00000X,Obstetrics & Gynecology,11,In_Network,F41.1,Z23|OTHER,80053,,0,Commercial,PPO,58,F,2.2702,,,377.19,261.38,176.65,3.57,37.0,44.16,115.81,0.0,0.0,0,,0.092,none,0,1,0,1,0,1.6e-05,0,0,KED_ESRD_Patients,P4P
CLM0000000091,MBR00000296,Medical_Institutional,Paid,Electronic_EDI,2023-07-17,2023-07-17,2023-07-17,2023-08-14,Manual_Review,28,1887322427,1133410177,208600000X,Surgery General,23,In_Network,OTHER,F32.9,revenue_code:0250,,0,Commercial,HMO,83,F,1.4969,,,31420.68,24724.48,19702.84,52.93,43.0,4925.71,6696.2,0.0,0.0,0,,0.065,billing_spike_recent,0,1,1,0,0,0.001824,0,0,,FFS
CLM0000000092,MBR00000035,Medical_Institutional,Paid,Electronic_EDI,2023-05-24,2023-05-24,2023-05-25,2023-06-14,Auto_Adjudicated,21,1310400164,1267212691,207RN0300X,Nephrology,23,In_Network,K21.0,,revenue_code:0200,,0,ACA_Marketplace,ACA_Platinum,46,M,0.6598,,,23335.51,16656.6,12994.16,345.9,68.0,3248.54,6678.91,0.0,0.0,0,,0.0277,none,0,1,1,0,0,0.001203,0,0,,FFS
CLM0000000093,MBR00000208,Medical_Institutional,Paid,Electronic_EDI,2023-01-15,2023-01-15,2023-01-15,2023-02-14,Auto_Adjudicated,30,1262622669,1827839595,207RN0300X,Nephrology,23,In_Network,I10,Z00.00,revenue_code:0300,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,22660.72,15595.15,12421.77,13.93,54.0,3105.44,7065.57,0.0,0.0,0,,0.1466,none,0,1,1,0,0,0.00115,0,0,,Shared_Savings
CLM0000000094,MBR00000256,Medical_Professional,Paid,Electronic_EDI,2023-08-31,2023-08-31,2023-08-31,2023-09-03,Auto_Adjudicated,3,1260336577,1419347445,207RE0101X,Endocrinology,21,In_Network,Z00.00,,27447,,0,Commercial,HDHP_HSA,71,F,0.3642,,,9146.93,5126.28,3655.69,556.66,0.0,913.92,4020.65,0.0,0.0,0,,0.199,phantom_billing_indicator,0,1,0,0,0,0.000338,0,0,,FFS
CLM0000000095,MBR00000048,Medical_Professional,Paid,Electronic_EDI,2023-05-16,2023-05-16,2023-05-16,2023-06-10,Auto_Adjudicated,25,1673449362,1339359594,207RN0300X,Nephrology,23,In_Network,Z12.11,L70.0|Z00.01|Z79.4,99223,,0,Commercial,POS,27,F,0.639,,,622.9,240.63,128.93,54.47,25.0,32.23,382.27,0.0,0.0,0,,0.0031,none,0,1,0,0,0,1.2e-05,0,0,CDC_HbA1c_Poor_Control,Capitation
CLM0000000096,MBR00000211,Vision,Paid,Electronic_EDI,2023-05-01,2023-05-01,2023-05-01,2023-05-28,Manual_Review,27,1379875145,1473869105,207RE0101X,Endocrinology,11,In_Network,OTHER,M17.11|OTHER,V2320,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,,,113.95,76.61,51.22,0.59,12.0,12.8,37.34,32.07,16.72,0,,0.0881,none,0,1,0,0,0,5e-06,0,0,,Shared_Savings
CLM0000000097,MBR00000144,Vision,Paid,Electronic_EDI,2023-07-19,2023-07-19,2023-07-19,2023-08-16,Auto_Adjudicated,28,1183801932,1704466150,225100000X,Physical Therapist,22,In_Network,M54.5,J20.9|I10|OTHER,V2115,,0,Commercial,HDHP_HSA,56,F,2.5926,,,416.5,150.36,0.0,150.36,0.0,0.0,266.14,0.0,0.0,0,,0.0934,none,0,1,0,0,0,0.0,0,0,AWV_Annual_Wellness_Visit,Capitation
CLM0000000098,MBR00000257,Medical_Institutional,Paid,Electronic_EDI,2023-10-27,2023-10-27,2023-10-30,2023-11-13,Auto_Adjudicated,17,1900799244,1767402068,207RG0100X,Gastroenterology,11,In_Network,J06.9,OTHER|Z23,revenue_code:0450,,0,Medicaid_MCO,MCO,76,F,0.8322,,,14290.69,9703.65,9695.65,0.0,8.0,0.0,4587.04,6272.07,2453.4,0,,0.0516,none,0,1,1,0,0,0.000897,0,0,,FFS
CLM0000000099,MBR00000274,Medical_Institutional,Paid,Electronic_EDI,2023-01-02,2023-01-02,2023-01-04,2023-01-17,Clinical_Review,15,1331829614,1995553359,207V00000X,Obstetrics & Gynecology,22,In_Network,M47.816,N18.3,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,22981.71,8903.18,7054.96,38.48,46.0,1763.74,14078.53,0.0,0.0,0,,0.0491,none,0,1,1,1,0,0.000653,0,0,,FFS
CLM0000000100,MBR00000263,Medical_Professional,Paid,Electronic_EDI,2023-12-11,2023-12-11,2023-12-11,2023-12-29,Auto_Adjudicated,18,1089569577,1945682535,207R00000X,Internal Medicine,24,In_Network,H52.4,J20.9,97012,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,,,580.95,220.6,149.51,14.72,19.0,37.38,360.35,0.0,0.0,0,,0.1363,npi_mismatch,0,1,0,0,0,1.4e-05,0,0,PPC_Prenatal_Care,FFS
CLM0000000101,MBR00000020,Medical_Professional,Paid,Electronic_EDI,2023-08-18,2023-08-18,2023-08-18,2023-09-15,Auto_Adjudicated,28,1853403237,1304018750,207RE0101X,Endocrinology,11,In_Network,N18.3,N39.0|Z00.01,99232,,0,Medicare_Advantage,MA_PPO,63,F,0.7119,,,300.25,190.23,138.52,11.08,6.0,34.63,110.02,0.0,0.0,0,,0.0525,none,0,1,0,0,0,1.3e-05,0,0,SPD_Spirometry_Testing,FFS
CLM0000000102,MBR00000222,Medical_Professional,Paid,Electronic_EDI,2023-07-16,2023-07-16,2023-07-16,2023-08-12,Auto_Adjudicated,27,1172766349,1114756459,207RP1001X,Pulmonary Disease,11,In_Network,J06.9,F41.1,99395,,0,Commercial,PPO,48,F,0.6945,,,408.44,330.87,151.47,102.53,39.0,37.87,77.57,0.0,0.0,0,,0.1508,temporal_clustering,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000000103,MBR00000278,Pharmacy,Paid,Electronic_EDI,2023-01-19,2023-01-19,2023-01-19,2023-02-17,Auto_Adjudicated,29,1035707913,1809122260,207V00000X,Obstetrics & Gynecology,24,In_Network,OTHER,E11.9|OTHER,16590051660,,1,Commercial,HMO,49,M,0.4107,,,188.03,133.81,0.0,133.81,0.0,0.0,54.22,0.0,0.0,0,,0.0863,none,0,1,0,0,0,0.0,0,1,,Bundled_Payment
CLM0000000104,MBR00000185,Medical_Professional,Paid,Paper,2023-09-13,2023-09-13,2023-09-13,2023-10-13,Auto_Adjudicated,30,1981623199,1804282800,207R00000X,Internal Medicine,21,In_Network,J06.9,OTHER,17000,,0,Medicaid_MCO,MCO,73,M,1.5417,,,785.87,550.28,547.28,0.0,3.0,0.0,235.59,0.0,0.0,0,,0.1077,none,0,1,0,0,0,5.1e-05,0,0,,P4P
CLM0000000105,MBR00000181,Medical_Professional,Paid,Electronic_EDI,2023-09-16,2023-09-16,2023-09-16,2023-10-05,Auto_Adjudicated,19,1918160357,1649705287,207R00000X,Internal Medicine,21,In_Network,E78.5,Z00.00,99213,,0,Commercial,PPO,82,F,1.0432,,,325.92,243.56,158.52,17.41,28.0,39.63,82.36,0.0,0.0,0,,0.0381,none,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000000106,MBR00000013,Medical_Professional,Paid,Electronic_EDI,2023-07-21,2023-07-21,2023-07-21,2023-07-29,Auto_Adjudicated,8,1424104563,1898471307,207RP1001X,Pulmonary Disease,22,In_Network,OTHER,H52.4,97035,,0,Commercial,PPO,64,F,1.428,,,3140.26,1822.31,1109.59,422.32,13.0,277.4,1317.95,0.0,0.0,0,,0.0041,none,0,1,0,0,0,0.000103,0,0,W30_Well_Child_Visit,Bundled_Payment
CLM0000000107,MBR00000259,Medical_Professional,Paid,Paper,2023-10-15,2023-10-15,2023-10-15,2023-10-20,Auto_Adjudicated,5,1965682436,1887266184,2084P0800X,Psychiatry,22,In_Network,OTHER,,99396,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,129.55,92.61,60.88,9.51,7.0,15.22,36.94,0.0,0.0,0,,0.0431,none,0,1,0,0,0,6e-06,0,0,,Bundled_Payment
CLM0000000108,MBR00000014,Medical_Institutional,Paid,Provider_Portal,2023-10-29,2023-10-29,2023-10-31,2023-11-25,Auto_Adjudicated,27,1272115456,1791502603,2086S0122X,Orthopedic Surgery,11,In_Network,OTHER,Z00.01,revenue_code:0360,,0,Commercial,HMO,77,M,2.8513,,,40535.49,23879.67,19041.47,42.84,35.0,4760.37,16655.82,0.0,0.0,0,,0.0579,none,0,1,1,0,0,0.001762,0,0,,FFS
CLM0000000109,MBR00000100,Medical_Institutional,Denied,Electronic_EDI,2023-10-29,2023-10-29,2023-10-31,2023-11-03,Auto_Adjudicated,5,1154652946,1878874025,207RP1001X,Pulmonary Disease,24,In_Network,N39.0,,revenue_code:0120,,0,ACA_Marketplace,ACA_Gold,87,M,1.435,2,Timely_Filing,18971.22,15648.55,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1398,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000110,MBR00000279,Medical_Institutional,Paid,Electronic_EDI,2023-04-28,2023-04-28,2023-04-29,2023-05-01,Auto_Adjudicated,3,1881170383,1320546364,246ZN0300X,Neuropsychology,11,In_Network,OTHER,Z00.00,revenue_code:0370,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,,,16965.68,11980.57,9532.36,35.12,30.0,2383.09,4985.11,0.0,0.0,0,,0.0487,none,0,1,1,0,0,0.000882,0,0,,Bundled_Payment
CLM0000000111,MBR00000288,Medical_Institutional,Paid,Electronic_EDI,2023-08-30,2023-08-30,2023-09-02,2023-09-14,Auto_Adjudicated,15,1298243993,1029818813,207RE0101X,Endocrinology,31,In_Network,I10,Z00.00,revenue_code:0100,,0,Commercial,HMO,36,M,0.8408,,,4018.07,2012.83,1493.29,68.22,78.0,373.32,2005.24,0.0,0.0,0,,0.1727,phantom_billing_indicator,0,1,0,0,0,0.000138,0,0,,Shared_Savings
CLM0000000112,MBR00000298,Medical_Institutional,Paid,Electronic_EDI,2023-01-21,2023-01-21,2023-01-23,2023-02-13,Auto_Adjudicated,23,1388566092,1811797489,207RG0100X,Gastroenterology,24,In_Network,OTHER,,revenue_code:0110,,0,Medicaid_MCO,MCO,75,M,0.8324,,,35618.87,18970.09,18970.09,0.0,0.0,0.0,16648.78,0.0,0.0,0,,0.0663,none,0,1,1,1,0,0.001756,0,0,,Shared_Savings
CLM0000000113,MBR00000146,Pharmacy,Paid,Electronic_EDI,2023-07-21,2023-07-21,2023-07-21,2023-08-13,Auto_Adjudicated,23,1825861601,1406199453,246ZN0300X,Neuropsychology,11,In_Network,OTHER,F32.9|OTHER,00078043215,,1,Medicaid_MCO,MCO,24,M,0.6484,,,76.03,50.92,46.92,0.0,4.0,0.0,25.11,0.0,0.0,0,,0.1169,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000000114,MBR00000056,Medical_Professional,Paid,Electronic_EDI,2023-02-22,2023-02-22,2023-02-22,2023-03-02,Auto_Adjudicated,8,1033622184,1607833568,225100000X,Physical Therapist,24,In_Network,Z23,,97140,,0,Commercial,EPO,74,F,1.3941,,,1895.29,1113.46,851.05,38.65,11.0,212.76,781.83,0.0,0.0,0,,0.183,provider_specialty_mismatch,0,1,0,0,0,7.9e-05,0,0,,Shared_Savings
CLM0000000115,MBR00000152,Medical_Professional,Partially_Paid,Electronic_EDI,2023-04-21,2023-04-21,2023-04-21,2023-05-07,Manual_Review,16,1012271279,1123879500,101YP2500X,Psychologist Clinical,23,In_Network,E11.9,M54.5|OTHER,90853,,0,Commercial,HMO,82,F,1.2506,256,Medical_Necessity,462.03,197.69,0.0,117.14,0.0,0.0,344.89,0.0,0.0,0,,0.1168,npi_mismatch,0,1,0,0,0,0.0,0,0,,P4P
CLM0000000116,MBR00000031,Dental,Denied,Electronic_EDI,2023-08-31,2023-08-31,2023-08-31,2023-09-27,Auto_Adjudicated,27,1033622184,1685903362,207Q00000X,Family Medicine,81,In_Network,OTHER,,D0120,,0,Commercial,PPO,71,M,0.6746,96,Eligibility,875.84,583.93,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0475,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000117,MBR00000263,Pharmacy,Paid,Electronic_EDI,2023-06-02,2023-06-02,2023-06-02,2023-06-26,Auto_Adjudicated,24,1298243993,1510751265,207R00000X,Internal Medicine,23,In_Network,K21.0,Z23|I10,00085163102,,1,Medicare_Advantage,MA_HMO,29,F,1.5001,,,106.72,70.36,24.76,20.41,19.0,6.19,36.36,0.0,0.0,0,,0.13,benford_violation|billing_spike_recent,0,1,0,1,0,2e-06,0,0,,FFS
CLM0000000118,MBR00000169,Medical_Institutional,Denied,Provider_Portal,2023-11-06,2023-11-06,2023-11-09,2023-12-04,Auto_Adjudicated,28,1231231881,1728466420,225100000X,Physical Therapist,21,In_Network,OTHER,F32.9,revenue_code:0100,683,0,Commercial,EPO,30,M,1.4348,3,Medical_Necessity,5446.13,1951.66,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.177,billing_spike_recent,0,1,0,1,1,0.0,0,0,AMR_Asthma_Medication_Ratio,Bundled_Payment
CLM0000000119,MBR00000129,Medical_Professional,Paid,Electronic_EDI,2023-02-01,2023-02-01,2023-02-01,2023-02-25,Manual_Review,24,1207676414,1228356980,207RE0101X,Endocrinology,22,In_Network,OTHER,Z79.4|M17.11,70553,,0,Medicare_Advantage,MA_PPO,9,F,0.8196,,,630.97,341.31,251.74,9.63,17.0,62.94,289.66,0.0,0.0,0,,0.0186,none,0,1,0,0,0,2.3e-05,0,0,,FFS
CLM0000000120,MBR00000024,Medical_Professional,Denied,Electronic_EDI,2023-12-15,2023-12-15,2023-12-15,2023-12-18,Manual_Review,3,1213747973,1007652766,207RN0300X,Nephrology,23,In_Network,OTHER,K21.0,80053,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,CO-45,Timely_Filing,401.48,287.57,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0235,none,0,1,0,1,0,0.0,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000000121,MBR00000129,Medical_Professional,Paid,Electronic_EDI,2023-09-11,2023-09-11,2023-09-11,2023-09-18,Auto_Adjudicated,7,1677021292,1112696614,2086S0122X,Orthopedic Surgery,24,In_Network,J06.9,I10,99383,,0,Medicare_Advantage,MA_PPO,9,F,0.8196,,,255.57,112.55,74.13,2.88,17.0,18.53,143.02,0.0,0.0,0,,0.126,none,0,1,0,1,0,7e-06,0,0,,FFS
CLM0000000122,MBR00000262,Dental,Denied,Paper,2023-06-04,2023-06-04,2023-06-04,2023-06-10,Auto_Adjudicated,6,1069440570,1301833092,207RP1001X,Pulmonary Disease,22,In_Network,C50.911,Z87.891|J06.9,D2391,,0,Medicare_Advantage,PFFS,77,F,1.7452,18,COB,994.18,771.62,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1141,high_volume_same_code,0,1,0,0,0,0.0,0,0,MPT_Annual_Monitoring,FFS
CLM0000000123,MBR00000208,Medical_Institutional,Paid,Electronic_EDI,2023-01-09,2023-01-09,2023-01-12,2023-01-13,Auto_Adjudicated,4,1331829614,1985590322,207Q00000X,Family Medicine,31,In_Network,Z00.121,OTHER,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,7651.27,4849.24,3833.72,3.09,54.0,958.43,2802.03,0.0,0.0,0,,0.1582,temporal_clustering,0,1,0,0,0,0.000355,0,0,,FFS
CLM0000000124,MBR00000025,Medical_Professional,Paid,Electronic_EDI,2023-01-15,2023-01-15,2023-01-15,2023-02-10,Clinical_Review,26,1411619682,1607833568,207RP1001X,Pulmonary Disease,11,In_Network,Z23,Z23,99213,,0,Commercial,POS,74,M,1.3309,,,313.73,173.63,38.19,100.89,25.0,9.55,140.1,0.0,0.0,0,,0.0985,none,0,1,0,0,0,4e-06,0,0,,Shared_Savings
CLM0000000125,MBR00000051,Medical_Professional,Paid,Electronic_EDI,2023-05-29,2023-05-29,2023-05-29,2023-06-20,Auto_Adjudicated,22,1327415110,1747596016,207R00000X,Internal Medicine,81,In_Network,Z00.01,E11.9,33510,,0,Medicare_Advantage,MA_PPO,17,F,1.0695,,,2055.93,1734.04,1358.12,22.39,14.0,339.53,321.89,0.0,0.0,0,,0.0067,none,0,1,0,0,0,0.000126,0,0,TRC_Transition_of_Care,FFS
CLM0000000126,MBR00000125,Medical_Professional,Paid,Electronic_EDI,2023-07-25,2023-07-25,2023-07-25,2023-08-22,Auto_Adjudicated,28,1664872214,1587454801,2084P0800X,Psychiatry,11,In_Network,H52.4,OTHER|E11.9,47562,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,797.22,533.28,411.61,7.77,11.0,102.9,263.94,0.0,0.0,0,,0.0192,none,0,1,0,0,0,3.8e-05,0,0,,P4P
CLM0000000127,MBR00000030,Medical_Professional,Paid,Electronic_EDI,2023-07-01,2023-07-01,2023-07-01,2023-07-11,Auto_Adjudicated,10,1887698203,1450837722,225100000X,Physical Therapist,11,In_Network,M54.5,I10,10060,,0,Medicaid_MCO,MCO,67,M,0.4581,,,1483.73,1206.12,1203.12,0.0,3.0,0.0,277.61,0.0,0.0,0,,0.068,billing_spike_recent,0,1,0,0,0,0.000111,0,0,,Capitation
CLM0000000128,MBR00000282,Medical_Institutional,Paid,Electronic_EDI,2023-04-17,2023-04-17,2023-04-20,2023-05-17,Auto_Adjudicated,30,1526973051,1365397818,207R00000X,Internal Medicine,11,Out_of_Network,I10,F10.10|M54.5|Z23,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,16,M,0.7304,,,20770.78,17645.77,14084.9,2.64,37.0,3521.23,3125.01,0.0,0.0,0,,0.0945,none,0,1,1,0,0,0.001304,0,0,MPT_Annual_Monitoring,Bundled_Payment
CLM0000000129,MBR00000194,Medical_Professional,Denied,Electronic_EDI,2023-08-22,2023-08-22,2023-08-22,2023-09-19,Clinical_Review,28,1091395764,1619587398,207Q00000X,Family Medicine,65,In_Network,Z00.00,,11200,,0,Commercial,PPO,77,M,0.9783,97,COB,1357.62,786.82,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1687,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000130,MBR00000028,Dental,Paid,Electronic_EDI,2023-08-09,2023-08-09,2023-08-09,2023-08-13,Manual_Review,4,1932483309,1339359594,2086S0122X,Orthopedic Surgery,24,In_Network,M54.5,,D2391,,0,Commercial,HMO,3,F,2.116,,,347.04,184.23,32.82,129.21,14.0,8.2,162.81,0.0,0.0,0,,0.0859,none,0,1,0,1,0,3e-06,0,0,,Shared_Savings
CLM0000000131,MBR00000233,Pharmacy,Paid,Electronic_EDI,2023-05-04,2023-05-04,2023-05-04,2023-05-31,Auto_Adjudicated,27,1002224900,1994275960,207RE0101X,Endocrinology,22,In_Network,M17.11,K21.0,16590051660,,1,Medicare_Advantage,MA_PPO,87,M,0.8034,,,299.09,234.52,155.37,37.31,3.0,38.84,64.57,0.0,0.0,0,,0.0138,none,0,1,0,0,0,1.4e-05,0,1,,FFS
CLM0000000132,MBR00000117,Dental,Paid,Electronic_EDI,2023-04-27,2023-04-27,2023-04-27,2023-05-01,Auto_Adjudicated,4,1196858674,1554490060,207RE0101X,Endocrinology,65,In_Network,Z00.00,OTHER|I25.10,D7140,,0,Medicaid_MCO,MLTSS,72,F,0.8628,,,1069.06,379.68,375.68,0.0,4.0,0.0,689.38,0.0,0.0,0,,0.1711,temporal_clustering,0,1,0,1,0,3.5e-05,0,0,,Shared_Savings
CLM0000000133,MBR00000076,Dental,Paid,Electronic_EDI,2023-06-08,2023-06-08,2023-06-08,2023-06-22,Manual_Review,14,1313352855,1738617370,208600000X,Surgery General,11,In_Network,E11.65,,D2391,,0,Commercial,HMO,26,M,2.1785,,,296.22,172.18,76.8,44.18,32.0,19.2,124.04,0.0,0.0,0,,0.0649,phantom_billing_indicator,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000000134,MBR00000171,Vision,Paid,Electronic_EDI,2023-09-24,2023-09-24,2023-09-24,2023-09-30,Auto_Adjudicated,6,1167433253,1575884274,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,,92014,,0,Commercial,PPO,27,F,0.819,,,354.36,238.14,0.0,238.14,0.0,0.0,116.22,0.0,0.0,0,,0.1147,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000135,MBR00000004,Behavioral_Health,Denied,Paper,2023-07-30,2023-07-30,2023-07-30,2023-08-17,Auto_Adjudicated,18,1826043246,1098360555,207Q00000X,Family Medicine,11,In_Network,J44.1,K29.70|OTHER|C50.911,99284,,0,Medicare_Advantage,MA_PPO,68,M,1.23,170,Medical_Necessity,160.87,121.49,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1411,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000136,MBR00000144,Medical_Professional,Paid,Electronic_EDI,2023-02-15,2023-02-15,2023-02-15,2023-02-16,Auto_Adjudicated,1,1929402739,1706603847,225100000X,Physical Therapist,22,In_Network,N39.0,E78.5,71250,,0,Commercial,HDHP_HSA,56,F,2.5926,,,1393.42,965.03,155.07,771.19,0.0,38.77,428.39,0.0,0.0,0,,0.0482,none,0,1,0,0,0,1.4e-05,0,0,,Shared_Savings
CLM0000000137,MBR00000253,Medical_Professional,Paid,Electronic_EDI,2023-11-28,2023-11-28,2023-11-28,2023-12-24,Auto_Adjudicated,26,1101385540,1354959095,246ZN0300X,Neuropsychology,22,Emergency,E11.9,OTHER,99284,,0,Commercial,EPO,44,M,0.3882,,,124.68,44.89,0.0,44.89,0.0,0.0,79.79,0.0,0.0,0,,0.0648,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000138,MBR00000279,Medical_Professional,Paid,Electronic_EDI,2023-03-14,2023-03-14,2023-03-14,2023-03-29,Auto_Adjudicated,15,1102590784,1477113725,208600000X,Surgery General,11,In_Network,K21.0,,71046,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,,,547.9,376.67,292.29,2.31,9.0,73.07,171.23,0.0,0.0,0,,0.0865,none,0,1,0,0,0,2.7e-05,0,0,,FFS
CLM0000000139,MBR00000107,Medical_Institutional,Paid,Electronic_EDI,2023-08-30,2023-08-30,2023-09-03,2023-09-26,Auto_Adjudicated,27,1097600151,1747935894,246ZN0300X,Neuropsychology,11,In_Network,J44.1,,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,44,M,1.0439,,,31106.01,21041.69,16799.06,11.86,31.0,4199.77,10064.32,0.0,0.0,0,,0.0331,none,0,1,1,0,0,0.001555,0,0,,P4P
CLM0000000140,MBR00000191,Pharmacy,Paid,Electronic_EDI,2023-01-07,2023-01-07,2023-01-07,2023-01-21,Auto_Adjudicated,14,1476262171,1228356980,101YP2500X,Psychologist Clinical,21,In_Network,OTHER,,00003014960,,1,Commercial,POS,85,F,0.9729,,,166.07,58.89,0.0,41.39,17.5,0.0,107.18,0.0,0.0,0,,0.0875,none,0,1,0,0,0,0.0,0,1,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000000141,MBR00000071,Medical_Professional,Paid,Electronic_EDI,2023-04-02,2023-04-02,2023-04-02,2023-04-19,Manual_Review,17,1770738194,1560230600,2084P0800X,Psychiatry,11,In_Network,OTHER,,99203,,0,Commercial,EPO,19,F,0.5699,,,117.35,58.62,14.09,19.01,22.0,3.52,58.73,11.28,2.16,0,,0.1273,none,0,1,0,0,0,1e-06,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000000142,MBR00000169,Pharmacy,Paid,Electronic_EDI,2023-07-22,2023-07-22,2023-07-22,2023-08-14,Auto_Adjudicated,23,1476262171,1450837722,207RC0000X,Cardiovascular Disease,22,In_Network,K21.0,OTHER,50458085930,,1,Commercial,EPO,30,M,1.4348,,,101.26,59.23,0.0,59.23,0.0,0.0,42.03,0.0,0.0,0,,0.076,service_date_weekend,0,1,0,1,0,0.0,0,1,AWV_Annual_Wellness_Visit,Capitation
CLM0000000143,MBR00000078,Pharmacy,Paid,Electronic_EDI,2023-11-01,2023-11-01,2023-11-01,2023-12-01,Auto_Adjudicated,30,1739169232,1587454801,207RE0101X,Endocrinology,22,In_Network,I10,,00006001954,,2,Commercial,EPO,65,F,1.3174,,,108.48,72.28,0.0,72.28,0.0,0.0,36.2,0.0,0.0,0,,0.0903,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000144,MBR00000171,Medical_Institutional,Paid,Electronic_EDI,2023-07-22,2023-07-22,2023-07-24,2023-08-03,Auto_Adjudicated,12,1732726112,1747596016,101YP2500X,Psychologist Clinical,11,In_Network,C50.911,K21.0,revenue_code:0250,,0,Commercial,PPO,27,F,0.819,,,51784.64,35742.78,28506.53,44.62,65.0,7126.63,16041.86,0.0,0.0,0,,0.1705,outlier_billing_amount,0,1,1,0,0,0.002639,0,0,,FFS
CLM0000000145,MBR00000054,Medical_Institutional,Paid,Provider_Portal,2023-01-20,2023-01-20,2023-01-21,2023-02-05,Auto_Adjudicated,16,1900781649,1576271272,225100000X,Physical Therapist,11,In_Network,OTHER,,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,,,25585.53,15909.03,12686.47,5.94,45.0,3171.62,9676.5,0.0,0.0,0,,0.0964,none,0,1,1,0,0,0.001174,0,0,CDC_HbA1c_Poor_Control,Shared_Savings
CLM0000000146,MBR00000285,Medical_Professional,Partially_Paid,Electronic_EDI,2023-12-10,2023-12-10,2023-12-10,2023-12-20,Manual_Review,10,1808451151,1402472115,207RG0100X,Gastroenterology,23,In_Network,OTHER,G47.33|F41.1|I10,33510,,0,Commercial,HDHP_HSA,56,M,0.9226,5,Medical_Necessity,1258.04,1065.0,483.0,62.93,0.0,120.75,591.35,416.01,59.47,0,,0.0167,none,0,1,0,0,0,4.5e-05,0,0,,P4P
CLM0000000147,MBR00000269,Medical_Institutional,Denied,Electronic_EDI,2023-04-08,2023-04-08,2023-04-11,2023-04-10,Auto_Adjudicated,2,1026612378,1738617370,207RG0100X,Gastroenterology,24,Emergency,OTHER,,revenue_code:0250,,0,Commercial,EPO,10,F,0.718,170,Duplicate,4144.81,2872.2,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0009,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000148,MBR00000106,Medical_Professional,Paid,Electronic_EDI,2023-05-11,2023-05-11,2023-05-11,2023-06-07,Auto_Adjudicated,27,1170319307,1300957944,207RN0300X,Nephrology,22,In_Network,E78.5,,47562,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,674.93,291.99,212.67,20.16,6.0,53.17,382.94,0.0,0.0,0,,0.0955,none,0,1,0,0,0,2e-05,0,0,DAE_Drug_Alcohol_Dependence,FFS
CLM0000000149,MBR00000229,Medical_Institutional,Paid,Electronic_EDI,2023-02-08,2023-02-08,2023-02-11,2023-02-25,Auto_Adjudicated,17,1682685390,1355732274,2086S0122X,Orthopedic Surgery,22,In_Network,OTHER,L70.0|K21.0,revenue_code:0370,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,50908.07,36360.48,29041.58,4.51,54.0,7260.39,14547.59,0.0,0.0,0,,0.1182,outlier_billing_amount,0,1,1,1,0,0.002688,0,0,,FFS
CLM0000000150,MBR00000028,Medical_Professional,Paid,Paper,2023-09-07,2023-09-07,2023-09-07,2023-09-19,Auto_Adjudicated,12,1881170383,1054984734,2084P0800X,Psychiatry,81,In_Network,Z00.00,J06.9|F32.9,99387,,0,Commercial,HMO,3,F,2.116,,,449.21,205.44,7.48,182.09,14.0,1.87,243.77,0.0,0.0,0,,0.027,none,0,1,0,0,0,1e-06,0,0,HBD_Hemoglobin_A1c_Testing,Shared_Savings
CLM0000000151,MBR00000217,Medical_Professional,Paid,Electronic_EDI,2023-06-10,2023-06-10,2023-06-10,2023-07-04,Manual_Review,24,1082088479,1197700958,2084P0800X,Psychiatry,24,In_Network,Z00.00,I25.10,99385,,0,ACA_Marketplace,ACA_Bronze,11,F,1.1619,,,222.63,96.63,0.0,96.63,0.0,0.0,126.0,0.0,0.0,0,,0.1618,high_volume_same_code|duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000152,MBR00000088,Medical_Institutional,Paid,Electronic_EDI,2023-03-20,2023-03-20,2023-03-22,2023-04-14,Manual_Review,25,1869706360,1319611206,207RG0100X,Gastroenterology,21,Out_of_Network,I50.9,Z00.121,revenue_code:0450,194,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,,,25442.55,16926.98,11523.34,375.07,90.0,4938.57,8515.57,0.0,0.0,0,,0.192,unusual_service_frequency,0,1,1,0,0,0.001067,0,0,SPD_Spirometry_Testing,Shared_Savings
CLM0000000153,MBR00000042,Medical_Institutional,Paid,Electronic_EDI,2023-08-17,2023-08-17,2023-08-18,2023-09-16,Auto_Adjudicated,30,1046058495,1489993356,207V00000X,Obstetrics & Gynecology,31,Out_of_Network,Z00.01,OTHER|E13.9,revenue_code:0120,,0,Commercial,HMO,78,F,1.1448,,,3948.34,2397.82,1844.4,22.33,70.0,461.1,1550.52,0.0,0.0,0,,0.1814,billing_spike_recent,0,1,0,0,0,0.000171,1,0,,FFS
CLM0000000154,MBR00000201,Medical_Professional,Paid,Provider_Portal,2023-03-12,2023-03-12,2023-03-12,2023-03-26,Auto_Adjudicated,14,1429653002,1564691686,208600000X,Surgery General,22,Emergency,Z12.11,OTHER|I10,10060,,0,Medicare_Advantage,MA_PPO,74,M,1.1575,,,369.18,303.94,233.52,6.05,6.0,58.38,65.24,0.0,0.0,0,,0.1389,unusual_service_frequency,0,1,0,0,0,2.2e-05,0,0,,FFS
CLM0000000155,MBR00000144,Vision,Paid,Electronic_EDI,2023-07-10,2023-07-10,2023-07-10,2023-07-14,Manual_Review,4,1469009511,1827839595,207RE0101X,Endocrinology,22,In_Network,Z00.00,I10,92002,,0,Commercial,HDHP_HSA,56,F,2.5926,,,111.91,71.79,0.0,71.79,0.0,0.0,40.12,0.0,0.0,0,,0.0661,none,0,1,0,0,0,0.0,0,0,W30_Well_Child_Visit,Capitation
CLM0000000156,MBR00000161,Medical_Professional,Paid,Electronic_EDI,2023-08-27,2023-08-27,2023-08-27,2023-09-11,Manual_Review,15,1539066691,1007652766,207RP1001X,Pulmonary Disease,23,In_Network,Z00.01,OTHER,71046,,0,Medicaid_MCO,MLTSS,9,F,0.8354,,,621.85,379.88,375.88,0.0,4.0,0.0,241.97,0.0,0.0,0,,0.2329,unusual_service_frequency|diagnosis_procedure_mismatch,0,2,0,0,0,3.5e-05,0,0,,FFS
CLM0000000157,MBR00000159,Dental,Paid,Electronic_EDI,2023-10-19,2023-10-19,2023-10-19,2023-11-02,Auto_Adjudicated,14,1711104790,1320546364,208600000X,Surgery General,21,In_Network,E11.9,,D3310,,0,Commercial,PPO,70,F,1.2009,,,527.1,220.42,141.35,29.73,14.0,35.34,306.68,0.0,0.0,0,,0.1747,geographic_mismatch,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000000158,MBR00000017,Medical_Professional,Paid,Electronic_EDI,2023-09-07,2023-09-07,2023-09-07,2023-09-14,Auto_Adjudicated,7,1379875145,1318978078,207Q00000X,Family Medicine,32,In_Network,J20.9,,97010,,0,Commercial,PPO,55,F,0.6174,,,342.62,267.5,162.21,25.74,39.0,40.55,75.12,0.0,0.0,0,,0.096,none,0,1,0,0,0,1.5e-05,0,0,,Bundled_Payment
CLM0000000159,MBR00000014,Medical_Professional,Paid,Electronic_EDI,2023-07-23,2023-07-23,2023-07-23,2023-08-10,Auto_Adjudicated,18,1433357203,1588993671,207RG0100X,Gastroenterology,11,In_Network,M54.5,,99385,,0,Commercial,HMO,77,M,2.8513,,,274.05,139.35,0.0,115.09,24.26,0.0,134.7,0.0,0.0,0,,0.093,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000000160,MBR00000181,Behavioral_Health,Paid,Electronic_EDI,2023-01-13,2023-01-13,2023-01-13,2023-01-26,Manual_Review,13,1466478716,1098360555,2084P0800X,Psychiatry,21,In_Network,E11.65,,43239,,0,Commercial,PPO,82,F,1.0432,,,148.17,82.74,42.31,1.85,28.0,10.58,65.43,0.0,0.0,0,,0.1591,benford_violation,0,1,0,1,0,4e-06,0,0,,FFS
CLM0000000161,MBR00000186,Pharmacy,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-25,2023-04-21,Auto_Adjudicated,27,1899326088,1330485436,208600000X,Surgery General,11,In_Network,R05.9,Z79.4|OTHER|K57.30,00071015523,,3,Commercial,PPO,65,M,1.6983,,,116.63,70.14,42.59,4.9,12.0,10.65,46.49,0.0,0.0,0,,0.1539,unusual_service_frequency,0,1,0,0,0,4e-06,0,0,,P4P
CLM0000000162,MBR00000014,Medical_Institutional,Paid,Electronic_EDI,2023-07-27,2023-07-27,2023-07-31,2023-07-29,Auto_Adjudicated,2,1556434733,1319611206,101YP2500X,Psychologist Clinical,23,In_Network,Z00.00,Z00.00|I50.9,revenue_code:0250,,0,Commercial,HMO,77,M,2.8513,,,4889.92,4050.07,3012.8,249.07,35.0,753.2,839.85,0.0,0.0,0,,0.0922,none,0,1,0,0,0,0.000279,0,0,,Capitation
CLM0000000163,MBR00000120,Pharmacy,Paid,Electronic_EDI,2023-07-12,2023-07-12,2023-07-12,2023-08-03,Manual_Review,22,1637260822,1433350836,207RG0100X,Gastroenterology,11,In_Network,OTHER,,00069420020,,1,Commercial,PPO,62,F,1.0823,,,505.2,242.13,0.0,242.13,0.0,0.0,263.07,0.0,0.0,0,,0.194,temporal_clustering|controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000164,MBR00000184,Medical_Institutional,Paid,Electronic_EDI,2023-07-11,2023-07-11,2023-07-12,2023-07-30,Auto_Adjudicated,19,1971354640,1318978078,207R00000X,Internal Medicine,21,In_Network,Z00.00,,revenue_code:0110,292,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,6731.18,4660.65,4660.65,0.0,0.0,0.0,2070.53,0.0,0.0,0,,0.0766,none,0,1,0,0,0,0.000431,0,0,MMA_Medication_Management,FFS
CLM0000000165,MBR00000196,Pharmacy,Paid,Electronic_EDI,2023-09-22,2023-09-22,2023-09-22,2023-09-29,Auto_Adjudicated,7,1456447970,1388050552,207RN0300X,Nephrology,32,Out_of_Network,OTHER,E11.9,50458085930,,2,Commercial,PPO,16,F,1.6015,,,153.32,107.75,0.0,107.75,0.0,0.0,45.57,0.0,0.0,0,,0.0412,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000166,MBR00000247,Medical_Professional,Paid,Electronic_EDI,2023-11-21,2023-11-21,2023-11-21,2023-12-02,Auto_Adjudicated,11,1550698436,1061113875,207RN0300X,Nephrology,11,In_Network,OTHER,K21.0,99205,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,220.64,79.98,44.63,19.19,5.0,11.16,140.66,0.0,0.0,0,,0.125,none,0,1,0,0,0,4e-06,0,0,,Shared_Savings
CLM0000000167,MBR00000133,Pharmacy,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-26,Auto_Adjudicated,26,1522998767,1296566243,207RN0300X,Nephrology,11,In_Network,OTHER,E13.9|R05.9,00169751112,,4,Medicaid_MCO,MCO,57,M,0.9592,,,240.83,131.54,130.54,0.0,1.0,0.0,109.29,0.0,0.0,0,,0.0679,controlled_substance_high_volume,0,1,0,0,0,1.2e-05,0,1,MMA_Medication_Management,FFS
CLM0000000168,MBR00000166,Vision,Paid,Electronic_EDI,2023-02-18,2023-02-18,2023-02-18,2023-03-01,Auto_Adjudicated,11,1147937670,1577226132,2084P0800X,Psychiatry,22,In_Network,J20.9,Z12.11|N40.0|OTHER,V2100,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,996.65,369.16,157.39,100.32,44.0,67.45,627.49,0.0,0.0,0,,0.0991,none,0,1,0,0,0,1.5e-05,0,0,,Capitation
CLM0000000169,MBR00000175,Dental,Paid,Electronic_EDI,2023-06-08,2023-06-08,2023-06-08,2023-06-28,Auto_Adjudicated,20,1086690796,1896197144,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,E11.9,D0150,,0,Commercial,PPO,14,F,1.5785,,,1917.76,810.33,593.45,58.52,10.0,148.36,1107.43,0.0,0.0,0,,0.2244,high_volume_same_code|duplicate_claim_indicator,0,2,0,0,0,5.5e-05,0,0,,FFS
CLM0000000170,MBR00000099,Pharmacy,Paid,Electronic_EDI,2023-04-01,2023-04-01,2023-04-01,2023-04-17,Auto_Adjudicated,16,1804302686,1986847322,207RG0100X,Gastroenterology,11,Out_of_Network,I10,,00071015523,,2,Commercial,HMO,10,F,0.7843,,,157.12,61.09,27.38,11.87,15.0,6.84,96.03,0.0,0.0,0,,0.022,none,0,1,0,0,0,3e-06,1,1,CBP_Controlling_BP,Capitation
CLM0000000171,MBR00000014,Pharmacy,Paid,Electronic_EDI,2023-07-09,2023-07-09,2023-07-09,2023-08-05,Manual_Review,27,1594322174,1622950074,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,Z00.01|I10,00169751112,,2,Commercial,HMO,77,M,2.8513,,,261.51,124.59,0.0,124.59,0.0,0.0,136.92,0.0,0.0,0,,0.1208,billing_spike_recent|upcoding_pattern,0,1,0,1,0,0.0,0,1,,FFS
CLM0000000172,MBR00000002,Medical_Institutional,Paid,Electronic_EDI,2023-07-31,2023-07-31,2023-07-31,2023-08-20,Manual_Review,20,1218947226,1575884274,207RC0000X,Cardiovascular Disease,11,In_Network,Z00.00,F32.9,revenue_code:0120,,0,Commercial,PPO,42,F,0.9012,,,29829.41,20784.08,16542.5,69.96,36.0,4135.62,9045.33,0.0,0.0,0,,0.0126,none,0,1,1,0,0,0.001531,0,0,SPC_Statin_Therapy,Shared_Savings
CLM0000000173,MBR00000250,Medical_Professional,Paid,Electronic_EDI,2023-07-16,2023-07-16,2023-07-16,2023-08-11,Auto_Adjudicated,26,1855186422,1034732777,207RG0100X,Gastroenterology,11,In_Network,J20.9,M54.5,99284,,0,Commercial,PPO,41,M,0.9245,,,537.97,228.16,0.0,228.16,0.0,0.0,309.81,0.0,0.0,0,,0.0927,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000174,MBR00000061,Dental,Paid,Electronic_EDI,2023-07-28,2023-07-28,2023-07-28,2023-08-25,Auto_Adjudicated,28,1976612978,1489993356,207R00000X,Internal Medicine,24,In_Network,F32.9,F32.9|Z00.01,D1110,,0,Commercial,PPO,66,M,2.3575,,,528.42,289.3,121.74,124.13,13.0,30.43,239.12,0.0,0.0,0,,0.0104,none,0,1,0,0,0,1.1e-05,0,0,,Bundled_Payment
CLM0000000175,MBR00000187,Medical_Institutional,Paid,Provider_Portal,2023-04-22,2023-04-22,2023-04-25,2023-04-26,Auto_Adjudicated,4,1571330665,1767402068,246ZN0300X,Neuropsychology,11,In_Network,OTHER,E11.9,revenue_code:0360,,0,Medicaid_MCO,MCO,36,F,1.191,,,33996.5,21636.61,21629.61,0.0,7.0,0.0,12359.89,0.0,0.0,0,,0.0399,none,0,1,1,0,0,0.002002,0,0,,FFS
CLM0000000176,MBR00000174,Medical_Institutional,Paid,Electronic_EDI,2023-03-05,2023-03-05,2023-03-05,2023-03-31,Auto_Adjudicated,26,1298243993,1447186817,208600000X,Surgery General,22,In_Network,J45.20,,revenue_code:0370,,0,Medicare_Advantage,MA_HMO,85,M,0.3901,,,18214.2,8237.05,6531.82,14.27,58.0,1632.96,9977.15,0.0,0.0,0,,0.0818,geographic_mismatch,0,1,1,0,0,0.000605,0,0,CBP_Controlling_BP,FFS
CLM0000000177,MBR00000128,Pharmacy,Paid,Electronic_EDI,2023-11-03,2023-11-03,2023-11-03,2023-12-02,Manual_Review,29,1770431137,1887266184,207R00000X,Internal Medicine,11,In_Network,M54.5,J06.9|OTHER,00003014960,,1,Commercial,PPO,13,F,1.4203,,,250.59,120.09,0.0,120.09,0.0,0.0,130.5,0.0,0.0,1,Upcoding,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|benford_violation|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.0,0,1,,Capitation
CLM0000000178,MBR00000249,Medical_Professional,Paid,Electronic_EDI,2023-05-25,2023-05-25,2023-05-25,2023-05-27,Auto_Adjudicated,2,1098094939,1220755708,207RN0300X,Nephrology,71,In_Network,I10,,11200,,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,742.57,466.23,49.98,364.82,30.0,21.42,276.34,0.0,0.0,0,,0.1325,none,0,1,0,0,0,5e-06,0,0,,Capitation
CLM0000000179,MBR00000207,Pharmacy,Partially_Paid,Provider_Portal,2023-03-16,2023-03-16,2023-03-16,2023-03-30,Manual_Review,14,1836409547,1282319940,225100000X,Physical Therapist,24,In_Network,OTHER,,00085163102,,3,Medicaid_MCO,MLTSS,11,F,1.6522,170,Medical_Necessity,245.21,171.61,116.93,0.0,0.0,0.0,128.28,0.0,0.0,0,,0.0378,none,0,1,0,0,0,1.1e-05,0,1,,FFS
CLM0000000180,MBR00000007,Pharmacy,Paid,Paper,2023-12-24,2023-12-24,2023-12-24,2024-01-01,Auto_Adjudicated,8,1243349799,1522426351,207R00000X,Internal Medicine,21,In_Network,OTHER,M54.5,59148001506,,1,Commercial,HDHP_HSA,72,F,0.7578,,,63.48,37.32,0.0,37.32,0.0,0.0,26.16,0.0,0.0,0,,0.0782,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000181,MBR00000229,Medical_Professional,Paid,Electronic_EDI,2023-01-12,2023-01-12,2023-01-12,2023-02-11,Auto_Adjudicated,30,1518661623,1880530717,101YP2500X,Psychologist Clinical,23,In_Network,Z00.01,,99214,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,479.06,254.65,153.54,48.72,14.0,38.39,224.41,0.0,0.0,1,Phantom Billing,1.0,unusual_service_frequency|temporal_clustering|high_volume_same_code|benford_violation|impossible_service_combo|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,1.4e-05,0,0,,Bundled_Payment
CLM0000000182,MBR00000156,Medical_Professional,Paid,Electronic_EDI,2023-05-05,2023-05-05,2023-05-05,2023-05-16,Auto_Adjudicated,11,1658382624,1591405274,208600000X,Surgery General,21,In_Network,L70.0,Z00.00|M54.5,74177,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,975.49,755.88,582.95,14.19,13.0,145.74,219.61,0.0,0.0,0,,0.0347,none,0,1,0,1,0,5.4e-05,0,0,,Shared_Savings
CLM0000000183,MBR00000110,Pharmacy,Paid,Electronic_EDI,2023-09-24,2023-09-24,2023-09-24,2023-09-30,Auto_Adjudicated,6,1713741288,1433350836,207RG0100X,Gastroenterology,11,In_Network,M17.11,OTHER|Z23|E11.9,16590051660,,2,Medicare_Advantage,MA_HMO,83,F,1.127,,,789.73,605.44,473.21,4.92,9.0,118.3,184.29,0.0,0.0,0,,0.1914,unusual_service_frequency|service_date_weekend,0,1,0,0,0,4.4e-05,0,1,MPT_Annual_Monitoring,P4P
CLM0000000184,MBR00000213,Medical_Professional,Paid,Electronic_EDI,2023-05-28,2023-05-28,2023-05-28,2023-05-31,Auto_Adjudicated,3,1211612843,1880530717,207RE0101X,Endocrinology,21,In_Network,M54.5,I10|F41.1|Z87.891,99223,,0,Commercial,PPO,17,M,1.5857,,,424.4,206.16,0.0,189.47,16.69,0.0,218.24,0.0,0.0,0,,0.2189,high_volume_same_code|unbundling_pattern,0,2,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000185,MBR00000205,Behavioral_Health,Denied,Electronic_EDI,2023-10-30,2023-10-30,2023-10-30,2023-11-23,Auto_Adjudicated,24,1588313061,1287935251,207R00000X,Internal Medicine,22,Emergency,Z00.00,,10060,,0,Medicaid_MCO,MCO,1,F,0.9425,2,Duplicate,206.16,146.01,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0009,none,0,1,0,0,0,0.0,0,0,POD_Persistence_of_Beta_Blocker,FFS
CLM0000000186,MBR00000098,Medical_Professional,Denied,Electronic_EDI,2023-05-09,2023-05-09,2023-05-09,2023-05-11,Auto_Adjudicated,2,1597245892,1898471307,101YP2500X,Psychologist Clinical,21,In_Network,G43.909,OTHER|E11.9|Z23,99203,,0,Medicare_Advantage,MA_HMO,7,M,0.511,170,Authorization,175.39,116.07,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0009,none,0,1,0,0,0,0.0,0,0,W30_Well_Child_Visit,Shared_Savings
CLM0000000187,MBR00000296,Medical_Professional,Paid,Electronic_EDI,2023-08-19,2023-08-19,2023-08-19,2023-08-29,Auto_Adjudicated,10,1617763056,1619587398,207RP1001X,Pulmonary Disease,21,In_Network,I10,,99205,,0,Commercial,HMO,83,F,1.4969,,,536.33,206.59,0.0,206.59,0.0,0.0,329.74,0.0,0.0,0,,0.0519,none,0,1,0,0,0,0.0,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000000188,MBR00000192,Medical_Professional,Denied,Electronic_EDI,2023-06-03,2023-06-03,2023-06-03,2023-06-20,Auto_Adjudicated,17,1055717021,1432077493,207RE0101X,Endocrinology,23,In_Network,OTHER,M17.11,83036,,0,Medicaid_MCO,MCO,22,F,1.1739,2,Coding_Error,842.85,321.58,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0823,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000000189,MBR00000183,Pharmacy,Paid,Electronic_EDI,2023-06-18,2023-06-18,2023-06-18,2023-06-20,Auto_Adjudicated,2,1630305772,1304018750,2084P0800X,Psychiatry,32,In_Network,E78.5,,59148001506,,1,Commercial,PPO,51,M,0.8463,,,14.5,5.08,0.0,5.08,0.0,0.0,9.42,0.0,0.0,0,,0.0427,none,0,1,0,0,0,0.0,0,0,COA_Care_Transitions,Capitation
CLM0000000190,MBR00000022,Medical_Institutional,Paid,Electronic_EDI,2023-06-28,2023-06-28,2023-07-01,2023-07-04,Auto_Adjudicated,6,1756856314,1330485436,207RN0300X,Nephrology,32,In_Network,J44.1,OTHER|Z23,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,34,M,0.9472,,,32136.27,13595.26,10830.93,5.59,51.0,2707.73,18541.01,0.0,0.0,0,,0.0803,none,0,1,1,0,0,0.001003,0,0,BPD_BP_Declined,FFS
CLM0000000191,MBR00000087,Pharmacy,Paid,Electronic_EDI,2023-12-17,2023-12-17,2023-12-17,2024-01-16,Auto_Adjudicated,30,1133265917,1643323506,207RN0300X,Nephrology,22,In_Network,E78.5,,00006001954,,3,Medicaid_MCO,MCO,70,F,0.9232,,,253.07,103.57,102.57,0.0,1.0,0.0,149.5,0.0,0.0,0,,0.1184,none,0,1,0,0,0,9e-06,0,1,,FFS
CLM0000000192,MBR00000139,Vision,Paid,Electronic_EDI,2023-09-30,2023-09-30,2023-09-30,2023-10-14,Manual_Review,14,1875632885,1542515060,207RG0100X,Gastroenterology,23,In_Network,Z87.891,Z00.121|E11.65,92002,,0,Commercial,PPO,74,M,1.7701,,,98.11,39.35,0.0,39.35,0.0,0.0,58.76,0.0,0.0,0,,0.058,none,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,Shared_Savings
CLM0000000193,MBR00000187,Medical_Institutional,Paid,Electronic_EDI,2023-05-14,2023-05-14,2023-05-18,2023-05-24,Auto_Adjudicated,10,1330688043,1123879500,207Q00000X,Family Medicine,22,In_Network,Z00.01,I10|Z00.00,revenue_code:0300,,0,Medicaid_MCO,MCO,36,F,1.191,,,22012.04,12144.8,12137.8,0.0,7.0,0.0,9867.24,0.0,0.0,0,,0.1425,none,0,1,1,1,0,0.001123,0,0,CBP_Controlling_BP,Capitation
CLM0000000194,MBR00000158,Medical_Professional,Paid,Electronic_EDI,2023-05-30,2023-05-30,2023-05-30,2023-06-26,Clinical_Review,27,1092800235,1007652766,101YP2500X,Psychologist Clinical,21,Out_of_Network,J06.9,OTHER,97110,,0,Commercial,HMO,65,M,1.5361,,,715.16,508.45,180.31,269.06,14.0,45.08,206.71,0.0,0.0,0,,0.1224,none,0,1,0,0,0,1.7e-05,0,0,,Capitation
CLM0000000195,MBR00000224,Medical_Professional,Paid,Electronic_EDI,2023-05-26,2023-05-26,2023-05-26,2023-05-29,Auto_Adjudicated,3,1611521069,1498781755,207RG0100X,Gastroenterology,24,In_Network,M17.11,OTHER|M17.11,33510,,0,Medicaid_MCO,MCO,86,F,1.3289,,,268.28,155.32,152.32,0.0,3.0,0.0,112.96,0.0,0.0,0,,0.058,geographic_mismatch,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000000196,MBR00000081,Dental,Paid,Electronic_EDI,2023-09-22,2023-09-22,2023-09-22,2023-09-30,Manual_Review,8,1629674542,1930040953,2084P0800X,Psychiatry,11,In_Network,I25.10,M79.3,D0120,,0,Medicare_Advantage,SNP,66,F,2.159,,,1226.86,767.87,595.72,18.22,5.0,148.93,458.99,0.0,0.0,0,,0.0058,none,0,1,0,0,0,5.5e-05,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000000197,MBR00000208,Medical_Professional,Paid,Electronic_EDI,2023-08-01,2023-08-01,2023-08-01,2023-08-27,Auto_Adjudicated,26,1002224900,1706603847,207V00000X,Obstetrics & Gynecology,32,In_Network,I25.10,,99205,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,357.76,185.33,120.34,28.91,6.0,30.08,172.43,0.0,0.0,0,,0.03,none,0,1,0,0,0,1.1e-05,0,0,,Shared_Savings
CLM0000000198,MBR00000243,Dental,Denied,Paper,2023-07-11,2023-07-11,2023-07-11,2023-08-03,Auto_Adjudicated,23,1292994726,1318978078,207RC0000X,Cardiovascular Disease,11,In_Network,Z00.00,E11.9,D4341,,0,Medicaid_MCO,MCO,21,M,0.4834,97,Medical_Necessity,269.88,183.21,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1302,none,0,1,0,0,0,0.0,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000000199,MBR00000225,Dental,Paid,Provider_Portal,2023-06-04,2023-06-04,2023-06-04,2023-06-17,Auto_Adjudicated,13,1956215244,1179350099,208600000X,Surgery General,11,In_Network,Z00.00,M79.3|F41.1,D2391,,0,Commercial,PPO,27,F,0.5948,,,225.52,116.31,0.0,116.31,0.0,0.0,109.21,0.0,0.0,0,,0.0604,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000200,MBR00000227,Medical_Institutional,Paid,Provider_Portal,2023-05-24,2023-05-24,2023-05-27,2023-06-23,Auto_Adjudicated,30,1793406356,1368666316,2084P0800X,Psychiatry,11,In_Network,E11.9,,revenue_code:0450,,0,Medicare_Advantage,MA_PPO,2,F,0.7835,,,10569.29,5337.89,4238.26,0.06,40.0,1059.57,5231.4,0.0,0.0,0,,0.0788,benford_violation,0,1,0,0,0,0.000392,0,0,,Bundled_Payment
CLM0000000201,MBR00000270,Medical_Institutional,Denied,Electronic_EDI,2023-07-19,2023-07-19,2023-07-20,2023-08-06,Auto_Adjudicated,18,1222934819,1847196500,2084P0800X,Psychiatry,24,In_Network,Z00.00,Z12.11|K57.30,revenue_code:0210,,0,Commercial,POS,1,F,1.6363,16,Eligibility,10884.16,8951.72,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.13,none,0,1,0,0,0,0.0,0,0,IET_Initiation_Substance_Use,FFS
CLM0000000202,MBR00000025,Vision,Paid,Electronic_EDI,2023-10-26,2023-10-26,2023-10-26,2023-11-18,Auto_Adjudicated,23,1411619682,1105733833,246ZN0300X,Neuropsychology,11,In_Network,E11.9,,V2100,,0,Commercial,POS,74,M,1.3309,,,382.97,218.13,148.85,7.07,25.0,37.21,164.84,0.0,0.0,0,,0.0111,none,0,1,0,1,0,1.4e-05,0,0,,Shared_Savings
CLM0000000203,MBR00000207,Pharmacy,Paid,Electronic_EDI,2023-12-13,2023-12-13,2023-12-13,2024-01-12,Manual_Review,30,1331264469,1607833568,208600000X,Surgery General,22,In_Network,Z00.00,Z00.01|M17.11,00003014960,,2,Medicaid_MCO,MLTSS,11,F,1.6522,,,154.68,88.7,88.7,0.0,0.0,0.0,65.98,0.0,0.0,0,,0.1226,none,0,1,0,0,0,8e-06,0,1,,Shared_Savings
CLM0000000204,MBR00000293,Pharmacy,Paid,Electronic_EDI,2023-01-22,2023-01-22,2023-01-22,2023-02-07,Manual_Review,16,1556072255,1829216053,207Q00000X,Family Medicine,21,Out_of_Network,N39.0,,00006001954,,1,Medicare_Advantage,MA_HMO,84,F,2.8513,,,134.55,51.98,15.98,21.01,11.0,3.99,82.57,11.21,4.17,0,,0.0977,none,0,1,0,1,0,1e-06,1,0,,Shared_Savings
CLM0000000205,MBR00000173,Medical_Institutional,Partially_Paid,Paper,2023-03-27,2023-03-27,2023-03-31,2023-04-11,Auto_Adjudicated,15,1736809698,1789540567,208600000X,Surgery General,23,In_Network,Z00.01,OTHER,revenue_code:0110,,0,Medicare_Advantage,PFFS,23,F,1.0279,18,Medical_Necessity,14468.31,11728.86,7246.42,30.49,40.0,1811.6,5339.8,0.0,0.0,0,,0.1321,unbundling_pattern,0,1,1,0,0,0.000671,0,0,,FFS
CLM0000000206,MBR00000066,Medical_Institutional,Paid,Electronic_EDI,2023-09-03,2023-09-03,2023-09-03,2023-09-23,Auto_Adjudicated,20,1211612843,1005335812,207Q00000X,Family Medicine,22,Out_of_Network,Z23,OTHER,revenue_code:0250,,0,Medicaid_MCO,MCO,54,M,0.6083,,,8469.71,4525.04,4525.04,0.0,0.0,0.0,3944.67,0.0,0.0,0,,0.1947,benford_violation|impossible_service_combo,0,1,0,0,0,0.000419,1,0,,Shared_Savings
CLM0000000207,MBR00000300,Medical_Professional,Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-23,2023-02-26,Auto_Adjudicated,3,1478458171,1415734567,2086S0122X,Orthopedic Surgery,81,In_Network,OTHER,F41.1,99387,,0,Commercial,PPO,64,F,1.0393,,,270.83,186.9,51.09,94.04,29.0,12.77,83.93,0.0,0.0,0,,0.1564,benford_violation,0,1,0,0,0,5e-06,0,0,,P4P
CLM0000000208,MBR00000055,Vision,Paid,Electronic_EDI,2023-08-08,2023-08-08,2023-08-08,2023-08-21,Manual_Review,13,1549436467,1577226132,207RG0100X,Gastroenterology,11,In_Network,OTHER,,V2115,,0,Commercial,PPO,68,F,1.2896,,,572.61,392.56,294.96,13.86,10.0,73.74,180.05,0.0,0.0,0,,0.1406,none,0,1,0,0,0,2.7e-05,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000000209,MBR00000106,Medical_Institutional,Paid,Electronic_EDI,2023-06-02,2023-06-02,2023-06-02,2023-06-23,Auto_Adjudicated,21,1594322174,1004714954,207R00000X,Internal Medicine,21,In_Network,E11.65,J06.9,revenue_code:0250,439,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,8114.69,6434.31,5101.33,22.65,35.0,1275.33,1680.38,0.0,0.0,0,,0.055,none,0,1,1,0,0,0.000472,0,0,MMA_Medication_Management,FFS
CLM0000000210,MBR00000054,Pharmacy,Paid,Electronic_EDI,2023-03-10,2023-03-10,2023-03-10,2023-03-22,Manual_Review,12,1325430913,1197700958,207Q00000X,Family Medicine,11,In_Network,Z00.00,,00071012831,,3,Medicare_Advantage,MA_HMO,66,F,0.8625,,,162.7,128.44,99.99,2.45,1.0,25.0,34.26,0.0,0.0,0,,0.0027,none,0,1,0,0,0,9e-06,0,1,LCS_Lung_Cancer_Screening,Capitation
CLM0000000211,MBR00000143,Medical_Professional,Paid,Provider_Portal,2023-06-30,2023-06-30,2023-06-30,2023-07-22,Auto_Adjudicated,22,1774425033,1898471307,2084P0800X,Psychiatry,22,Out_of_Network,N39.0,,99383,,0,Commercial,POS,85,M,1.6078,,,191.14,81.59,0.0,81.59,0.0,0.0,109.55,0.0,0.0,0,,0.1448,none,0,1,0,0,0,0.0,1,0,,P4P
CLM0000000212,MBR00000133,Dental,Denied,Electronic_EDI,2023-07-02,2023-07-02,2023-07-02,2023-07-15,Auto_Adjudicated,13,1487261286,1965244699,2086S0122X,Orthopedic Surgery,31,In_Network,E78.5,,D0120,,0,Medicaid_MCO,MCO,57,M,0.9592,18,COB,679.29,274.73,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0636,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000213,MBR00000152,Medical_Institutional,Denied,Paper,2023-09-14,2023-09-14,2023-09-15,2023-09-20,Auto_Adjudicated,6,1594587354,1942423230,207Q00000X,Family Medicine,11,In_Network,E11.65,I25.10|I10,revenue_code:0100,,0,Commercial,HMO,82,F,1.2506,1,Network,2622.99,2084.19,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.074,none,0,1,0,0,0,0.0,0,0,FLU_Flu_Vaccination,Capitation
CLM0000000214,MBR00000279,Pharmacy,Paid,Electronic_EDI,2023-10-24,2023-10-24,2023-10-24,2023-10-29,Auto_Adjudicated,5,1415701059,1112696614,207RN0300X,Nephrology,81,Emergency,OTHER,,16590051660,,1,Medicare_Advantage,MA_PPO,81,M,1.6817,,,92.62,45.1,25.88,3.75,9.0,6.47,47.52,0.0,0.0,0,,0.1133,benford_violation,0,1,0,0,0,2e-06,0,1,,Capitation
CLM0000000215,MBR00000147,Medical_Professional,Paid,Electronic_EDI,2023-12-09,2023-12-09,2023-12-09,2023-12-26,Auto_Adjudicated,17,1327415110,1040061910,207RN0300X,Nephrology,11,In_Network,J44.1,Z00.01,81001,,0,Commercial,PPO,31,F,0.7098,,,1071.3,823.02,442.88,243.42,26.0,110.72,248.28,0.0,0.0,0,,0.1196,service_date_weekend,0,1,0,0,0,4.1e-05,0,0,,FFS
CLM0000000216,MBR00000158,Dental,Denied,Electronic_EDI,2023-06-07,2023-06-07,2023-06-07,2023-06-13,Auto_Adjudicated,6,1888245409,1540743888,207V00000X,Obstetrics & Gynecology,24,In_Network,OTHER,,D0120,,0,Commercial,HMO,65,M,1.5361,96,Network,319.8,177.08,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0156,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000217,MBR00000269,Pharmacy,Paid,Electronic_EDI,2023-09-05,2023-09-05,2023-09-05,2023-09-17,Manual_Review,12,1046058495,1705448933,2086S0122X,Orthopedic Surgery,23,In_Network,E11.9,OTHER,00085163102,,3,Commercial,EPO,10,F,0.718,,,364.75,191.23,90.94,46.56,31.0,22.73,173.52,0.0,0.0,0,,0.1357,none,0,1,0,0,0,8e-06,0,0,FLU_Flu_Vaccination,Bundled_Payment
CLM0000000218,MBR00000243,Medical_Institutional,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-12,2023-10-26,Auto_Adjudicated,16,1699014308,1252125670,207R00000X,Internal Medicine,65,In_Network,E78.5,I10,revenue_code:0200,,0,Medicaid_MCO,MCO,21,M,0.4834,,,10085.3,4427.29,4423.29,0.0,4.0,0.0,5658.01,0.0,0.0,0,,0.0137,none,0,1,0,0,0,0.000409,0,0,,FFS
CLM0000000219,MBR00000075,Medical_Professional,Paid,Provider_Portal,2023-12-21,2023-12-21,2023-12-21,2023-12-23,Auto_Adjudicated,2,1526973051,1061113875,207RN0300X,Nephrology,22,In_Network,I10,,99223,,0,Medicaid_MCO,MCO,5,M,1.0573,,,200.08,167.33,163.33,0.0,4.0,0.0,32.75,0.0,0.0,0,,0.1699,high_volume_same_code|service_date_weekend,0,1,0,0,0,1.5e-05,0,0,,Shared_Savings
CLM0000000220,MBR00000004,Medical_Professional,Paid,Electronic_EDI,2023-08-22,2023-08-22,2023-08-22,2023-09-04,Auto_Adjudicated,13,1193571728,1622950074,207V00000X,Obstetrics & Gynecology,23,In_Network,Z00.00,Z23|OTHER|J20.9,99232,,0,Medicare_Advantage,MA_PPO,68,M,1.23,,,263.39,100.61,30.87,54.02,8.0,7.72,162.78,0.0,0.0,0,,0.1062,none,0,1,0,1,0,3e-06,0,0,,FFS
CLM0000000221,MBR00000187,Medical_Professional,Denied,Electronic_EDI,2023-03-30,2023-03-30,2023-03-30,2023-04-09,Auto_Adjudicated,10,1098094939,1447186817,208600000X,Surgery General,11,In_Network,Z00.00,OTHER|I50.9|E78.5,74177,,0,Medicaid_MCO,MCO,36,F,1.191,256,Authorization,263.17,161.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0646,none,0,1,0,0,0,0.0,0,0,IET_Initiation_Substance_Use,Shared_Savings
CLM0000000222,MBR00000254,Medical_Professional,Paid,Paper,2023-05-03,2023-05-03,2023-05-03,2023-05-13,Auto_Adjudicated,10,1980039511,1690197969,207RP1001X,Pulmonary Disease,21,In_Network,OTHER,,99231,,0,Commercial,PPO,22,F,0.9285,,,185.29,131.45,54.21,35.68,28.0,13.55,53.84,0.0,0.0,0,,0.1647,controlled_substance_high_volume,0,1,0,1,0,5e-06,0,0,DAE_Drug_Alcohol_Dependence,FFS
CLM0000000223,MBR00000167,Medical_Institutional,Paid,Electronic_EDI,2023-03-16,2023-03-16,2023-03-19,2023-04-13,Auto_Adjudicated,28,1124477249,1325999602,207RC0000X,Cardiovascular Disease,24,In_Network,K21.0,J06.9|I10,revenue_code:0450,,0,Commercial,PPO,77,F,0.9377,,,27281.33,15249.9,12117.56,69.95,33.0,3029.39,12031.43,0.0,0.0,0,,0.0351,none,0,1,1,0,0,0.001122,0,0,,Bundled_Payment
CLM0000000224,MBR00000064,Medical_Institutional,Paid,Electronic_EDI,2023-03-12,2023-03-12,2023-03-13,2023-04-09,Auto_Adjudicated,28,1879212418,1809122260,207RG0100X,Gastroenterology,11,In_Network,OTHER,J20.9|Z00.00,revenue_code:0300,,0,Medicare_Advantage,SNP,73,M,1.0644,,,9506.88,4732.41,3743.33,0.24,53.0,935.83,4774.47,0.0,0.0,0,,0.045,none,0,1,0,1,0,0.000346,0,0,,FFS
CLM0000000225,MBR00000217,Medical_Institutional,Paid,Provider_Portal,2023-04-21,2023-04-21,2023-04-25,2023-05-01,Auto_Adjudicated,10,1380824221,1591405274,207RN0300X,Nephrology,24,In_Network,OTHER,OTHER|E11.9|Z12.11,revenue_code:0110,,0,ACA_Marketplace,ACA_Bronze,11,F,1.1619,,,11677.9,5005.67,2506.05,828.92,0.0,1670.7,6672.23,0.0,0.0,0,,0.1367,duplicate_claim_indicator,0,1,0,0,0,0.000232,0,0,,P4P
CLM0000000226,MBR00000198,Pharmacy,Denied,Electronic_EDI,2023-06-28,2023-06-28,2023-06-28,2023-07-25,Auto_Adjudicated,27,1699014308,1061113875,207Q00000X,Family Medicine,11,In_Network,J45.20,,00310075090,,1,Medicaid_MCO,MCO,81,F,1.4199,256,Duplicate,198.87,89.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0749,none,0,1,0,0,0,0.0,0,1,CDC_BP_Control,FFS
CLM0000000227,MBR00000170,Medical_Institutional,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-14,2023-10-17,Auto_Adjudicated,7,1594587354,1623053477,207RE0101X,Endocrinology,21,In_Network,OTHER,M54.5|I10,revenue_code:0110,683,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,2925.08,2405.73,1882.91,6.1,46.0,470.73,519.35,1251.16,348.41,0,,0.1494,none,0,1,0,1,0,0.000174,0,0,,FFS
CLM0000000228,MBR00000261,Medical_Professional,Paid,Electronic_EDI,2023-04-15,2023-04-15,2023-04-15,2023-04-26,Auto_Adjudicated,11,1214787184,1175334579,2084P0800X,Psychiatry,23,In_Network,E78.5,OTHER,90847,,0,Medicare_Advantage,MA_PPO,13,F,0.4259,,,218.3,121.46,86.12,12.81,1.0,21.53,96.84,0.0,0.0,0,,0.0281,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000000229,MBR00000232,Dental,Paid,Electronic_EDI,2023-03-08,2023-03-08,2023-03-08,2023-04-06,Auto_Adjudicated,29,1067329999,1300957944,208600000X,Surgery General,11,In_Network,OTHER,E78.5,D2391,,0,Medicaid_MCO,MCO,40,M,1.1083,,,440.05,161.22,159.22,0.0,2.0,0.0,278.83,0.0,0.0,0,,0.089,none,0,1,0,0,0,1.5e-05,0,0,,Capitation
CLM0000000230,MBR00000198,Medical_Institutional,Paid,Electronic_EDI,2023-02-15,2023-02-15,2023-02-16,2023-02-19,Auto_Adjudicated,4,1084831484,1228356980,207RE0101X,Endocrinology,22,In_Network,K57.30,K29.70,revenue_code:0450,,0,Medicaid_MCO,MCO,81,F,1.4199,,,8294.1,4524.98,4522.98,0.0,2.0,0.0,3769.12,0.0,0.0,0,,0.1084,none,0,1,0,0,0,0.000419,0,0,,FFS
CLM0000000231,MBR00000197,Pharmacy,Paid,Electronic_EDI,2023-03-12,2023-03-12,2023-03-12,2023-03-24,Clinical_Review,12,1147937670,1358873132,207RN0300X,Nephrology,65,Emergency,J44.1,G43.909|E11.9,00078043215,,3,Medicare_Advantage,MA_HMO,59,M,1.1414,,,150.93,98.92,60.7,10.04,13.0,15.18,52.01,0.0,0.0,0,,0.0979,none,0,1,0,0,0,6e-06,0,0,COL_Colorectal_Cancer_Screening,Shared_Savings
CLM0000000232,MBR00000197,Vision,Denied,Provider_Portal,2023-06-05,2023-06-05,2023-06-05,2023-06-30,Manual_Review,25,1428403730,1354265777,207RE0101X,Endocrinology,11,Out_of_Network,F33.0,E78.5|N39.0|OTHER,V2100,,0,Medicare_Advantage,MA_HMO,59,M,1.1414,170,Network,380.86,251.03,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1984,high_volume_same_code,0,1,0,0,0,0.0,0,0,PPC_Prenatal_Care,FFS
CLM0000000233,MBR00000160,Pharmacy,Paid,Paper,2023-05-28,2023-05-28,2023-05-28,2023-06-26,Auto_Adjudicated,29,1673449362,1589482133,207R00000X,Internal Medicine,11,In_Network,OTHER,,00071012831,,3,Commercial,HMO,73,M,1.9608,,,85.22,33.84,0.0,33.84,0.0,0.0,51.38,0.0,0.0,0,,0.0642,benford_violation,0,1,0,0,0,0.0,0,1,,FFS
CLM0000000234,MBR00000143,Medical_Institutional,Paid,Electronic_EDI,2023-05-24,2023-05-24,2023-05-24,2023-06-22,Manual_Review,29,1368580443,1616762819,207RE0101X,Endocrinology,11,In_Network,OTHER,,revenue_code:0210,,0,Commercial,POS,85,M,1.6078,,,7205.35,3462.8,2573.93,205.39,40.0,643.48,3742.55,0.0,0.0,0,,0.0221,none,0,1,0,1,0,0.000238,0,0,,FFS
CLM0000000235,MBR00000210,Medical_Institutional,Paid,Provider_Portal,2023-04-24,2023-04-24,2023-04-27,2023-05-21,Auto_Adjudicated,27,1267286378,1007652766,208600000X,Surgery General,22,In_Network,I10,K29.70,revenue_code:0100,,0,Medicare_Advantage,SNP,49,M,0.6952,,,8736.89,6268.84,4988.29,1.47,32.0,1247.07,2468.05,0.0,0.0,0,,0.1015,none,0,1,0,0,0,0.000462,0,0,,FFS
CLM0000000236,MBR00000184,Pharmacy,Paid,Electronic_EDI,2023-06-12,2023-06-12,2023-06-12,2023-07-11,Auto_Adjudicated,29,1588313061,1865266296,207Q00000X,Family Medicine,24,In_Network,Z00.00,M54.5,00169751112,,1,Medicaid_MCO,MLTSS,30,M,2.8302,,,235.62,198.66,196.66,0.0,2.0,0.0,36.96,0.0,0.0,0,,0.1374,none,0,1,0,0,0,1.8e-05,0,0,FLU_Flu_Vaccination,FFS
CLM0000000237,MBR00000152,Pharmacy,Partially_Paid,Paper,2023-08-21,2023-08-21,2023-08-21,2023-09-05,Auto_Adjudicated,15,1683650935,1576271272,207R00000X,Internal Medicine,65,In_Network,E78.5,Z00.00,16590051660,,1,Commercial,HMO,82,F,1.2506,256,Medical_Necessity,135.02,81.85,0.0,64.05,0.0,0.0,70.97,0.0,0.0,0,,0.0611,none,0,1,0,0,0,0.0,0,0,W30_Well_Child_Visit,P4P
CLM0000000238,MBR00000038,Medical_Professional,Paid,Electronic_EDI,2023-01-16,2023-01-16,2023-01-16,2023-01-26,Manual_Review,10,1539066691,1912895973,207RC0000X,Cardiovascular Disease,21,In_Network,OTHER,N18.3|F32.9,85025,,0,Commercial,EPO,46,M,1.1295,,,417.37,164.03,0.0,153.2,10.83,0.0,253.34,0.0,0.0,0,,0.0693,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000000239,MBR00000208,Medical_Institutional,Denied,Paper,2023-11-16,2023-11-16,2023-11-16,2023-11-28,Auto_Adjudicated,12,1119160702,1774401124,2084P0800X,Psychiatry,11,In_Network,Z00.01,J06.9|M79.3,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,256,COB,55097.95,43384.05,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1133,outlier_billing_amount,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000240,MBR00000192,Dental,Paid,Provider_Portal,2023-04-20,2023-04-20,2023-04-20,2023-04-24,Manual_Review,4,1995916350,1741177636,101YP2500X,Psychologist Clinical,11,In_Network,G47.33,OTHER|M17.11,D1110,,0,Medicaid_MCO,MCO,22,F,1.1739,,,358.49,203.86,203.86,0.0,0.0,0.0,154.63,0.0,0.0,0,,0.0992,none,0,1,0,0,0,1.9e-05,0,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000000241,MBR00000107,Pharmacy,Paid,Electronic_EDI,2023-02-19,2023-02-19,2023-02-19,2023-02-24,Auto_Adjudicated,5,1718336220,1747596016,207V00000X,Obstetrics & Gynecology,21,In_Network,Z23,,00078043215,,1,Medicare_Advantage,MA_PPO,44,M,1.0439,,,303.92,217.89,139.16,35.94,8.0,34.79,86.03,123.01,14.46,0,,0.0858,none,0,1,0,0,0,1.3e-05,0,1,,Shared_Savings
CLM0000000242,MBR00000112,Medical_Professional,Paid,Electronic_EDI,2023-03-04,2023-03-04,2023-03-04,2023-04-03,Auto_Adjudicated,30,1415701059,1728466420,207R00000X,Internal Medicine,22,In_Network,OTHER,,99395,,0,Medicare_Advantage,MA_HMO,18,M,1.01,,,165.29,78.09,39.11,23.2,6.0,9.78,87.2,25.02,12.58,1,Date of Service Falsification,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|high_volume_same_code|benford_violation|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|phantom_billing_indicator|npi_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,4e-06,0,0,,FFS
CLM0000000243,MBR00000076,Medical_Institutional,Paid,Electronic_EDI,2023-07-16,2023-07-16,2023-07-17,2023-07-22,Manual_Review,6,1928139578,1878874025,207R00000X,Internal Medicine,65,In_Network,OTHER,OTHER|Z12.11,revenue_code:0450,,0,Commercial,HMO,26,M,2.1785,,,20328.8,15981.04,12751.12,2.13,40.0,3187.78,4347.76,0.0,0.0,0,,0.0165,none,0,1,1,1,0,0.00118,0,0,,FFS
CLM0000000244,MBR00000291,Medical_Institutional,Paid,Electronic_EDI,2023-07-06,2023-07-06,2023-07-09,2023-07-25,Auto_Adjudicated,19,1253087808,1132693989,207R00000X,Internal Medicine,11,In_Network,M17.11,Z00.01,revenue_code:0120,,0,Commercial,PPO,78,M,1.4773,,,9660.75,4670.08,3317.97,446.61,76.0,829.49,4990.67,2291.96,605.01,0,,0.0689,geographic_mismatch,0,1,0,0,0,0.000307,0,0,,Shared_Savings
CLM0000000245,MBR00000259,Medical_Professional,Partially_Paid,Electronic_EDI,2023-02-01,2023-02-01,2023-02-01,2023-02-08,Auto_Adjudicated,7,1965812565,1365397818,207Q00000X,Family Medicine,24,In_Network,Z12.11,K21.0,99386,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,1,Medical_Necessity,230.82,160.87,51.45,9.3,7.0,12.86,150.21,0.0,0.0,0,,0.0124,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000000246,MBR00000169,Pharmacy,Paid,Electronic_EDI,2023-06-29,2023-06-29,2023-06-29,2023-07-19,Auto_Adjudicated,20,1519736600,1339359594,2086S0122X,Orthopedic Surgery,22,In_Network,OTHER,,59148001506,,4,Commercial,EPO,30,M,1.4348,,,84.15,46.31,0.0,46.31,0.0,0.0,37.84,0.0,0.0,0,,0.0576,none,0,1,0,0,0,0.0,0,1,,Capitation
CLM0000000247,MBR00000128,Medical_Institutional,Denied,Electronic_EDI,2023-03-21,2023-03-21,2023-03-21,2023-04-05,Auto_Adjudicated,15,1826043246,1898471307,207RG0100X,Gastroenterology,32,Out_of_Network,E11.9,G47.33|OTHER,revenue_code:0360,,0,Commercial,PPO,13,F,1.4203,4,Duplicate,28839.7,15370.76,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2343,unbundling_pattern|npi_mismatch,0,2,0,0,0,0.0,1,0,,Shared_Savings
CLM0000000248,MBR00000215,Medical_Professional,Paid,Electronic_EDI,2023-11-24,2023-11-24,2023-11-24,2023-11-28,Manual_Review,4,1864546991,1564691686,208600000X,Surgery General,31,Out_of_Network,J20.9,,90837,,0,ACA_Marketplace,ACA_Silver,69,M,0.8895,,,1027.68,457.74,0.0,457.74,0.0,0.0,569.94,0.0,0.0,0,,0.0379,none,0,1,0,0,0,0.0,1,0,,FFS
CLM0000000249,MBR00000160,Medical_Professional,Partially_Paid,Electronic_EDI,2023-04-21,2023-04-21,2023-04-21,2023-05-03,Auto_Adjudicated,12,1718336220,1912895973,208600000X,Surgery General,31,In_Network,OTHER,OTHER|M17.11,99231,,0,Commercial,HMO,73,M,1.9608,4,Medical_Necessity,271.02,208.59,6.36,101.1,23.0,1.59,138.97,0.0,0.0,0,,0.0953,none,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000000250,MBR00000294,Dental,Paid,Electronic_EDI,2023-12-25,2023-12-25,2023-12-25,2024-01-16,Auto_Adjudicated,22,1375098560,1825450791,207V00000X,Obstetrics & Gynecology,21,In_Network,N18.3,,D2140,,0,Medicare_Advantage,MA_HMO,8,M,0.6878,,,405.63,231.38,163.65,8.82,18.0,40.91,174.25,0.0,0.0,0,,0.1482,none,0,1,0,0,0,1.5e-05,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000000251,MBR00000015,Dental,Denied,Electronic_EDI,2023-07-27,2023-07-27,2023-07-27,2023-08-21,Auto_Adjudicated,25,1078527460,1666461892,2084P0800X,Psychiatry,21,Out_of_Network,OTHER,,D2391,,0,Medicaid_MCO,MCO,43,F,0.3775,22,Medical_Necessity,291.48,162.71,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.091,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000252,MBR00000011,Pharmacy,Paid,Electronic_EDI,2023-12-13,2023-12-13,2023-12-13,2023-12-22,Auto_Adjudicated,9,1469822310,1694343357,246ZN0300X,Neuropsychology,11,In_Network,K21.0,Z12.11,00310075090,,1,Medicare_Advantage,SNP,35,F,1.0833,,,104.15,42.22,18.41,2.21,17.0,4.6,61.93,0.0,0.0,0,,0.1481,none,0,1,0,0,0,2e-06,0,1,,FFS
CLM0000000253,MBR00000170,Dental,Paid,Electronic_EDI,2023-07-19,2023-07-19,2023-07-19,2023-07-28,Auto_Adjudicated,9,1156265220,1747935894,207RG0100X,Gastroenterology,11,In_Network,Z79.4,,D7140,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,256.38,108.06,60.06,29.99,3.0,15.01,148.32,0.0,0.0,0,,0.1111,upcoding_pattern,0,1,0,0,0,6e-06,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000000254,MBR00000061,Vision,Paid,Electronic_EDI,2023-02-15,2023-02-15,2023-02-15,2023-03-09,Auto_Adjudicated,22,1478458171,1809122260,101YP2500X,Psychologist Clinical,22,In_Network,OTHER,E78.5|N18.3|M47.816,92002,,0,Commercial,PPO,66,M,2.3575,,,410.34,219.49,115.23,62.45,13.0,28.81,190.85,0.0,0.0,0,,0.1256,none,0,1,0,0,0,1.1e-05,0,0,,Shared_Savings
CLM0000000255,MBR00000182,Medical_Institutional,Paid,Electronic_EDI,2023-08-19,2023-08-19,2023-08-20,2023-09-01,Auto_Adjudicated,13,1049153238,1164525386,207R00000X,Internal Medicine,81,Emergency,H52.4,Z79.4,revenue_code:0360,,0,Commercial,HMO,82,F,0.8489,,,8412.9,3125.95,2380.18,116.73,34.0,595.04,5286.95,0.0,0.0,0,,0.1755,phantom_billing_indicator,0,1,0,0,0,0.00022,0,0,,FFS
CLM0000000256,MBR00000231,Medical_Professional,Paid,Electronic_EDI,2023-06-21,2023-06-21,2023-06-21,2023-06-24,Clinical_Review,3,1356408757,1489993356,208600000X,Surgery General,22,In_Network,OTHER,E11.9,99396,,0,ACA_Marketplace,ACA_Silver,12,M,0.6456,,,288.15,187.14,0.0,187.14,0.0,0.0,101.01,0.0,0.0,0,,0.1161,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000257,MBR00000043,Pharmacy,Paid,Electronic_EDI,2023-10-21,2023-10-21,2023-10-21,2023-10-25,Manual_Review,4,1702283246,1252125670,246ZN0300X,Neuropsychology,21,In_Network,OTHER,,00071012831,,1,Commercial,PPO,68,F,0.4593,,,127.65,56.62,0.0,56.62,0.0,0.0,71.03,0.0,0.0,0,,0.118,billing_spike_recent,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000000258,MBR00000138,Medical_Institutional,Denied,Electronic_EDI,2023-05-21,2023-05-21,2023-05-25,2023-06-02,Auto_Adjudicated,12,1091271799,1301869102,207RG0100X,Gastroenterology,11,In_Network,Z00.00,K21.0,revenue_code:0360,,0,Commercial,HDHP_HSA,47,M,0.996,97,Medical_Necessity,27955.55,19950.83,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1264,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000259,MBR00000205,Medical_Professional,Paid,Electronic_EDI,2023-03-09,2023-03-09,2023-03-09,2023-03-18,Manual_Review,9,1263063839,1406199453,207RN0300X,Nephrology,23,In_Network,E78.5,,80053,,0,Medicaid_MCO,MCO,1,F,0.9425,,,412.35,277.77,276.77,0.0,1.0,0.0,134.58,0.0,0.0,0,,0.0754,none,0,1,0,0,0,2.6e-05,0,0,CBP_Controlling_BP,Shared_Savings
CLM0000000260,MBR00000249,Behavioral_Health,Denied,Paper,2023-02-10,2023-02-10,2023-02-10,2023-02-14,Clinical_Review,4,1813729693,1164525386,2086S0122X,Orthopedic Surgery,11,In_Network,J45.20,Z00.00,33510,,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,4,Network,472.09,276.54,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0135,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000261,MBR00000154,Medical_Professional,Paid,Electronic_EDI,2023-09-24,2023-09-24,2023-09-24,2023-10-18,Auto_Adjudicated,24,1711104790,1538261819,2084P0800X,Psychiatry,11,In_Network,OTHER,N39.0|E11.9|OTHER,99383,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,210.2,94.84,66.71,11.45,0.0,16.68,115.36,0.0,0.0,0,,0.1221,none,0,1,0,0,0,6e-06,0,0,TRC_Transition_of_Care,Shared_Savings
CLM0000000262,MBR00000062,Dental,Denied,Electronic_EDI,2023-03-25,2023-03-25,2023-03-25,2023-04-08,Auto_Adjudicated,14,1886549972,1301833092,207RN0300X,Nephrology,11,In_Network,OTHER,OTHER,D7140,,0,Commercial,HMO,46,F,0.5516,22,Timely_Filing,248.28,183.02,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1505,phantom_billing_indicator|diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000263,MBR00000176,Medical_Institutional,Paid,Electronic_EDI,2023-08-28,2023-08-28,2023-08-31,2023-09-19,Manual_Review,22,1617928396,1589482133,2086S0122X,Orthopedic Surgery,31,In_Network,M54.5,L70.0|Z00.01,revenue_code:0450,,0,Commercial,POS,4,M,0.8792,,,72818.84,61615.62,49134.4,157.63,40.0,12283.6,11203.22,0.0,0.0,0,,0.0718,outlier_billing_amount,0,1,1,0,0,0.004548,0,0,,Capitation
CLM0000000264,MBR00000141,Medical_Professional,Partially_Paid,Electronic_EDI,2023-02-18,2023-02-18,2023-02-18,2023-02-19,Auto_Adjudicated,1,1667149552,1878017518,208600000X,Surgery General,21,Emergency,F33.0,K21.0|I10|Z00.00,90837,,0,Commercial,HMO,47,F,0.6724,16,Medical_Necessity,308.09,217.37,65.31,59.31,26.0,16.33,141.15,0.0,0.0,0,,0.0929,high_oop_waiver,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000000265,MBR00000227,Dental,Paid,Electronic_EDI,2023-01-29,2023-01-29,2023-01-29,2023-02-11,Auto_Adjudicated,13,1506426842,1447657873,2084P0800X,Psychiatry,71,In_Network,G47.33,Z23|M54.5|OTHER,D0120,,0,Medicare_Advantage,MA_PPO,2,F,0.7835,,,342.24,244.01,183.95,0.07,14.0,45.99,98.23,0.0,0.0,0,,0.1742,benford_violation,0,1,0,0,0,1.7e-05,0,0,,FFS
CLM0000000266,MBR00000168,Pharmacy,Denied,Electronic_EDI,2023-09-13,2023-09-13,2023-09-13,2023-09-28,Auto_Adjudicated,15,1719850506,1983760474,207R00000X,Internal Medicine,22,In_Network,K21.0,OTHER|Z00.00,16590051660,,1,Commercial,HMO,76,M,1.2791,CO-45,Timely_Filing,404.36,181.19,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1408,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000267,MBR00000087,Medical_Institutional,Paid,Provider_Portal,2023-05-04,2023-05-04,2023-05-07,2023-05-22,Auto_Adjudicated,18,1170257806,1432077493,207RN0300X,Nephrology,23,Out_of_Network,J44.1,M17.11|Z00.00,revenue_code:0100,,0,Medicaid_MCO,MCO,70,F,0.9232,,,2991.55,1649.7,1646.7,0.0,3.0,0.0,1341.85,0.0,0.0,0,,0.1034,none,0,1,0,0,0,0.000152,0,0,,Bundled_Payment
CLM0000000268,MBR00000221,Medical_Institutional,Paid,Provider_Portal,2023-07-23,2023-07-23,2023-07-27,2023-08-22,Auto_Adjudicated,30,1865750966,1228356980,246ZN0300X,Neuropsychology,31,In_Network,OTHER,N18.3,revenue_code:0100,,0,Commercial,HDHP_HSA,28,M,1.6683,,,15139.12,5926.78,4607.94,166.85,0.0,1151.99,9212.34,0.0,0.0,0,,0.038,none,0,1,0,0,0,0.000427,0,0,DDE_Diabetes_Short_Term_Complications,P4P
CLM0000000269,MBR00000158,Medical_Professional,Paid,Provider_Portal,2023-01-10,2023-01-10,2023-01-10,2023-01-24,Auto_Adjudicated,14,1636337876,1522426351,207Q00000X,Family Medicine,32,In_Network,J20.9,M17.11,33510,,0,Commercial,HMO,65,M,1.5361,,,221.33,86.57,28.74,36.64,14.0,7.19,134.76,0.0,0.0,0,,0.1402,none,0,1,0,1,0,3e-06,0,0,,FFS
CLM0000000270,MBR00000056,Medical_Professional,Paid,Electronic_EDI,2023-03-09,2023-03-09,2023-03-09,2023-03-24,Auto_Adjudicated,15,1522998767,1994275960,208600000X,Surgery General,11,In_Network,E11.9,K21.0|Z00.00,99212,,0,Commercial,EPO,74,F,1.3941,,,285.18,163.53,66.34,69.6,11.0,16.59,121.65,0.0,0.0,0,,0.0596,none,0,1,0,0,0,6e-06,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000000271,MBR00000169,Medical_Professional,Paid,Electronic_EDI,2023-02-02,2023-02-02,2023-02-02,2023-03-01,Manual_Review,27,1451464799,1564691686,207RG0100X,Gastroenterology,11,In_Network,M17.11,,99385,,0,Commercial,EPO,30,M,1.4348,,,774.91,368.22,20.81,320.2,22.0,5.2,406.69,0.0,0.0,0,,0.117,none,0,1,0,0,0,2e-06,0,0,,Shared_Savings
CLM0000000272,MBR00000287,Medical_Professional,Denied,Electronic_EDI,2023-04-11,2023-04-11,2023-04-11,2023-04-23,Manual_Review,12,1393200616,1301869102,207RC0000X,Cardiovascular Disease,11,In_Network,I10,Z00.01,99283,,0,Commercial,PPO,4,M,0.7685,96,Medical_Necessity,86.42,58.14,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0025,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000000273,MBR00000208,Medical_Professional,Paid,Electronic_EDI,2023-04-12,2023-04-12,2023-04-12,2023-04-24,Auto_Adjudicated,12,1454203715,1912895973,207RN0300X,Nephrology,22,In_Network,E13.9,M54.5,99383,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,269.62,220.02,160.3,13.65,6.0,40.07,49.6,0.0,0.0,0,,0.0556,none,0,1,0,0,0,1.5e-05,0,0,CCS_Cervical_Cancer_Screening,Capitation
CLM0000000274,MBR00000094,Medical_Institutional,Paid,Electronic_EDI,2023-05-15,2023-05-15,2023-05-18,2023-05-20,Auto_Adjudicated,5,1641779816,1831337866,101YP2500X,Psychologist Clinical,11,Out_of_Network,OTHER,,revenue_code:0250,,0,Commercial,POS,36,F,0.3997,,,7969.15,4499.2,3501.82,55.93,66.0,875.45,3469.95,0.0,0.0,0,,0.1236,unbundling_pattern,0,1,0,0,0,0.000324,1,0,,FFS
CLM0000000275,MBR00000211,Medical_Professional,Paid,Electronic_EDI,2023-03-29,2023-03-29,2023-03-29,2023-04-20,Auto_Adjudicated,22,1433357203,1396850418,207RN0300X,Nephrology,23,In_Network,K57.30,E11.9,97035,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,,,321.14,132.68,96.09,0.57,12.0,24.02,188.46,0.0,0.0,0,,0.0395,none,0,1,0,0,0,9e-06,0,0,,Capitation
CLM0000000276,MBR00000088,Medical_Institutional,Paid,Electronic_EDI,2023-06-13,2023-06-13,2023-06-15,2023-06-14,Auto_Adjudicated,1,1647029816,1738617370,225100000X,Physical Therapist,21,Emergency,OTHER,I10|OTHER,revenue_code:0250,682,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,,,3028.07,1372.45,697.05,286.66,90.0,298.74,1655.62,0.0,0.0,0,,0.0981,none,0,1,0,0,0,6.5e-05,0,0,,FFS
CLM0000000277,MBR00000165,Medical_Professional,Paid,Electronic_EDI,2023-11-20,2023-11-20,2023-11-20,2023-11-27,Auto_Adjudicated,7,1017424540,1623053477,101YP2500X,Psychologist Clinical,81,In_Network,G43.909,Z00.00,99212,,0,ACA_Marketplace,ACA_Bronze,55,M,0.9775,,,485.07,280.74,0.0,280.74,0.0,0.0,204.33,0.0,0.0,0,,0.0592,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000278,MBR00000160,Medical_Professional,Paid,Electronic_EDI,2023-01-31,2023-01-31,2023-01-31,2023-02-13,Auto_Adjudicated,13,1377412382,1296566243,207RG0100X,Gastroenterology,31,In_Network,K21.0,E11.9,43239,,0,Commercial,HMO,73,M,1.9608,,,746.5,434.1,242.11,108.46,23.0,60.53,312.4,0.0,0.0,0,,0.0122,none,0,1,0,0,0,2.2e-05,0,0,,FFS
CLM0000000279,MBR00000076,Vision,Partially_Paid,Electronic_EDI,2023-11-17,2023-11-17,2023-11-17,2023-12-01,Auto_Adjudicated,14,1190787795,1034732777,207RN0300X,Nephrology,23,In_Network,J20.9,OTHER,V2103,,0,Commercial,HMO,26,M,2.1785,3,Medical_Necessity,110.54,68.86,0.0,12.48,25.22,0.0,72.84,0.0,0.0,0,,0.1002,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000280,MBR00000110,Behavioral_Health,Paid,Electronic_EDI,2023-05-29,2023-05-29,2023-05-29,2023-05-31,Auto_Adjudicated,2,1364746046,1825450791,101YP2500X,Psychologist Clinical,23,In_Network,N39.0,,99221,,0,Medicare_Advantage,MA_HMO,83,F,1.127,,,137.4,110.05,75.51,6.67,9.0,18.88,27.35,0.0,0.0,0,,0.0908,impossible_service_combo,0,1,0,0,0,7e-06,0,0,,Shared_Savings
CLM0000000281,MBR00000285,Pharmacy,Paid,Paper,2023-07-27,2023-07-27,2023-07-27,2023-08-12,Manual_Review,16,1170319307,1493836023,208600000X,Surgery General,11,In_Network,Z12.11,,00069420020,,5,Commercial,HDHP_HSA,56,M,0.9226,,,116.04,93.49,0.0,93.49,0.0,0.0,22.55,0.0,0.0,0,,0.1601,billing_spike_recent,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000282,MBR00000078,Medical_Professional,Paid,Electronic_EDI,2023-08-30,2023-08-30,2023-08-30,2023-09-29,Manual_Review,30,1292994726,1741177636,207V00000X,Obstetrics & Gynecology,11,In_Network,Z00.01,,99232,,0,Commercial,EPO,65,F,1.3174,,,127.63,85.55,0.0,85.55,0.0,0.0,42.08,0.0,0.0,0,,0.0033,none,0,1,0,0,0,0.0,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000000283,MBR00000237,Pharmacy,Paid,Electronic_EDI,2023-09-21,2023-09-21,2023-09-21,2023-09-25,Auto_Adjudicated,4,1067329999,1209882852,207V00000X,Obstetrics & Gynecology,21,In_Network,Z87.891,OTHER|J06.9|Z00.01,00069420020,,4,Commercial,PPO,45,M,0.7983,,,193.08,82.5,0.0,82.5,0.0,0.0,110.58,0.0,0.0,0,,0.1592,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000284,MBR00000198,Medical_Professional,Paid,Electronic_EDI,2023-12-05,2023-12-05,2023-12-05,2023-12-20,Auto_Adjudicated,15,1918160357,1432077493,207V00000X,Obstetrics & Gynecology,65,In_Network,Z00.00,M79.3|OTHER,99285,,0,Medicaid_MCO,MCO,81,F,1.4199,,,318.09,137.94,135.94,0.0,2.0,0.0,180.15,0.0,0.0,0,,0.0173,none,0,1,0,0,0,1.3e-05,0,0,MMA_Medication_Management,FFS
CLM0000000285,MBR00000162,Medical_Institutional,Paid,Electronic_EDI,2023-12-25,2023-12-25,2023-12-28,2024-01-12,Auto_Adjudicated,18,1334227781,1390802135,207V00000X,Obstetrics & Gynecology,11,Out_of_Network,E11.9,F32.9,revenue_code:0370,,0,Medicaid_MCO,MLTSS,84,F,1.324,,,14904.75,7448.73,7439.73,0.0,9.0,0.0,7456.02,0.0,0.0,0,,0.0195,none,0,1,1,0,0,0.000689,1,0,POD_Persistence_of_Beta_Blocker,Shared_Savings
CLM0000000286,MBR00000042,Dental,Paid,Electronic_EDI,2023-02-05,2023-02-05,2023-02-05,2023-02-15,Auto_Adjudicated,10,1886549972,1912895973,207RN0300X,Nephrology,21,In_Network,F32.9,I10,D2140,,0,Commercial,HMO,78,F,1.1448,,,1176.59,838.13,647.75,8.44,20.0,161.94,338.46,0.0,0.0,0,,0.0856,none,0,1,0,1,0,6e-05,0,0,,FFS
CLM0000000287,MBR00000061,Medical_Professional,Paid,Electronic_EDI,2023-05-28,2023-05-28,2023-05-28,2023-06-15,Auto_Adjudicated,18,1557212800,1912895973,207RC0000X,Cardiovascular Disease,24,In_Network,OTHER,I25.10|I48.91|OTHER,74177,,0,Commercial,PPO,66,M,2.3575,,,336.44,259.16,83.05,142.35,13.0,20.76,77.28,0.0,0.0,0,,0.0284,none,0,1,0,1,0,8e-06,0,0,IET_Initiation_Substance_Use,Shared_Savings
CLM0000000288,MBR00000056,Vision,Paid,Electronic_EDI,2023-07-13,2023-07-13,2023-07-13,2023-07-24,Auto_Adjudicated,11,1292994726,1912895973,208600000X,Surgery General,21,Out_of_Network,M54.5,,V2320,,0,Commercial,EPO,74,F,1.3941,,,221.03,149.68,69.19,52.19,11.0,17.3,71.35,47.9,17.23,0,,0.1156,none,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000000289,MBR00000177,Pharmacy,Paid,Electronic_EDI,2023-07-07,2023-07-07,2023-07-07,2023-07-12,Auto_Adjudicated,5,1115589144,1704466150,207V00000X,Obstetrics & Gynecology,65,In_Network,OTHER,,16590051660,,1,Commercial,HMO,42,F,1.2774,,,118.07,91.19,0.0,91.19,0.0,0.0,26.88,0.0,0.0,0,,0.0375,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000290,MBR00000293,Medical_Professional,Paid,Electronic_EDI,2023-12-22,2023-12-22,2023-12-22,2024-01-17,Auto_Adjudicated,26,1389116733,1560230600,207V00000X,Obstetrics & Gynecology,65,In_Network,Z23,Z12.11,99386,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,429.28,201.68,134.64,22.38,11.0,33.66,227.6,0.0,0.0,0,,0.1116,temporal_clustering,0,1,0,0,0,1.2e-05,0,0,,Capitation
CLM0000000291,MBR00000265,Medical_Professional,Paid,Electronic_EDI,2023-08-22,2023-08-22,2023-08-22,2023-09-21,Auto_Adjudicated,30,1706065807,1469881892,207RG0100X,Gastroenterology,11,In_Network,E11.9,E78.5,20610,,0,Commercial,PPO,84,F,0.7969,,,1095.08,755.9,480.07,130.81,25.0,120.02,339.18,0.0,0.0,0,,0.1926,service_date_weekend,0,1,0,0,0,4.4e-05,0,0,,FFS
CLM0000000292,MBR00000008,Pharmacy,Paid,Electronic_EDI,2023-05-25,2023-05-25,2023-05-25,2023-06-06,Auto_Adjudicated,12,1932483309,1704466150,2084P0800X,Psychiatry,22,In_Network,Z00.00,E13.9|E78.5|E11.9,00169751112,,1,Medicaid_MCO,MCO,74,M,0.8375,,,72.85,35.44,34.44,0.0,1.0,0.0,37.41,0.0,0.0,0,,0.1327,none,0,1,0,0,0,3e-06,0,0,,FFS
CLM0000000293,MBR00000085,Medical_Institutional,Paid,Electronic_EDI,2023-11-27,2023-11-27,2023-11-29,2023-11-30,Auto_Adjudicated,3,1556072255,1477113725,101YP2500X,Psychologist Clinical,11,In_Network,Z00.01,I10|J06.9,revenue_code:0450,,0,Medicare_Advantage,SNP,2,M,0.7823,,,44060.16,29854.58,23829.08,31.24,37.0,5957.27,14205.58,0.0,0.0,0,,0.0825,none,0,1,1,0,0,0.002206,0,0,MMA_Medication_Management,Capitation
CLM0000000294,MBR00000050,Medical_Professional,Paid,Electronic_EDI,2023-09-20,2023-09-20,2023-09-20,2023-09-25,Manual_Review,5,1484613641,1164525386,207Q00000X,Family Medicine,22,In_Network,Z23,K21.0|G43.909|Z00.01,71046,,0,Medicare_Advantage,MA_PPO,12,F,0.8486,,,344.25,125.36,98.72,1.96,0.0,24.68,218.89,0.0,0.0,0,,0.0481,none,0,1,0,0,0,9e-06,0,0,,Capitation
CLM0000000295,MBR00000294,Medical_Professional,Paid,Electronic_EDI,2023-10-14,2023-10-14,2023-10-14,2023-11-10,Manual_Review,27,1388566092,1765164601,207RG0100X,Gastroenterology,65,In_Network,Z23,Z23|G47.33,20610,,0,Medicare_Advantage,MA_HMO,8,M,0.6878,,,1181.69,773.89,597.29,9.28,18.0,149.32,407.8,0.0,0.0,0,,0.088,none,0,1,0,0,0,5.5e-05,0,0,,Shared_Savings
CLM0000000296,MBR00000074,Vision,Paid,Paper,2023-08-14,2023-08-14,2023-08-14,2023-09-10,Auto_Adjudicated,27,1067329999,1396850418,207RC0000X,Cardiovascular Disease,11,In_Network,Z79.4,J20.9|OTHER|I10,V2100,,0,Medicare_Advantage,MA_PPO,21,F,0.8719,,,416.37,331.1,240.34,11.68,19.0,60.08,85.27,0.0,0.0,0,,0.134,none,0,1,0,0,0,2.2e-05,0,0,,Capitation
CLM0000000297,MBR00000061,Medical_Professional,Paid,Electronic_EDI,2023-01-24,2023-01-24,2023-01-24,2023-02-08,Auto_Adjudicated,15,1789174420,1188760037,207RP1001X,Pulmonary Disease,65,In_Network,Z00.00,OTHER|E78.5,99213,,0,Commercial,PPO,66,M,2.3575,,,341.65,164.32,45.67,94.23,13.0,11.42,177.33,0.0,0.0,0,,0.0545,none,0,1,0,0,0,4e-06,0,0,,Bundled_Payment
CLM0000000298,MBR00000185,Vision,Paid,Electronic_EDI,2023-12-15,2023-12-15,2023-12-15,2024-01-11,Auto_Adjudicated,27,1746688640,1054984734,207Q00000X,Family Medicine,81,In_Network,E78.5,OTHER,92012,,0,Medicaid_MCO,MCO,73,M,1.5417,,,237.48,185.76,182.76,0.0,3.0,0.0,51.72,0.0,0.0,0,,0.1039,none,0,1,0,1,0,1.7e-05,0,0,,FFS
CLM0000000299,MBR00000168,Pharmacy,Paid,Electronic_EDI,2023-09-13,2023-09-13,2023-09-13,2023-09-20,Auto_Adjudicated,7,1315569619,1432077493,207RE0101X,Endocrinology,23,Out_of_Network,Z00.00,M17.11,00071012831,,5,Commercial,HMO,76,M,1.2791,,,140.36,52.95,0.0,52.95,0.0,0.0,87.41,0.0,0.0,0,,0.0086,none,0,1,0,0,0,0.0,0,0,LCS_Lung_Cancer_Screening,Shared_Savings
CLM0000000300,MBR00000070,Medical_Professional,Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-23,2023-03-08,Auto_Adjudicated,13,1482771601,1040061910,2084P0800X,Psychiatry,21,In_Network,OTHER,OTHER|I48.91|I10,73721,,0,Commercial,POS,42,F,0.8468,,,910.38,617.01,387.54,117.59,15.0,96.88,293.37,0.0,0.0,0,,0.0535,none,0,1,0,0,0,3.6e-05,0,0,,Capitation
CLM0000000301,MBR00000199,Medical_Professional,Paid,Electronic_EDI,2023-04-01,2023-04-01,2023-04-01,2023-04-05,Auto_Adjudicated,4,1356408757,1318978078,207R00000X,Internal Medicine,11,In_Network,Z12.11,,74177,,0,Medicaid_MCO,MLTSS,17,F,1.0776,,,939.56,525.95,523.95,0.0,2.0,0.0,413.61,0.0,0.0,0,,0.0685,none,0,1,0,0,0,4.8e-05,0,0,,FFS
CLM0000000302,MBR00000028,Pharmacy,Denied,Electronic_EDI,2023-05-03,2023-05-03,2023-05-03,2023-05-20,Auto_Adjudicated,17,1952322604,1354265777,207RN0300X,Nephrology,21,In_Network,I25.10,H52.4,00006001954,,3,Commercial,HMO,3,F,2.116,1,Timely_Filing,433.47,157.76,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Provider Impersonation,0.9316,geographic_mismatch|provider_specialty_mismatch|temporal_clustering|billing_spike_recent|duplicate_claim_indicator|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,0.0,0,1,,FFS
CLM0000000303,MBR00000006,Medical_Institutional,Paid,Electronic_EDI,2023-04-02,2023-04-02,2023-04-03,2023-04-23,Auto_Adjudicated,21,1243052462,1287472731,207RP1001X,Pulmonary Disease,11,In_Network,C50.911,Z00.00,revenue_code:0360,,0,Commercial,EPO,88,M,1.4365,,,16331.51,10955.01,8677.8,46.75,61.0,2169.45,5376.5,0.0,0.0,0,,0.0601,none,0,1,1,0,0,0.000803,0,0,,FFS
CLM0000000304,MBR00000025,Medical_Professional,Paid,Electronic_EDI,2023-08-11,2023-08-11,2023-08-11,2023-09-09,Clinical_Review,29,1594322174,1055872102,207RC0000X,Cardiovascular Disease,11,Out_of_Network,E78.5,OTHER|E11.9,83036,,0,Commercial,POS,74,M,1.3309,,,1748.16,751.66,533.73,59.5,25.0,133.43,996.5,0.0,0.0,0,,0.015,none,0,1,0,0,0,4.9e-05,1,0,,Capitation
CLM0000000305,MBR00000115,Medical_Professional,Paid,Paper,2023-07-16,2023-07-16,2023-07-16,2023-08-08,Auto_Adjudicated,23,1017424540,1842149518,207RP1001X,Pulmonary Disease,11,In_Network,I10,Z12.11,99283,,0,Commercial,PPO,15,F,0.7398,,,207.41,124.09,0.0,124.09,0.0,0.0,83.32,0.0,0.0,0,,0.1169,none,0,1,0,0,0,0.0,0,0,TRC_Transition_of_Care,Bundled_Payment
CLM0000000306,MBR00000293,Dental,Paid,Electronic_EDI,2023-03-18,2023-03-18,2023-03-18,2023-04-07,Auto_Adjudicated,20,1055095309,1164525386,2086S0122X,Orthopedic Surgery,23,Out_of_Network,I25.10,OTHER,D3310,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,359.03,169.89,117.44,12.09,11.0,29.36,189.14,0.0,0.0,0,,0.0726,none,0,1,0,0,0,1.1e-05,0,0,,Capitation
CLM0000000307,MBR00000166,Pharmacy,Paid,Provider_Portal,2023-09-07,2023-09-07,2023-09-07,2023-09-28,Auto_Adjudicated,21,1719850506,1282319940,246ZN0300X,Neuropsychology,11,In_Network,OTHER,F41.1|G47.33,00006001954,,3,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,115.17,47.45,0.0,47.45,0.0,0.0,67.72,0.0,0.0,0,,0.1395,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000308,MBR00000221,Medical_Institutional,Paid,Electronic_EDI,2023-04-13,2023-04-13,2023-04-17,2023-05-02,Manual_Review,19,1147452455,1865266296,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,J06.9,revenue_code:0360,,0,Commercial,HDHP_HSA,28,M,1.6683,,,108218.91,43911.75,34941.51,234.86,0.0,8735.38,64307.16,0.0,0.0,0,,0.1434,outlier_billing_amount|npi_mismatch,0,1,1,0,0,0.003234,0,0,,Shared_Savings
CLM0000000309,MBR00000102,Medical_Professional,Paid,Paper,2023-02-27,2023-02-27,2023-02-27,2023-03-12,Auto_Adjudicated,13,1207523397,1132693989,208600000X,Surgery General,23,In_Network,M54.5,,99232,,0,Commercial,POS,68,M,1.6864,,,410.32,272.79,57.14,169.36,32.0,14.29,137.53,0.0,0.0,0,,0.1027,none,0,1,0,0,0,5e-06,0,0,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000000310,MBR00000212,Medical_Institutional,Paid,Paper,2023-12-10,2023-12-10,2023-12-12,2023-12-26,Auto_Adjudicated,16,1853403237,1690197969,246ZN0300X,Neuropsychology,11,Out_of_Network,E78.5,J20.9,revenue_code:0120,,0,Commercial,HMO,57,F,2.5456,,,29872.42,13411.68,10596.5,98.06,68.0,2649.12,16460.74,0.0,0.0,0,,0.0835,none,0,1,1,0,0,0.000981,1,0,,Capitation
CLM0000000311,MBR00000293,Pharmacy,Denied,Electronic_EDI,2023-04-23,2023-04-23,2023-04-23,2023-04-29,Auto_Adjudicated,6,1014482814,1878017518,207RC0000X,Cardiovascular Disease,21,In_Network,J06.9,,16590051660,,2,Medicare_Advantage,MA_HMO,84,F,2.8513,256,Authorization,257.25,129.79,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0072,none,0,1,0,0,0,0.0,0,1,CCS_Cervical_Cancer_Screening,P4P
CLM0000000312,MBR00000113,Medical_Professional,Paid,Provider_Portal,2023-03-25,2023-03-25,2023-03-25,2023-03-26,Auto_Adjudicated,1,1666911728,1188760037,207V00000X,Obstetrics & Gynecology,11,In_Network,E11.9,OTHER|J06.9,99285,,0,Medicaid_MCO,MLTSS,29,F,1.1621,,,272.21,122.75,121.75,0.0,1.0,0.0,149.46,0.0,0.0,0,,0.0823,none,0,1,0,0,0,1.1e-05,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000000313,MBR00000300,Behavioral_Health,Paid,Electronic_EDI,2023-09-15,2023-09-15,2023-09-15,2023-10-09,Manual_Review,24,1881170383,1300957944,207RE0101X,Endocrinology,11,In_Network,OTHER,F10.10|F32.9|OTHER,71046,,0,Commercial,PPO,64,F,1.0393,,,836.31,345.58,233.37,24.87,29.0,58.34,490.73,158.0,66.9,0,,0.0123,none,0,1,0,0,0,2.2e-05,0,0,MPT_Annual_Monitoring,Capitation
CLM0000000314,MBR00000189,Dental,Paid,Provider_Portal,2023-10-02,2023-10-02,2023-10-02,2023-10-17,Auto_Adjudicated,15,1252009836,1068662623,208600000X,Surgery General,11,In_Network,Z00.00,,D0120,,0,Medicaid_MCO,MCO,71,F,0.9722,,,725.77,255.02,251.02,0.0,4.0,0.0,470.75,0.0,0.0,0,,0.0221,none,0,1,0,0,0,2.3e-05,0,0,ACR_Urine_Protein,FFS
CLM0000000315,MBR00000220,Medical_Professional,Paid,Electronic_EDI,2023-02-24,2023-02-24,2023-02-24,2023-03-23,Auto_Adjudicated,27,1324142620,1061149198,2086S0122X,Orthopedic Surgery,11,In_Network,I10,,85025,,0,Commercial,HMO,38,M,0.7736,,,519.28,306.74,171.89,56.87,35.0,42.97,212.54,0.0,0.0,0,,0.1067,none,0,1,0,1,0,1.6e-05,0,0,PPC_Prenatal_Care,FFS
CLM0000000316,MBR00000078,Dental,Paid,Electronic_EDI,2023-01-21,2023-01-21,2023-01-21,2023-01-25,Auto_Adjudicated,4,1747318937,1789540567,207V00000X,Obstetrics & Gynecology,22,In_Network,Z00.00,,D4341,,0,Commercial,EPO,65,F,1.3174,,,297.29,218.38,0.0,218.38,0.0,0.0,78.91,0.0,0.0,0,,0.0015,none,0,1,0,1,0,0.0,0,0,,P4P
CLM0000000317,MBR00000191,Pharmacy,Paid,Electronic_EDI,2023-11-02,2023-11-02,2023-11-02,2023-11-14,Auto_Adjudicated,12,1379875145,1408846353,207RN0300X,Nephrology,11,In_Network,OTHER,G43.909|K21.0,00085163102,,1,Commercial,POS,85,F,0.9729,,,214.98,82.71,0.0,82.71,0.0,0.0,132.27,0.0,0.0,0,,0.0235,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000318,MBR00000157,Pharmacy,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-08,Auto_Adjudicated,8,1344162462,1433350836,207RP1001X,Pulmonary Disease,11,In_Network,F32.9,,16590051660,,2,Medicare_Advantage,MA_HMO,26,F,0.9164,,,116.78,50.93,25.15,2.49,17.0,6.29,65.85,0.0,0.0,0,,0.0479,none,0,1,0,0,0,2e-06,0,1,,FFS
CLM0000000319,MBR00000290,Medical_Professional,Paid,Electronic_EDI,2023-06-13,2023-06-13,2023-06-13,2023-07-09,Manual_Review,26,1411619682,1209882852,207RC0000X,Cardiovascular Disease,23,In_Network,E11.9,F41.1,20610,,0,Commercial,PPO,9,M,0.5261,,,509.6,404.9,0.0,399.64,5.26,0.0,104.7,0.0,0.0,0,,0.0888,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000320,MBR00000274,Dental,Paid,Electronic_EDI,2023-05-31,2023-05-31,2023-05-31,2023-06-12,Auto_Adjudicated,12,1091395764,1068662623,207RC0000X,Cardiovascular Disease,23,In_Network,Z12.11,I10,D7140,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,140.63,113.42,81.71,11.29,0.0,20.43,27.21,0.0,0.0,0,,0.1924,geographic_mismatch,0,1,0,0,0,8e-06,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000000321,MBR00000126,Medical_Institutional,Paid,Paper,2023-07-30,2023-07-30,2023-08-02,2023-08-19,Auto_Adjudicated,20,1898658234,1489434038,207R00000X,Internal Medicine,21,In_Network,Z00.01,OTHER|E78.5,revenue_code:0370,439,0,Medicaid_MCO,MLTSS,48,F,0.637,,,1389.64,1154.19,1148.19,0.0,6.0,0.0,235.45,0.0,0.0,0,,0.0375,none,0,1,0,0,0,0.000106,0,0,,FFS
CLM0000000322,MBR00000287,Pharmacy,Paid,Electronic_EDI,2023-08-30,2023-08-30,2023-08-30,2023-09-02,Auto_Adjudicated,3,1774425033,1452088018,2086S0122X,Orthopedic Surgery,65,In_Network,Z00.01,I10,50458085930,,3,Commercial,PPO,4,M,0.7685,,,875.24,581.17,317.74,158.0,26.0,79.43,294.07,0.0,0.0,0,,0.1278,none,0,1,0,0,0,2.9e-05,0,1,,FFS
CLM0000000323,MBR00000268,Medical_Professional,Paid,Provider_Portal,2023-01-29,2023-01-29,2023-01-29,2023-02-14,Auto_Adjudicated,16,1313352855,1291071007,208600000X,Surgery General,24,In_Network,OTHER,K21.0,97010,,0,Medicaid_MCO,MCO,13,M,0.3526,,,456.03,163.19,163.19,0.0,0.0,0.0,292.84,0.0,0.0,0,,0.0365,none,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000000324,MBR00000177,Medical_Professional,Paid,Electronic_EDI,2023-04-06,2023-04-06,2023-04-06,2023-04-20,Manual_Review,14,1921056264,1564636990,246ZN0300X,Neuropsychology,22,In_Network,M47.816,G43.909,71250,,0,Commercial,HMO,42,F,1.2774,,,525.41,217.47,70.36,102.52,27.0,17.59,307.94,0.0,0.0,0,,0.0599,none,0,1,0,0,0,7e-06,0,0,FUM_Follow_Up_ED_Mental_Health,Shared_Savings
CLM0000000325,MBR00000025,Vision,Paid,Electronic_EDI,2023-12-09,2023-12-09,2023-12-09,2023-12-28,Auto_Adjudicated,19,1393200616,1560230600,2084P0800X,Psychiatry,21,In_Network,M79.3,K57.30|E78.5,92014,,0,Commercial,POS,74,M,1.3309,,,289.83,133.3,0.0,133.3,0.0,0.0,156.53,0.0,0.0,0,,0.014,none,0,1,0,0,0,0.0,0,0,AMR_Asthma_Medication_Ratio,Shared_Savings
CLM0000000326,MBR00000051,Medical_Institutional,Paid,Electronic_EDI,2023-03-01,2023-03-01,2023-03-03,2023-03-19,Auto_Adjudicated,18,1295273693,1965244699,207V00000X,Obstetrics & Gynecology,11,In_Network,F32.9,E78.5,revenue_code:0370,,0,Medicare_Advantage,MA_PPO,17,F,1.0695,,,22450.23,11813.86,9395.83,45.07,24.0,2348.96,10636.37,0.0,0.0,0,,0.1965,duplicate_claim_indicator,0,1,1,0,0,0.00087,0,0,,P4P
CLM0000000327,MBR00000024,Medical_Professional,Paid,Electronic_EDI,2023-11-22,2023-11-22,2023-11-22,2023-11-26,Manual_Review,4,1175448241,1649705287,101YP2500X,Psychologist Clinical,21,Out_of_Network,F41.1,E11.9,47562,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,1118.9,587.54,584.54,0.0,3.0,0.0,531.36,0.0,0.0,0,,0.0085,none,0,1,0,0,0,5.4e-05,1,0,SPD_Spirometry_Testing,Capitation
CLM0000000328,MBR00000033,Pharmacy,Paid,Electronic_EDI,2023-05-25,2023-05-25,2023-05-25,2023-05-27,Auto_Adjudicated,2,1816378991,1354265777,207RP1001X,Pulmonary Disease,22,In_Network,OTHER,,00071015523,,1,Medicare_Advantage,PFFS,31,F,0.821,,,410.04,179.96,126.24,17.16,5.0,31.56,230.08,0.0,0.0,0,,0.0717,none,0,1,0,0,0,1.2e-05,0,1,,FFS
CLM0000000329,MBR00000294,Medical_Professional,Paid,Electronic_EDI,2023-03-10,2023-03-10,2023-03-10,2023-03-14,Auto_Adjudicated,4,1326896487,1643323506,246ZN0300X,Neuropsychology,81,In_Network,Z00.00,,99284,,0,Medicare_Advantage,MA_HMO,8,M,0.6878,,,373.24,163.65,105.99,13.16,18.0,26.5,209.59,0.0,0.0,0,,0.1062,none,0,1,0,0,0,1e-05,0,0,,Bundled_Payment
CLM0000000330,MBR00000064,Dental,Denied,Electronic_EDI,2023-08-02,2023-08-02,2023-08-02,2023-08-09,Auto_Adjudicated,7,1402424417,1765164601,2086S0122X,Orthopedic Surgery,71,In_Network,I50.9,N18.3,D0120,,0,Medicare_Advantage,SNP,73,M,1.0644,50,Duplicate,298.02,246.56,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1408,geographic_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000331,MBR00000206,Dental,Denied,Electronic_EDI,2023-08-27,2023-08-27,2023-08-27,2023-09-18,Manual_Review,22,1719850506,1368666316,207RC0000X,Cardiovascular Disease,11,In_Network,J20.9,OTHER,D3310,,0,Medicaid_MCO,MLTSS,21,M,1.4038,22,Authorization,747.47,295.46,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0715,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000332,MBR00000188,Medical_Professional,Paid,Provider_Portal,2023-05-06,2023-05-06,2023-05-06,2023-05-15,Auto_Adjudicated,9,1170319307,1128148362,208600000X,Surgery General,81,In_Network,M54.5,OTHER|M17.11,11200,,0,Commercial,HMO,8,F,1.5853,,,573.63,206.26,123.43,26.98,25.0,30.86,367.37,83.35,35.93,0,,0.0026,none,0,1,0,0,0,1.1e-05,0,0,AMR_Asthma_Medication_Ratio,Bundled_Payment
CLM0000000333,MBR00000187,Medical_Institutional,Paid,Electronic_EDI,2023-10-12,2023-10-12,2023-10-12,2023-11-11,Auto_Adjudicated,30,1267286378,1560230600,207RN0300X,Nephrology,24,In_Network,E11.9,Z12.11|OTHER|M17.11,revenue_code:0300,,0,Medicaid_MCO,MCO,36,F,1.191,,,30367.6,11003.7,10996.7,0.0,7.0,0.0,19363.9,0.0,0.0,0,,0.0988,none,0,1,1,0,0,0.001018,0,0,,Capitation
CLM0000000334,MBR00000063,Behavioral_Health,Paid,Electronic_EDI,2023-01-23,2023-01-23,2023-01-23,2023-01-26,Auto_Adjudicated,3,1650193199,1461075342,207R00000X,Internal Medicine,23,In_Network,OTHER,,99205,,0,ACA_Marketplace,ACA_Silver,56,M,0.8198,,,101.87,64.08,0.0,64.08,0.0,0.0,37.79,0.0,0.0,0,,0.0497,none,0,1,0,0,0,0.0,0,0,W30_Well_Child_Visit,FFS
CLM0000000335,MBR00000175,Vision,Denied,Electronic_EDI,2023-02-13,2023-02-13,2023-02-13,2023-03-01,Auto_Adjudicated,16,1944105498,1643673796,2086S0122X,Orthopedic Surgery,65,In_Network,OTHER,Z00.00,92002,,0,Commercial,PPO,14,F,1.5785,50,Timely_Filing,536.72,247.42,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0527,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000336,MBR00000186,Medical_Institutional,Paid,Electronic_EDI,2023-08-12,2023-08-12,2023-08-12,2023-09-03,Auto_Adjudicated,22,1462532026,1574982369,2086S0122X,Orthopedic Surgery,21,Emergency,Z00.01,Z00.00|F41.1,revenue_code:0200,292,0,Commercial,PPO,65,M,1.6983,,,5379.09,3174.44,2354.94,180.76,50.0,588.74,2204.65,0.0,0.0,0,,0.0364,none,0,1,0,0,0,0.000218,0,0,,Shared_Savings
CLM0000000337,MBR00000171,Pharmacy,Denied,Electronic_EDI,2023-07-27,2023-07-27,2023-07-27,2023-07-29,Auto_Adjudicated,2,1288855406,1983760474,225100000X,Physical Therapist,21,In_Network,I10,N39.0,00085163102,,1,Commercial,PPO,27,F,0.819,170,Network,56.43,32.87,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1376,impossible_service_combo,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000338,MBR00000058,Medical_Institutional,Paid,Electronic_EDI,2023-09-08,2023-09-08,2023-09-12,2023-09-24,Auto_Adjudicated,16,1887363539,1274911960,101YP2500X,Psychologist Clinical,32,In_Network,I50.9,OTHER,revenue_code:0200,,0,Commercial,PPO,56,F,1.1626,,,3727.52,2988.92,2215.55,144.49,75.0,553.89,738.6,1624.1,428.21,0,,0.0951,high_volume_same_code,0,1,0,0,0,0.000205,0,0,,Capitation
CLM0000000339,MBR00000212,Medical_Professional,Paid,Electronic_EDI,2023-11-02,2023-11-02,2023-11-02,2023-11-05,Manual_Review,3,1008470017,1287472731,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,I10,27130,,0,Commercial,HMO,57,F,2.5456,,,20746.4,8938.16,6935.29,251.05,18.0,1733.82,11808.24,0.0,0.0,0,,0.0632,none,0,1,1,0,0,0.000642,0,0,HBD_Hemoglobin_A1c_Testing,Capitation
CLM0000000340,MBR00000023,Pharmacy,Paid,Electronic_EDI,2023-11-30,2023-11-30,2023-11-30,2023-12-24,Auto_Adjudicated,24,1110312325,1896197144,207RE0101X,Endocrinology,23,In_Network,F41.1,OTHER,00310075090,,4,Medicare_Advantage,MA_PPO,87,M,1.084,,,1120.69,566.97,414.01,34.45,15.0,103.5,553.72,365.11,38.76,0,,0.1866,geographic_mismatch|duplicate_claim_indicator,0,1,0,0,0,3.8e-05,0,1,,FFS
CLM0000000341,MBR00000178,Medical_Professional,Denied,Electronic_EDI,2023-07-01,2023-07-01,2023-07-01,2023-07-16,Auto_Adjudicated,15,1346717076,1469697158,207RE0101X,Endocrinology,24,In_Network,OTHER,,90837,,0,Medicaid_MCO,MCO,89,M,0.7057,3,Duplicate,566.64,390.87,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1238,service_date_weekend|diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000342,MBR00000136,Medical_Professional,Paid,Electronic_EDI,2023-06-29,2023-06-29,2023-06-29,2023-07-25,Auto_Adjudicated,26,1591624417,1151295616,207V00000X,Obstetrics & Gynecology,32,In_Network,OTHER,,99284,,0,Commercial,POS,2,F,1.2611,,,264.71,162.64,64.98,71.41,10.0,16.25,102.07,0.0,0.0,0,,0.087,none,0,1,0,0,0,6e-06,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000000343,MBR00000077,Medical_Institutional,Paid,Electronic_EDI,2023-11-28,2023-11-28,2023-11-30,2023-12-18,Auto_Adjudicated,20,1089569577,1884259357,207RC0000X,Cardiovascular Disease,11,In_Network,I10,,revenue_code:0300,,0,Medicare_Advantage,MA_HMO,27,F,0.9229,,,23962.37,15381.83,12269.58,6.85,38.0,3067.4,8580.54,0.0,0.0,0,,0.0729,none,0,1,1,0,0,0.001136,0,0,CDC_HbA1c_Poor_Control,Shared_Savings
CLM0000000344,MBR00000239,Dental,Denied,Provider_Portal,2023-12-11,2023-12-11,2023-12-11,2023-12-21,Auto_Adjudicated,10,1706018784,1825450791,207RG0100X,Gastroenterology,23,In_Network,I10,OTHER|Z12.11|I10,D7140,,0,Commercial,HMO,1,F,1.1193,2,Coding_Error,247.76,144.45,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.106,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000345,MBR00000055,Medical_Professional,Paid,Paper,2023-01-18,2023-01-18,2023-01-18,2023-01-23,Manual_Review,5,1192302048,1804282800,101YP2500X,Psychologist Clinical,11,In_Network,Z00.01,,99213,,0,Commercial,PPO,68,F,1.2896,,,259.82,197.53,29.29,150.92,10.0,7.32,62.29,0.0,0.0,0,,0.0218,none,0,1,0,0,0,3e-06,0,0,COA_Care_Transitions,FFS
CLM0000000346,MBR00000281,Medical_Professional,Paid,Electronic_EDI,2023-07-01,2023-07-01,2023-07-01,2023-07-06,Auto_Adjudicated,5,1331903993,1029818813,207RC0000X,Cardiovascular Disease,31,In_Network,OTHER,,80053,,0,Medicare_Advantage,MA_HMO,3,M,0.8531,,,509.28,209.0,162.94,2.33,3.0,40.73,300.28,0.0,0.0,0,,0.1363,none,0,1,0,0,0,1.5e-05,0,0,,Bundled_Payment
CLM0000000347,MBR00000268,Medical_Professional,Paid,Electronic_EDI,2023-11-26,2023-11-26,2023-11-26,2023-11-27,Auto_Adjudicated,1,1048378959,1355732274,225100000X,Physical Therapist,22,In_Network,E11.65,E11.9,99395,,0,Medicaid_MCO,MCO,13,M,0.3526,,,748.76,618.81,618.81,0.0,0.0,0.0,129.95,0.0,0.0,0,,0.1448,high_volume_same_code,0,1,0,0,0,5.7e-05,0,0,,Bundled_Payment
CLM0000000348,MBR00000114,Medical_Professional,Paid,Electronic_EDI,2023-01-19,2023-01-19,2023-01-19,2023-01-29,Auto_Adjudicated,10,1113370285,1804282800,207Q00000X,Family Medicine,22,In_Network,OTHER,G47.33|Z00.00|OTHER,99214,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,290.79,128.2,73.8,16.95,19.0,18.45,162.59,0.0,0.0,0,,0.1245,benford_violation|npi_mismatch,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000000349,MBR00000097,Behavioral_Health,Paid,Electronic_EDI,2023-12-17,2023-12-17,2023-12-17,2024-01-08,Auto_Adjudicated,22,1376791933,1040061910,2086S0122X,Orthopedic Surgery,31,In_Network,L70.0,,99397,,0,Commercial,EPO,34,M,1.3765,,,319.88,141.86,0.0,141.86,0.0,0.0,178.02,0.0,0.0,0,,0.1308,unusual_service_frequency,0,1,0,0,0,0.0,0,0,DDE_Diabetes_Short_Term_Complications,Shared_Savings
CLM0000000350,MBR00000042,Medical_Institutional,Denied,Electronic_EDI,2023-09-26,2023-09-26,2023-09-28,2023-10-07,Auto_Adjudicated,11,1269720844,1432077493,2084P0800X,Psychiatry,22,In_Network,L70.0,Z00.121|OTHER,revenue_code:0100,,0,Commercial,HMO,78,F,1.1448,PR-1,COB,6321.26,2943.35,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0896,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000351,MBR00000277,Medical_Professional,Denied,Electronic_EDI,2023-02-25,2023-02-25,2023-02-25,2023-03-02,Auto_Adjudicated,5,1156265220,1005335812,207V00000X,Obstetrics & Gynecology,22,In_Network,I10,,20610,,0,Medicaid_MCO,MCO,30,M,1.8495,22,Eligibility,292.86,211.03,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0457,none,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000000352,MBR00000186,Vision,Paid,Electronic_EDI,2023-08-19,2023-08-19,2023-08-19,2023-08-22,Auto_Adjudicated,3,1233824762,1319611206,2086S0122X,Orthopedic Surgery,22,In_Network,Z00.01,,V2320,,0,Commercial,PPO,65,M,1.6983,,,390.23,253.35,126.53,83.18,12.0,31.63,136.88,0.0,0.0,0,,0.0939,none,0,1,0,0,0,1.2e-05,0,0,,Capitation
CLM0000000353,MBR00000010,Medical_Professional,Paid,Electronic_EDI,2023-06-04,2023-06-04,2023-06-04,2023-06-18,Auto_Adjudicated,14,1117755591,1452088018,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,K29.70|I10|L70.0,99213,,0,Medicare_Advantage,MA_HMO,44,F,1.4631,,,317.73,127.58,77.8,26.33,4.0,19.45,190.15,0.0,0.0,0,,0.0564,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000000354,MBR00000157,Medical_Institutional,Paid,Electronic_EDI,2023-05-01,2023-05-01,2023-05-01,2023-05-08,Auto_Adjudicated,7,1897146144,1447657873,207R00000X,Internal Medicine,23,In_Network,F41.1,J44.1|Z00.00,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,26,F,0.9164,,,30325.22,23855.88,19058.76,4.43,28.0,4764.69,6469.34,0.0,0.0,0,,0.0561,none,0,1,1,0,0,0.001764,0,0,,Capitation
CLM0000000355,MBR00000026,Pharmacy,Paid,Electronic_EDI,2023-08-11,2023-08-11,2023-08-11,2023-09-03,Auto_Adjudicated,23,1454203715,1128148362,207RN0300X,Nephrology,24,In_Network,OTHER,E78.5,16590051660,,4,Medicaid_MCO,MCO,17,M,1.0686,,,88.55,74.78,73.78,0.0,1.0,0.0,13.77,0.0,0.0,0,,0.1293,impossible_service_combo,0,1,0,0,0,7e-06,0,0,,Bundled_Payment
CLM0000000356,MBR00000173,Pharmacy,Paid,Provider_Portal,2023-09-21,2023-09-21,2023-09-21,2023-10-02,Auto_Adjudicated,11,1331903993,1995553359,101YP2500X,Psychologist Clinical,11,In_Network,M54.5,,00310075090,,4,Medicare_Advantage,PFFS,23,F,1.0279,,,167.17,100.1,46.46,28.03,14.0,11.61,67.07,0.0,0.0,0,,0.1746,controlled_substance_high_volume,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000000357,MBR00000156,Medical_Professional,Paid,Electronic_EDI,2023-11-17,2023-11-17,2023-11-17,2023-11-21,Clinical_Review,4,1067329999,1301833092,2086S0122X,Orthopedic Surgery,21,In_Network,F33.0,Z23,99396,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,147.03,53.12,28.75,4.18,13.0,7.19,93.91,0.0,0.0,0,,0.0549,none,0,1,0,0,0,3e-06,0,0,SPD_Spirometry_Testing,Bundled_Payment
CLM0000000358,MBR00000025,Pharmacy,Partially_Paid,Electronic_EDI,2023-05-30,2023-05-30,2023-05-30,2023-06-08,Manual_Review,9,1263063839,1625992541,246ZN0300X,Neuropsychology,21,In_Network,I25.10,,00071012831,,1,Commercial,POS,74,M,1.3309,16,Medical_Necessity,121.2,73.45,0.0,47.89,0.71,0.0,72.6,0.0,0.0,0,,0.0861,none,0,1,0,0,0,0.0,0,0,PCR_Plan_All_Cause_Readmission,Capitation
CLM0000000359,MBR00000242,Medical_Institutional,Denied,Electronic_EDI,2023-02-27,2023-02-27,2023-03-02,2023-03-13,Manual_Review,14,1793406356,1672803287,207R00000X,Internal Medicine,11,In_Network,Z00.00,J20.9,revenue_code:0450,,0,Medicaid_MCO,MLTSS,75,F,0.7104,3,Medical_Necessity,3267.67,2090.13,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0124,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000360,MBR00000081,Pharmacy,Paid,Electronic_EDI,2023-11-07,2023-11-07,2023-11-07,2023-11-09,Auto_Adjudicated,2,1321381114,1179350099,207RG0100X,Gastroenterology,24,In_Network,M17.11,I10|N39.0,00071015523,,1,Medicare_Advantage,SNP,66,F,2.159,,,143.38,64.24,46.0,1.74,5.0,11.5,79.14,0.0,0.0,0,,0.1539,high_volume_same_code|billing_spike_recent,0,1,0,0,0,4e-06,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000000361,MBR00000165,Medical_Professional,Paid,Paper,2023-04-30,2023-04-30,2023-04-30,2023-05-04,Clinical_Review,4,1808451151,1319611206,207RN0300X,Nephrology,22,In_Network,OTHER,OTHER,99385,,0,ACA_Marketplace,ACA_Bronze,55,M,0.9775,,,538.46,197.67,0.0,197.67,0.0,0.0,340.79,0.0,0.0,0,,0.1398,upcoding_pattern|diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000362,MBR00000189,Pharmacy,Denied,Electronic_EDI,2023-09-30,2023-09-30,2023-09-30,2023-10-29,Auto_Adjudicated,29,1886549972,1650774392,207RG0100X,Gastroenterology,11,In_Network,F32.9,J06.9|I10,00085163102,,1,Medicaid_MCO,MCO,71,F,0.9722,170,Timely_Filing,90.6,53.78,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0476,none,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000000363,MBR00000292,Medical_Institutional,Paid,Electronic_EDI,2023-10-14,2023-10-14,2023-10-15,2023-10-25,Auto_Adjudicated,11,1264432433,1177602659,207V00000X,Obstetrics & Gynecology,23,In_Network,F32.9,,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,4,M,1.1779,,,5480.78,4309.73,3403.25,26.67,29.0,850.81,1171.05,2588.46,408.09,0,,0.1037,none,0,1,0,0,0,0.000315,0,0,,FFS
CLM0000000364,MBR00000153,Pharmacy,Paid,Electronic_EDI,2023-01-21,2023-01-21,2023-01-21,2023-02-13,Auto_Adjudicated,23,1897146144,1164525386,207Q00000X,Family Medicine,21,In_Network,Z87.891,F32.9|K21.0,00006001954,,4,Commercial,POS,12,F,0.6525,,,157.49,74.66,0.0,74.66,0.0,0.0,82.83,0.0,0.0,0,,0.0993,none,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000000365,MBR00000277,Vision,Paid,Electronic_EDI,2023-05-28,2023-05-28,2023-05-28,2023-06-25,Auto_Adjudicated,28,1584745499,1013600387,2084P0800X,Psychiatry,23,In_Network,OTHER,OTHER|F32.9|E11.9,V2103,,0,Medicaid_MCO,MCO,30,M,1.8495,,,255.38,136.53,133.53,0.0,3.0,0.0,118.85,86.08,26.4,0,,0.0108,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000000366,MBR00000112,Dental,Paid,Electronic_EDI,2023-01-31,2023-01-31,2023-01-31,2023-02-04,Auto_Adjudicated,4,1591624417,1477113725,208600000X,Surgery General,11,In_Network,OTHER,E11.9|Z00.00|K29.70,D0150,,0,Medicare_Advantage,MA_HMO,18,M,1.01,,,555.56,445.65,332.12,24.51,6.0,83.03,109.91,0.0,0.0,0,,0.2329,unusual_service_frequency|high_volume_same_code,0,2,0,0,0,3.1e-05,0,0,,Capitation
CLM0000000367,MBR00000259,Pharmacy,Paid,Electronic_EDI,2023-08-06,2023-08-06,2023-08-06,2023-08-27,Auto_Adjudicated,21,1388662212,1912895973,246ZN0300X,Neuropsychology,11,In_Network,K21.0,,00003014960,,1,Medicare_Advantage,MA_PPO,5,M,1.6554,,,63.67,41.7,27.32,0.55,7.0,6.83,21.97,0.0,0.0,0,,0.0984,none,0,1,0,0,0,3e-06,0,0,,FFS
CLM0000000368,MBR00000074,Medical_Professional,Denied,Electronic_EDI,2023-10-13,2023-10-13,2023-10-13,2023-11-07,Auto_Adjudicated,25,1326896487,1765164601,207R00000X,Internal Medicine,11,Out_of_Network,K21.0,,99283,,0,Medicare_Advantage,MA_PPO,21,F,0.8719,3,Network,80.07,50.82,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1126,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,FLU_Flu_Vaccination,FFS
CLM0000000369,MBR00000209,Medical_Professional,Paid,Electronic_EDI,2023-07-21,2023-07-21,2023-07-21,2023-07-22,Auto_Adjudicated,1,1176378924,1560230600,101YP2500X,Psychologist Clinical,22,In_Network,F32.9,E78.5,99392,,0,Medicare_Advantage,MA_HMO,10,F,0.5199,,,289.03,148.6,109.32,9.94,2.0,27.33,140.43,0.0,0.0,0,,0.0536,none,0,1,0,0,0,1e-05,0,0,KED_ESRD_Patients,Shared_Savings
CLM0000000370,MBR00000027,Medical_Institutional,Paid,Electronic_EDI,2023-04-27,2023-04-27,2023-04-29,2023-05-07,Auto_Adjudicated,10,1983779639,1007652766,207Q00000X,Family Medicine,24,In_Network,OTHER,OTHER,revenue_code:0300,,0,Medicare_Advantage,MA_HMO,45,M,0.6886,,,54954.63,45680.08,36501.04,5.78,48.0,9125.26,9274.55,0.0,0.0,0,,0.157,outlier_billing_amount,0,1,1,1,0,0.003379,0,0,,FFS
CLM0000000371,MBR00000297,Medical_Professional,Denied,Paper,2023-12-16,2023-12-16,2023-12-16,2023-12-21,Auto_Adjudicated,5,1793406356,1607833568,207RE0101X,Endocrinology,22,In_Network,OTHER,J20.9|C50.911,17000,,0,Commercial,HMO,88,M,1.5311,5,Network,567.51,396.8,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1158,geographic_mismatch,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000372,MBR00000289,Pharmacy,Paid,Electronic_EDI,2023-01-31,2023-01-31,2023-01-31,2023-02-01,Manual_Review,1,1584745499,1390802135,207RC0000X,Cardiovascular Disease,11,In_Network,F33.0,E11.9,50458085930,,3,Commercial,POS,51,M,1.0534,,,247.09,99.12,45.37,3.4,39.0,11.34,147.97,0.0,0.0,0,,0.0635,none,0,1,0,0,0,4e-06,0,0,,Capitation
CLM0000000373,MBR00000139,Pharmacy,Paid,Electronic_EDI,2023-02-20,2023-02-20,2023-02-20,2023-03-01,Auto_Adjudicated,9,1218947226,1175334579,225100000X,Physical Therapist,22,In_Network,E78.5,I10,00071012831,,1,Commercial,PPO,74,M,1.7701,,,168.9,63.07,9.24,30.52,21.0,2.31,105.83,0.0,0.0,0,,0.0843,none,0,1,0,0,0,1e-06,0,1,,Shared_Savings
CLM0000000374,MBR00000160,Medical_Institutional,Denied,Electronic_EDI,2023-05-12,2023-05-12,2023-05-13,2023-05-18,Manual_Review,6,1208538971,1809122260,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,,revenue_code:0450,,0,Commercial,HMO,73,M,1.9608,256,Timely_Filing,23473.89,15452.88,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0282,none,0,1,0,0,0,0.0,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000000375,MBR00000180,Medical_Professional,Paid,Provider_Portal,2023-12-07,2023-12-07,2023-12-07,2024-01-03,Manual_Review,27,1532359759,1691162131,207RG0100X,Gastroenterology,24,Out_of_Network,I10,Z23|J06.9|M17.11,90837,,0,Medicare_Advantage,MA_PPO,72,F,1.1909,,,528.96,256.3,177.5,17.43,17.0,44.37,272.66,0.0,0.0,0,,0.1032,none,0,1,0,0,0,1.6e-05,0,0,SPD_Spirometry_Testing,P4P
CLM0000000376,MBR00000085,Dental,Paid,Provider_Portal,2023-11-18,2023-11-18,2023-11-18,2023-11-26,Auto_Adjudicated,8,1317654726,1616762819,207RG0100X,Gastroenterology,11,In_Network,Z00.01,,D3310,,0,Medicare_Advantage,SNP,2,M,0.7823,,,334.86,135.31,68.85,34.24,15.0,17.21,199.55,0.0,0.0,0,,0.1381,none,0,1,0,0,0,6e-06,0,0,DDE_Diabetes_Short_Term_Complications,Capitation
CLM0000000377,MBR00000200,Medical_Institutional,Paid,Electronic_EDI,2023-07-22,2023-07-22,2023-07-23,2023-08-14,Auto_Adjudicated,23,1295273693,1829216053,207V00000X,Obstetrics & Gynecology,23,In_Network,Z23,I48.91|OTHER|J44.1,revenue_code:0360,,0,Commercial,HDHP_HSA,29,M,0.8011,,,52418.03,37519.11,29606.29,511.25,0.0,7401.57,14898.92,0.0,0.0,0,,0.0735,outlier_billing_amount,0,1,1,0,0,0.00274,0,0,,FFS
CLM0000000378,MBR00000207,Medical_Institutional,Paid,Electronic_EDI,2023-12-08,2023-12-08,2023-12-08,2023-12-10,Auto_Adjudicated,2,1145498455,1068662623,207RN0300X,Nephrology,23,In_Network,E13.9,E11.9|M54.5,revenue_code:0360,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,33601.49,26303.8,26297.8,0.0,6.0,0.0,7297.69,0.0,0.0,0,,0.0937,none,0,1,1,0,0,0.002434,0,0,MPT_Annual_Monitoring,FFS
CLM0000000379,MBR00000160,Medical_Institutional,Paid,Electronic_EDI,2023-11-21,2023-11-21,2023-11-25,2023-12-10,Manual_Review,19,1435110996,1589482133,207R00000X,Internal Medicine,22,Emergency,Z00.00,,revenue_code:0200,,0,Commercial,HMO,73,M,1.9608,,,6438.73,3700.02,2778.2,187.27,40.0,694.55,2738.71,2319.86,311.27,0,,0.0197,none,0,1,0,0,0,0.000257,0,0,,FFS
CLM0000000380,MBR00000046,Medical_Professional,Paid,Electronic_EDI,2023-07-30,2023-07-30,2023-07-30,2023-08-20,Clinical_Review,21,1889525696,1368666316,208600000X,Surgery General,21,In_Network,M54.5,OTHER|E11.9,99396,,0,Commercial,HMO,76,F,0.9613,,,274.3,137.5,69.2,16.0,35.0,17.3,136.8,48.4,16.89,1,Upcoding,1.0,unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|benford_violation|impossible_service_combo|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,6e-06,0,0,CCS_Cervical_Cancer_Screening,Shared_Savings
CLM0000000381,MBR00000277,Pharmacy,Denied,Electronic_EDI,2023-02-12,2023-02-12,2023-02-12,2023-02-17,Auto_Adjudicated,5,1830816512,1690197969,208600000X,Surgery General,11,In_Network,OTHER,Z00.01,00085163102,,5,Medicaid_MCO,MCO,30,M,1.8495,170,COB,73.25,30.62,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1158,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000000382,MBR00000036,Medical_Professional,Paid,Electronic_EDI,2023-11-19,2023-11-19,2023-11-19,2023-12-02,Manual_Review,13,1260336577,1461075342,208600000X,Surgery General,11,In_Network,G47.33,,90837,,0,Commercial,EPO,17,M,2.0136,,,441.57,304.18,95.43,151.89,33.0,23.86,137.39,0.0,0.0,0,,0.0217,none,0,1,0,1,0,9e-06,0,0,,FFS
CLM0000000383,MBR00000187,Medical_Institutional,Paid,Electronic_EDI,2023-08-19,2023-08-19,2023-08-19,2023-09-16,Manual_Review,28,1026612378,1930040953,101YP2500X,Psychologist Clinical,31,In_Network,Z00.01,OTHER,revenue_code:0370,,0,Medicaid_MCO,MCO,36,F,1.191,,,10757.05,3839.7,3832.7,0.0,7.0,0.0,6917.35,0.0,0.0,0,,0.0867,none,0,1,0,0,0,0.000355,0,0,,FFS
CLM0000000384,MBR00000031,Medical_Professional,Paid,Provider_Portal,2023-02-20,2023-02-20,2023-02-20,2023-03-11,Auto_Adjudicated,19,1377412382,1320546364,207R00000X,Internal Medicine,22,In_Network,E11.9,Z00.00|I48.91|I10,99386,,0,Commercial,PPO,71,M,0.6746,,,190.2,131.41,91.73,0.74,16.0,22.93,58.79,0.0,0.0,0,,0.1751,temporal_clustering,0,1,0,0,0,8e-06,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000000385,MBR00000046,Medical_Professional,Paid,Electronic_EDI,2023-10-29,2023-10-29,2023-10-29,2023-11-23,Auto_Adjudicated,25,1055095309,1288028182,207RP1001X,Pulmonary Disease,22,In_Network,G43.909,G47.33,27447,,0,Commercial,HMO,76,F,0.9613,,,25748.7,21322.02,16964.58,81.3,35.0,4241.14,4426.68,0.0,0.0,0,,0.0884,none,0,1,1,0,0,0.00157,0,0,,FFS
CLM0000000386,MBR00000006,Medical_Professional,Paid,Provider_Portal,2023-05-24,2023-05-24,2023-05-24,2023-06-06,Auto_Adjudicated,13,1428403730,1365397818,207RC0000X,Cardiovascular Disease,22,Emergency,Z00.01,,99385,,0,Commercial,EPO,88,M,1.4365,,,121.27,66.07,10.52,19.93,33.0,2.63,55.2,0.0,0.0,0,,0.1847,provider_specialty_mismatch,0,1,0,0,0,1e-06,0,0,,Shared_Savings
CLM0000000387,MBR00000114,Medical_Professional,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-10,2023-10-18,Auto_Adjudicated,8,1617763056,1469697158,207V00000X,Obstetrics & Gynecology,11,Out_of_Network,Z00.00,I10,80053,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,284.59,203.11,127.61,24.6,19.0,31.9,81.48,0.0,0.0,0,,0.1196,none,0,1,0,0,0,1.2e-05,0,0,,P4P
CLM0000000388,MBR00000189,Dental,Denied,Electronic_EDI,2023-04-04,2023-04-04,2023-04-04,2023-04-19,Manual_Review,15,1853233709,1151295616,207RG0100X,Gastroenterology,21,In_Network,OTHER,OTHER,D0150,,0,Medicaid_MCO,MCO,71,F,0.9722,PR-1,Duplicate,519.78,196.58,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0826,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000389,MBR00000159,Pharmacy,Paid,Electronic_EDI,2023-01-04,2023-01-04,2023-01-04,2023-01-17,Auto_Adjudicated,13,1915327071,1039962073,207Q00000X,Family Medicine,22,In_Network,N18.3,,00078043215,,2,Commercial,PPO,70,F,1.2009,,,823.61,428.75,308.72,28.84,14.0,77.18,394.86,0.0,0.0,0,,0.1397,none,0,1,0,0,0,2.9e-05,0,1,,FFS
CLM0000000390,MBR00000200,Medical_Professional,Paid,Provider_Portal,2023-06-12,2023-06-12,2023-06-12,2023-07-12,Auto_Adjudicated,30,1390393668,1493836023,208600000X,Surgery General,11,In_Network,K21.0,,99232,,0,Commercial,HDHP_HSA,29,M,0.8011,,,317.74,183.79,47.89,123.93,0.0,11.97,133.95,41.0,4.55,0,,0.0502,none,0,1,0,0,0,4e-06,0,0,,Bundled_Payment
CLM0000000391,MBR00000200,Medical_Professional,Paid,Paper,2023-06-12,2023-06-12,2023-06-12,2023-06-25,Auto_Adjudicated,13,1780111559,1765164601,207RN0300X,Nephrology,65,In_Network,J44.1,,90834,,0,Commercial,HDHP_HSA,29,M,0.8011,,,362.5,243.78,52.48,178.18,0.0,13.12,118.72,0.0,0.0,0,,0.0188,none,0,1,0,1,0,5e-06,0,0,,Capitation
CLM0000000392,MBR00000044,Pharmacy,Denied,Paper,2023-11-07,2023-11-07,2023-11-07,2023-11-26,Auto_Adjudicated,19,1850379080,1419347445,2086S0122X,Orthopedic Surgery,11,In_Network,I50.9,Z00.00,00003014960,,4,Commercial,PPO,29,M,0.7512,50,Timely_Filing,73.88,36.94,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1767,high_volume_same_code|controlled_substance_high_volume,0,1,0,0,0,0.0,0,1,,FFS
CLM0000000393,MBR00000016,Medical_Professional,Paid,Electronic_EDI,2023-02-11,2023-02-11,2023-02-11,2023-03-01,Manual_Review,18,1232573801,1896197144,2086S0122X,Orthopedic Surgery,23,In_Network,F41.1,M54.5,99223,,0,Commercial,HDHP_HSA,20,F,0.5843,,,232.1,156.39,43.62,101.86,0.0,10.91,75.71,0.0,0.0,0,,0.1268,none,0,1,0,1,0,4e-06,0,0,,Capitation
CLM0000000394,MBR00000186,Medical_Institutional,Paid,Electronic_EDI,2023-11-24,2023-11-24,2023-11-24,2023-12-06,Auto_Adjudicated,12,1567711165,1694343357,2086S0122X,Orthopedic Surgery,11,In_Network,G47.33,OTHER|E11.65,revenue_code:0200,,0,Commercial,PPO,65,M,1.6983,,,37518.11,26703.18,21287.07,44.34,50.0,5321.77,10814.93,0.0,0.0,0,,0.074,none,0,1,1,0,0,0.00197,0,0,,Capitation
CLM0000000395,MBR00000194,Medical_Professional,Partially_Paid,Electronic_EDI,2023-02-24,2023-02-24,2023-02-24,2023-03-08,Auto_Adjudicated,12,1588313061,1903401648,207RP1001X,Pulmonary Disease,31,In_Network,C50.911,,99202,,0,Commercial,PPO,77,M,0.9783,18,Medical_Necessity,362.09,154.81,0.0,112.96,0.0,0.0,249.13,0.0,0.0,0,,0.1362,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000396,MBR00000168,Medical_Institutional,Paid,Provider_Portal,2023-12-02,2023-12-02,2023-12-03,2023-12-28,Auto_Adjudicated,26,1089569577,1170002937,207RE0101X,Endocrinology,31,In_Network,I10,Z23|K21.0,revenue_code:0110,,0,Commercial,HMO,76,M,1.2791,,,3941.56,3040.73,2247.74,155.05,76.0,561.94,900.83,0.0,0.0,0,,0.1171,none,0,1,0,0,0,0.000208,0,0,,FFS
CLM0000000397,MBR00000076,Behavioral_Health,Paid,Paper,2023-09-11,2023-09-11,2023-09-11,2023-09-18,Auto_Adjudicated,7,1741980770,1450837722,246ZN0300X,Neuropsychology,21,In_Network,Z23,M17.11,12001,,0,Commercial,HMO,26,M,2.1785,,,263.7,182.66,119.0,1.91,32.0,29.75,81.04,0.0,0.0,0,,0.0441,none,0,1,0,0,0,1.1e-05,0,0,BCS_Breast_Cancer_Screening,Bundled_Payment
CLM0000000398,MBR00000241,Medical_Professional,Paid,Electronic_EDI,2023-05-10,2023-05-10,2023-05-10,2023-05-23,Auto_Adjudicated,13,1810800968,1591405274,246ZN0300X,Neuropsychology,22,In_Network,M54.5,,99232,,0,Medicare_Advantage,MA_HMO,77,M,1.2169,,,573.72,484.83,359.56,18.37,17.0,89.89,88.89,0.0,0.0,0,,0.0153,none,0,1,0,0,0,3.3e-05,0,0,ACR_Urine_Protein,FFS
CLM0000000399,MBR00000024,Vision,Paid,Electronic_EDI,2023-12-10,2023-12-10,2023-12-10,2023-12-31,Auto_Adjudicated,21,1618564043,1694343357,208600000X,Surgery General,81,In_Network,OTHER,OTHER|I50.9|F41.1,V2103,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,505.33,373.17,370.17,0.0,3.0,0.0,132.16,0.0,0.0,0,,0.0163,none,0,1,0,0,0,3.4e-05,0,0,CDC_BP_Control,FFS
CLM0000000400,MBR00000188,Dental,Paid,Electronic_EDI,2023-05-09,2023-05-09,2023-05-09,2023-05-11,Clinical_Review,2,1485543430,1473869105,225100000X,Physical Therapist,22,Out_of_Network,OTHER,M54.5|M17.11,D3310,,0,Commercial,HMO,8,F,1.5853,,,777.64,568.19,371.24,79.14,25.0,92.81,209.45,0.0,0.0,0,,0.1075,none,0,1,0,1,0,3.4e-05,0,0,SPD_Spirometry_Testing,P4P
CLM0000000401,MBR00000037,Behavioral_Health,Paid,Electronic_EDI,2023-08-16,2023-08-16,2023-08-16,2023-09-06,Manual_Review,21,1151127621,1163639177,207RN0300X,Nephrology,11,In_Network,OTHER,OTHER,99205,,0,Medicaid_MCO,MLTSS,11,M,1.043,,,328.25,117.97,116.97,0.0,1.0,0.0,210.28,0.0,0.0,0,,0.057,phantom_billing_indicator,0,1,0,0,0,1.1e-05,0,0,,Bundled_Payment
CLM0000000402,MBR00000195,Pharmacy,Paid,Electronic_EDI,2023-01-06,2023-01-06,2023-01-06,2023-01-31,Manual_Review,25,1414670047,1469642907,207RE0101X,Endocrinology,24,In_Network,K21.0,,00071015523,,1,Commercial,PPO,13,F,0.5967,,,64.53,36.21,1.5,21.33,13.0,0.38,28.32,0.0,0.0,0,,0.0448,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000000403,MBR00000132,Dental,Paid,Electronic_EDI,2023-02-06,2023-02-06,2023-02-06,2023-02-20,Auto_Adjudicated,14,1130461876,1288028182,207RN0300X,Nephrology,21,In_Network,I25.10,,D7140,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,,,215.62,108.7,82.01,0.18,6.0,20.5,106.92,50.53,15.93,0,,0.0294,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000000404,MBR00000212,Medical_Institutional,Denied,Electronic_EDI,2023-05-07,2023-05-07,2023-05-11,2023-05-25,Auto_Adjudicated,18,1098094939,1977073565,207RN0300X,Nephrology,11,In_Network,Z87.891,E11.9,revenue_code:0370,,0,Commercial,HMO,57,F,2.5456,97,Eligibility,57426.23,42311.59,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0968,outlier_billing_amount,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000405,MBR00000014,Dental,Denied,Electronic_EDI,2023-03-29,2023-03-29,2023-03-29,2023-04-13,Auto_Adjudicated,15,1388662212,1811797489,207RC0000X,Cardiovascular Disease,31,In_Network,M54.5,J06.9|Z00.00,D0120,,0,Commercial,HMO,77,M,2.8513,22,Duplicate,285.39,193.8,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1345,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000406,MBR00000168,Medical_Professional,Paid,Electronic_EDI,2023-03-23,2023-03-23,2023-03-23,2023-04-12,Auto_Adjudicated,20,1520692162,1358873132,207RN0300X,Nephrology,81,In_Network,OTHER,Z79.4,97140,,0,Commercial,HMO,76,M,1.2791,,,172.33,104.33,0.0,104.33,0.0,0.0,68.0,0.0,0.0,0,,0.1211,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000000407,MBR00000045,Pharmacy,Paid,Electronic_EDI,2023-05-17,2023-05-17,2023-05-17,2023-05-19,Auto_Adjudicated,2,1928139578,1994275960,207RC0000X,Cardiovascular Disease,11,In_Network,Z12.11,,00069420020,,3,Commercial,HMO,78,F,1.0658,,,292.38,155.4,84.08,18.3,32.0,21.02,136.98,0.0,0.0,0,,0.1031,none,0,1,0,0,0,8e-06,0,0,,Bundled_Payment
CLM0000000408,MBR00000203,Medical_Institutional,Paid,Provider_Portal,2023-08-07,2023-08-07,2023-08-10,2023-08-26,Manual_Review,19,1272115456,1704466150,208600000X,Surgery General,21,Emergency,N39.0,OTHER,revenue_code:0210,872,0,Commercial,PPO,49,F,0.3046,,,31210.92,12485.65,9763.83,228.87,52.0,2440.96,18725.27,0.0,0.0,0,,0.1331,none,0,1,1,0,0,0.000904,0,0,,Bundled_Payment
CLM0000000409,MBR00000037,Medical_Professional,Paid,Electronic_EDI,2023-02-15,2023-02-15,2023-02-15,2023-03-01,Manual_Review,14,1739169232,1650774392,207RN0300X,Nephrology,11,In_Network,OTHER,Z79.4,81001,,0,Medicaid_MCO,MLTSS,11,M,1.043,,,614.43,311.21,310.21,0.0,1.0,0.0,303.22,0.0,0.0,0,,0.056,impossible_service_combo,0,1,0,0,0,2.9e-05,0,0,,FFS
CLM0000000410,MBR00000023,Medical_Professional,Partially_Paid,Electronic_EDI,2023-09-27,2023-09-27,2023-09-27,2023-09-29,Manual_Review,2,1487261286,1763260577,246ZN0300X,Neuropsychology,65,In_Network,I48.91,,99214,,0,Medicare_Advantage,MA_PPO,87,M,1.084,256,Medical_Necessity,368.58,240.16,77.5,33.37,15.0,19.38,223.33,0.0,0.0,0,,0.1365,duplicate_claim_indicator,0,1,0,0,0,7e-06,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000000411,MBR00000211,Medical_Professional,Paid,Electronic_EDI,2023-11-01,2023-11-01,2023-11-01,2023-11-26,Clinical_Review,25,1550698436,1450837722,207RN0300X,Nephrology,32,In_Network,M17.11,OTHER|H52.4,99231,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,,,185.06,91.99,63.08,1.14,12.0,15.77,93.07,0.0,0.0,0,,0.149,none,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000000412,MBR00000019,Medical_Institutional,Paid,Electronic_EDI,2023-10-28,2023-10-28,2023-11-01,2023-11-02,Manual_Review,5,1780111559,1320546364,225100000X,Physical Therapist,65,In_Network,Z23,K21.0,revenue_code:0100,,0,Commercial,PPO,77,M,0.6521,,,7901.33,3223.47,2496.69,67.6,35.0,624.17,4677.86,0.0,0.0,0,,0.0019,none,0,1,0,0,0,0.000231,0,0,ACR_Urine_Protein,Capitation
CLM0000000413,MBR00000070,Medical_Professional,Paid,Electronic_EDI,2023-03-11,2023-03-11,2023-03-11,2023-03-29,Auto_Adjudicated,18,1826919173,1951488764,208600000X,Surgery General,11,Emergency,Z79.4,Z00.01|N39.0,73721,,0,Commercial,POS,42,F,0.8468,,,183.23,65.56,0.0,65.56,0.0,0.0,117.67,0.0,0.0,0,,0.0002,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000414,MBR00000246,Medical_Professional,Paid,Electronic_EDI,2023-11-13,2023-11-13,2023-11-13,2023-12-09,Auto_Adjudicated,26,1114266188,1473869105,2086S0122X,Orthopedic Surgery,11,In_Network,K21.0,,90837,,0,Commercial,PPO,80,F,0.7925,,,306.58,246.51,0.0,246.51,0.0,0.0,60.07,0.0,0.0,0,,0.0377,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000415,MBR00000240,Medical_Professional,Paid,Electronic_EDI,2023-02-16,2023-02-16,2023-02-16,2023-03-16,Auto_Adjudicated,28,1721465780,1705448933,246ZN0300X,Neuropsychology,22,In_Network,J44.1,,85025,,0,Medicaid_MCO,MCO,9,F,0.386,,,1776.98,820.26,818.26,0.0,2.0,0.0,956.72,543.96,246.18,0,,0.023,none,0,1,0,0,0,7.6e-05,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000000416,MBR00000258,Medical_Institutional,Paid,Electronic_EDI,2023-02-08,2023-02-08,2023-02-09,2023-02-27,Auto_Adjudicated,19,1078527460,1291071007,207RG0100X,Gastroenterology,11,In_Network,OTHER,OTHER,revenue_code:0100,,0,Commercial,EPO,9,F,0.5431,,,607.5,495.88,355.3,8.75,43.0,88.83,111.62,0.0,0.0,0,,0.1561,service_date_weekend,0,1,0,1,0,3.3e-05,0,0,SPC_Statin_Therapy,Capitation
CLM0000000417,MBR00000103,Medical_Professional,Paid,Electronic_EDI,2023-09-18,2023-09-18,2023-09-18,2023-10-10,Manual_Review,22,1272115456,1034732777,101YP2500X,Psychologist Clinical,11,In_Network,I10,Z23,97012,,0,Medicaid_MCO,MCO,24,M,0.4785,,,495.63,179.05,178.05,0.0,1.0,0.0,316.58,0.0,0.0,0,,0.0759,npi_mismatch,0,1,0,0,0,1.6e-05,0,0,,P4P
CLM0000000418,MBR00000160,Medical_Professional,Paid,Provider_Portal,2023-09-30,2023-09-30,2023-09-30,2023-10-18,Auto_Adjudicated,18,1965682436,1574982369,101YP2500X,Psychologist Clinical,11,In_Network,M47.816,K21.0,99212,,0,Commercial,HMO,73,M,1.9608,,,214.41,120.79,0.0,116.59,4.2,0.0,93.62,0.0,0.0,0,,0.0883,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000419,MBR00000228,Medical_Professional,Paid,Electronic_EDI,2023-02-15,2023-02-15,2023-02-15,2023-03-11,Auto_Adjudicated,24,1882720848,1878017518,207R00000X,Internal Medicine,23,In_Network,Z00.00,H52.4|Z00.00,99284,,0,Commercial,PPO,55,F,0.7203,,,376.92,225.13,0.0,225.13,0.0,0.0,151.79,0.0,0.0,0,,0.0644,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000420,MBR00000042,Medical_Institutional,Paid,Electronic_EDI,2023-05-30,2023-05-30,2023-06-03,2023-06-29,Auto_Adjudicated,30,1457568950,1542515060,207RE0101X,Endocrinology,23,In_Network,H52.4,R05.9|C50.911,revenue_code:0360,,0,Commercial,HMO,78,F,1.1448,,,1759.26,962.75,713.93,0.34,70.0,178.48,796.51,0.0,0.0,0,,0.1235,none,0,1,0,0,0,6.6e-05,0,0,,FFS
CLM0000000421,MBR00000213,Medical_Professional,Paid,Electronic_EDI,2023-05-28,2023-05-28,2023-05-28,2023-06-11,Auto_Adjudicated,14,1364214492,1197700958,207RG0100X,Gastroenterology,24,Out_of_Network,E11.9,OTHER|L70.0,99285,,0,Commercial,PPO,17,M,1.5857,,,191.15,76.27,0.0,76.27,0.0,0.0,114.88,0.0,0.0,0,,0.0188,none,0,1,0,0,0,0.0,1,0,,Capitation
CLM0000000422,MBR00000029,Behavioral_Health,Paid,Electronic_EDI,2023-09-17,2023-09-17,2023-09-17,2023-09-30,Auto_Adjudicated,13,1648123576,1220755708,207R00000X,Internal Medicine,11,In_Network,F41.1,,99387,,0,Medicaid_MCO,MCO,13,F,0.9053,,,163.93,129.18,128.18,0.0,1.0,0.0,34.75,0.0,0.0,0,,0.0238,none,0,1,0,0,0,1.2e-05,0,0,SPD_Spirometry_Testing,Shared_Savings
CLM0000000423,MBR00000276,Medical_Professional,Denied,Electronic_EDI,2023-07-05,2023-07-05,2023-07-05,2023-07-11,Auto_Adjudicated,6,1952322604,1930040953,207R00000X,Internal Medicine,24,In_Network,E78.5,I10,10060,,0,Commercial,POS,38,M,0.8085,CO-45,Coding_Error,863.2,698.66,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1234,none,0,1,0,1,0,0.0,0,0,BPD_BP_Declined,Shared_Savings
CLM0000000424,MBR00000188,Medical_Professional,Paid,Electronic_EDI,2023-08-04,2023-08-04,2023-08-04,2023-09-03,Auto_Adjudicated,30,1137079475,1553094822,207RC0000X,Cardiovascular Disease,22,In_Network,M54.5,F41.1,90847,,0,Commercial,HMO,8,F,1.5853,,,645.62,469.44,342.27,16.61,25.0,85.57,176.18,0.0,0.0,0,,0.1259,none,0,1,0,1,0,3.2e-05,0,0,,P4P
CLM0000000425,MBR00000153,Medical_Institutional,Paid,Electronic_EDI,2023-01-29,2023-01-29,2023-01-29,2023-02-26,Auto_Adjudicated,28,1214787184,1356856197,207R00000X,Internal Medicine,21,In_Network,Z79.4,Z23,revenue_code:0300,439,0,Commercial,POS,12,F,0.6525,,,2703.32,1092.15,757.53,75.24,70.0,189.38,1611.17,0.0,0.0,0,,0.0379,none,0,1,0,0,0,7e-05,0,0,,FFS
CLM0000000426,MBR00000150,Dental,Paid,Paper,2023-12-17,2023-12-17,2023-12-17,2024-01-08,Auto_Adjudicated,22,1976612978,1473869105,207RP1001X,Pulmonary Disease,22,In_Network,K21.0,Z23,D2140,,0,Medicare_Advantage,MA_HMO,1,F,0.2444,,,285.62,135.93,99.45,2.62,9.0,24.86,149.69,0.0,0.0,0,,0.0744,none,0,1,0,0,0,9e-06,0,0,,P4P
CLM0000000427,MBR00000056,Medical_Institutional,Paid,Electronic_EDI,2023-07-19,2023-07-19,2023-07-19,2023-08-08,Auto_Adjudicated,20,1490172833,1747596016,207RN0300X,Nephrology,24,In_Network,F41.1,OTHER|I25.10|L70.0,revenue_code:0450,,0,Commercial,EPO,74,F,1.3941,,,5960.88,2963.23,1955.13,472.31,47.0,488.78,2997.65,0.0,0.0,0,,0.1167,impossible_service_combo,0,1,0,0,0,0.000181,0,0,,Shared_Savings
CLM0000000428,MBR00000109,Medical_Professional,Paid,Electronic_EDI,2023-08-29,2023-08-29,2023-08-29,2023-09-05,Manual_Review,7,1083045036,1330485436,101YP2500X,Psychologist Clinical,11,Out_of_Network,OTHER,,99397,,0,Commercial,HMO,8,F,0.5723,,,353.03,290.19,88.37,141.73,38.0,22.09,62.84,0.0,0.0,0,,0.0264,none,0,1,0,0,0,8e-06,1,0,,Shared_Savings
CLM0000000429,MBR00000213,Medical_Institutional,Paid,Paper,2023-06-22,2023-06-22,2023-06-24,2023-07-20,Auto_Adjudicated,28,1901054209,1607833568,207R00000X,Internal Medicine,24,In_Network,I10,I48.91|E13.9|OTHER,revenue_code:0300,,0,Commercial,PPO,17,M,1.5857,,,9615.47,7210.05,5555.86,222.22,43.0,1388.97,2405.42,0.0,0.0,0,,0.0784,none,0,1,1,0,0,0.000514,0,0,,P4P
CLM0000000430,MBR00000164,Medical_Institutional,Paid,Electronic_EDI,2023-03-30,2023-03-30,2023-04-01,2023-04-01,Clinical_Review,2,1327415110,1538261819,208600000X,Surgery General,22,In_Network,Z12.11,E11.9|Z00.01,revenue_code:0210,,0,ACA_Marketplace,ACA_Silver,3,F,0.7155,,,57894.68,32885.43,22945.49,18.15,88.0,9833.78,25009.25,0.0,0.0,0,,0.1389,outlier_billing_amount,0,1,1,0,0,0.002124,0,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000000431,MBR00000161,Medical_Institutional,Paid,Electronic_EDI,2023-08-28,2023-08-28,2023-08-29,2023-09-16,Auto_Adjudicated,19,1887363539,1554490060,207RP1001X,Pulmonary Disease,22,In_Network,N39.0,I10,revenue_code:0110,,0,Medicaid_MCO,MLTSS,9,F,0.8354,,,6601.96,3974.97,3969.97,0.0,5.0,0.0,2626.99,3220.09,439.54,0,,0.0292,none,0,1,0,0,0,0.000367,0,0,CBP_Controlling_BP,Shared_Savings
CLM0000000432,MBR00000060,Behavioral_Health,Paid,Electronic_EDI,2023-04-14,2023-04-14,2023-04-14,2023-04-22,Manual_Review,8,1826567270,1884259357,2084P0800X,Psychiatry,32,In_Network,OTHER,,97110,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,165.62,124.03,0.0,124.03,0.0,0.0,41.59,0.0,0.0,0,,0.0218,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000433,MBR00000206,Behavioral_Health,Denied,Electronic_EDI,2023-03-20,2023-03-20,2023-03-20,2023-04-03,Auto_Adjudicated,14,1909649019,1767402068,207RG0100X,Gastroenterology,23,In_Network,E78.5,OTHER,99203,,0,Medicaid_MCO,MLTSS,21,M,1.4038,PR-1,Authorization,168.61,64.26,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1005,none,0,1,0,0,0,0.0,0,0,PPC_Prenatal_Care,Bundled_Payment
CLM0000000434,MBR00000125,Medical_Institutional,Paid,Electronic_EDI,2023-07-18,2023-07-18,2023-07-18,2023-07-21,Manual_Review,3,1428403730,1589482133,246ZN0300X,Neuropsychology,22,In_Network,Z12.11,,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,10086.51,5509.37,4367.74,4.69,45.0,1091.94,4577.14,0.0,0.0,0,,0.1081,provider_specialty_mismatch,0,1,0,0,0,0.000404,0,0,COA_Care_Transitions,Capitation
CLM0000000435,MBR00000057,Medical_Professional,Paid,Electronic_EDI,2023-05-09,2023-05-09,2023-05-09,2023-05-14,Auto_Adjudicated,5,1414670047,1938465393,207RP1001X,Pulmonary Disease,21,Emergency,OTHER,OTHER|Z00.00|Z00.121,90832,,0,Medicare_Advantage,MA_PPO,45,M,0.6701,,,1171.71,440.36,316.24,43.06,2.0,79.06,731.35,0.0,0.0,0,,0.0123,none,0,1,0,0,0,2.9e-05,0,0,PPC_Prenatal_Care,P4P
CLM0000000436,MBR00000286,Medical_Institutional,Paid,Electronic_EDI,2023-11-18,2023-11-18,2023-11-19,2023-11-30,Auto_Adjudicated,12,1853403237,1767402068,207RP1001X,Pulmonary Disease,22,In_Network,N39.0,,revenue_code:0210,,0,Medicare_Advantage,PFFS,40,F,1.2751,,,8060.07,6499.62,5144.86,18.55,50.0,1286.21,1560.45,0.0,0.0,0,,0.0477,none,0,1,1,0,0,0.000476,0,0,,FFS
CLM0000000437,MBR00000156,Vision,Paid,Electronic_EDI,2023-08-25,2023-08-25,2023-08-25,2023-09-06,Auto_Adjudicated,12,1875632885,1878874025,207V00000X,Obstetrics & Gynecology,31,In_Network,OTHER,OTHER,92012,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,229.77,131.15,67.22,34.13,13.0,16.8,98.62,0.0,0.0,0,,0.1962,billing_spike_recent,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000000438,MBR00000160,Vision,Paid,Electronic_EDI,2023-05-15,2023-05-15,2023-05-15,2023-06-11,Auto_Adjudicated,27,1853233709,1704466150,101YP2500X,Psychologist Clinical,81,In_Network,Z00.00,E11.9,V2100,,0,Commercial,HMO,73,M,1.9608,,,334.72,147.19,0.0,147.19,0.0,0.0,187.53,0.0,0.0,0,,0.0182,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000439,MBR00000296,Medical_Professional,Paid,Electronic_EDI,2023-01-13,2023-01-13,2023-01-13,2023-01-31,Auto_Adjudicated,18,1567711165,1040061910,207RN0300X,Nephrology,24,In_Network,E78.5,,99386,,0,Commercial,HMO,83,F,1.4969,,,174.45,146.47,43.65,60.9,31.0,10.91,27.98,0.0,0.0,0,,0.1008,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000000440,MBR00000116,Medical_Professional,Paid,Electronic_EDI,2023-05-03,2023-05-03,2023-05-03,2023-05-04,Auto_Adjudicated,1,1007414142,1148659045,207Q00000X,Family Medicine,24,In_Network,E11.65,E11.65,27130,,0,Medicaid_MCO,MLTSS,79,F,0.4614,,,27990.64,22081.03,22078.03,0.0,3.0,0.0,5909.61,0.0,0.0,0,,0.1412,none,0,1,1,0,0,0.002044,0,0,,Shared_Savings
CLM0000000441,MBR00000286,Medical_Professional,Paid,Electronic_EDI,2023-02-11,2023-02-11,2023-02-11,2023-03-11,Auto_Adjudicated,28,1976612978,1763260577,207RN0300X,Nephrology,23,In_Network,I10,OTHER|F32.9,99205,,0,Medicare_Advantage,PFFS,40,F,1.2751,,,453.7,274.08,207.81,11.32,3.0,51.95,179.62,186.19,17.28,1,Duplicate Billing,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|impossible_service_combo|service_date_weekend|duplicate_claim_indicator|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,1.9e-05,0,0,,Bundled_Payment
CLM0000000442,MBR00000207,Pharmacy,Paid,Electronic_EDI,2023-03-20,2023-03-20,2023-03-20,2023-04-08,Clinical_Review,19,1368580443,1542515060,207RC0000X,Cardiovascular Disease,24,In_Network,F41.1,,00006001954,,3,Medicaid_MCO,MLTSS,11,F,1.6522,,,41.33,33.57,33.57,0.0,0.0,0.0,7.76,0.0,0.0,0,,0.0668,none,0,1,0,0,0,3e-06,0,0,,Capitation
CLM0000000443,MBR00000188,Medical_Institutional,Paid,Electronic_EDI,2023-04-12,2023-04-12,2023-04-13,2023-05-07,Auto_Adjudicated,25,1496489953,1591405274,225100000X,Physical Therapist,11,In_Network,Z00.00,,revenue_code:0210,,0,Commercial,HMO,8,F,1.5853,,,4450.6,1964.03,1491.48,53.68,46.0,372.87,2486.57,0.0,0.0,0,,0.046,none,0,1,0,0,0,0.000138,0,0,,Capitation
CLM0000000444,MBR00000074,Medical_Professional,Paid,Electronic_EDI,2023-08-23,2023-08-23,2023-08-23,2023-09-20,Auto_Adjudicated,28,1699014308,1114756459,207RN0300X,Nephrology,21,In_Network,M17.11,OTHER,99212,,0,Medicare_Advantage,MA_PPO,21,F,0.8719,,,252.52,184.92,108.18,30.7,19.0,27.04,67.6,0.0,0.0,0,,0.1271,unusual_service_frequency,0,1,0,0,0,1e-05,0,0,,Shared_Savings
CLM0000000445,MBR00000014,Medical_Professional,Paid,Electronic_EDI,2023-02-08,2023-02-08,2023-02-08,2023-02-24,Auto_Adjudicated,16,1943769986,1304018750,207RG0100X,Gastroenterology,22,In_Network,OTHER,J20.9,99213,,0,Commercial,HMO,77,M,2.8513,,,267.36,196.95,0.0,196.95,0.0,0.0,70.41,0.0,0.0,0,,0.1591,upcoding_pattern|diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,PCR_Plan_All_Cause_Readmission,Bundled_Payment
CLM0000000446,MBR00000137,Medical_Professional,Paid,Electronic_EDI,2023-02-28,2023-02-28,2023-02-28,2023-03-06,Auto_Adjudicated,6,1456447970,1312595355,207RN0300X,Nephrology,22,In_Network,OTHER,J06.9,99204,,0,Commercial,PPO,87,M,0.5201,,,242.91,156.97,96.02,11.94,25.0,24.01,85.94,0.0,0.0,0,,0.0168,none,0,1,0,0,0,9e-06,0,0,,P4P
CLM0000000447,MBR00000004,Dental,Denied,Electronic_EDI,2023-01-15,2023-01-15,2023-01-15,2023-01-29,Auto_Adjudicated,14,1346717076,1055872102,2084P0800X,Psychiatry,22,In_Network,M54.5,,D0150,,0,Medicare_Advantage,MA_PPO,68,M,1.23,256,Timely_Filing,144.03,78.97,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1152,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000448,MBR00000022,Medical_Institutional,Paid,Electronic_EDI,2023-11-26,2023-11-26,2023-11-29,2023-12-17,Auto_Adjudicated,21,1059948944,1354265777,101YP2500X,Psychologist Clinical,81,In_Network,Z00.00,I10,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,34,M,0.9472,,,9917.21,4864.16,3815.62,43.63,51.0,953.91,5053.05,0.0,0.0,0,,0.0208,none,0,1,0,0,0,0.000353,0,0,POD_Persistence_of_Beta_Blocker,Bundled_Payment
CLM0000000449,MBR00000180,Medical_Professional,Paid,Electronic_EDI,2023-12-21,2023-12-21,2023-12-21,2023-12-22,Auto_Adjudicated,1,1428403730,1055872102,2086S0122X,Orthopedic Surgery,31,Out_of_Network,OTHER,Z00.01,99383,,0,Medicare_Advantage,MA_PPO,72,F,1.1909,,,128.8,86.52,40.34,19.09,17.0,10.09,42.28,0.0,0.0,0,,0.0028,none,0,1,0,1,0,4e-06,0,0,FLU_Flu_Vaccination,Shared_Savings
CLM0000000450,MBR00000213,Pharmacy,Denied,Electronic_EDI,2023-04-18,2023-04-18,2023-04-18,2023-05-17,Auto_Adjudicated,29,1014995735,1320546364,208600000X,Surgery General,31,In_Network,E11.65,,50458085930,,1,Commercial,PPO,17,M,1.5857,CO-45,Medical_Necessity,65.17,33.33,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0948,none,0,1,0,0,0,0.0,0,0,MMA_Medication_Management,P4P
CLM0000000451,MBR00000053,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-06-13,2023-06-13,2023-06-14,2023-06-24,Manual_Review,11,1097563011,1985590322,2086S0122X,Orthopedic Surgery,31,In_Network,I25.10,C50.911,revenue_code:0370,,0,Medicaid_MCO,MLTSS,74,F,0.9277,1,Medical_Necessity,31864.97,13226.07,8798.68,0.0,4.0,0.0,23062.29,0.0,0.0,0,,0.1124,none,0,1,1,0,0,0.000814,0,0,,Capitation
CLM0000000452,MBR00000214,Pharmacy,Partially_Paid,Electronic_EDI,2023-04-19,2023-04-19,2023-04-19,2023-05-09,Clinical_Review,20,1428403730,1396850418,207RN0300X,Nephrology,24,Out_of_Network,OTHER,M54.5,00085163102,,2,Commercial,HDHP_HSA,76,M,1.7526,5,Medical_Necessity,161.55,125.42,0.0,92.53,0.0,0.0,69.02,0.0,0.0,0,,0.0524,none,0,1,0,0,0,0.0,0,1,,Capitation
CLM0000000453,MBR00000288,Pharmacy,Paid,Paper,2023-07-11,2023-07-11,2023-07-11,2023-08-10,Manual_Review,30,1323379997,1179350099,207R00000X,Internal Medicine,23,In_Network,Z12.11,Z23,00071015523,,3,Commercial,HMO,36,M,0.8408,,,252.28,189.12,95.46,35.8,34.0,23.86,63.16,70.8,13.18,0,,0.0905,none,0,1,0,0,0,9e-06,0,0,,Bundled_Payment
CLM0000000454,MBR00000217,Medical_Professional,Paid,Electronic_EDI,2023-07-17,2023-07-17,2023-07-17,2023-08-12,Auto_Adjudicated,26,1611521069,1622950074,101YP2500X,Psychologist Clinical,11,In_Network,Z23,,90837,,0,ACA_Marketplace,ACA_Bronze,11,F,1.1619,,,1732.19,864.07,351.58,278.11,0.0,234.39,868.12,0.0,0.0,0,,0.12,benford_violation,0,1,0,0,0,3.3e-05,0,0,DAE_Drug_Alcohol_Dependence,Shared_Savings
CLM0000000455,MBR00000232,Medical_Professional,Denied,Electronic_EDI,2023-04-02,2023-04-02,2023-04-02,2023-04-25,Auto_Adjudicated,23,1670125610,1330485436,246ZN0300X,Neuropsychology,31,In_Network,OTHER,OTHER|E11.9,81001,,0,Medicaid_MCO,MCO,40,M,1.1083,16,Medical_Necessity,610.56,216.12,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0599,none,0,1,0,1,0,0.0,0,0,CCS_Cervical_Cancer_Screening,Bundled_Payment
CLM0000000456,MBR00000208,Medical_Professional,Denied,Electronic_EDI,2023-08-20,2023-08-20,2023-08-20,2023-08-29,Auto_Adjudicated,9,1145887050,1884259357,246ZN0300X,Neuropsychology,11,In_Network,F41.1,,99222,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,3,Network,445.46,208.94,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0816,billing_spike_recent,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000457,MBR00000070,Pharmacy,Paid,Electronic_EDI,2023-01-03,2023-01-03,2023-01-03,2023-01-19,Manual_Review,16,1520692162,1012893364,225100000X,Physical Therapist,23,Emergency,H52.4,,00169751112,,1,Commercial,POS,42,F,0.8468,,,239.14,151.41,8.55,125.73,15.0,2.14,87.73,0.0,0.0,0,,0.1309,controlled_substance_high_volume,0,1,0,0,0,1e-06,0,1,,FFS
CLM0000000458,MBR00000114,Vision,Paid,Electronic_EDI,2023-08-20,2023-08-20,2023-08-20,2023-09-05,Auto_Adjudicated,16,1661091022,1942423230,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,Z12.11|OTHER,V2320,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,192.29,133.41,69.89,27.05,19.0,17.47,58.88,0.0,0.0,0,,0.1491,diagnosis_procedure_mismatch|high_oop_waiver,0,1,0,1,0,6e-06,0,0,COL_Colorectal_Cancer_Screening,Bundled_Payment
CLM0000000459,MBR00000288,Medical_Professional,Paid,Electronic_EDI,2023-09-27,2023-09-27,2023-09-27,2023-10-23,Auto_Adjudicated,26,1181941909,1197700958,101YP2500X,Psychologist Clinical,22,In_Network,Z12.11,OTHER|Z12.11|Z00.01,99385,,0,Commercial,HMO,36,M,0.8408,,,256.3,141.47,57.63,35.43,34.0,14.41,114.83,0.0,0.0,0,,0.1436,none,0,1,0,0,0,5e-06,0,0,BPD_BP_Declined,P4P
CLM0000000460,MBR00000196,Pharmacy,Paid,Electronic_EDI,2023-01-20,2023-01-20,2023-01-20,2023-01-22,Auto_Adjudicated,2,1292920374,1197700958,101YP2500X,Psychologist Clinical,21,In_Network,OTHER,OTHER|N40.0|E78.5,00085163102,,1,Commercial,PPO,16,F,1.6015,,,96.14,74.87,24.65,21.05,23.0,6.16,21.27,0.0,0.0,0,,0.157,provider_specialty_mismatch,0,1,0,0,0,2e-06,0,0,ACR_Urine_Protein,FFS
CLM0000000461,MBR00000234,Pharmacy,Paid,Electronic_EDI,2023-09-17,2023-09-17,2023-09-17,2023-09-18,Manual_Review,1,1394029346,1493836023,207RE0101X,Endocrinology,23,In_Network,M54.5,R05.9,00003014960,,2,Medicare_Advantage,MA_HMO,59,M,0.395,,,285.97,137.51,107.05,3.7,0.0,26.76,148.46,0.0,0.0,0,,0.0608,none,0,1,0,0,0,1e-05,0,0,DAE_Drug_Alcohol_Dependence,Capitation
CLM0000000462,MBR00000293,Behavioral_Health,Paid,Electronic_EDI,2023-09-22,2023-09-22,2023-09-22,2023-09-26,Auto_Adjudicated,4,1484438840,1942423230,208600000X,Surgery General,31,In_Network,OTHER,,43239,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,356.3,292.79,197.33,35.13,11.0,49.33,63.51,0.0,0.0,0,,0.1046,none,0,1,0,0,0,1.8e-05,0,0,,FFS
CLM0000000463,MBR00000073,Medical_Institutional,Paid,Electronic_EDI,2023-12-16,2023-12-16,2023-12-17,2024-01-14,Auto_Adjudicated,29,1727787144,1388050552,207R00000X,Internal Medicine,11,In_Network,M54.5,Z87.891|OTHER,revenue_code:0450,,0,Commercial,POS,79,M,1.1768,,,3403.45,2292.83,1512.97,329.61,72.0,378.24,1110.62,0.0,0.0,0,,0.1143,none,0,1,0,0,0,0.00014,0,0,,Bundled_Payment
CLM0000000464,MBR00000102,Medical_Professional,Paid,Electronic_EDI,2023-10-17,2023-10-17,2023-10-17,2023-11-03,Auto_Adjudicated,17,1813729693,1300957944,207RG0100X,Gastroenterology,11,In_Network,E11.9,I10|E78.5,81001,,0,Commercial,POS,68,M,1.6864,,,343.23,248.73,76.75,120.79,32.0,19.19,94.5,0.0,0.0,0,,0.0688,none,0,1,0,0,0,7e-06,0,0,,Bundled_Payment
CLM0000000465,MBR00000191,Pharmacy,Paid,Electronic_EDI,2023-01-08,2023-01-08,2023-01-08,2023-01-29,Auto_Adjudicated,21,1810800968,1157814306,207R00000X,Internal Medicine,65,In_Network,F10.10,Z23|OTHER|E11.9,00071012831,,1,Commercial,POS,85,F,0.9729,,,131.67,81.63,0.0,81.63,0.0,0.0,50.04,0.0,0.0,0,,0.1323,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000000466,MBR00000008,Pharmacy,Denied,Electronic_EDI,2023-01-30,2023-01-30,2023-01-30,2023-02-02,Clinical_Review,3,1159640414,1880530717,207RN0300X,Nephrology,11,In_Network,OTHER,M17.11,00071015523,,3,Medicaid_MCO,MCO,74,M,0.8375,170,Medical_Necessity,91.3,77.6,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1784,controlled_substance_high_volume,0,1,0,0,0,0.0,0,1,SPD_Spirometry_Testing,Capitation
CLM0000000467,MBR00000171,Pharmacy,Denied,Electronic_EDI,2023-02-19,2023-02-19,2023-02-19,2023-02-20,Auto_Adjudicated,1,1167433253,1164525386,246ZN0300X,Neuropsychology,24,In_Network,OTHER,N18.3,16590051660,,1,Commercial,PPO,27,F,0.819,18,COB,145.3,62.81,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1141,none,0,1,0,1,0,0.0,0,0,MMA_Medication_Management,FFS
CLM0000000468,MBR00000240,Dental,Paid,Electronic_EDI,2023-07-28,2023-07-28,2023-07-28,2023-08-17,Auto_Adjudicated,20,1210349885,1354265777,208600000X,Surgery General,31,In_Network,K29.70,,D0150,,0,Medicaid_MCO,MCO,9,F,0.386,,,426.55,246.15,244.15,0.0,2.0,0.0,180.4,0.0,0.0,0,,0.0648,none,0,1,0,0,0,2.3e-05,0,0,,FFS
CLM0000000469,MBR00000184,Medical_Professional,Denied,Electronic_EDI,2023-09-13,2023-09-13,2023-09-13,2023-10-05,Auto_Adjudicated,22,1887698203,1355732274,207RP1001X,Pulmonary Disease,24,In_Network,OTHER,,99394,,0,Medicaid_MCO,MLTSS,30,M,2.8302,5,Medical_Necessity,523.83,252.46,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1045,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000470,MBR00000092,Pharmacy,Denied,Electronic_EDI,2023-08-25,2023-08-25,2023-08-25,2023-09-07,Auto_Adjudicated,13,1897146144,1625992541,101YP2500X,Psychologist Clinical,11,In_Network,E11.65,I10|OTHER,00071015523,,5,Medicaid_MCO,MLTSS,68,F,1.3217,22,Coding_Error,116.96,56.75,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0928,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000000471,MBR00000213,Medical_Professional,Denied,Electronic_EDI,2023-04-29,2023-04-29,2023-04-29,2023-05-02,Manual_Review,3,1921056264,1942423230,207RN0300X,Nephrology,24,In_Network,OTHER,F32.9|OTHER|J20.9,33510,,0,Commercial,PPO,17,M,1.5857,2,Authorization,431.41,326.18,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1058,none,0,1,0,1,0,0.0,0,0,PPC_Prenatal_Care,Capitation
CLM0000000472,MBR00000046,Medical_Institutional,Paid,Electronic_EDI,2023-03-14,2023-03-14,2023-03-16,2023-03-29,Manual_Review,15,1346717076,1764064254,208600000X,Surgery General,81,Out_of_Network,Z00.00,OTHER,revenue_code:0200,,0,Commercial,HMO,76,F,0.9613,,,16274.65,10359.17,8218.8,44.67,41.0,2054.7,5915.48,0.0,0.0,0,,0.0678,none,0,1,1,0,0,0.000761,1,0,,FFS
CLM0000000473,MBR00000271,Medical_Professional,Denied,Electronic_EDI,2023-01-23,2023-01-23,2023-01-23,2023-02-12,Auto_Adjudicated,20,1808451151,1469697158,225100000X,Physical Therapist,21,In_Network,I10,,97010,,0,Medicaid_MCO,MCO,4,F,0.6696,18,Timely_Filing,612.31,246.06,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1644,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,AWV_Annual_Wellness_Visit,Bundled_Payment
CLM0000000474,MBR00000030,Medical_Professional,Denied,Provider_Portal,2023-05-15,2023-05-15,2023-05-15,2023-05-22,Auto_Adjudicated,7,1897146144,1128148362,207Q00000X,Family Medicine,23,In_Network,E78.5,Z00.00,99284,,0,Medicaid_MCO,MCO,67,M,0.4581,3,Authorization,126.26,102.86,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.101,controlled_substance_high_volume,0,1,0,1,0,0.0,0,0,,FFS
CLM0000000475,MBR00000261,Medical_Professional,Paid,Electronic_EDI,2023-04-19,2023-04-19,2023-04-19,2023-04-29,Auto_Adjudicated,10,1670125610,1447657873,207RE0101X,Endocrinology,11,In_Network,OTHER,,12001,,0,Medicare_Advantage,MA_PPO,13,F,0.4259,,,346.97,146.41,103.5,16.04,1.0,25.87,200.56,0.0,0.0,0,,0.1311,unusual_service_frequency,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000000476,MBR00000154,Pharmacy,Paid,Paper,2023-04-20,2023-04-20,2023-04-20,2023-05-13,Auto_Adjudicated,23,1222934819,1691162131,207RN0300X,Nephrology,81,In_Network,E11.9,K21.0|Z23|E11.9,00078043215,,3,Medicare_Advantage,MA_HMO,54,F,1.9463,,,132.28,93.32,71.52,3.92,0.0,17.88,38.96,0.0,0.0,0,,0.0832,none,0,1,0,0,0,7e-06,0,1,,FFS
CLM0000000477,MBR00000135,Dental,Paid,Electronic_EDI,2023-02-01,2023-02-01,2023-02-01,2023-02-08,Clinical_Review,7,1897701389,1527857018,2084P0800X,Psychiatry,11,In_Network,Z12.11,,D7140,,0,Commercial,PPO,58,F,2.2702,,,546.14,376.37,270.64,1.08,37.0,67.66,169.77,0.0,0.0,0,,0.0613,none,0,1,0,1,0,2.5e-05,0,0,,FFS
CLM0000000478,MBR00000155,Medical_Professional,Paid,Paper,2023-04-15,2023-04-15,2023-04-15,2023-04-18,Auto_Adjudicated,3,1627776731,1473869105,207RG0100X,Gastroenterology,11,In_Network,Z00.00,,99204,,0,ACA_Marketplace,ACA_Bronze,9,F,0.8196,,,478.91,365.48,0.0,365.48,0.0,0.0,113.43,0.0,0.0,0,,0.0669,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000479,MBR00000061,Medical_Institutional,Paid,Electronic_EDI,2023-10-28,2023-10-28,2023-10-30,2023-11-16,Auto_Adjudicated,19,1966338974,1706603847,207RN0300X,Nephrology,11,In_Network,Z00.00,E11.65,revenue_code:0370,,0,Commercial,PPO,66,M,2.3575,,,4466.37,2987.77,2229.4,167.03,34.0,557.35,1478.6,0.0,0.0,0,,0.2013,unbundling_pattern,0,2,0,0,0,0.000206,0,0,,Shared_Savings
CLM0000000480,MBR00000142,Medical_Professional,Paid,Electronic_EDI,2023-03-28,2023-03-28,2023-03-28,2023-03-29,Manual_Review,1,1879212418,1489434038,207Q00000X,Family Medicine,71,In_Network,I25.10,M25.511,99384,,0,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,186.96,101.06,0.0,101.06,0.0,0.0,85.9,0.0,0.0,0,,0.061,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000000481,MBR00000255,Medical_Institutional,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-13,2023-11-25,Manual_Review,14,1832660692,1049766043,207RE0101X,Endocrinology,22,In_Network,Z00.01,F41.1|OTHER,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,21,M,0.6945,,,25210.37,11378.39,9078.18,6.66,24.0,2269.55,13831.98,0.0,0.0,0,,0.1662,service_date_weekend,0,1,1,1,0,0.00084,0,0,,Capitation
CLM0000000482,MBR00000237,Medical_Professional,Paid,Provider_Portal,2023-02-01,2023-02-01,2023-02-01,2023-02-19,Auto_Adjudicated,18,1313587359,1619587398,246ZN0300X,Neuropsychology,11,Out_of_Network,OTHER,M54.5,99203,,0,Commercial,PPO,45,M,0.7983,,,218.03,135.15,0.0,129.7,5.45,0.0,82.88,0.0,0.0,0,,0.0927,none,0,1,0,1,0,0.0,1,0,FUM_Follow_Up_ED_Mental_Health,Bundled_Payment
CLM0000000483,MBR00000052,Medical_Institutional,Paid,Electronic_EDI,2023-08-17,2023-08-17,2023-08-17,2023-08-19,Auto_Adjudicated,2,1654042271,1289435414,2086S0122X,Orthopedic Surgery,11,In_Network,OTHER,M54.5|I10,revenue_code:0110,,0,Commercial,PPO,0,F,1.325,,,15983.91,5857.15,4624.51,0.51,76.0,1156.13,10126.76,0.0,0.0,0,,0.0947,duplicate_claim_indicator,0,1,0,1,0,0.000428,0,0,,FFS
CLM0000000484,MBR00000200,Dental,Partially_Paid,Paper,2023-02-08,2023-02-08,2023-02-08,2023-02-28,Auto_Adjudicated,20,1699074676,1577226132,207RN0300X,Nephrology,32,In_Network,F33.0,OTHER,D2140,,0,Commercial,HDHP_HSA,29,M,0.8011,18,Medical_Necessity,304.88,186.51,0.0,125.37,0.0,0.0,179.51,0.0,0.0,0,,0.0157,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000485,MBR00000259,Medical_Institutional,Paid,Electronic_EDI,2023-05-19,2023-05-19,2023-05-23,2023-06-13,Auto_Adjudicated,25,1673449362,1209882852,208600000X,Surgery General,11,In_Network,Z12.11,,revenue_code:0360,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,11916.98,5200.86,4128.28,4.51,36.0,1032.07,6716.12,2660.23,1067.47,0,,0.0703,none,0,1,0,1,0,0.000382,0,0,,FFS
CLM0000000486,MBR00000244,Pharmacy,Paid,Paper,2023-12-09,2023-12-09,2023-12-09,2024-01-08,Clinical_Review,30,1952322604,1352413270,207RP1001X,Pulmonary Disease,23,In_Network,OTHER,,00069420020,,4,Commercial,PPO,52,M,0.6677,,,125.16,84.17,0.0,84.17,0.0,0.0,40.99,0.0,0.0,0,,0.0821,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000000487,MBR00000135,Pharmacy,Paid,Electronic_EDI,2023-10-03,2023-10-03,2023-10-03,2023-10-11,Auto_Adjudicated,8,1181941909,1148659045,207V00000X,Obstetrics & Gynecology,22,In_Network,F41.1,I10,00006001954,,1,Commercial,PPO,58,F,2.2702,,,425.89,236.76,158.13,2.09,37.0,39.53,189.13,0.0,0.0,0,,0.0767,none,0,1,0,0,0,1.5e-05,0,1,,FFS
CLM0000000488,MBR00000014,Medical_Professional,Paid,Provider_Portal,2023-07-04,2023-07-04,2023-07-04,2023-07-14,Auto_Adjudicated,10,1803277343,1513198866,246ZN0300X,Neuropsychology,24,Emergency,I10,I10,99384,,0,Commercial,HMO,77,M,2.8513,,,126.34,92.18,0.0,92.18,0.0,0.0,34.16,0.0,0.0,0,,0.1186,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000489,MBR00000281,Medical_Professional,Denied,Electronic_EDI,2023-08-15,2023-08-15,2023-08-15,2023-09-03,Auto_Adjudicated,19,1629674542,1662516615,101YP2500X,Psychologist Clinical,23,Emergency,J06.9,Z00.00,99282,,0,Medicare_Advantage,MA_HMO,3,M,0.8531,1,Network,225.05,145.18,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1504,npi_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000490,MBR00000126,Medical_Professional,Paid,Electronic_EDI,2023-08-26,2023-08-26,2023-08-26,2023-09-13,Auto_Adjudicated,18,1593056613,1132693989,246ZN0300X,Neuropsychology,31,In_Network,J06.9,,10060,,0,Medicaid_MCO,MLTSS,48,F,0.637,,,1293.87,775.54,773.54,0.0,2.0,0.0,518.33,0.0,0.0,0,,0.134,none,0,1,0,0,0,7.2e-05,0,0,,P4P
CLM0000000491,MBR00000114,Medical_Institutional,Paid,Electronic_EDI,2023-10-12,2023-10-12,2023-10-14,2023-10-31,Auto_Adjudicated,19,1082088479,1878017518,207R00000X,Internal Medicine,11,In_Network,I25.10,,revenue_code:0200,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,9548.48,6482.39,5168.11,2.25,20.0,1292.03,3066.09,0.0,0.0,0,,0.0969,upcoding_pattern,0,1,1,0,0,0.000478,0,0,PPC_Prenatal_Care,FFS
CLM0000000492,MBR00000223,Dental,Denied,Electronic_EDI,2023-08-01,2023-08-01,2023-08-01,2023-08-11,Auto_Adjudicated,10,1026612378,1068662623,208600000X,Surgery General,21,In_Network,Z23,,D0150,,0,Commercial,PPO,65,F,0.3534,PR-1,Eligibility,318.54,146.81,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0817,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000493,MBR00000081,Medical_Institutional,Paid,Electronic_EDI,2023-07-03,2023-07-03,2023-07-04,2023-07-05,Auto_Adjudicated,2,1641779816,1878017518,2086S0122X,Orthopedic Surgery,11,In_Network,OTHER,Z12.11|K21.0,revenue_code:0250,,0,Medicare_Advantage,SNP,66,F,2.159,,,27258.08,22122.31,17652.61,12.54,44.0,4413.15,5135.77,0.0,0.0,0,,0.0352,none,0,1,1,0,0,0.001634,0,0,,Bundled_Payment
CLM0000000494,MBR00000249,Medical_Institutional,Paid,Electronic_EDI,2023-01-28,2023-01-28,2023-01-31,2023-01-29,Auto_Adjudicated,1,1069440570,1473869105,207RP1001X,Pulmonary Disease,21,Emergency,Z79.4,K21.0,revenue_code:0370,682,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,17428.39,6716.46,4385.62,363.28,88.0,1879.55,10711.93,0.0,0.0,0,,0.1087,none,0,1,0,0,0,0.000406,0,0,,FFS
CLM0000000495,MBR00000024,Medical_Professional,Paid,Electronic_EDI,2023-12-11,2023-12-11,2023-12-11,2024-01-10,Auto_Adjudicated,30,1360102160,1128148362,101YP2500X,Psychologist Clinical,22,In_Network,E78.5,,99222,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,1002.34,523.01,520.01,0.0,3.0,0.0,479.33,0.0,0.0,1,DME Fraud,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|temporal_clustering|high_volume_same_code|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|npi_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,1,0,4.8e-05,0,0,,FFS
CLM0000000496,MBR00000217,Medical_Professional,Paid,Electronic_EDI,2023-07-23,2023-07-23,2023-07-23,2023-08-05,Auto_Adjudicated,13,1932483309,1747935894,208600000X,Surgery General,22,In_Network,Z23,OTHER,99203,,0,ACA_Marketplace,ACA_Bronze,11,F,1.1619,,,132.65,50.23,0.0,50.23,0.0,0.0,82.42,0.0,0.0,0,,0.1156,none,0,1,0,0,0,0.0,0,0,SPD_Spirometry_Testing,FFS
CLM0000000497,MBR00000292,Vision,Paid,Electronic_EDI,2023-04-15,2023-04-15,2023-04-15,2023-04-29,Manual_Review,14,1069440570,1689327034,2084P0800X,Psychiatry,65,In_Network,G43.909,Z23|Z00.00|N18.3,92014,,0,Medicare_Advantage,MA_HMO,4,M,1.1779,,,217.08,139.59,99.83,11.81,3.0,24.96,77.49,0.0,0.0,0,,0.0926,unusual_service_frequency,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000000498,MBR00000299,Medical_Professional,Paid,Electronic_EDI,2023-02-18,2023-02-18,2023-02-18,2023-03-09,Clinical_Review,19,1006962798,1287935251,225100000X,Physical Therapist,65,In_Network,E11.9,,20610,,0,Medicaid_MCO,MCO,74,F,0.8833,,,351.98,190.19,188.19,0.0,2.0,0.0,161.79,0.0,0.0,0,,0.0833,service_date_weekend,0,1,0,0,0,1.7e-05,0,0,FUM_Follow_Up_ED_Mental_Health,Capitation
CLM0000000499,MBR00000279,Pharmacy,Paid,Electronic_EDI,2023-08-05,2023-08-05,2023-08-05,2023-08-12,Auto_Adjudicated,7,1918359820,1289435414,207RN0300X,Nephrology,11,In_Network,Z00.01,,16590051660,,1,Medicare_Advantage,MA_PPO,81,M,1.6817,,,223.37,84.54,46.62,17.26,9.0,11.66,138.83,0.0,0.0,0,,0.1314,high_oop_waiver,0,1,0,1,0,4e-06,0,0,CDC_HbA1c_Poor_Control,Bundled_Payment
CLM0000000500,MBR00000263,Medical_Professional,Partially_Paid,Provider_Portal,2023-10-08,2023-10-08,2023-10-08,2023-10-20,Auto_Adjudicated,12,1642333103,1151295616,208600000X,Surgery General,23,In_Network,C50.911,I10,99214,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,2,Medical_Necessity,458.03,313.04,95.51,44.4,19.0,23.88,275.25,0.0,0.0,0,,0.0746,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000000501,MBR00000087,Medical_Professional,Paid,Electronic_EDI,2023-10-18,2023-10-18,2023-10-18,2023-11-01,Auto_Adjudicated,14,1323379997,1945682535,225100000X,Physical Therapist,23,Emergency,Z23,,99205,,0,Medicaid_MCO,MCO,70,F,0.9232,,,77.97,64.64,63.64,0.0,1.0,0.0,13.33,0.0,0.0,0,,0.0189,none,0,1,0,0,0,6e-06,0,0,FUM_Follow_Up_ED_Mental_Health,Capitation
CLM0000000502,MBR00000293,Medical_Professional,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-11-18,Manual_Review,3,1736809698,1133410177,207RN0300X,Nephrology,71,In_Network,I10,,99387,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,123.31,49.75,28.25,3.44,11.0,7.06,73.56,0.0,0.0,0,,0.0758,none,0,1,0,0,0,3e-06,0,0,ACR_Urine_Protein,FFS
CLM0000000503,MBR00000279,Dental,Denied,Electronic_EDI,2023-11-17,2023-11-17,2023-11-17,2023-12-06,Auto_Adjudicated,19,1713741288,1867626800,207RE0101X,Endocrinology,11,In_Network,F41.1,Z00.00|OTHER|E11.9,D7140,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,18,Timely_Filing,97.45,44.85,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0687,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000504,MBR00000162,Medical_Professional,Paid,Electronic_EDI,2023-08-12,2023-08-12,2023-08-12,2023-08-18,Auto_Adjudicated,6,1617763056,1489993356,207Q00000X,Family Medicine,22,In_Network,E11.65,Z00.121|M79.3,73721,,0,Medicaid_MCO,MLTSS,84,F,1.324,,,340.44,165.56,164.56,0.0,1.0,0.0,174.88,0.0,0.0,0,,0.0783,benford_violation,0,1,0,1,0,1.5e-05,0,0,SPC_Statin_Therapy,Capitation
CLM0000000505,MBR00000128,Pharmacy,Paid,Electronic_EDI,2023-12-06,2023-12-06,2023-12-06,2023-12-07,Auto_Adjudicated,1,1683650935,1489434038,207R00000X,Internal Medicine,21,In_Network,Z00.00,OTHER|J06.9,00071012831,,1,Commercial,PPO,13,F,1.4203,,,175.3,120.96,49.66,45.89,13.0,12.41,54.34,0.0,0.0,0,,0.078,none,0,1,0,0,0,5e-06,0,0,FLU_Flu_Vaccination,Bundled_Payment
CLM0000000506,MBR00000034,Medical_Professional,Denied,Electronic_EDI,2023-01-27,2023-01-27,2023-01-27,2023-02-15,Auto_Adjudicated,19,1232573801,1591405274,246ZN0300X,Neuropsychology,21,In_Network,OTHER,R05.9|E11.65|OTHER,33510,,0,Medicare_Advantage,MA_HMO,35,M,0.7712,96,Coding_Error,1909.47,1037.25,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0692,billing_spike_recent,0,1,0,0,0,0.0,0,0,KED_ESRD_Patients,P4P
CLM0000000507,MBR00000177,Medical_Institutional,Paid,Electronic_EDI,2023-05-22,2023-05-22,2023-05-24,2023-06-01,Auto_Adjudicated,10,1897231867,1196833348,207R00000X,Internal Medicine,22,In_Network,F41.1,,revenue_code:0110,,0,Commercial,HMO,42,F,1.2774,,,3433.29,2497.16,1809.4,158.41,77.0,452.35,936.13,0.0,0.0,0,,0.0547,none,0,1,0,0,0,0.000167,0,0,CBP_Controlling_BP,FFS
CLM0000000508,MBR00000208,Medical_Institutional,Paid,Provider_Portal,2023-06-23,2023-06-23,2023-06-23,2023-07-15,Manual_Review,22,1046207613,1689327034,207RN0300X,Nephrology,11,In_Network,Z00.00,M54.5|J44.1,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,95852.18,55733.1,44519.14,30.18,54.0,11129.78,40119.08,0.0,0.0,0,,0.0754,outlier_billing_amount,0,1,1,1,0,0.004121,0,0,,FFS
CLM0000000509,MBR00000129,Medical_Institutional,Paid,Electronic_EDI,2023-09-09,2023-09-09,2023-09-12,2023-09-26,Auto_Adjudicated,17,1900781649,1296566243,207R00000X,Internal Medicine,11,In_Network,OTHER,J20.9|Z00.00|OTHER,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,9,F,0.8196,,,17787.94,6434.36,5094.74,6.94,59.0,1273.68,11353.58,0.0,0.0,0,,0.1073,none,0,1,1,1,0,0.000472,0,0,SPC_Statin_Therapy,Bundled_Payment
CLM0000000510,MBR00000129,Medical_Professional,Paid,Provider_Portal,2023-04-18,2023-04-18,2023-04-18,2023-04-19,Auto_Adjudicated,1,1124477249,1589482133,207RE0101X,Endocrinology,24,In_Network,I25.10,M79.3,99222,,0,Medicare_Advantage,MA_PPO,9,F,0.8196,,,354.86,155.06,109.82,0.78,17.0,27.46,199.8,0.0,0.0,0,,0.1992,benford_violation,0,1,0,0,0,1e-05,0,0,,Shared_Savings
CLM0000000511,MBR00000172,Medical_Professional,Paid,Electronic_EDI,2023-04-15,2023-04-15,2023-04-15,2023-05-06,Auto_Adjudicated,21,1026612378,1942423230,2084P0800X,Psychiatry,11,In_Network,OTHER,N18.3|J45.20|Z00.00,11200,,0,Medicaid_MCO,MCO,50,F,0.2787,,,1007.28,513.74,513.74,0.0,0.0,0.0,493.54,0.0,0.0,0,,0.1372,none,0,1,0,0,0,4.8e-05,0,0,,Shared_Savings
CLM0000000512,MBR00000010,Dental,Paid,Electronic_EDI,2023-11-21,2023-11-21,2023-11-21,2023-11-23,Auto_Adjudicated,2,1209940651,1878017518,207RE0101X,Endocrinology,21,In_Network,E78.5,E11.9|R05.9,D2391,,0,Medicare_Advantage,MA_HMO,44,F,1.4631,,,141.98,94.72,52.87,24.64,4.0,13.22,47.26,0.0,0.0,0,,0.0947,none,0,1,0,0,0,5e-06,0,0,,Shared_Savings
CLM0000000513,MBR00000291,Medical_Institutional,Paid,Paper,2023-08-22,2023-08-22,2023-08-22,2023-09-01,Auto_Adjudicated,10,1994365754,1746676564,207R00000X,Internal Medicine,22,In_Network,Z23,F10.10,revenue_code:0300,,0,Commercial,PPO,78,M,1.4773,,,6493.92,4483.46,3144.46,476.89,76.0,786.11,2010.46,0.0,0.0,0,,0.0267,none,0,1,0,0,0,0.000291,0,0,,P4P
CLM0000000514,MBR00000091,Medical_Professional,Paid,Electronic_EDI,2023-08-16,2023-08-16,2023-08-16,2023-09-06,Manual_Review,21,1119083414,1867389043,101YP2500X,Psychologist Clinical,22,In_Network,G47.33,Z79.4,43239,,0,Commercial,PPO,13,F,1.2451,,,297.9,199.6,0.0,199.6,0.0,0.0,98.3,0.0,0.0,0,,0.0174,none,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000000515,MBR00000044,Medical_Institutional,Paid,Electronic_EDI,2023-03-08,2023-03-08,2023-03-09,2023-03-21,Auto_Adjudicated,13,1950560596,1527857018,208600000X,Surgery General,23,In_Network,OTHER,Z23|J44.1,revenue_code:0300,,0,Commercial,PPO,29,M,0.7512,,,19707.43,7505.77,5794.45,189.7,73.0,1448.61,12201.66,0.0,0.0,0,,0.0632,none,0,1,1,0,0,0.000536,0,0,IET_Initiation_Substance_Use,Capitation
CLM0000000516,MBR00000003,Medical_Professional,Paid,Electronic_EDI,2023-06-29,2023-06-29,2023-06-29,2023-07-11,Auto_Adjudicated,12,1874109311,1477113725,208600000X,Surgery General,81,In_Network,OTHER,Z87.891,99285,,0,Commercial,PPO,79,F,1.3879,,,169.65,90.69,45.76,8.48,25.0,11.44,78.96,0.0,0.0,0,,0.1194,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000000517,MBR00000259,Medical_Institutional,Paid,Electronic_EDI,2023-06-01,2023-06-01,2023-06-04,2023-06-08,Auto_Adjudicated,7,1377412382,1287935251,207RN0300X,Nephrology,21,In_Network,M79.3,Z23,revenue_code:0110,683,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,9059.68,6048.22,4803.55,7.78,36.0,1200.89,3011.46,0.0,0.0,0,,0.0181,none,0,1,0,0,0,0.000445,0,0,,Bundled_Payment
CLM0000000518,MBR00000261,Medical_Institutional,Paid,Electronic_EDI,2023-08-11,2023-08-11,2023-08-14,2023-08-25,Auto_Adjudicated,14,1980039511,1951488764,225100000X,Physical Therapist,11,In_Network,OTHER,,revenue_code:0120,,0,Medicare_Advantage,MA_PPO,13,F,0.4259,,,6026.18,4036.16,3192.5,1.53,44.0,798.13,1990.02,0.0,0.0,0,,0.2026,impossible_service_combo,0,2,0,0,0,0.000295,0,0,,FFS
CLM0000000519,MBR00000028,Medical_Professional,Denied,Electronic_EDI,2023-11-27,2023-11-27,2023-11-27,2023-12-06,Auto_Adjudicated,9,1374458552,1831337866,207RN0300X,Nephrology,11,In_Network,Z00.01,,27447,,0,Commercial,HMO,3,F,2.116,16,Authorization,45632.57,29194.41,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0959,upcoding_pattern,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000520,MBR00000048,Medical_Institutional,Partially_Paid,Provider_Portal,2023-04-10,2023-04-10,2023-04-14,2023-05-09,Auto_Adjudicated,29,1638309014,1860951128,208600000X,Surgery General,22,In_Network,G43.909,,revenue_code:0120,,0,Commercial,POS,27,F,0.639,3,Medical_Necessity,6338.89,3569.02,2160.03,54.35,50.0,540.01,3534.5,0.0,0.0,0,,0.0722,impossible_service_combo,0,1,0,0,0,0.0002,0,0,,FFS
CLM0000000521,MBR00000139,Medical_Institutional,Paid,Electronic_EDI,2023-10-19,2023-10-19,2023-10-22,2023-11-09,Auto_Adjudicated,21,1825861601,1986847322,2086S0122X,Orthopedic Surgery,21,In_Network,I25.10,E11.65,revenue_code:0360,247,0,Commercial,PPO,74,M,1.7701,,,4070.8,1443.07,1089.0,48.82,33.0,272.25,2627.73,0.0,0.0,0,,0.2043,billing_spike_recent,0,2,0,0,0,0.000101,0,0,,Shared_Savings
CLM0000000522,MBR00000058,Vision,Paid,Electronic_EDI,2023-08-16,2023-08-16,2023-08-16,2023-09-13,Manual_Review,28,1205744244,1013600387,207RE0101X,Endocrinology,65,In_Network,E78.5,,V2320,,0,Commercial,PPO,56,F,1.1626,,,338.65,213.21,140.85,22.15,15.0,35.21,125.44,0.0,0.0,0,,0.0699,impossible_service_combo,0,1,0,0,0,1.3e-05,0,0,,P4P
CLM0000000523,MBR00000215,Pharmacy,Paid,Electronic_EDI,2023-06-28,2023-06-28,2023-06-28,2023-07-09,Auto_Adjudicated,11,1218294278,1553094822,207R00000X,Internal Medicine,22,In_Network,E11.9,,00310075090,,2,ACA_Marketplace,ACA_Silver,69,M,0.8895,,,157.92,75.93,0.0,75.93,0.0,0.0,81.99,0.0,0.0,0,,0.1322,npi_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000524,MBR00000016,Medical_Institutional,Paid,Electronic_EDI,2023-12-08,2023-12-08,2023-12-09,2024-01-06,Auto_Adjudicated,29,1866366547,1013600387,225100000X,Physical Therapist,22,In_Network,E78.5,Z00.00|I10|OTHER,revenue_code:0450,,0,Commercial,HDHP_HSA,20,F,0.5843,,,38761.34,20397.62,16308.56,11.92,0.0,4077.14,18363.72,0.0,0.0,0,,0.0819,none,0,1,1,0,0,0.00151,0,0,BPD_BP_Declined,Capitation
CLM0000000525,MBR00000166,Pharmacy,Paid,Electronic_EDI,2023-02-22,2023-02-22,2023-02-22,2023-03-03,Auto_Adjudicated,9,1838794554,1690197969,207RG0100X,Gastroenterology,31,In_Network,I10,Z12.11,00085163102,,1,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,212.31,137.73,0.0,137.73,0.0,0.0,74.58,0.0,0.0,0,,0.0721,phantom_billing_indicator,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000000526,MBR00000121,Medical_Professional,Denied,Electronic_EDI,2023-09-01,2023-09-01,2023-09-01,2023-09-11,Manual_Review,10,1183801932,1330485436,207RG0100X,Gastroenterology,24,In_Network,E78.5,OTHER|I50.9|J06.9,97110,,0,Medicare_Advantage,MA_PPO,58,M,1.226,97,Eligibility,733.66,432.31,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1075,upcoding_pattern,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000527,MBR00000143,Pharmacy,Paid,Electronic_EDI,2023-05-24,2023-05-24,2023-05-24,2023-06-02,Auto_Adjudicated,9,1821999097,1432077493,207RN0300X,Nephrology,23,In_Network,Z00.00,,00085163102,,1,Commercial,POS,85,M,1.6078,,,335.42,189.91,0.0,189.91,0.0,0.0,145.51,0.0,0.0,0,,0.0539,none,0,1,0,1,0,0.0,0,1,,Shared_Savings
CLM0000000528,MBR00000134,Medical_Professional,Paid,Paper,2023-09-02,2023-09-02,2023-09-02,2023-09-20,Auto_Adjudicated,18,1193571728,1938465393,207RP1001X,Pulmonary Disease,22,In_Network,I50.9,OTHER,74177,,0,Medicare_Advantage,MA_PPO,33,M,1.115,,,836.18,462.24,346.46,16.17,13.0,86.61,373.94,0.0,0.0,0,,0.1628,temporal_clustering,0,1,0,0,0,3.2e-05,0,0,,Shared_Savings
CLM0000000529,MBR00000049,Medical_Professional,Paid,Electronic_EDI,2023-02-19,2023-02-19,2023-02-19,2023-03-10,Auto_Adjudicated,19,1788188920,1650774392,207RC0000X,Cardiovascular Disease,11,In_Network,M17.11,I10|K21.0,99386,,0,Medicare_Advantage,PFFS,67,M,0.978,,,395.75,289.85,213.35,19.16,4.0,53.34,105.9,0.0,0.0,0,,0.0961,none,0,1,0,0,0,2e-05,0,0,,FFS
CLM0000000530,MBR00000068,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-09-22,2023-09-22,2023-09-25,2023-09-24,Manual_Review,2,1218947226,1339359594,207R00000X,Internal Medicine,22,In_Network,I10,R05.9|M54.5|OTHER,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,28,F,0.8494,5,Medical_Necessity,20743.91,12392.75,7248.83,12.33,40.0,1812.21,11630.55,0.0,0.0,0,,0.0203,none,0,1,1,0,0,0.000671,0,0,AWV_Annual_Wellness_Visit,Bundled_Payment
CLM0000000531,MBR00000020,Medical_Professional,Denied,Electronic_EDI,2023-01-25,2023-01-25,2023-01-25,2023-02-11,Auto_Adjudicated,17,1611521069,1509799493,101YP2500X,Psychologist Clinical,11,Out_of_Network,M47.816,OTHER|Z00.00,99284,,0,Medicare_Advantage,MA_PPO,63,F,0.7119,2,Medical_Necessity,226.07,149.16,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1281,none,0,1,0,0,0,0.0,1,0,,Capitation
CLM0000000532,MBR00000036,Pharmacy,Paid,Electronic_EDI,2023-05-06,2023-05-06,2023-05-06,2023-06-04,Clinical_Review,29,1866366547,1705448933,207RE0101X,Endocrinology,22,In_Network,I10,OTHER|E78.5|I10,00071012831,,2,Commercial,EPO,17,M,2.0136,,,63.58,25.24,0.0,25.24,0.0,0.0,38.34,0.0,0.0,0,,0.18,temporal_clustering,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000533,MBR00000295,Medical_Institutional,Denied,Electronic_EDI,2023-11-22,2023-11-22,2023-11-25,2023-12-05,Auto_Adjudicated,13,1469009511,1994275960,207RN0300X,Nephrology,31,In_Network,F41.1,,revenue_code:0200,,0,Commercial,HDHP_HSA,78,F,0.8618,3,Duplicate,9353.16,6127.33,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1259,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000534,MBR00000087,Medical_Professional,Paid,Paper,2023-08-16,2023-08-16,2023-08-16,2023-09-06,Manual_Review,21,1243052462,1538261819,207RN0300X,Nephrology,22,Out_of_Network,OTHER,Z00.00,33510,,0,Medicaid_MCO,MCO,70,F,0.9232,,,297.35,112.56,111.56,0.0,1.0,0.0,184.79,0.0,0.0,1,Kickback Arrangement,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|impossible_service_combo|billing_spike_recent|duplicate_claim_indicator|phantom_billing_indicator|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,1,0,1e-05,1,0,POD_Persistence_of_Beta_Blocker,FFS
CLM0000000535,MBR00000097,Medical_Professional,Paid,Paper,2023-06-26,2023-06-26,2023-06-26,2023-07-15,Auto_Adjudicated,19,1990244466,1148659045,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,OTHER|N18.3,90847,,0,Commercial,EPO,34,M,1.3765,,,459.78,338.31,158.97,115.6,24.0,39.74,121.47,0.0,0.0,0,,0.0282,none,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000000536,MBR00000038,Medical_Institutional,Denied,Electronic_EDI,2023-04-29,2023-04-29,2023-05-02,2023-05-29,Auto_Adjudicated,30,1389534304,1005335812,207RP1001X,Pulmonary Disease,11,In_Network,I25.10,Z00.00,revenue_code:0200,,0,Commercial,EPO,46,M,1.1295,2,Network,73969.96,26277.92,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Upcoding,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|benford_violation|impossible_service_combo|service_date_weekend|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,0.0,0,0,,P4P
CLM0000000537,MBR00000221,Pharmacy,Paid,Electronic_EDI,2023-02-02,2023-02-02,2023-02-02,2023-02-22,Auto_Adjudicated,20,1461820376,1581533104,207RG0100X,Gastroenterology,31,In_Network,I25.10,,00085163102,,1,Commercial,HDHP_HSA,28,M,1.6683,,,676.32,488.51,0.0,488.51,0.0,0.0,187.81,0.0,0.0,0,,0.0946,none,0,1,0,0,0,0.0,0,0,CBP_Controlling_BP,FFS
CLM0000000538,MBR00000279,Pharmacy,Paid,Electronic_EDI,2023-02-09,2023-02-09,2023-02-09,2023-02-24,Auto_Adjudicated,15,1556072255,1764064254,101YP2500X,Psychologist Clinical,11,In_Network,Z00.00,,16590051660,,4,Medicare_Advantage,MA_PPO,81,M,1.6817,,,242.44,149.01,105.15,8.58,9.0,26.29,93.43,0.0,0.0,0,,0.0687,none,0,1,0,1,0,1e-05,0,0,,Shared_Savings
CLM0000000539,MBR00000234,Medical_Professional,Paid,Electronic_EDI,2023-09-15,2023-09-15,2023-09-15,2023-09-16,Auto_Adjudicated,1,1733777382,1574982369,208600000X,Surgery General,22,In_Network,Z23,E11.9|OTHER,99282,,0,Medicare_Advantage,MA_HMO,59,M,0.395,,,117.96,82.99,54.71,14.61,0.0,13.68,34.97,37.86,11.12,0,,0.1307,none,0,1,0,1,0,5e-06,0,0,,P4P
CLM0000000540,MBR00000184,Pharmacy,Partially_Paid,Provider_Portal,2023-04-09,2023-04-09,2023-04-09,2023-05-04,Auto_Adjudicated,25,1532359759,1114756459,246ZN0300X,Neuropsychology,24,In_Network,M54.5,,00085163102,,3,Medicaid_MCO,MLTSS,30,M,2.8302,PR-1,Medical_Necessity,416.41,196.67,145.72,0.0,2.0,0.0,268.69,0.0,0.0,0,,0.0948,none,0,1,0,0,0,1.3e-05,0,1,,Bundled_Payment
CLM0000000541,MBR00000241,Medical_Professional,Denied,Paper,2023-01-27,2023-01-27,2023-01-27,2023-02-07,Auto_Adjudicated,11,1299958874,1689327034,207RN0300X,Nephrology,11,In_Network,F32.9,N18.3,33510,,0,Medicare_Advantage,MA_HMO,77,M,1.2169,2,Timely_Filing,1259.05,771.54,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1147,geographic_mismatch|diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000542,MBR00000129,Medical_Professional,Paid,Electronic_EDI,2023-06-07,2023-06-07,2023-06-07,2023-07-05,Manual_Review,28,1556072255,1330485436,101YP2500X,Psychologist Clinical,24,In_Network,OTHER,,99396,,0,Medicare_Advantage,MA_PPO,9,F,0.8196,,,115.23,88.97,49.95,9.53,17.0,12.49,26.26,0.0,0.0,0,,0.1046,none,0,1,0,0,0,5e-06,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000000543,MBR00000259,Medical_Institutional,Paid,Paper,2023-05-23,2023-05-23,2023-05-26,2023-05-31,Auto_Adjudicated,8,1918578486,1574982369,2086S0122X,Orthopedic Surgery,11,In_Network,OTHER,,revenue_code:0370,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,21112.76,9634.06,7675.44,3.76,36.0,1918.86,11478.7,0.0,0.0,0,,0.0049,none,0,1,1,0,0,0.00071,0,0,,FFS
CLM0000000544,MBR00000236,Medical_Professional,Paid,Electronic_EDI,2023-12-10,2023-12-10,2023-12-10,2023-12-24,Auto_Adjudicated,14,1688560518,1220755708,246ZN0300X,Neuropsychology,24,In_Network,N18.3,OTHER,99203,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,548.94,199.22,196.22,0.0,3.0,0.0,349.72,0.0,0.0,0,,0.1518,unusual_service_frequency,0,1,0,0,0,1.8e-05,0,0,,FFS
CLM0000000545,MBR00000001,Medical_Professional,Paid,Paper,2023-03-24,2023-03-24,2023-03-24,2023-04-18,Auto_Adjudicated,25,1990244466,1985590322,246ZN0300X,Neuropsychology,11,Out_of_Network,Z87.891,,99203,,0,Commercial,EPO,73,M,0.6527,,,91.32,66.34,0.0,66.34,0.0,0.0,24.98,0.0,0.0,0,,0.0427,none,0,1,0,0,0,0.0,0,0,SPD_Spirometry_Testing,Capitation
CLM0000000546,MBR00000152,Medical_Professional,Paid,Electronic_EDI,2023-04-07,2023-04-07,2023-04-07,2023-04-12,Clinical_Review,5,1732726112,1825450791,207RP1001X,Pulmonary Disease,11,In_Network,L70.0,I10|OTHER,99214,,0,Commercial,HMO,82,F,1.2506,,,155.61,109.21,0.0,109.21,0.0,0.0,46.4,0.0,0.0,0,,0.0865,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000547,MBR00000081,Pharmacy,Paid,Electronic_EDI,2023-03-01,2023-03-01,2023-03-01,2023-03-10,Auto_Adjudicated,9,1898658234,1177602659,101YP2500X,Psychologist Clinical,11,In_Network,F32.9,,00085163102,,1,Medicare_Advantage,SNP,66,F,2.159,,,356.19,151.41,110.66,8.09,5.0,27.66,204.78,0.0,0.0,0,,0.1096,none,0,1,0,0,0,1e-05,0,1,,Shared_Savings
CLM0000000548,MBR00000026,Dental,Paid,Electronic_EDI,2023-03-09,2023-03-09,2023-03-09,2023-04-02,Auto_Adjudicated,24,1543927384,1148659045,207RG0100X,Gastroenterology,32,In_Network,OTHER,E11.9|M54.5,D4341,,0,Medicaid_MCO,MCO,17,M,1.0686,,,297.07,154.77,153.77,0.0,1.0,0.0,142.3,0.0,0.0,0,,0.0749,high_volume_same_code,0,1,0,0,0,1.4e-05,0,0,,Bundled_Payment
CLM0000000549,MBR00000254,Vision,Paid,Electronic_EDI,2023-07-11,2023-07-11,2023-07-11,2023-07-21,Clinical_Review,10,1732193518,1274911960,207RP1001X,Pulmonary Disease,22,Out_of_Network,F33.0,OTHER,V2100,,0,Commercial,PPO,22,F,0.9285,,,560.31,313.0,225.42,3.22,28.0,56.36,247.31,148.2,42.73,0,,0.044,none,0,1,0,1,0,2.1e-05,1,0,,FFS
CLM0000000550,MBR00000003,Medical_Professional,Paid,Electronic_EDI,2023-03-22,2023-03-22,2023-03-22,2023-04-20,Auto_Adjudicated,29,1731980913,1878874025,207RE0101X,Endocrinology,31,Out_of_Network,K29.70,M54.5,99283,,0,Commercial,PPO,79,F,1.3879,,,429.83,158.81,100.39,8.32,25.0,25.1,271.02,0.0,0.0,0,,0.1142,none,0,1,0,0,0,9e-06,1,0,SPC_Statin_Therapy,FFS
CLM0000000551,MBR00000214,Medical_Institutional,Paid,Electronic_EDI,2023-09-16,2023-09-16,2023-09-20,2023-10-03,Auto_Adjudicated,17,1887363539,1591405274,2084P0800X,Psychiatry,22,In_Network,Z00.00,J44.1,revenue_code:0300,,0,Commercial,HDHP_HSA,76,M,1.7526,,,23467.18,12684.62,9758.05,487.06,0.0,2439.51,10782.56,0.0,0.0,0,,0.0827,none,0,1,1,0,0,0.000903,0,0,,FFS
CLM0000000552,MBR00000297,Pharmacy,Paid,Electronic_EDI,2023-10-21,2023-10-21,2023-10-21,2023-11-15,Auto_Adjudicated,25,1086690796,1144950506,207Q00000X,Family Medicine,24,In_Network,J20.9,J06.9,00003014960,,1,Commercial,HMO,88,M,1.5311,,,428.48,170.09,94.09,25.48,27.0,23.52,258.39,0.0,0.0,0,,0.1572,provider_specialty_mismatch,0,1,0,0,0,9e-06,0,0,TRC_Transition_of_Care,FFS
CLM0000000553,MBR00000148,Medical_Professional,Paid,Electronic_EDI,2023-06-24,2023-06-24,2023-06-24,2023-07-11,Auto_Adjudicated,17,1869706360,1098360555,207RG0100X,Gastroenterology,22,In_Network,J06.9,,99394,,0,Commercial,EPO,51,F,0.6534,,,178.33,150.99,34.82,74.46,33.0,8.71,27.34,0.0,0.0,0,,0.1412,none,0,1,0,0,0,3e-06,0,0,ACR_Urine_Protein,FFS
CLM0000000554,MBR00000118,Medical_Professional,Denied,Electronic_EDI,2023-03-27,2023-03-27,2023-03-27,2023-03-29,Auto_Adjudicated,2,1078576574,1564636990,207RP1001X,Pulmonary Disease,22,In_Network,Z00.00,K29.70,99283,,0,Medicaid_MCO,MCO,69,M,1.2773,97,Network,230.05,193.44,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0413,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000555,MBR00000183,Medical_Professional,Paid,Paper,2023-10-22,2023-10-22,2023-10-22,2023-11-16,Auto_Adjudicated,25,1469822310,1049766043,207RG0100X,Gastroenterology,23,In_Network,M79.3,M54.5,73721,,0,Commercial,PPO,51,M,0.8463,,,2394.89,1516.65,1020.94,201.48,39.0,255.23,878.24,0.0,0.0,0,,0.0162,none,0,1,0,0,0,9.4e-05,0,0,,FFS
CLM0000000556,MBR00000238,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-12-13,2023-12-13,2023-12-15,2023-12-26,Manual_Review,13,1770738194,1098360555,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,,revenue_code:0250,,0,Commercial,PPO,74,F,0.4382,256,Medical_Necessity,8124.45,4790.83,2608.66,49.04,47.0,652.17,4767.58,1640.9,483.89,0,,0.075,billing_spike_recent,0,1,0,0,0,0.000241,0,0,PPC_Prenatal_Care,FFS
CLM0000000557,MBR00000076,Pharmacy,Denied,Electronic_EDI,2023-11-26,2023-11-26,2023-11-26,2023-12-08,Auto_Adjudicated,12,1550698436,1704466150,207RE0101X,Endocrinology,65,In_Network,L70.0,K21.0|Z00.01,59148001506,,2,Commercial,HMO,26,M,2.1785,18,Timely_Filing,404.23,336.73,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0944,temporal_clustering,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000558,MBR00000078,Medical_Professional,Paid,Electronic_EDI,2023-11-27,2023-11-27,2023-11-27,2023-12-20,Manual_Review,23,1484613641,1025886739,101YP2500X,Psychologist Clinical,65,In_Network,Z00.00,OTHER,97110,,0,Commercial,EPO,65,F,1.3174,,,534.01,365.11,108.72,192.21,37.0,27.18,168.9,0.0,0.0,0,,0.1197,none,0,1,0,0,0,1e-05,0,0,MPT_Annual_Monitoring,Capitation
CLM0000000559,MBR00000183,Medical_Professional,Partially_Paid,Electronic_EDI,2023-10-17,2023-10-17,2023-10-17,2023-10-26,Auto_Adjudicated,9,1679629515,1013600387,208600000X,Surgery General,11,In_Network,Z00.00,,99284,,0,Commercial,PPO,51,M,0.8463,22,Medical_Necessity,183.14,76.22,0.0,56.45,0.0,0.0,126.69,0.0,0.0,0,,0.1008,none,0,1,0,0,0,0.0,0,0,IET_Initiation_Substance_Use,P4P
CLM0000000560,MBR00000285,Pharmacy,Denied,Electronic_EDI,2023-09-23,2023-09-23,2023-09-23,2023-10-06,Auto_Adjudicated,13,1147937670,1666461892,207RG0100X,Gastroenterology,65,In_Network,J06.9,,50458085930,,2,Commercial,HDHP_HSA,56,M,0.9226,16,Timely_Filing,76.48,34.89,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1002,high_oop_waiver,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000561,MBR00000093,Medical_Institutional,Paid,Electronic_EDI,2023-12-10,2023-12-10,2023-12-14,2023-12-29,Auto_Adjudicated,19,1054449469,1391074619,207RC0000X,Cardiovascular Disease,11,In_Network,E11.9,,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,43,F,0.6162,,,18322.71,12417.96,9881.65,24.89,41.0,2470.41,5904.75,0.0,0.0,0,,0.1788,provider_specialty_mismatch,0,1,1,0,0,0.000915,0,0,DDE_Diabetes_Short_Term_Complications,Capitation
CLM0000000562,MBR00000120,Medical_Professional,Denied,Electronic_EDI,2023-05-02,2023-05-02,2023-05-02,2023-05-20,Auto_Adjudicated,18,1484613641,1587454801,207V00000X,Obstetrics & Gynecology,23,In_Network,Z00.00,,17000,,0,Commercial,PPO,62,F,1.0823,96,Network,1528.4,1259.24,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1604,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000563,MBR00000298,Medical_Professional,Paid,Electronic_EDI,2023-11-30,2023-11-30,2023-11-30,2023-12-22,Auto_Adjudicated,22,1272115456,1860951128,208600000X,Surgery General,31,In_Network,Z00.00,OTHER,20610,,0,Medicaid_MCO,MCO,75,M,0.8324,,,864.1,446.05,446.05,0.0,0.0,0.0,418.05,0.0,0.0,0,,0.0575,phantom_billing_indicator,0,1,0,0,0,4.1e-05,0,0,HBD_Hemoglobin_A1c_Testing,Bundled_Payment
CLM0000000564,MBR00000055,Vision,Paid,Electronic_EDI,2023-01-08,2023-01-08,2023-01-08,2023-01-11,Auto_Adjudicated,3,1331903993,1831337866,225100000X,Physical Therapist,11,Out_of_Network,J06.9,,V2103,,0,Commercial,PPO,68,F,1.2896,,,305.14,124.65,74.31,21.77,10.0,18.58,180.49,0.0,0.0,0,,0.0021,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000000565,MBR00000024,Medical_Institutional,Paid,Electronic_EDI,2023-10-26,2023-10-26,2023-10-29,2023-11-25,Manual_Review,30,1154652946,1978943761,207RN0300X,Nephrology,11,In_Network,I10,OTHER,revenue_code:0100,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,3964.29,2892.03,2890.03,0.0,2.0,0.0,1072.26,0.0,0.0,0,,0.123,none,0,1,0,0,0,0.000267,0,0,,FFS
CLM0000000566,MBR00000177,Medical_Institutional,Paid,Electronic_EDI,2023-04-30,2023-04-30,2023-04-30,2023-05-19,Manual_Review,19,1990244466,1163639177,101YP2500X,Psychologist Clinical,24,In_Network,E11.9,,revenue_code:0120,,0,Commercial,HMO,42,F,1.2774,,,11155.04,5050.36,3960.71,22.48,77.0,990.18,6104.68,0.0,0.0,0,,0.0266,none,0,1,0,0,0,0.000367,0,0,,Shared_Savings
CLM0000000567,MBR00000008,Medical_Institutional,Paid,Electronic_EDI,2023-04-16,2023-04-16,2023-04-16,2023-05-05,Auto_Adjudicated,19,1591624417,1291071007,207RN0300X,Nephrology,22,Out_of_Network,OTHER,OTHER|N18.3|Z00.01,revenue_code:0100,,0,Medicaid_MCO,MCO,74,M,0.8375,,,13111.6,5220.55,5217.55,0.0,3.0,0.0,7891.05,0.0,0.0,0,,0.0641,none,0,1,1,1,0,0.000483,1,0,,Bundled_Payment
CLM0000000568,MBR00000056,Vision,Paid,Electronic_EDI,2023-08-31,2023-08-31,2023-08-31,2023-09-27,Manual_Review,27,1711104790,1352413270,207RP1001X,Pulmonary Disease,22,In_Network,OTHER,Z00.00,92014,,0,Commercial,EPO,74,F,1.3941,,,173.1,120.29,0.0,120.29,0.0,0.0,52.81,0.0,0.0,0,,0.1381,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000569,MBR00000185,Medical_Professional,Paid,Electronic_EDI,2023-03-04,2023-03-04,2023-03-04,2023-03-19,Auto_Adjudicated,15,1388566092,1591405274,207RP1001X,Pulmonary Disease,24,Out_of_Network,OTHER,OTHER|M17.11,74177,,0,Medicaid_MCO,MCO,73,M,1.5417,,,831.78,518.3,515.3,0.0,3.0,0.0,313.48,0.0,0.0,0,,0.1495,none,0,1,0,0,0,4.8e-05,1,0,,Capitation
CLM0000000570,MBR00000196,Medical_Professional,Paid,Electronic_EDI,2023-12-23,2023-12-23,2023-12-23,2023-12-24,Auto_Adjudicated,1,1642333103,1741177636,207RE0101X,Endocrinology,11,Out_of_Network,E11.9,E78.5,99395,,0,Commercial,PPO,16,F,1.6015,,,190.46,108.51,0.0,108.51,0.0,0.0,81.95,0.0,0.0,0,,0.084,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000000571,MBR00000157,Medical_Professional,Denied,Paper,2023-09-18,2023-09-18,2023-09-18,2023-09-22,Auto_Adjudicated,4,1677021292,1005335812,207RN0300X,Nephrology,11,In_Network,I10,,99231,,0,Medicare_Advantage,MA_HMO,26,F,0.9164,PR-1,COB,220.9,83.21,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2365,duplicate_claim_indicator|diagnosis_procedure_mismatch,0,2,0,0,0,0.0,0,0,,FFS
CLM0000000572,MBR00000121,Pharmacy,Denied,Electronic_EDI,2023-01-07,2023-01-07,2023-01-07,2023-02-05,Auto_Adjudicated,29,1629674542,1510751265,207RG0100X,Gastroenterology,71,In_Network,I25.10,Z00.00,00310075090,,1,Medicare_Advantage,MA_PPO,58,M,1.226,96,Duplicate,313.14,111.64,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0365,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000573,MBR00000173,Medical_Professional,Denied,Electronic_EDI,2023-10-31,2023-10-31,2023-10-31,2023-11-30,Auto_Adjudicated,30,1639236553,1330485436,207RC0000X,Cardiovascular Disease,23,In_Network,OTHER,OTHER,97012,,0,Medicare_Advantage,PFFS,23,F,1.0279,5,Timely_Filing,1880.77,1050.05,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0575,none,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,Capitation
CLM0000000574,MBR00000191,Medical_Professional,Paid,Paper,2023-02-08,2023-02-08,2023-02-08,2023-02-11,Manual_Review,3,1076251878,1691162131,208600000X,Surgery General,23,In_Network,R05.9,Z00.01,80053,,0,Commercial,POS,85,F,0.9729,,,1769.5,1152.46,790.02,126.93,38.0,197.51,617.04,0.0,0.0,0,,0.1173,none,0,1,0,0,0,7.3e-05,0,0,,FFS
CLM0000000575,MBR00000238,Medical_Professional,Denied,Electronic_EDI,2023-10-23,2023-10-23,2023-10-23,2023-11-13,Auto_Adjudicated,21,1466478716,1469881892,207RN0300X,Nephrology,21,In_Network,OTHER,J06.9|K57.30|F33.0,99285,,0,Commercial,PPO,74,F,0.4382,96,Authorization,250.58,197.56,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1438,none,0,1,0,0,0,0.0,0,0,ACR_Urine_Protein,Capitation
CLM0000000576,MBR00000235,Medical_Institutional,Paid,Electronic_EDI,2023-10-19,2023-10-19,2023-10-21,2023-11-08,Auto_Adjudicated,20,1728728765,1884259357,246ZN0300X,Neuropsychology,81,In_Network,F41.1,,revenue_code:0200,,0,Commercial,HDHP_HSA,85,F,1.4308,,,18300.84,11865.59,9032.65,574.78,0.0,2258.16,6435.25,0.0,0.0,0,,0.0674,none,0,1,1,0,0,0.000836,0,0,,FFS
CLM0000000577,MBR00000197,Medical_Institutional,Denied,Electronic_EDI,2023-08-20,2023-08-20,2023-08-22,2023-08-25,Auto_Adjudicated,5,1272115456,1666461892,207V00000X,Obstetrics & Gynecology,11,In_Network,OTHER,,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,59,M,1.1414,CO-45,Coding_Error,19783.13,11745.44,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0549,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000578,MBR00000271,Medical_Professional,Denied,Electronic_EDI,2023-08-04,2023-08-04,2023-08-04,2023-08-28,Auto_Adjudicated,24,1485543430,1688513262,207RG0100X,Gastroenterology,11,In_Network,OTHER,I10|F33.0,12001,,0,Medicaid_MCO,MCO,4,F,0.6696,97,Coding_Error,954.97,418.22,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0888,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000579,MBR00000250,Medical_Professional,Paid,Electronic_EDI,2023-10-25,2023-10-25,2023-10-25,2023-11-08,Auto_Adjudicated,14,1181941909,1672803287,246ZN0300X,Neuropsychology,21,In_Network,Z00.00,,99212,,0,Commercial,PPO,41,M,0.9245,,,286.98,123.03,0.0,123.03,0.0,0.0,163.95,0.0,0.0,0,,0.1144,none,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000000580,MBR00000041,Pharmacy,Paid,Electronic_EDI,2023-11-02,2023-11-02,2023-11-02,2023-11-09,Auto_Adjudicated,7,1470105939,1510751265,207RE0101X,Endocrinology,24,In_Network,J06.9,J06.9|I10,50458085930,,5,Commercial,PPO,42,F,0.8283,,,477.13,312.84,0.0,308.18,4.66,0.0,164.29,0.0,0.0,0,,0.1316,geographic_mismatch,0,1,0,0,0,0.0,0,0,COA_Care_Transitions,FFS
CLM0000000581,MBR00000290,Medical_Professional,Paid,Electronic_EDI,2023-09-11,2023-09-11,2023-09-11,2023-09-28,Manual_Review,17,1117755591,1827839595,207RG0100X,Gastroenterology,11,In_Network,E11.65,F33.0|OTHER,10060,,0,Commercial,PPO,9,M,0.5261,,,400.97,211.48,78.28,74.63,39.0,19.57,189.49,64.02,12.63,0,,0.0944,billing_spike_recent,0,1,0,0,0,7e-06,0,0,,Shared_Savings
CLM0000000582,MBR00000270,Pharmacy,Paid,Electronic_EDI,2023-03-03,2023-03-03,2023-03-03,2023-03-31,Auto_Adjudicated,28,1667149552,1133410177,207RN0300X,Nephrology,21,In_Network,E11.9,M25.511|I10,00310075090,,2,Commercial,POS,1,F,1.6363,,,67.95,29.08,0.0,29.08,0.0,0.0,38.87,0.0,0.0,0,,0.1424,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000583,MBR00000102,Medical_Professional,Denied,Paper,2023-08-27,2023-08-27,2023-08-27,2023-09-03,Auto_Adjudicated,7,1424104563,1587454801,246ZN0300X,Neuropsychology,22,In_Network,Z23,,71046,,0,Commercial,POS,68,M,1.6864,PR-1,Network,789.35,433.5,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2939,unusual_service_frequency|duplicate_claim_indicator|high_oop_waiver,0,2,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000584,MBR00000006,Dental,Paid,Paper,2023-03-14,2023-03-14,2023-03-14,2023-04-02,Clinical_Review,19,1719850506,1354959095,207RP1001X,Pulmonary Disease,23,In_Network,Z79.4,,D3310,,0,Commercial,EPO,88,M,1.4365,,,277.38,199.14,130.45,3.07,33.0,32.61,78.24,0.0,0.0,0,,0.1951,temporal_clustering,0,1,0,0,0,1.2e-05,0,0,W30_Well_Child_Visit,FFS
CLM0000000585,MBR00000182,Medical_Institutional,Paid,Electronic_EDI,2023-01-17,2023-01-17,2023-01-21,2023-02-08,Auto_Adjudicated,22,1369267360,1447186817,207RC0000X,Cardiovascular Disease,11,In_Network,J20.9,I10,revenue_code:0300,,0,Commercial,HMO,82,F,0.8489,,,62917.65,24470.61,19433.24,145.06,34.0,4858.31,38447.04,0.0,0.0,0,,0.1824,outlier_billing_amount,0,1,1,0,0,0.001799,0,0,,Shared_Savings
CLM0000000586,MBR00000137,Medical_Institutional,Paid,Electronic_EDI,2023-02-24,2023-02-24,2023-02-27,2023-03-15,Auto_Adjudicated,19,1629674542,1388050552,207Q00000X,Family Medicine,23,In_Network,OTHER,F32.9,revenue_code:0100,,0,Commercial,PPO,87,M,0.5201,,,7373.28,3071.06,2398.49,12.95,60.0,599.62,4302.22,1458.03,794.92,0,,0.0477,none,0,1,0,0,0,0.000222,0,0,AMR_Asthma_Medication_Ratio,Bundled_Payment
CLM0000000587,MBR00000220,Medical_Professional,Paid,Electronic_EDI,2023-06-15,2023-06-15,2023-06-15,2023-07-05,Auto_Adjudicated,20,1059948944,1415734567,207RP1001X,Pulmonary Disease,21,In_Network,E78.5,Z00.00|M54.5,99212,,0,Commercial,HMO,38,M,0.7736,,,452.12,290.56,49.67,193.47,35.0,12.42,161.56,0.0,0.0,0,,0.0384,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000000588,MBR00000160,Medical_Professional,Paid,Electronic_EDI,2023-12-12,2023-12-12,2023-12-12,2024-01-03,Manual_Review,22,1102040918,1312595355,207RN0300X,Nephrology,21,In_Network,OTHER,Z00.01,99205,,0,Commercial,HMO,73,M,1.9608,,,341.66,213.61,48.4,130.11,23.0,12.1,128.05,0.0,0.0,0,,0.1811,upcoding_pattern,0,1,0,1,0,4e-06,0,0,,P4P
CLM0000000589,MBR00000024,Pharmacy,Paid,Electronic_EDI,2023-01-13,2023-01-13,2023-01-13,2023-01-21,Auto_Adjudicated,8,1881358103,1581533104,2084P0800X,Psychiatry,11,In_Network,M54.5,J20.9,00071012831,,4,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,55.33,23.64,20.64,0.0,3.0,0.0,31.69,0.0,0.0,0,,0.1492,none,0,1,0,0,0,2e-06,0,0,TRC_Transition_of_Care,FFS
CLM0000000590,MBR00000076,Medical_Institutional,Paid,Paper,2023-01-27,2023-01-27,2023-01-27,2023-01-31,Auto_Adjudicated,4,1064567615,1433350836,208600000X,Surgery General,81,In_Network,OTHER,,revenue_code:0370,,0,Commercial,HMO,26,M,2.1785,,,19135.18,12453.04,9902.77,34.57,40.0,2475.69,6682.14,0.0,0.0,0,,0.0624,none,0,1,1,0,0,0.000917,0,0,,Capitation
CLM0000000591,MBR00000266,Pharmacy,Paid,Electronic_EDI,2023-02-03,2023-02-03,2023-02-03,2023-03-05,Auto_Adjudicated,30,1853233709,1005335812,207RN0300X,Nephrology,23,In_Network,E78.5,Z00.00,00006001954,,2,Commercial,EPO,14,M,1.075,,,100.65,67.05,0.0,51.0,16.05,0.0,33.6,0.0,0.0,0,,0.0494,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000000592,MBR00000012,Medical_Institutional,Denied,Electronic_EDI,2023-03-10,2023-03-10,2023-03-12,2023-03-20,Auto_Adjudicated,10,1082088479,1005335812,2084P0800X,Psychiatry,11,In_Network,M17.11,E11.9,revenue_code:0200,,0,Commercial,HMO,84,M,1.3904,PR-1,Duplicate,97516.61,38176.63,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0849,outlier_billing_amount,0,1,0,0,0,0.0,0,0,COL_Colorectal_Cancer_Screening,P4P
CLM0000000593,MBR00000215,Medical_Institutional,Paid,Electronic_EDI,2023-07-14,2023-07-14,2023-07-16,2023-08-12,Auto_Adjudicated,29,1207676414,1589482133,207V00000X,Obstetrics & Gynecology,21,In_Network,OTHER,Z00.00,revenue_code:0250,682,0,ACA_Marketplace,ACA_Silver,69,M,0.8895,,,5514.55,3930.96,2386.17,448.15,74.0,1022.64,1583.59,0.0,0.0,0,,0.1737,provider_specialty_mismatch,0,1,0,0,0,0.000221,0,0,,Capitation
CLM0000000594,MBR00000091,Dental,Paid,Electronic_EDI,2023-10-22,2023-10-22,2023-10-22,2023-10-31,Auto_Adjudicated,9,1415701059,1690197969,2086S0122X,Orthopedic Surgery,11,In_Network,E78.5,,D7140,,0,Commercial,PPO,13,F,1.2451,,,192.42,78.18,0.0,78.18,0.0,0.0,114.24,0.0,0.0,0,,0.1061,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000595,MBR00000140,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-01-18,2023-01-18,2023-01-22,2023-01-26,Manual_Review,8,1617928396,1649705287,207Q00000X,Family Medicine,22,In_Network,OTHER,N39.0,revenue_code:0300,,0,Medicare_Advantage,MA_HMO,7,M,1.3997,3,Medical_Necessity,1574.51,1148.14,565.5,16.16,55.0,141.38,796.47,0.0,0.0,0,,0.134,none,0,1,0,0,0,5.2e-05,0,0,DAE_Drug_Alcohol_Dependence,Shared_Savings
CLM0000000596,MBR00000161,Dental,Paid,Electronic_EDI,2023-10-16,2023-10-16,2023-10-16,2023-10-17,Auto_Adjudicated,1,1263063839,1741177636,207RG0100X,Gastroenterology,23,In_Network,M17.11,J06.9|Z00.01,D2391,,0,Medicaid_MCO,MLTSS,9,F,0.8354,,,211.43,99.55,95.55,0.0,4.0,0.0,111.88,0.0,0.0,0,,0.1292,impossible_service_combo,0,1,0,0,0,9e-06,0,0,,Shared_Savings
CLM0000000597,MBR00000077,Medical_Professional,Denied,Electronic_EDI,2023-11-24,2023-11-24,2023-11-24,2023-12-08,Manual_Review,14,1034110592,1738617370,207V00000X,Obstetrics & Gynecology,11,Out_of_Network,Z23,,47562,,0,Medicare_Advantage,MA_HMO,27,F,0.9229,96,Timely_Filing,1026.05,474.74,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1088,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000598,MBR00000194,Medical_Professional,Paid,Electronic_EDI,2023-01-29,2023-01-29,2023-01-29,2023-02-27,Auto_Adjudicated,29,1323379997,1860951128,207RE0101X,Endocrinology,65,Out_of_Network,G47.33,,33510,,0,Commercial,PPO,77,M,0.9783,,,299.77,205.35,74.26,94.52,18.0,18.57,94.42,0.0,0.0,0,,0.0999,none,0,1,0,0,0,7e-06,1,0,,FFS
CLM0000000599,MBR00000206,Pharmacy,Paid,Electronic_EDI,2023-06-11,2023-06-11,2023-06-11,2023-07-08,Manual_Review,27,1375680589,1884259357,207RN0300X,Nephrology,21,In_Network,E11.9,J06.9|Z00.00,00078043215,,4,Medicaid_MCO,MLTSS,21,M,1.4038,,,256.09,174.43,173.43,0.0,1.0,0.0,81.66,0.0,0.0,0,,0.0165,none,0,1,0,0,0,1.6e-05,0,0,,FFS
CLM0000000600,MBR00000026,Medical_Professional,Paid,Electronic_EDI,2023-10-20,2023-10-20,2023-10-20,2023-10-30,Auto_Adjudicated,10,1014995735,1402472115,207R00000X,Internal Medicine,11,In_Network,G47.33,OTHER|J06.9,12001,,0,Medicaid_MCO,MCO,17,M,1.0686,,,739.35,358.6,357.6,0.0,1.0,0.0,380.75,0.0,0.0,0,,0.0926,service_date_weekend,0,1,0,0,0,3.3e-05,0,0,,Bundled_Payment
CLM0000000601,MBR00000118,Medical_Professional,Paid,Electronic_EDI,2023-09-09,2023-09-09,2023-09-09,2023-09-22,Auto_Adjudicated,13,1593056613,1662516615,207RE0101X,Endocrinology,11,In_Network,I10,,73721,,0,Medicaid_MCO,MCO,69,M,1.2773,,,311.76,259.63,258.63,0.0,1.0,0.0,52.13,0.0,0.0,0,,0.1732,upcoding_pattern,0,1,0,0,0,2.4e-05,0,0,AWV_Annual_Wellness_Visit,Shared_Savings
CLM0000000602,MBR00000218,Medical_Professional,Paid,Electronic_EDI,2023-03-08,2023-03-08,2023-03-08,2023-03-29,Auto_Adjudicated,21,1475070784,1581533104,207RE0101X,Endocrinology,11,In_Network,C50.911,,99284,,0,Commercial,HDHP_HSA,11,F,0.4964,,,254.24,138.35,0.0,138.35,0.0,0.0,115.89,0.0,0.0,0,,0.1462,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000603,MBR00000212,Medical_Institutional,Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-26,2023-03-24,Manual_Review,29,1630305772,1589482133,207RP1001X,Pulmonary Disease,31,In_Network,N18.3,G47.33|C50.911,revenue_code:0370,,0,Commercial,HMO,57,F,2.5456,,,4811.06,2657.96,1806.81,331.45,68.0,451.7,2153.1,0.0,0.0,0,,0.0753,none,0,1,0,0,0,0.000167,0,0,,FFS
CLM0000000604,MBR00000166,Medical_Institutional,Paid,Electronic_EDI,2023-06-10,2023-06-10,2023-06-10,2023-06-29,Auto_Adjudicated,19,1388566092,1402472115,101YP2500X,Psychologist Clinical,22,In_Network,I10,J20.9,revenue_code:0200,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,24321.58,10952.23,7414.75,292.73,67.0,3177.75,13369.35,0.0,0.0,0,,0.1307,none,0,1,1,0,0,0.000686,0,0,MMA_Medication_Management,Bundled_Payment
CLM0000000605,MBR00000229,Medical_Professional,Paid,Electronic_EDI,2023-11-01,2023-11-01,2023-11-01,2023-11-08,Manual_Review,7,1658382624,1061149198,246ZN0300X,Neuropsychology,24,In_Network,Z00.01,J44.1,74178,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,172.4,65.35,10.68,38.0,14.0,2.67,107.05,0.0,0.0,0,,0.1066,none,0,1,0,1,0,1e-06,0,0,,Bundled_Payment
CLM0000000606,MBR00000033,Medical_Professional,Denied,Electronic_EDI,2023-12-07,2023-12-07,2023-12-07,2023-12-18,Clinical_Review,11,1393200616,1339359594,207RC0000X,Cardiovascular Disease,11,Out_of_Network,N18.3,,99203,,0,Medicare_Advantage,PFFS,31,F,0.821,97,Timely_Filing,390.08,296.32,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0624,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,1,0,,FFS
CLM0000000607,MBR00000036,Medical_Professional,Paid,Electronic_EDI,2023-06-21,2023-06-21,2023-06-21,2023-07-13,Auto_Adjudicated,22,1995916350,1930040953,207Q00000X,Family Medicine,21,In_Network,I10,K21.0|Z23,74177,,0,Commercial,EPO,17,M,2.0136,,,372.35,192.61,93.99,42.12,33.0,23.5,179.74,0.0,0.0,0,,0.0895,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000000608,MBR00000196,Medical_Professional,Paid,Electronic_EDI,2023-07-10,2023-07-10,2023-07-10,2023-07-11,Auto_Adjudicated,1,1164721841,1356856197,207RN0300X,Nephrology,21,Emergency,F33.0,,90847,,0,Commercial,PPO,16,F,1.6015,,,669.66,398.55,223.58,96.08,23.0,55.89,271.11,0.0,0.0,0,,0.153,high_volume_same_code,0,1,0,0,0,2.1e-05,0,0,,P4P
CLM0000000609,MBR00000206,Medical_Professional,Paid,Electronic_EDI,2023-07-20,2023-07-20,2023-07-20,2023-08-07,Auto_Adjudicated,18,1734752728,1151295616,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,M54.5,99212,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,340.6,252.74,251.74,0.0,1.0,0.0,87.86,0.0,0.0,0,,0.0384,none,0,1,0,0,0,2.3e-05,0,0,TRC_Transition_of_Care,P4P
CLM0000000610,MBR00000242,Medical_Professional,Denied,Electronic_EDI,2023-06-25,2023-06-25,2023-06-25,2023-07-19,Auto_Adjudicated,24,1896279539,1408846353,2084P0800X,Psychiatry,11,Emergency,I10,Z00.00|J06.9,81001,,0,Medicaid_MCO,MLTSS,75,F,0.7104,PR-1,Medical_Necessity,1740.94,702.69,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Code Substitution,1.0,outlier_billing_amount|temporal_clustering|high_volume_same_code|impossible_service_combo|service_date_weekend|billing_spike_recent|upcoding_pattern|unbundling_pattern|npi_mismatch,1,5,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000611,MBR00000056,Pharmacy,Paid,Paper,2023-08-21,2023-08-21,2023-08-21,2023-09-01,Auto_Adjudicated,11,1172766349,1175334579,225100000X,Physical Therapist,11,In_Network,F32.9,F32.9,59148001506,,1,Commercial,EPO,74,F,1.3941,,,121.46,80.05,0.0,80.05,0.0,0.0,41.41,0.0,0.0,0,,0.1485,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000612,MBR00000158,Pharmacy,Paid,Electronic_EDI,2023-04-09,2023-04-09,2023-04-09,2023-04-26,Auto_Adjudicated,17,1944105498,1842149518,207RC0000X,Cardiovascular Disease,81,In_Network,OTHER,,00006001954,,4,Commercial,HMO,65,M,1.5361,,,56.76,30.18,0.0,30.18,0.0,0.0,26.58,0.0,0.0,0,,0.0075,none,0,1,0,0,0,0.0,0,1,,Capitation
CLM0000000613,MBR00000196,Medical_Professional,Partially_Paid,Electronic_EDI,2023-07-13,2023-07-13,2023-07-13,2023-08-04,Auto_Adjudicated,22,1770738194,1764064254,207R00000X,Internal Medicine,23,In_Network,OTHER,,97010,,0,Commercial,PPO,16,F,1.6015,3,Medical_Necessity,2824.71,2168.36,1081.34,119.81,23.0,270.33,1330.23,0.0,0.0,0,,0.0495,none,0,1,0,0,0,0.0001,0,0,,FFS
CLM0000000614,MBR00000070,Medical_Professional,Paid,Electronic_EDI,2023-08-09,2023-08-09,2023-08-09,2023-08-27,Auto_Adjudicated,18,1402424417,1133410177,2086S0122X,Orthopedic Surgery,11,In_Network,Z00.00,I10|OTHER,33510,,0,Commercial,POS,42,F,0.8468,,,800.44,435.87,211.28,156.77,15.0,52.82,364.57,0.0,0.0,0,,0.113,none,0,1,0,0,0,2e-05,0,0,,P4P
CLM0000000615,MBR00000158,Medical_Professional,Paid,Electronic_EDI,2023-07-22,2023-07-22,2023-07-22,2023-07-23,Manual_Review,1,1218294278,1012893364,207RN0300X,Nephrology,24,In_Network,OTHER,Z00.00|E11.9,99203,,0,Commercial,HMO,65,M,1.5361,,,291.46,241.0,0.0,241.0,0.0,0.0,50.46,0.0,0.0,0,,0.0273,none,0,1,0,0,0,0.0,0,0,TRC_Transition_of_Care,Shared_Savings
CLM0000000616,MBR00000189,Medical_Professional,Paid,Electronic_EDI,2023-12-16,2023-12-16,2023-12-16,2024-01-03,Auto_Adjudicated,18,1618546650,1804282800,207RE0101X,Endocrinology,21,Emergency,E11.9,K57.30|OTHER|F32.9,99231,,0,Medicaid_MCO,MCO,71,F,0.9722,,,828.45,444.68,440.68,0.0,4.0,0.0,383.77,0.0,0.0,0,,0.0479,none,0,1,0,0,0,4.1e-05,0,0,,FFS
CLM0000000617,MBR00000065,Medical_Professional,Paid,Electronic_EDI,2023-09-25,2023-09-25,2023-09-25,2023-10-02,Auto_Adjudicated,7,1211612843,1419347445,207RP1001X,Pulmonary Disease,24,In_Network,I48.91,J44.1|E78.5,90847,,0,Commercial,HDHP_HSA,63,M,0.7795,,,247.65,90.58,0.0,90.58,0.0,0.0,157.07,0.0,0.0,0,,0.1203,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000618,MBR00000119,Dental,Paid,Electronic_EDI,2023-09-21,2023-09-21,2023-09-21,2023-10-14,Auto_Adjudicated,23,1718336220,1581533104,207RN0300X,Nephrology,71,In_Network,J06.9,OTHER,D1110,,0,Commercial,POS,42,M,0.4987,,,319.45,199.22,0.0,199.22,0.0,0.0,120.23,0.0,0.0,0,,0.2495,unusual_service_frequency|provider_specialty_mismatch,0,2,0,1,0,0.0,0,0,,FFS
CLM0000000619,MBR00000066,Pharmacy,Paid,Electronic_EDI,2023-10-17,2023-10-17,2023-10-17,2023-10-25,Auto_Adjudicated,8,1078527460,1865266296,207V00000X,Obstetrics & Gynecology,11,In_Network,E11.9,M79.3|I10,59148001506,,2,Medicaid_MCO,MCO,54,M,0.6083,,,71.54,29.67,26.67,0.0,3.0,0.0,41.87,0.0,0.0,0,,0.0841,none,0,1,0,0,0,2e-06,0,1,,P4P
CLM0000000620,MBR00000274,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-07-09,2023-07-09,2023-07-09,2023-08-08,Auto_Adjudicated,30,1086690796,1325999602,207V00000X,Obstetrics & Gynecology,81,In_Network,F32.9,H52.4,revenue_code:0200,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,50,Medical_Necessity,10240.68,4296.79,1724.72,13.27,46.0,431.18,8025.5,0.0,0.0,0,,0.1373,none,0,1,0,0,0,0.00016,0,0,,FFS
CLM0000000621,MBR00000075,Medical_Professional,Paid,Electronic_EDI,2023-04-20,2023-04-20,2023-04-20,2023-04-24,Manual_Review,4,1216417633,1896197144,207RN0300X,Nephrology,11,In_Network,I10,I10|Z23,90834,,0,Medicaid_MCO,MCO,5,M,1.0573,,,227.85,134.65,130.65,0.0,4.0,0.0,93.2,98.19,22.08,0,,0.0353,none,0,1,0,0,0,1.2e-05,0,0,DAE_Drug_Alcohol_Dependence,Shared_Savings
CLM0000000622,MBR00000037,Pharmacy,Paid,Electronic_EDI,2023-07-12,2023-07-12,2023-07-12,2023-08-08,Auto_Adjudicated,27,1808451151,1791502603,101YP2500X,Psychologist Clinical,11,In_Network,Z23,F41.1,00078043215,,1,Medicaid_MCO,MLTSS,11,M,1.043,,,183.68,90.68,89.68,0.0,1.0,0.0,93.0,0.0,0.0,0,,0.0875,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000000623,MBR00000011,Vision,Paid,Electronic_EDI,2023-11-28,2023-11-28,2023-11-28,2023-11-30,Auto_Adjudicated,2,1208538971,1880530717,207RP1001X,Pulmonary Disease,23,In_Network,Z12.11,F10.10,V2320,,0,Medicare_Advantage,SNP,35,F,1.0833,,,273.53,170.02,120.14,2.84,17.0,30.04,103.51,0.0,0.0,0,,0.0716,high_oop_waiver,0,1,0,0,0,1.1e-05,0,0,,P4P
CLM0000000624,MBR00000013,Medical_Professional,Paid,Electronic_EDI,2023-11-12,2023-11-12,2023-11-12,2023-12-03,Auto_Adjudicated,21,1324142620,1746676564,207RN0300X,Nephrology,23,In_Network,OTHER,,17000,,0,Commercial,PPO,64,F,1.428,,,607.11,412.63,72.99,308.4,13.0,18.25,194.48,0.0,0.0,0,,0.2264,unusual_service_frequency|controlled_substance_high_volume,0,2,0,0,0,7e-06,0,0,W30_Well_Child_Visit,FFS
CLM0000000625,MBR00000059,Pharmacy,Paid,Electronic_EDI,2023-05-08,2023-05-08,2023-05-08,2023-05-19,Auto_Adjudicated,11,1478783612,1358873132,207V00000X,Obstetrics & Gynecology,11,In_Network,J20.9,OTHER,00069420020,,1,Medicare_Advantage,SNP,12,F,1.266,,,27.88,22.3,4.2,1.04,16.0,1.05,5.58,0.0,0.0,0,,0.1085,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000000626,MBR00000184,Medical_Professional,Paid,Provider_Portal,2023-06-23,2023-06-23,2023-06-23,2023-06-29,Auto_Adjudicated,6,1196858674,1469881892,2086S0122X,Orthopedic Surgery,11,In_Network,M47.816,Z12.11,90834,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,1065.76,526.18,524.18,0.0,2.0,0.0,539.58,0.0,0.0,0,,0.1382,none,0,1,0,0,0,4.9e-05,0,0,FLU_Flu_Vaccination,FFS
CLM0000000627,MBR00000006,Pharmacy,Paid,Electronic_EDI,2023-04-08,2023-04-08,2023-04-08,2023-04-15,Auto_Adjudicated,7,1389116733,1061113875,208600000X,Surgery General,11,In_Network,I10,I50.9,00169751112,,2,Commercial,EPO,88,M,1.4365,,,142.58,86.3,13.0,37.05,33.0,3.25,56.28,10.66,2.09,0,,0.1287,none,0,1,0,0,0,1e-06,0,0,IET_Initiation_Substance_Use,Capitation
CLM0000000628,MBR00000090,Medical_Professional,Paid,Electronic_EDI,2023-01-05,2023-01-05,2023-01-05,2023-01-07,Auto_Adjudicated,2,1485543430,1930040953,2084P0800X,Psychiatry,21,In_Network,OTHER,I50.9,90837,,0,Medicare_Advantage,MA_HMO,49,F,0.4351,,,3923.83,2866.81,2264.98,20.59,15.0,566.24,1057.02,0.0,0.0,0,,0.1356,none,0,1,0,0,0,0.00021,0,0,,Bundled_Payment
CLM0000000629,MBR00000016,Medical_Institutional,Paid,Electronic_EDI,2023-04-22,2023-04-22,2023-04-23,2023-04-26,Manual_Review,4,1593056613,1105871325,207R00000X,Internal Medicine,21,In_Network,F41.1,I10|M79.3,revenue_code:0200,291,0,Commercial,HDHP_HSA,20,F,0.5843,,,7453.75,4780.64,3480.09,430.53,0.0,870.02,2673.11,0.0,0.0,0,,0.1347,none,0,1,0,1,0,0.000322,0,0,,Shared_Savings
CLM0000000630,MBR00000128,Medical_Professional,Paid,Electronic_EDI,2023-02-06,2023-02-06,2023-02-06,2023-02-18,Auto_Adjudicated,12,1007266616,1622950074,207RE0101X,Endocrinology,11,In_Network,Z00.00,OTHER|E11.65,90837,,0,Commercial,PPO,13,F,1.4203,,,399.93,212.18,14.56,180.98,13.0,3.64,187.75,0.0,0.0,0,,0.0993,none,0,1,0,0,0,1e-06,0,0,KED_ESRD_Patients,Shared_Savings
CLM0000000631,MBR00000014,Medical_Institutional,Paid,Electronic_EDI,2023-05-09,2023-05-09,2023-05-11,2023-05-14,Auto_Adjudicated,5,1510562885,1874728994,207V00000X,Obstetrics & Gynecology,81,In_Network,N18.3,F41.1,revenue_code:0210,,0,Commercial,HMO,77,M,2.8513,,,13180.53,5180.8,3766.65,437.49,35.0,941.66,7999.73,0.0,0.0,0,,0.1358,none,0,1,0,0,0,0.000349,0,0,,Shared_Savings
CLM0000000632,MBR00000183,Medical_Institutional,Paid,Electronic_EDI,2023-01-20,2023-01-20,2023-01-20,2023-02-19,Auto_Adjudicated,30,1958171947,1622950074,207R00000X,Internal Medicine,24,In_Network,M54.5,R05.9|OTHER,revenue_code:0110,,0,Commercial,PPO,51,M,0.8463,,,3756.86,1671.82,1109.14,228.39,57.0,277.29,2085.04,0.0,0.0,0,,0.0656,none,0,1,0,0,0,0.000103,0,0,,Capitation
CLM0000000633,MBR00000205,Medical_Institutional,Denied,Electronic_EDI,2023-04-24,2023-04-24,2023-04-27,2023-05-19,Auto_Adjudicated,25,1478783612,1339359594,207RC0000X,Cardiovascular Disease,81,In_Network,M54.5,E11.9,revenue_code:0110,,0,Medicaid_MCO,MCO,1,F,0.9425,50,Authorization,34386.72,12668.74,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0782,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000634,MBR00000214,Pharmacy,Partially_Paid,Provider_Portal,2023-09-14,2023-09-14,2023-09-14,2023-09-29,Auto_Adjudicated,15,1534538584,1368666316,207V00000X,Obstetrics & Gynecology,11,In_Network,M54.5,I10,00071015523,,2,Commercial,HDHP_HSA,76,M,1.7526,1,Medical_Necessity,81.59,53.63,3.73,27.11,0.0,0.93,49.82,0.0,0.0,0,,0.1443,none,0,1,0,0,0,0.0,0,1,,Bundled_Payment
CLM0000000635,MBR00000070,Medical_Professional,Paid,Electronic_EDI,2023-10-30,2023-10-30,2023-10-30,2023-11-02,Manual_Review,3,1170257806,1930040953,101YP2500X,Psychologist Clinical,11,In_Network,K21.0,R05.9|Z00.00|OTHER,99386,,0,Commercial,POS,42,F,0.8468,,,180.24,108.68,32.14,53.5,15.0,8.04,71.56,0.0,0.0,0,,0.0228,none,0,1,0,0,0,3e-06,0,0,DAE_Drug_Alcohol_Dependence,Shared_Savings
CLM0000000636,MBR00000262,Pharmacy,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-12-15,Auto_Adjudicated,30,1470105939,1884259357,207RC0000X,Cardiovascular Disease,22,In_Network,E78.5,,59148001506,,1,Medicare_Advantage,PFFS,77,F,1.7452,,,338.5,169.16,131.95,0.23,4.0,32.99,169.34,0.0,0.0,0,,0.0628,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000000637,MBR00000206,Medical_Professional,Denied,Electronic_EDI,2023-07-21,2023-07-21,2023-07-21,2023-08-12,Auto_Adjudicated,22,1380824221,1177602659,207R00000X,Internal Medicine,22,In_Network,OTHER,M54.5|Z00.01,99204,,0,Medicaid_MCO,MLTSS,21,M,1.4038,170,Network,311.29,256.76,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0804,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000638,MBR00000016,Pharmacy,Paid,Electronic_EDI,2023-07-16,2023-07-16,2023-07-16,2023-07-22,Auto_Adjudicated,6,1462532026,1433350836,2084P0800X,Psychiatry,23,In_Network,I10,,59148001506,,1,Commercial,HDHP_HSA,20,F,0.5843,,,546.25,328.05,114.37,185.09,0.0,28.59,218.2,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|geographic_mismatch|high_volume_same_code|impossible_service_combo|service_date_weekend|upcoding_pattern|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,1.1e-05,0,1,,FFS
CLM0000000639,MBR00000138,Medical_Professional,Paid,Electronic_EDI,2023-12-14,2023-12-14,2023-12-14,2023-12-16,Auto_Adjudicated,2,1130461876,1672803287,207R00000X,Internal Medicine,11,Out_of_Network,I10,OTHER|E11.9,71250,,0,Commercial,HDHP_HSA,47,M,0.996,,,1282.92,1083.96,549.58,396.98,0.0,137.4,198.96,0.0,0.0,0,,0.0456,none,0,1,0,0,0,5.1e-05,1,0,DAE_Drug_Alcohol_Dependence,P4P
CLM0000000640,MBR00000226,Medical_Institutional,Paid,Electronic_EDI,2023-07-19,2023-07-19,2023-07-19,2023-08-07,Auto_Adjudicated,19,1321381114,1747935894,225100000X,Physical Therapist,31,In_Network,Z00.01,Z23|OTHER,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,84,M,1.0796,,,11437.4,6106.07,4855.99,0.08,36.0,1214.0,5331.33,3208.33,1322.07,1,Date of Service Falsification,0.9693,unusual_service_frequency|geographic_mismatch|benford_violation|impossible_service_combo|billing_spike_recent|upcoding_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.000449,0,0,,FFS
CLM0000000641,MBR00000099,Medical_Professional,Paid,Electronic_EDI,2023-01-31,2023-01-31,2023-01-31,2023-02-02,Auto_Adjudicated,2,1331903993,1209882852,207RN0300X,Nephrology,22,In_Network,Z23,E78.5,90837,,0,Commercial,HMO,10,F,0.7843,,,841.97,556.69,311.39,152.45,15.0,77.85,285.28,0.0,0.0,0,,0.197,geographic_mismatch,0,1,0,0,0,2.9e-05,0,0,,Bundled_Payment
CLM0000000642,MBR00000121,Vision,Paid,Electronic_EDI,2023-12-02,2023-12-02,2023-12-02,2023-12-21,Auto_Adjudicated,19,1855186422,1887266184,207R00000X,Internal Medicine,21,In_Network,Z00.01,,V2100,,0,Medicare_Advantage,MA_PPO,58,M,1.226,,,251.48,127.0,85.75,1.81,18.0,21.44,124.48,0.0,0.0,0,,0.0107,none,0,1,0,0,0,8e-06,0,0,TRC_Transition_of_Care,FFS
CLM0000000643,MBR00000187,Medical_Institutional,Paid,Electronic_EDI,2023-08-09,2023-08-09,2023-08-09,2023-08-23,Auto_Adjudicated,14,1061181028,1666461892,207R00000X,Internal Medicine,22,In_Network,Z00.00,,revenue_code:0250,,0,Medicaid_MCO,MCO,36,F,1.191,,,9675.95,7896.36,7889.36,0.0,7.0,0.0,1779.59,7042.54,702.79,0,,0.1455,none,0,1,1,0,0,0.00073,0,0,,FFS
CLM0000000644,MBR00000015,Medical_Professional,Paid,Paper,2023-08-28,2023-08-28,2023-08-28,2023-09-24,Auto_Adjudicated,27,1756856314,1164525386,207V00000X,Obstetrics & Gynecology,11,In_Network,M54.5,,47562,,0,Medicaid_MCO,MCO,43,F,0.3775,,,1395.34,667.46,663.46,0.0,4.0,0.0,727.88,0.0,0.0,1,Prescription Drug Diversion,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|benford_violation|impossible_service_combo|billing_spike_recent|duplicate_claim_indicator|unbundling_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,6.1e-05,0,0,,FFS
CLM0000000645,MBR00000293,Pharmacy,Paid,Paper,2023-02-04,2023-02-04,2023-02-04,2023-02-16,Auto_Adjudicated,12,1617763056,1842149518,208600000X,Surgery General,11,In_Network,OTHER,Z79.4|OTHER,00078043215,,3,Medicare_Advantage,MA_HMO,84,F,2.8513,,,44.42,19.91,0.0,19.91,0.0,0.0,24.51,0.0,0.0,0,,0.0654,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000646,MBR00000055,Medical_Professional,Paid,Electronic_EDI,2023-06-18,2023-06-18,2023-06-18,2023-07-02,Auto_Adjudicated,14,1007414142,1705448933,207RG0100X,Gastroenterology,81,In_Network,Z00.00,J44.1,99223,,0,Commercial,PPO,68,F,1.2896,,,236.26,157.92,39.84,98.13,10.0,9.96,78.34,0.0,0.0,0,,0.0424,none,0,1,0,0,0,4e-06,0,0,,Shared_Savings
CLM0000000647,MBR00000009,Medical_Professional,Paid,Electronic_EDI,2023-06-14,2023-06-14,2023-06-14,2023-07-01,Auto_Adjudicated,17,1466922283,1690197969,225100000X,Physical Therapist,22,In_Network,Z00.00,,43239,,0,Commercial,HMO,11,F,0.5327,,,795.11,407.72,217.65,100.66,35.0,54.41,387.39,0.0,0.0,0,,0.1309,none,0,1,0,0,0,2e-05,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000000648,MBR00000003,Medical_Professional,Paid,Electronic_EDI,2023-10-20,2023-10-20,2023-10-20,2023-11-19,Auto_Adjudicated,30,1482771601,1289435414,2084P0800X,Psychiatry,11,In_Network,I25.10,I10,99394,,0,Commercial,PPO,79,F,1.3879,,,306.1,240.59,164.0,10.59,25.0,41.0,65.51,0.0,0.0,0,,0.1059,impossible_service_combo,0,1,0,0,0,1.5e-05,0,0,,Shared_Savings
CLM0000000649,MBR00000128,Pharmacy,Denied,Paper,2023-05-18,2023-05-18,2023-05-18,2023-06-09,Auto_Adjudicated,22,1243052462,1325999602,207RN0300X,Nephrology,11,In_Network,F41.1,E78.5,00085163102,,2,Commercial,PPO,13,F,1.4203,PR-1,COB,155.97,64.07,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0034,none,0,1,0,1,0,0.0,0,0,IET_Initiation_Substance_Use,FFS
CLM0000000650,MBR00000268,Vision,Denied,Paper,2023-05-04,2023-05-04,2023-05-04,2023-05-25,Auto_Adjudicated,21,1667149552,1810068286,207RN0300X,Nephrology,11,In_Network,Z00.01,N39.0|M54.5,92002,,0,Medicaid_MCO,MCO,13,M,0.3526,96,Timely_Filing,934.78,355.82,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1297,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000651,MBR00000244,Vision,Paid,Electronic_EDI,2023-09-02,2023-09-02,2023-09-02,2023-09-12,Auto_Adjudicated,10,1897231867,1831337866,207RE0101X,Endocrinology,65,In_Network,OTHER,M17.11,V2115,,0,Commercial,PPO,52,M,0.6677,,,642.02,233.51,36.54,176.84,11.0,9.13,408.51,27.37,5.84,0,,0.1857,temporal_clustering,0,1,0,0,0,3e-06,0,0,,Bundled_Payment
CLM0000000652,MBR00000275,Medical_Professional,Paid,Electronic_EDI,2023-01-06,2023-01-06,2023-01-06,2023-01-21,Auto_Adjudicated,15,1205349488,1896197144,101YP2500X,Psychologist Clinical,24,In_Network,I50.9,J20.9|H52.4,99385,,0,Medicare_Advantage,MA_PPO,67,M,0.8169,,,153.61,77.06,30.33,24.14,15.0,7.58,76.55,0.0,0.0,0,,0.1156,none,0,1,0,0,0,3e-06,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000000653,MBR00000162,Medical_Professional,Denied,Electronic_EDI,2023-09-25,2023-09-25,2023-09-25,2023-10-01,Manual_Review,6,1039678579,1591405274,207RE0101X,Endocrinology,22,In_Network,F41.1,F33.0|M47.816,99283,,0,Medicaid_MCO,MLTSS,84,F,1.324,PR-1,COB,141.19,106.32,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1702,upcoding_pattern,0,1,0,0,0,0.0,0,0,TRC_Transition_of_Care,Bundled_Payment
CLM0000000654,MBR00000140,Pharmacy,Denied,Electronic_EDI,2023-01-03,2023-01-03,2023-01-03,2023-01-15,Auto_Adjudicated,12,1145498455,1894215172,207RC0000X,Cardiovascular Disease,71,In_Network,J20.9,,50458085930,,1,Medicare_Advantage,MA_HMO,7,M,1.3997,18,Medical_Necessity,519.97,421.74,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0402,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000655,MBR00000122,Medical_Professional,Denied,Provider_Portal,2023-03-27,2023-03-27,2023-03-27,2023-04-21,Auto_Adjudicated,25,1042080259,1098360555,207V00000X,Obstetrics & Gynecology,21,In_Network,OTHER,E11.9,73721,,0,Commercial,EPO,64,F,0.8625,97,Medical_Necessity,1370.23,1098.44,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0754,geographic_mismatch,0,1,0,0,0,0.0,0,0,SPD_Spirometry_Testing,FFS
CLM0000000656,MBR00000014,Medical_Institutional,Paid,Provider_Portal,2023-06-28,2023-06-28,2023-06-28,2023-07-01,Auto_Adjudicated,3,1317654726,1985590322,207V00000X,Obstetrics & Gynecology,32,In_Network,Z00.01,Z23,revenue_code:0210,,0,Commercial,HMO,77,M,2.8513,,,45444.18,37066.69,29615.15,12.75,35.0,7403.79,8377.49,0.0,0.0,0,,0.0713,none,0,1,1,0,0,0.002741,0,0,MPT_Annual_Monitoring,Bundled_Payment
CLM0000000657,MBR00000274,Behavioral_Health,Paid,Electronic_EDI,2023-03-11,2023-03-11,2023-03-11,2023-03-16,Clinical_Review,5,1393200616,1105733833,2086S0122X,Orthopedic Surgery,22,In_Network,OTHER,OTHER|M25.511|I10,84443,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,176.19,87.98,64.23,7.7,0.0,16.06,88.21,0.0,0.0,0,,0.0621,none,0,1,0,0,0,6e-06,0,0,,Bundled_Payment
CLM0000000658,MBR00000154,Medical_Professional,Paid,Electronic_EDI,2023-01-13,2023-01-13,2023-01-13,2023-01-31,Auto_Adjudicated,18,1707022770,1289435414,207R00000X,Internal Medicine,31,Out_of_Network,Z00.01,,99384,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,258.43,161.81,120.2,11.56,0.0,30.05,96.62,0.0,0.0,0,,0.0371,none,0,1,0,0,0,1.1e-05,1,0,,Shared_Savings
CLM0000000659,MBR00000142,Medical_Professional,Paid,Electronic_EDI,2023-05-31,2023-05-31,2023-05-31,2023-06-24,Manual_Review,24,1713741288,1553094822,207R00000X,Internal Medicine,65,In_Network,F32.9,Z00.00,12001,,0,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,187.2,98.33,0.0,98.33,0.0,0.0,88.87,0.0,0.0,0,,0.2141,benford_violation|high_oop_waiver,0,2,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000660,MBR00000158,Dental,Paid,Provider_Portal,2023-09-11,2023-09-11,2023-09-11,2023-10-11,Auto_Adjudicated,30,1496489953,1055872102,207RN0300X,Nephrology,22,In_Network,E78.5,R05.9,D3310,,0,Commercial,HMO,65,M,1.5361,,,381.57,268.19,194.47,11.1,14.0,48.62,113.38,0.0,0.0,0,,0.0968,none,0,1,0,0,0,1.8e-05,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000000661,MBR00000235,Medical_Institutional,Paid,Electronic_EDI,2023-03-28,2023-03-28,2023-03-28,2023-04-15,Auto_Adjudicated,18,1159640414,1267212691,207RC0000X,Cardiovascular Disease,11,In_Network,G47.33,K21.0,revenue_code:0200,,0,Commercial,HDHP_HSA,85,F,1.4308,,,6753.42,5432.37,3929.61,520.36,0.0,982.4,1321.05,0.0,0.0,0,,0.0589,none,0,1,0,0,0,0.000364,0,0,MPT_Annual_Monitoring,Shared_Savings
CLM0000000662,MBR00000070,Vision,Paid,Electronic_EDI,2023-04-09,2023-04-09,2023-04-09,2023-04-29,Auto_Adjudicated,20,1906448800,1325999602,207RN0300X,Nephrology,11,In_Network,OTHER,,V2103,,0,Commercial,POS,42,F,0.8468,,,189.51,81.95,15.6,47.45,15.0,3.9,107.56,0.0,0.0,0,,0.0861,none,0,1,0,0,0,1e-06,0,0,COA_Care_Transitions,FFS
CLM0000000663,MBR00000210,Medical_Institutional,Paid,Electronic_EDI,2023-08-31,2023-08-31,2023-09-02,2023-09-09,Auto_Adjudicated,9,1995916350,1123879500,246ZN0300X,Neuropsychology,11,Out_of_Network,F33.0,Z23,revenue_code:0300,,0,Medicare_Advantage,SNP,49,M,0.6952,,,27557.52,16283.19,12985.12,19.79,32.0,3246.28,11274.33,0.0,0.0,0,,0.0905,none,0,1,1,0,0,0.001202,1,0,,FFS
CLM0000000664,MBR00000211,Medical_Professional,Paid,Electronic_EDI,2023-12-07,2023-12-07,2023-12-07,2023-12-20,Clinical_Review,13,1865750966,1287472731,2084P0800X,Psychiatry,11,In_Network,E11.9,,99285,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,,,259.0,148.76,109.01,0.49,12.0,27.25,110.24,0.0,0.0,0,,0.169,service_date_weekend,0,1,0,0,0,1e-05,0,0,,Bundled_Payment
CLM0000000665,MBR00000255,Pharmacy,Paid,Electronic_EDI,2023-07-05,2023-07-05,2023-07-05,2023-07-15,Auto_Adjudicated,10,1594587354,1560230600,2084P0800X,Psychiatry,21,In_Network,OTHER,Z00.00,50458085930,,5,Medicare_Advantage,MA_HMO,21,M,0.6945,,,348.21,279.92,207.17,2.96,18.0,51.79,68.29,0.0,0.0,0,,0.068,none,0,1,0,0,0,1.9e-05,0,1,,FFS
CLM0000000666,MBR00000003,Pharmacy,Paid,Provider_Portal,2023-07-20,2023-07-20,2023-07-20,2023-07-24,Auto_Adjudicated,4,1813729693,1542515060,225100000X,Physical Therapist,22,In_Network,OTHER,Z12.11|I10,00006001954,,4,Commercial,PPO,79,F,1.3879,,,165.11,130.92,76.32,10.52,25.0,19.08,34.19,0.0,0.0,0,,0.1031,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000000667,MBR00000054,Vision,Denied,Electronic_EDI,2023-10-24,2023-10-24,2023-10-24,2023-11-05,Auto_Adjudicated,12,1639236553,1157814306,207RN0300X,Nephrology,11,In_Network,I10,Z00.00|Z12.11|OTHER,V2320,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,256,Medical_Necessity,368.29,287.49,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1174,npi_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000668,MBR00000144,Medical_Institutional,Paid,Electronic_EDI,2023-01-24,2023-01-24,2023-01-28,2023-01-31,Auto_Adjudicated,7,1373899620,1994275960,207RG0100X,Gastroenterology,65,In_Network,E78.5,OTHER,revenue_code:0120,,0,Commercial,HDHP_HSA,56,F,2.5926,,,3682.68,2662.52,1944.96,231.32,0.0,486.24,1020.16,0.0,0.0,0,,0.1359,none,0,1,0,0,0,0.00018,0,0,,Bundled_Payment
CLM0000000669,MBR00000256,Medical_Institutional,Paid,Paper,2023-12-19,2023-12-19,2023-12-23,2024-01-06,Auto_Adjudicated,18,1205744244,1767402068,207RC0000X,Cardiovascular Disease,11,In_Network,N39.0,,revenue_code:0210,,0,Commercial,HDHP_HSA,71,F,0.3642,,,4936.32,3991.1,2847.48,431.76,0.0,711.87,945.22,0.0,0.0,0,,0.0706,none,0,1,0,0,0,0.000264,0,0,CDC_HbA1c_Poor_Control,Shared_Savings
CLM0000000670,MBR00000292,Medical_Professional,Paid,Electronic_EDI,2023-06-20,2023-06-20,2023-06-20,2023-07-13,Manual_Review,23,1780111559,1112696614,207RN0300X,Nephrology,11,In_Network,K29.70,E11.9,99213,,0,Medicare_Advantage,MA_HMO,4,M,1.1779,,,351.24,298.02,227.67,10.43,3.0,56.92,53.22,0.0,0.0,0,,0.1366,none,0,1,0,1,0,2.1e-05,0,0,,Bundled_Payment
CLM0000000671,MBR00000180,Medical_Professional,Denied,Electronic_EDI,2023-05-16,2023-05-16,2023-05-16,2023-06-15,Auto_Adjudicated,30,1214787184,1061113875,207V00000X,Obstetrics & Gynecology,11,In_Network,I10,,27447,,0,Medicare_Advantage,MA_PPO,72,F,1.1909,22,COB,58856.76,24431.04,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1812,outlier_billing_amount,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000672,MBR00000064,Behavioral_Health,Paid,Electronic_EDI,2023-08-10,2023-08-10,2023-08-10,2023-09-06,Clinical_Review,27,1913217838,1829216053,246ZN0300X,Neuropsychology,81,In_Network,Z00.00,E78.5,82947,,0,Medicare_Advantage,SNP,73,M,1.0644,,,277.77,223.86,169.96,1.41,10.0,42.49,53.91,0.0,0.0,0,,0.0888,none,0,1,0,0,0,1.6e-05,0,0,,Capitation
CLM0000000673,MBR00000058,Behavioral_Health,Paid,Electronic_EDI,2023-11-24,2023-11-24,2023-11-24,2023-12-04,Auto_Adjudicated,10,1838794554,1827839595,2086S0122X,Orthopedic Surgery,21,In_Network,E11.65,,84443,,0,Commercial,PPO,56,F,1.1626,,,221.7,138.82,0.0,138.82,0.0,0.0,82.88,0.0,0.0,0,,0.0965,none,0,1,0,1,0,0.0,0,0,,P4P
CLM0000000674,MBR00000189,Medical_Institutional,Paid,Electronic_EDI,2023-12-03,2023-12-03,2023-12-07,2024-01-01,Auto_Adjudicated,29,1897146144,1170002937,207RN0300X,Nephrology,11,In_Network,OTHER,Z00.01,revenue_code:0360,,0,Medicaid_MCO,MCO,71,F,0.9722,,,46385.17,22467.17,22460.17,0.0,7.0,0.0,23918.0,0.0,0.0,0,,0.1354,provider_specialty_mismatch,0,1,1,0,0,0.002079,0,0,,FFS
CLM0000000675,MBR00000064,Vision,Paid,Electronic_EDI,2023-10-07,2023-10-07,2023-10-07,2023-11-05,Auto_Adjudicated,29,1196858674,1287935251,207RN0300X,Nephrology,11,In_Network,M54.5,,V2115,,0,Medicare_Advantage,SNP,73,M,1.0644,,,251.07,159.34,119.32,0.19,10.0,29.83,91.73,98.75,12.81,0,,0.0641,none,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000000676,MBR00000167,Medical_Professional,Paid,Electronic_EDI,2023-06-23,2023-06-23,2023-06-23,2023-07-09,Auto_Adjudicated,16,1966338974,1804282800,2084P0800X,Psychiatry,21,In_Network,I25.10,,84443,,0,Commercial,PPO,77,F,0.9377,,,372.18,222.61,66.95,126.93,12.0,16.74,149.57,0.0,0.0,0,,0.1144,none,0,1,0,0,0,6e-06,0,0,,Shared_Savings
CLM0000000677,MBR00000249,Pharmacy,Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-23,2023-03-02,Manual_Review,7,1078576574,1105733833,207RP1001X,Pulmonary Disease,81,In_Network,OTHER,OTHER|Z00.00,50458085930,,4,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,180.99,112.3,0.0,112.3,0.0,0.0,68.69,0.0,0.0,0,,0.0129,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000000678,MBR00000125,Medical_Institutional,Paid,Electronic_EDI,2023-03-10,2023-03-10,2023-03-13,2023-04-03,Auto_Adjudicated,24,1731980913,1810068286,207V00000X,Obstetrics & Gynecology,22,In_Network,Z00.00,OTHER|M79.3|I10,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,16783.42,8997.89,7160.93,1.73,45.0,1790.23,7785.53,0.0,0.0,0,,0.0891,none,0,1,1,0,0,0.000663,0,0,,Shared_Savings
CLM0000000679,MBR00000120,Pharmacy,Paid,Electronic_EDI,2023-10-28,2023-10-28,2023-10-28,2023-11-01,Auto_Adjudicated,4,1485543430,1542515060,207R00000X,Internal Medicine,21,Out_of_Network,J06.9,N18.3|Z00.01,00071015523,,1,Commercial,PPO,62,F,1.0823,,,65.36,43.99,0.0,43.99,0.0,0.0,21.37,0.0,0.0,0,,0.0869,none,0,1,0,0,0,0.0,1,0,,Bundled_Payment
CLM0000000680,MBR00000011,Pharmacy,Paid,Electronic_EDI,2023-02-14,2023-02-14,2023-02-14,2023-02-25,Manual_Review,11,1313352855,1151295616,2084P0800X,Psychiatry,21,Emergency,M54.5,,00071015523,,3,Medicare_Advantage,SNP,35,F,1.0833,,,199.58,137.43,94.75,1.99,17.0,23.69,62.15,0.0,0.0,0,,0.1117,none,0,1,0,0,0,9e-06,0,0,,Capitation
CLM0000000681,MBR00000078,Medical_Institutional,Denied,Electronic_EDI,2023-06-22,2023-06-22,2023-06-24,2023-07-08,Auto_Adjudicated,16,1826567270,1746676564,246ZN0300X,Neuropsychology,11,In_Network,F10.10,G47.33,revenue_code:0100,,0,Commercial,EPO,65,F,1.3174,1,Duplicate,2542.25,968.45,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0663,high_oop_waiver,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000682,MBR00000207,Dental,Paid,Electronic_EDI,2023-05-27,2023-05-27,2023-05-27,2023-06-22,Auto_Adjudicated,26,1015411732,1965244699,207V00000X,Obstetrics & Gynecology,22,In_Network,G47.33,J44.1,D0150,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,292.26,214.86,214.86,0.0,0.0,0.0,77.4,0.0,0.0,0,,0.0832,none,0,1,0,1,0,2e-05,0,0,HBD_Hemoglobin_A1c_Testing,Shared_Savings
CLM0000000683,MBR00000114,Medical_Professional,Denied,Electronic_EDI,2023-09-12,2023-09-12,2023-09-12,2023-10-12,Auto_Adjudicated,30,1147452455,1527857018,207RN0300X,Nephrology,21,In_Network,OTHER,OTHER|M79.3,99212,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,256,Medical_Necessity,258.91,161.18,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0674,high_oop_waiver,0,1,0,0,0,0.0,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000000684,MBR00000050,Pharmacy,Paid,Electronic_EDI,2023-05-04,2023-05-04,2023-05-04,2023-05-29,Auto_Adjudicated,25,1272115456,1098360555,246ZN0300X,Neuropsychology,23,In_Network,J20.9,OTHER|F41.1,00071015523,,2,Medicare_Advantage,MA_PPO,12,F,0.8486,,,175.42,138.06,103.23,9.02,0.0,25.81,37.36,0.0,0.0,0,,0.0534,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000000685,MBR00000033,Medical_Professional,Paid,Electronic_EDI,2023-09-10,2023-09-10,2023-09-10,2023-09-25,Auto_Adjudicated,15,1625939855,1132693989,207RN0300X,Nephrology,11,In_Network,E11.9,,99285,,0,Medicare_Advantage,PFFS,31,F,0.821,,,105.19,71.05,14.88,47.45,5.0,3.72,34.14,0.0,0.0,0,,0.1131,controlled_substance_high_volume,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000000686,MBR00000028,Medical_Professional,Paid,Electronic_EDI,2023-07-02,2023-07-02,2023-07-02,2023-07-05,Manual_Review,3,1832660692,1951488764,207RE0101X,Endocrinology,11,In_Network,K21.0,J20.9,99396,,0,Commercial,HMO,3,F,2.116,,,294.43,249.33,170.06,22.75,14.0,42.52,45.1,0.0,0.0,0,,0.1175,provider_specialty_mismatch,0,1,0,0,0,1.6e-05,0,0,POD_Persistence_of_Beta_Blocker,FFS
CLM0000000687,MBR00000196,Pharmacy,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-12-09,Auto_Adjudicated,24,1061181028,1396850418,207V00000X,Obstetrics & Gynecology,22,In_Network,Z12.11,,00169751112,,3,Commercial,PPO,16,F,1.6015,,,362.16,261.18,161.88,35.83,23.0,40.47,100.98,0.0,0.0,0,,0.0542,none,0,1,0,0,0,1.5e-05,0,0,,Shared_Savings
CLM0000000688,MBR00000184,Pharmacy,Denied,Electronic_EDI,2023-03-09,2023-03-09,2023-03-09,2023-04-04,Manual_Review,26,1364746046,1049766043,2086S0122X,Orthopedic Surgery,24,In_Network,I50.9,Z00.00,50458085930,,1,Medicaid_MCO,MLTSS,30,M,2.8302,50,Timely_Filing,555.25,317.2,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1304,unbundling_pattern,0,1,0,0,0,0.0,0,1,BPD_BP_Declined,Shared_Savings
CLM0000000689,MBR00000159,Dental,Paid,Electronic_EDI,2023-10-01,2023-10-01,2023-10-01,2023-10-16,Auto_Adjudicated,15,1874109311,1300957944,225100000X,Physical Therapist,22,In_Network,OTHER,Z00.01|I10|E11.9,D0120,,0,Commercial,PPO,70,F,1.2009,,,836.89,392.83,296.24,8.53,14.0,74.06,444.06,0.0,0.0,0,,0.0023,none,0,1,0,0,0,2.7e-05,0,0,,FFS
CLM0000000690,MBR00000154,Medical_Professional,Denied,Electronic_EDI,2023-09-17,2023-09-17,2023-09-17,2023-10-04,Auto_Adjudicated,17,1699014308,1706603847,207RC0000X,Cardiovascular Disease,24,In_Network,F32.9,E78.5|C50.911,99232,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,170,Medical_Necessity,283.58,189.02,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1493,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000691,MBR00000049,Medical_Professional,Paid,Electronic_EDI,2023-10-24,2023-10-24,2023-10-24,2023-11-19,Auto_Adjudicated,26,1866366547,1391074619,208600000X,Surgery General,31,In_Network,M79.3,,85025,,0,Medicare_Advantage,PFFS,67,M,0.978,,,3684.74,2205.95,1750.69,13.58,4.0,437.67,1478.79,0.0,0.0,0,,0.0767,phantom_billing_indicator,0,1,0,0,0,0.000162,0,0,,Shared_Savings
CLM0000000692,MBR00000155,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-06-25,2023-06-25,2023-06-26,2023-06-29,Auto_Adjudicated,4,1741980770,1623053477,207Q00000X,Family Medicine,65,In_Network,I10,F41.1|OTHER,revenue_code:0100,,0,ACA_Marketplace,ACA_Bronze,9,F,0.8196,1,Medical_Necessity,6054.69,3427.71,965.98,923.23,0.0,643.98,3521.5,652.13,224.06,0,,0.07,duplicate_claim_indicator,0,1,0,0,0,8.9e-05,0,0,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000000693,MBR00000017,Dental,Paid,Electronic_EDI,2023-04-26,2023-04-26,2023-04-26,2023-05-21,Auto_Adjudicated,25,1952322604,1188760037,2084P0800X,Psychiatry,21,In_Network,I25.10,J06.9,D0150,,0,Commercial,PPO,55,F,0.6174,,,226.08,172.77,55.99,63.78,39.0,14.0,53.31,0.0,0.0,0,,0.1306,none,0,1,0,0,0,5e-06,0,0,,Shared_Savings
CLM0000000694,MBR00000279,Behavioral_Health,Denied,Electronic_EDI,2023-07-05,2023-07-05,2023-07-05,2023-07-21,Manual_Review,16,1092800235,1289435414,207V00000X,Obstetrics & Gynecology,65,In_Network,L70.0,,80053,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,96,COB,222.0,179.52,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0628,none,0,1,0,1,0,0.0,0,0,AWV_Annual_Wellness_Visit,Bundled_Payment
CLM0000000695,MBR00000016,Dental,Paid,Electronic_EDI,2023-12-16,2023-12-16,2023-12-16,2024-01-06,Clinical_Review,21,1466922283,1591405274,207RN0300X,Nephrology,23,In_Network,OTHER,Z00.00|OTHER,D3310,,0,Commercial,HDHP_HSA,20,F,0.5843,,,574.93,332.59,212.0,67.59,0.0,53.0,242.34,0.0,0.0,0,,0.1385,none,0,1,0,0,0,2e-05,0,0,PPC_Prenatal_Care,FFS
CLM0000000696,MBR00000134,Medical_Institutional,Paid,Electronic_EDI,2023-03-11,2023-03-11,2023-03-13,2023-03-17,Auto_Adjudicated,6,1102040918,1128148362,246ZN0300X,Neuropsychology,22,In_Network,OTHER,OTHER|J06.9,revenue_code:0370,,0,Medicare_Advantage,MA_PPO,33,M,1.115,,,21409.86,7824.67,6223.77,22.95,22.0,1555.94,13585.19,0.0,0.0,0,,0.0414,none,0,1,1,0,0,0.000576,0,0,,FFS
CLM0000000697,MBR00000001,Dental,Paid,Electronic_EDI,2023-08-26,2023-08-26,2023-08-26,2023-09-14,Auto_Adjudicated,19,1907932706,1623053477,207Q00000X,Family Medicine,22,In_Network,OTHER,,D2391,,0,Commercial,EPO,73,M,0.6527,,,84.52,66.74,0.0,66.74,0.0,0.0,17.78,0.0,0.0,0,,0.1492,unusual_service_frequency,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,FFS
CLM0000000698,MBR00000232,Medical_Professional,Paid,Electronic_EDI,2023-03-22,2023-03-22,2023-03-22,2023-03-31,Auto_Adjudicated,9,1976612978,1123879500,225100000X,Physical Therapist,11,In_Network,M17.11,Z00.00|OTHER,99202,,0,Medicaid_MCO,MCO,40,M,1.1083,,,299.56,111.37,109.37,0.0,2.0,0.0,188.19,0.0,0.0,1,Prescription Drug Diversion,0.928,outlier_billing_amount|provider_specialty_mismatch|service_date_weekend|upcoding_pattern|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,1e-05,0,0,,P4P
CLM0000000699,MBR00000052,Vision,Denied,Electronic_EDI,2023-10-05,2023-10-05,2023-10-05,2023-10-21,Manual_Review,16,1414670047,1554490060,207RG0100X,Gastroenterology,22,In_Network,OTHER,,V2320,,0,Commercial,PPO,0,F,1.325,4,Coding_Error,179.55,103.18,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1812,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000700,MBR00000279,Medical_Institutional,Paid,Electronic_EDI,2023-06-02,2023-06-02,2023-06-06,2023-06-18,Auto_Adjudicated,16,1945264928,1452088018,207RE0101X,Endocrinology,24,In_Network,H52.4,OTHER,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,,,10687.18,5513.52,4371.66,18.95,30.0,1092.91,5173.66,3918.74,313.27,0,,0.1916,diagnosis_procedure_mismatch,0,1,0,0,0,0.000405,0,0,,FFS
CLM0000000701,MBR00000013,Medical_Professional,Paid,Electronic_EDI,2023-11-05,2023-11-05,2023-11-05,2023-12-04,Auto_Adjudicated,29,1838794554,1325999602,207RE0101X,Endocrinology,81,In_Network,N39.0,OTHER|Z12.11|I10,99231,,0,Commercial,PPO,64,F,1.428,,,335.07,177.74,0.0,177.74,0.0,0.0,157.33,0.0,0.0,0,,0.1379,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000702,MBR00000245,Medical_Institutional,Paid,Electronic_EDI,2023-02-28,2023-02-28,2023-02-28,2023-03-21,Auto_Adjudicated,21,1893886964,1105871325,207RN0300X,Nephrology,21,In_Network,Z00.00,Z12.11|I25.10,revenue_code:0100,871,0,Medicaid_MCO,MCO,60,F,0.7502,,,18544.88,12420.55,12419.55,0.0,1.0,0.0,6124.33,0.0,0.0,0,,0.0792,npi_mismatch,0,1,1,0,0,0.00115,0,0,,Capitation
CLM0000000703,MBR00000196,Pharmacy,Paid,Electronic_EDI,2023-02-14,2023-02-14,2023-02-14,2023-03-03,Manual_Review,17,1667149552,1296566243,207RG0100X,Gastroenterology,81,In_Network,OTHER,Z00.00,00069420020,,2,Commercial,PPO,16,F,1.6015,,,358.35,278.74,0.0,278.74,0.0,0.0,79.61,0.0,0.0,0,,0.0665,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000000704,MBR00000077,Medical_Professional,Partially_Paid,Electronic_EDI,2023-12-08,2023-12-08,2023-12-08,2023-12-21,Auto_Adjudicated,13,1375680589,1690197969,207RE0101X,Endocrinology,11,Out_of_Network,OTHER,E78.5,99392,,0,Medicare_Advantage,MA_HMO,27,F,0.9229,CO-45,Medical_Necessity,528.66,375.36,213.13,10.07,4.0,53.28,248.18,0.0,0.0,0,,0.121,provider_specialty_mismatch,0,1,0,1,0,2e-05,0,0,,FFS
CLM0000000705,MBR00000061,Medical_Professional,Denied,Electronic_EDI,2023-05-01,2023-05-01,2023-05-01,2023-05-12,Auto_Adjudicated,11,1231231881,1581533104,208600000X,Surgery General,71,In_Network,M17.11,OTHER|Z00.00,10060,,0,Commercial,PPO,66,M,2.3575,PR-1,Coding_Error,1012.09,574.7,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1342,none,0,1,0,0,0,0.0,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000000706,MBR00000113,Pharmacy,Partially_Paid,Electronic_EDI,2023-01-31,2023-01-31,2023-01-31,2023-02-20,Auto_Adjudicated,20,1560886857,1396850418,246ZN0300X,Neuropsychology,22,In_Network,J06.9,I10|I25.10|OTHER,00003014960,,1,Medicaid_MCO,MLTSS,29,F,1.1621,CO-45,Medical_Necessity,67.42,49.59,31.14,0.0,1.0,0.0,35.28,0.0,0.0,0,,0.1867,diagnosis_procedure_mismatch,0,1,0,1,0,3e-06,0,1,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000000707,MBR00000247,Vision,Paid,Electronic_EDI,2023-10-28,2023-10-28,2023-10-28,2023-11-24,Clinical_Review,27,1375098560,1170002937,207Q00000X,Family Medicine,23,In_Network,Z00.01,,V2100,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,375.41,252.69,187.41,13.42,5.0,46.85,122.72,0.0,0.0,0,,0.1322,none,0,1,0,0,0,1.7e-05,0,0,,Capitation
CLM0000000708,MBR00000260,Medical_Institutional,Paid,Electronic_EDI,2023-05-29,2023-05-29,2023-06-02,2023-06-16,Auto_Adjudicated,18,1097702209,1148659045,2086S0122X,Orthopedic Surgery,22,In_Network,Z00.00,,revenue_code:0110,,0,Medicare_Advantage,SNP,59,M,0.3786,,,31768.71,18919.54,15105.61,4.52,33.0,3776.4,12849.17,0.0,0.0,0,,0.0788,phantom_billing_indicator,0,1,1,0,0,0.001398,0,0,FUH_Follow_Up_Hospitalization,Shared_Savings
CLM0000000709,MBR00000055,Medical_Professional,Paid,Provider_Portal,2023-11-27,2023-11-27,2023-11-27,2023-12-17,Clinical_Review,20,1068197532,1809122260,225100000X,Physical Therapist,81,In_Network,OTHER,OTHER,43239,,0,Commercial,PPO,68,F,1.2896,,,892.85,461.65,321.17,50.19,10.0,80.29,431.2,0.0,0.0,0,,0.1386,high_volume_same_code,0,1,0,0,0,3e-05,0,0,,FFS
CLM0000000710,MBR00000112,Medical_Institutional,Paid,Provider_Portal,2023-06-07,2023-06-07,2023-06-11,2023-06-17,Auto_Adjudicated,10,1855186422,1356856197,207Q00000X,Family Medicine,11,In_Network,Z23,E78.5,revenue_code:0360,,0,Medicare_Advantage,MA_HMO,18,M,1.01,,,38308.12,22749.31,18143.07,40.48,30.0,4535.77,15558.81,0.0,0.0,0,,0.0368,none,0,1,1,0,0,0.001679,0,0,,FFS
CLM0000000711,MBR00000075,Medical_Professional,Denied,Electronic_EDI,2023-09-29,2023-09-29,2023-09-29,2023-10-16,Manual_Review,17,1133265917,1027261156,207V00000X,Obstetrics & Gynecology,21,In_Network,E11.65,,99203,,0,Medicaid_MCO,MCO,5,M,1.0573,18,Duplicate,595.01,442.23,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|service_date_weekend|duplicate_claim_indicator|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000712,MBR00000037,Medical_Professional,Paid,Electronic_EDI,2023-07-27,2023-07-27,2023-07-27,2023-08-14,Auto_Adjudicated,18,1506426842,1477113725,207V00000X,Obstetrics & Gynecology,32,In_Network,M54.5,N18.3,90834,,0,Medicaid_MCO,MLTSS,11,M,1.043,,,359.26,248.89,247.89,0.0,1.0,0.0,110.37,0.0,0.0,0,,0.0596,none,0,1,0,0,0,2.3e-05,0,0,,Capitation
CLM0000000713,MBR00000192,Medical_Professional,Paid,Electronic_EDI,2023-06-23,2023-06-23,2023-06-23,2023-07-14,Auto_Adjudicated,21,1881358103,1296566243,207RN0300X,Nephrology,11,Out_of_Network,N18.3,OTHER,99203,,0,Medicaid_MCO,MCO,22,F,1.1739,,,774.3,583.85,583.85,0.0,0.0,0.0,190.45,464.28,70.01,0,,0.1266,unbundling_pattern,0,1,0,0,0,5.4e-05,1,0,,P4P
CLM0000000714,MBR00000109,Medical_Institutional,Paid,Electronic_EDI,2023-06-24,2023-06-24,2023-06-24,2023-07-04,Clinical_Review,10,1091271799,1296566243,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,Z79.4|E11.9|M47.816,revenue_code:0100,,0,Commercial,HMO,8,F,0.5723,,,4683.89,3945.43,3102.02,12.9,55.0,775.51,738.46,0.0,0.0,0,,0.0643,npi_mismatch,0,1,0,0,0,0.000287,0,0,SPC_Statin_Therapy,FFS
CLM0000000715,MBR00000070,Medical_Professional,Paid,Electronic_EDI,2023-04-01,2023-04-01,2023-04-01,2023-04-12,Auto_Adjudicated,11,1728728765,1179350099,207RG0100X,Gastroenterology,22,In_Network,OTHER,,97140,,0,Commercial,POS,42,F,0.8468,,,647.83,541.08,201.91,273.69,15.0,50.48,106.75,0.0,0.0,0,,0.0196,none,0,1,0,0,0,1.9e-05,0,0,,Shared_Savings
CLM0000000716,MBR00000262,Medical_Professional,Denied,Electronic_EDI,2023-09-22,2023-09-22,2023-09-22,2023-10-03,Auto_Adjudicated,11,1879212418,1898471307,207RN0300X,Nephrology,24,In_Network,F41.1,M17.11|F41.1,99386,,0,Medicare_Advantage,PFFS,77,F,1.7452,97,Timely_Filing,234.31,189.64,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1731,service_date_weekend,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000717,MBR00000219,Medical_Professional,Denied,Electronic_EDI,2023-07-08,2023-07-08,2023-07-08,2023-07-21,Auto_Adjudicated,13,1957378066,1163639177,2086S0122X,Orthopedic Surgery,65,Out_of_Network,M54.5,F41.1|Z00.01|OTHER,12001,,0,Medicare_Advantage,MA_HMO,84,M,0.9513,22,Network,255.45,185.76,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.039,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000718,MBR00000228,Medical_Institutional,Paid,Electronic_EDI,2023-01-01,2023-01-01,2023-01-02,2023-01-10,Manual_Review,9,1067329999,1765164601,207V00000X,Obstetrics & Gynecology,11,Out_of_Network,Z00.00,J06.9,revenue_code:0370,,0,Commercial,PPO,55,F,0.7203,,,26689.24,22595.55,17779.44,329.25,42.0,4444.86,4093.69,0.0,0.0,0,,0.1251,none,0,1,1,0,0,0.001646,1,0,,Capitation
CLM0000000719,MBR00000012,Medical_Professional,Paid,Electronic_EDI,2023-05-23,2023-05-23,2023-05-23,2023-05-29,Auto_Adjudicated,6,1683994149,1354265777,207Q00000X,Family Medicine,23,In_Network,OTHER,,90847,,0,Commercial,HMO,84,M,1.3904,,,921.72,541.45,400.1,13.32,28.0,100.03,380.27,0.0,0.0,0,,0.0222,none,0,1,0,0,0,3.7e-05,0,0,,Bundled_Payment
CLM0000000720,MBR00000277,Medical_Professional,Paid,Provider_Portal,2023-05-26,2023-05-26,2023-05-26,2023-06-11,Manual_Review,16,1505049857,1616762819,207RE0101X,Endocrinology,22,In_Network,OTHER,I10|K21.0,99203,,0,Medicaid_MCO,MCO,30,M,1.8495,,,316.33,133.4,130.4,0.0,3.0,0.0,182.93,0.0,0.0,0,,0.1629,provider_specialty_mismatch,0,1,0,0,0,1.2e-05,0,0,,Shared_Savings
CLM0000000721,MBR00000173,Medical_Institutional,Paid,Paper,2023-11-14,2023-11-14,2023-11-15,2023-12-10,Auto_Adjudicated,26,1838794554,1983760474,207RP1001X,Pulmonary Disease,23,In_Network,J06.9,M79.3,revenue_code:0300,,0,Medicare_Advantage,PFFS,23,F,1.0279,,,6822.78,5141.79,4056.52,31.13,40.0,1014.13,1680.99,0.0,0.0,0,,0.0562,none,0,1,0,0,0,0.000375,0,0,AMR_Asthma_Medication_Ratio,Capitation
CLM0000000722,MBR00000156,Pharmacy,Paid,Electronic_EDI,2023-06-03,2023-06-03,2023-06-03,2023-06-04,Manual_Review,1,1141106555,1789540567,2086S0122X,Orthopedic Surgery,11,In_Network,E11.9,J20.9,00071012831,,1,Medicare_Advantage,MA_PPO,66,F,1.8933,,,282.5,123.32,78.63,12.03,13.0,19.66,159.18,0.0,0.0,0,,0.0536,none,0,1,0,1,0,7e-06,0,1,LCS_Lung_Cancer_Screening,Bundled_Payment
CLM0000000723,MBR00000004,Pharmacy,Paid,Provider_Portal,2023-07-23,2023-07-23,2023-07-23,2023-08-12,Manual_Review,20,1006962798,1951488764,101YP2500X,Psychologist Clinical,11,In_Network,I50.9,,00071012831,,1,Medicare_Advantage,MA_PPO,68,M,1.23,,,146.07,88.59,48.98,19.36,8.0,12.25,57.48,0.0,0.0,0,,0.1499,none,0,1,0,0,0,5e-06,0,0,TRC_Transition_of_Care,Shared_Savings
CLM0000000724,MBR00000272,Medical_Institutional,Denied,Electronic_EDI,2023-01-30,2023-01-30,2023-02-03,2023-02-24,Auto_Adjudicated,25,1110312325,1151295616,246ZN0300X,Neuropsychology,22,In_Network,Z00.121,OTHER,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,15,M,0.8525,256,Medical_Necessity,18501.14,14815.65,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1073,high_volume_same_code,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000725,MBR00000165,Pharmacy,Paid,Electronic_EDI,2023-05-21,2023-05-21,2023-05-21,2023-06-15,Auto_Adjudicated,25,1836409547,1068662623,207RE0101X,Endocrinology,11,In_Network,F10.10,OTHER,50458085930,,2,ACA_Marketplace,ACA_Bronze,55,M,0.9775,,,567.86,421.49,0.0,421.49,0.0,0.0,146.37,0.0,0.0,0,,0.1194,unbundling_pattern,0,1,0,0,0,0.0,0,0,,P4P
CLM0000000726,MBR00000246,Pharmacy,Paid,Electronic_EDI,2023-04-12,2023-04-12,2023-04-12,2023-05-08,Auto_Adjudicated,26,1039678579,1649705287,101YP2500X,Psychologist Clinical,23,In_Network,Z00.00,F33.0|J20.9,00071015523,,3,Commercial,PPO,80,F,0.7925,,,25.48,12.94,0.0,12.94,0.0,0.0,12.54,0.0,0.0,0,,0.1382,none,0,1,0,0,0,0.0,0,0,CBP_Controlling_BP,FFS
CLM0000000727,MBR00000195,Pharmacy,Paid,Electronic_EDI,2023-06-28,2023-06-28,2023-06-28,2023-07-08,Manual_Review,10,1603037534,1662516615,246ZN0300X,Neuropsychology,11,In_Network,OTHER,E11.65|Z12.11|F32.9,00085163102,,2,Commercial,PPO,13,F,0.5967,,,401.28,187.29,71.91,84.41,13.0,17.98,213.99,0.0,0.0,0,,0.1009,upcoding_pattern,0,1,0,0,0,7e-06,0,1,,FFS
CLM0000000728,MBR00000236,Medical_Institutional,Paid,Electronic_EDI,2023-11-19,2023-11-19,2023-11-21,2023-11-23,Clinical_Review,4,1836409547,1489993356,208600000X,Surgery General,65,In_Network,J20.9,N39.0,revenue_code:0120,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,101598.45,66469.09,66463.09,0.0,6.0,0.0,35129.36,0.0,0.0,0,,0.255,outlier_billing_amount|unusual_service_frequency,0,2,1,0,0,0.006152,0,0,,FFS
CLM0000000729,MBR00000206,Medical_Professional,Paid,Electronic_EDI,2023-12-02,2023-12-02,2023-12-02,2024-01-01,Auto_Adjudicated,30,1315569619,1965244699,207RP1001X,Pulmonary Disease,31,Out_of_Network,N18.3,,99385,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,661.96,482.01,481.01,0.0,1.0,0.0,179.95,362.5,89.97,0,,0.0627,none,0,1,0,0,0,4.5e-05,0,0,FUM_Follow_Up_ED_Mental_Health,Shared_Savings
CLM0000000730,MBR00000277,Medical_Professional,Paid,Provider_Portal,2023-04-14,2023-04-14,2023-04-14,2023-05-05,Auto_Adjudicated,21,1706046899,1209882852,207RN0300X,Nephrology,22,In_Network,Z00.00,OTHER,99397,,0,Medicaid_MCO,MCO,30,M,1.8495,,,412.11,301.76,298.76,0.0,3.0,0.0,110.35,0.0,0.0,0,,0.098,controlled_substance_high_volume,0,1,0,0,0,2.8e-05,0,0,,Bundled_Payment
CLM0000000731,MBR00000070,Medical_Professional,Paid,Electronic_EDI,2023-08-09,2023-08-09,2023-08-09,2023-08-20,Auto_Adjudicated,11,1080383191,1685903362,207R00000X,Internal Medicine,32,In_Network,Z00.00,,47562,,0,Commercial,POS,42,F,0.8468,,,1530.54,1121.83,717.3,210.21,15.0,179.32,408.71,0.0,0.0,0,,0.0185,none,0,1,0,1,0,6.6e-05,0,0,,Bundled_Payment
CLM0000000732,MBR00000061,Medical_Professional,Paid,Provider_Portal,2023-12-09,2023-12-09,2023-12-09,2024-01-04,Auto_Adjudicated,26,1147452455,1995553359,207RE0101X,Endocrinology,81,In_Network,I10,,99391,,0,Commercial,PPO,66,M,2.3575,,,183.09,64.34,40.35,0.9,13.0,10.09,118.75,0.0,0.0,0,,0.0698,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000000733,MBR00000211,Vision,Paid,Electronic_EDI,2023-03-24,2023-03-24,2023-03-24,2023-04-04,Auto_Adjudicated,11,1732193518,1867626800,207RG0100X,Gastroenterology,24,In_Network,Z12.11,I48.91,92002,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,,,315.75,221.18,167.19,0.2,12.0,41.8,94.57,0.0,0.0,0,,0.1041,service_date_weekend,0,1,0,0,0,1.5e-05,0,0,IET_Initiation_Substance_Use,FFS
CLM0000000734,MBR00000155,Medical_Professional,Denied,Electronic_EDI,2023-06-07,2023-06-07,2023-06-07,2023-06-30,Manual_Review,23,1083045036,1055872102,207V00000X,Obstetrics & Gynecology,23,In_Network,OTHER,,43239,,0,ACA_Marketplace,ACA_Bronze,9,F,0.8196,22,COB,585.22,397.21,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0702,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000735,MBR00000181,Medical_Institutional,Denied,Electronic_EDI,2023-06-29,2023-06-29,2023-07-02,2023-07-28,Auto_Adjudicated,29,1865750966,1705448933,208600000X,Surgery General,22,In_Network,G43.909,,revenue_code:0370,,0,Commercial,PPO,82,F,1.0432,22,Medical_Necessity,7881.08,4339.47,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1297,none,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000000736,MBR00000210,Behavioral_Health,Partially_Paid,Paper,2023-01-02,2023-01-02,2023-01-02,2023-01-26,Auto_Adjudicated,24,1966338974,1903401648,2086S0122X,Orthopedic Surgery,31,In_Network,OTHER,,99282,,0,Medicare_Advantage,SNP,49,M,0.6952,18,Medical_Necessity,360.6,306.26,110.07,40.16,18.0,27.52,164.86,0.0,0.0,0,,0.1495,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000000737,MBR00000166,Medical_Institutional,Denied,Electronic_EDI,2023-06-17,2023-06-17,2023-06-20,2023-07-07,Auto_Adjudicated,20,1898658234,1151295616,207RN0300X,Nephrology,23,In_Network,K57.30,,revenue_code:0370,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,22,Medical_Necessity,10045.87,5770.62,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0645,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000000738,MBR00000233,Medical_Professional,Denied,Electronic_EDI,2023-02-13,2023-02-13,2023-02-13,2023-02-19,Auto_Adjudicated,6,1633089013,1542515060,207RG0100X,Gastroenterology,22,In_Network,Z00.01,E11.9|OTHER,99213,,0,Medicare_Advantage,MA_PPO,87,M,0.8034,1,Eligibility,110.79,42.67,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0504,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000739,MBR00000101,Vision,Denied,Electronic_EDI,2023-04-22,2023-04-22,2023-04-22,2023-05-21,Auto_Adjudicated,29,1068197532,1896197144,207RP1001X,Pulmonary Disease,22,In_Network,M47.816,OTHER,92002,,0,Commercial,PPO,83,M,0.3627,22,Authorization,348.63,132.42,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1963,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000740,MBR00000259,Medical_Professional,Paid,Electronic_EDI,2023-02-11,2023-02-11,2023-02-11,2023-02-24,Manual_Review,13,1111846258,1691162131,2086S0122X,Orthopedic Surgery,11,In_Network,M79.3,E78.5|OTHER|N39.0,99387,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,276.14,155.47,115.51,4.09,7.0,28.88,120.67,0.0,0.0,0,,0.0009,none,0,1,0,0,0,1.1e-05,0,0,,P4P
CLM0000000741,MBR00000033,Medical_Professional,Paid,Electronic_EDI,2023-09-22,2023-09-22,2023-09-22,2023-10-11,Auto_Adjudicated,19,1216417633,1587454801,207Q00000X,Family Medicine,24,In_Network,OTHER,E11.9|F10.10,99283,,0,Medicare_Advantage,PFFS,31,F,0.821,,,395.98,260.55,168.65,44.73,5.0,42.16,135.43,0.0,0.0,0,,0.0601,none,0,1,0,0,0,1.6e-05,0,0,,FFS
CLM0000000742,MBR00000188,Medical_Institutional,Paid,Electronic_EDI,2023-10-27,2023-10-27,2023-10-27,2023-11-15,Auto_Adjudicated,19,1648123576,1354959095,2084P0800X,Psychiatry,32,In_Network,J20.9,Z00.00|E13.9,revenue_code:0370,,0,Commercial,HMO,8,F,1.5853,,,8299.23,7050.46,5538.66,81.14,46.0,1384.66,1248.77,0.0,0.0,0,,0.0636,none,0,1,1,0,0,0.000513,0,0,,Capitation
CLM0000000743,MBR00000270,Medical_Professional,Paid,Electronic_EDI,2023-04-07,2023-04-07,2023-04-07,2023-04-15,Auto_Adjudicated,8,1793406356,1355732274,207R00000X,Internal Medicine,11,Out_of_Network,E11.9,,20610,,0,Commercial,POS,1,F,1.6363,,,194.61,110.5,0.0,110.5,0.0,0.0,84.11,0.0,0.0,0,,0.0955,none,0,1,0,0,0,0.0,1,0,,FFS
CLM0000000744,MBR00000078,Pharmacy,Paid,Electronic_EDI,2023-01-15,2023-01-15,2023-01-15,2023-02-03,Clinical_Review,19,1360102160,1498781755,207RN0300X,Nephrology,11,In_Network,L70.0,OTHER,00310075090,,1,Commercial,EPO,65,F,1.3174,,,82.56,52.57,0.0,52.57,0.0,0.0,29.99,0.0,0.0,0,,0.1322,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000745,MBR00000104,Medical_Professional,Paid,Electronic_EDI,2023-06-26,2023-06-26,2023-06-26,2023-07-08,Auto_Adjudicated,12,1557212800,1061113875,2084P0800X,Psychiatry,81,In_Network,M25.511,J06.9,27130,,0,Medicaid_MCO,MCO,87,F,1.2297,,,9484.35,7318.01,7318.01,0.0,0.0,0.0,2166.34,6054.3,980.95,0,,0.1449,billing_spike_recent,0,1,1,0,0,0.000677,0,0,,FFS
CLM0000000746,MBR00000097,Pharmacy,Paid,Electronic_EDI,2023-02-11,2023-02-11,2023-02-11,2023-02-22,Auto_Adjudicated,11,1264432433,1789540567,207RE0101X,Endocrinology,11,In_Network,M17.11,J06.9,00071012831,,3,Commercial,EPO,34,M,1.3765,,,79.11,55.76,0.0,55.76,0.0,0.0,23.35,0.0,0.0,0,,0.1063,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000747,MBR00000170,Medical_Professional,Paid,Electronic_EDI,2023-06-08,2023-06-08,2023-06-08,2023-07-04,Auto_Adjudicated,26,1469822310,1672803287,2086S0122X,Orthopedic Surgery,24,In_Network,Z00.01,,99231,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,211.34,170.24,133.44,0.43,3.0,33.36,41.1,0.0,0.0,0,,0.1308,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000000748,MBR00000131,Vision,Paid,Electronic_EDI,2023-07-15,2023-07-15,2023-07-15,2023-08-06,Auto_Adjudicated,22,1076251878,1406199453,2086S0122X,Orthopedic Surgery,22,In_Network,Z23,,92012,,0,Commercial,EPO,15,F,0.9228,,,402.79,269.75,0.0,269.75,0.0,0.0,133.04,0.0,0.0,0,,0.015,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000749,MBR00000033,Medical_Professional,Paid,Electronic_EDI,2023-06-17,2023-06-17,2023-06-17,2023-07-02,Auto_Adjudicated,15,1059948944,1469697158,225100000X,Physical Therapist,22,Out_of_Network,OTHER,E78.5,71250,,0,Medicare_Advantage,PFFS,31,F,0.821,,,247.18,202.43,156.47,1.84,5.0,39.12,44.75,0.0,0.0,0,,0.1914,benford_violation,0,1,0,0,0,1.4e-05,1,0,,Bundled_Payment
CLM0000000750,MBR00000270,Vision,Paid,Electronic_EDI,2023-07-07,2023-07-07,2023-07-07,2023-07-08,Auto_Adjudicated,1,1923332120,1396850418,207RC0000X,Cardiovascular Disease,11,In_Network,M54.5,Z23|I25.10,92004,,0,Commercial,POS,1,F,1.6363,,,435.42,291.98,220.42,4.45,12.0,55.11,143.44,0.0,0.0,0,,0.1487,none,0,1,0,0,0,2e-05,0,0,,FFS
CLM0000000751,MBR00000062,Medical_Professional,Paid,Electronic_EDI,2023-07-23,2023-07-23,2023-07-23,2023-08-14,Auto_Adjudicated,22,1055095309,1945682535,246ZN0300X,Neuropsychology,11,In_Network,L70.0,OTHER,17000,,0,Commercial,HMO,46,F,0.5516,,,267.24,110.64,66.07,7.06,21.0,16.52,156.6,0.0,0.0,0,,0.072,none,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000000752,MBR00000162,Dental,Paid,Electronic_EDI,2023-02-28,2023-02-28,2023-02-28,2023-03-23,Manual_Review,23,1112402001,1447657873,207RE0101X,Endocrinology,22,In_Network,E78.5,,D0120,,0,Medicaid_MCO,MLTSS,84,F,1.324,,,278.46,145.29,144.29,0.0,1.0,0.0,133.17,0.0,0.0,0,,0.0839,upcoding_pattern,0,1,0,1,0,1.3e-05,0,0,,FFS
CLM0000000753,MBR00000179,Pharmacy,Denied,Electronic_EDI,2023-09-03,2023-09-03,2023-09-03,2023-09-08,Manual_Review,5,1375680589,1704466150,246ZN0300X,Neuropsychology,21,In_Network,M54.5,OTHER,00006001954,,3,Medicare_Advantage,SNP,82,F,0.5266,96,Eligibility,174.94,101.77,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1189,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000000754,MBR00000012,Medical_Institutional,Paid,Electronic_EDI,2023-08-28,2023-08-28,2023-08-31,2023-09-20,Auto_Adjudicated,23,1808451151,1288028182,207V00000X,Obstetrics & Gynecology,24,In_Network,J06.9,J20.9|F32.9,revenue_code:0250,,0,Commercial,HMO,84,M,1.3904,,,9163.17,6876.51,5376.41,100.0,56.0,1344.1,2286.66,0.0,0.0,0,,0.0716,none,0,1,1,0,0,0.000498,0,0,SPD_Spirometry_Testing,FFS
CLM0000000755,MBR00000028,Medical_Professional,Paid,Electronic_EDI,2023-02-21,2023-02-21,2023-02-21,2023-03-05,Manual_Review,12,1514646292,1339359594,207V00000X,Obstetrics & Gynecology,81,In_Network,I10,Z12.11|J44.1,20610,,0,Commercial,HMO,3,F,2.116,,,1004.54,500.81,20.6,461.06,14.0,5.15,503.73,0.0,0.0,0,,0.0083,none,0,1,0,0,0,2e-06,0,0,,FFS
CLM0000000756,MBR00000293,Medical_Institutional,Paid,Electronic_EDI,2023-06-05,2023-06-05,2023-06-08,2023-06-27,Auto_Adjudicated,22,1404237143,1896197144,207RG0100X,Gastroenterology,24,In_Network,J06.9,I10|F32.9,revenue_code:0370,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,10884.52,6491.53,5133.51,42.64,32.0,1283.38,4392.99,3677.54,764.95,0,,0.0309,none,0,1,1,0,0,0.000475,0,0,,Capitation
CLM0000000757,MBR00000197,Medical_Institutional,Paid,Paper,2023-04-14,2023-04-14,2023-04-18,2023-05-10,Auto_Adjudicated,26,1897231867,1144950506,207R00000X,Internal Medicine,21,Emergency,G43.909,M17.11,revenue_code:0110,291,0,Medicare_Advantage,MA_HMO,59,M,1.1414,,,10419.73,4815.06,3818.29,6.2,36.0,954.57,5604.67,0.0,0.0,0,,0.1441,none,0,1,0,0,0,0.000353,0,0,W30_Well_Child_Visit,FFS
CLM0000000758,MBR00000011,Medical_Institutional,Paid,Electronic_EDI,2023-05-23,2023-05-23,2023-05-27,2023-06-14,Auto_Adjudicated,22,1555292468,1829216053,207RN0300X,Nephrology,22,In_Network,Z23,Z79.4,revenue_code:0300,,0,Medicare_Advantage,SNP,35,F,1.0833,,,1413.63,759.42,573.15,1.98,41.0,143.29,654.21,0.0,0.0,0,,0.044,none,0,1,0,0,0,5.3e-05,0,0,,P4P
CLM0000000759,MBR00000235,Medical_Institutional,Denied,Electronic_EDI,2023-10-05,2023-10-05,2023-10-07,2023-11-03,Auto_Adjudicated,29,1921056264,1319611206,207RN0300X,Nephrology,11,In_Network,M54.5,Z00.00,revenue_code:0100,,0,Commercial,HDHP_HSA,85,F,1.4308,22,Coding_Error,17211.62,8435.43,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1192,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000760,MBR00000156,Vision,Paid,Electronic_EDI,2023-08-03,2023-08-03,2023-08-03,2023-08-06,Auto_Adjudicated,3,1699074676,1878874025,207RC0000X,Cardiovascular Disease,23,In_Network,Z87.891,,92004,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,716.31,587.2,437.74,27.02,13.0,109.44,129.11,0.0,0.0,0,,0.0492,none,0,1,0,0,0,4.1e-05,0,0,,Shared_Savings
CLM0000000761,MBR00000023,Behavioral_Health,Denied,Electronic_EDI,2023-11-22,2023-11-22,2023-11-22,2023-12-02,Auto_Adjudicated,10,1888245409,1694343357,207R00000X,Internal Medicine,22,Out_of_Network,M17.11,K21.0,99285,,0,Medicare_Advantage,MA_PPO,87,M,1.084,5,Network,172.03,138.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0206,none,0,1,0,1,0,0.0,1,0,AWV_Annual_Wellness_Visit,Bundled_Payment
CLM0000000762,MBR00000202,Medical_Institutional,Denied,Paper,2023-07-24,2023-07-24,2023-07-28,2023-07-26,Auto_Adjudicated,2,1728728765,1878017518,207RG0100X,Gastroenterology,31,In_Network,K21.0,OTHER|Z23,revenue_code:0360,,0,Commercial,PPO,87,F,0.6213,1,COB,21744.16,15552.02,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0617,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000763,MBR00000154,Medical_Professional,Denied,Provider_Portal,2023-01-17,2023-01-17,2023-01-17,2023-01-23,Manual_Review,6,1231231881,1607833568,207R00000X,Internal Medicine,23,In_Network,OTHER,OTHER,99394,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,97,Network,185.47,76.28,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0601,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000764,MBR00000062,Medical_Professional,Paid,Electronic_EDI,2023-09-13,2023-09-13,2023-09-13,2023-09-25,Auto_Adjudicated,12,1804302686,1867626800,207V00000X,Obstetrics & Gynecology,11,In_Network,Z12.11,Z00.121,80053,,0,Commercial,HMO,46,F,0.5516,,,1295.63,1063.94,772.17,77.72,21.0,193.04,231.69,0.0,0.0,0,,0.0844,none,0,1,0,0,0,7.1e-05,0,0,COA_Care_Transitions,Capitation
CLM0000000765,MBR00000265,Pharmacy,Paid,Electronic_EDI,2023-01-27,2023-01-27,2023-01-27,2023-01-28,Manual_Review,1,1402424417,1903401648,207RE0101X,Endocrinology,21,Out_of_Network,J20.9,,50458085930,,1,Commercial,PPO,84,F,0.7969,,,272.63,116.79,0.0,116.79,0.0,0.0,155.84,0.0,0.0,0,,0.0445,none,0,1,0,0,0,0.0,0,1,,Bundled_Payment
CLM0000000766,MBR00000091,Behavioral_Health,Paid,Electronic_EDI,2023-05-03,2023-05-03,2023-05-03,2023-05-15,Auto_Adjudicated,12,1639236553,1133410177,207RG0100X,Gastroenterology,23,In_Network,Z00.00,OTHER,70553,,0,Commercial,PPO,13,F,1.2451,,,425.52,160.53,0.0,160.53,0.0,0.0,264.99,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|geographic_mismatch|temporal_clustering|benford_violation|service_date_weekend|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,0.0,0,0,,FFS
CLM0000000767,MBR00000088,Medical_Institutional,Paid,Electronic_EDI,2023-12-02,2023-12-02,2023-12-02,2023-12-06,Manual_Review,4,1539066691,1965244699,225100000X,Physical Therapist,31,In_Network,J06.9,,revenue_code:0370,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,,,21449.84,7981.1,5210.65,447.31,90.0,2233.14,13468.74,0.0,0.0,0,,0.1082,none,0,1,1,0,0,0.000482,0,0,,FFS
CLM0000000768,MBR00000085,Medical_Professional,Paid,Provider_Portal,2023-12-22,2023-12-22,2023-12-22,2023-12-26,Clinical_Review,4,1364214492,1767402068,246ZN0300X,Neuropsychology,21,In_Network,E11.9,OTHER,90837,,0,Medicare_Advantage,SNP,2,M,0.7823,,,668.89,327.73,229.23,26.2,15.0,57.31,341.16,184.74,25.23,0,,0.0529,none,0,1,0,0,0,2.1e-05,0,0,FUH_Follow_Up_Hospitalization,Shared_Savings
CLM0000000769,MBR00000226,Medical_Professional,Denied,Electronic_EDI,2023-02-23,2023-02-23,2023-02-23,2023-03-21,Auto_Adjudicated,26,1114266188,1509799493,207RN0300X,Nephrology,23,In_Network,OTHER,L70.0,74177,,0,Medicare_Advantage,MA_PPO,84,M,1.0796,96,Timely_Filing,274.52,118.19,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.14,unbundling_pattern,0,1,0,0,0,0.0,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000000770,MBR00000208,Medical_Professional,Denied,Electronic_EDI,2023-12-20,2023-12-20,2023-12-20,2024-01-12,Auto_Adjudicated,23,1602370875,1694343357,207RP1001X,Pulmonary Disease,11,In_Network,Z00.00,,27447,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,97,Eligibility,6176.38,2688.68,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1449,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000771,MBR00000274,Behavioral_Health,Paid,Electronic_EDI,2023-12-18,2023-12-18,2023-12-18,2024-01-01,Auto_Adjudicated,14,1617763056,1706603847,207R00000X,Internal Medicine,65,Out_of_Network,Z87.891,OTHER,99385,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,295.23,145.25,115.54,0.83,0.0,28.88,149.98,0.0,0.0,0,,0.0445,none,0,1,0,0,0,1.1e-05,1,0,FLU_Flu_Vaccination,FFS
CLM0000000772,MBR00000072,Pharmacy,Paid,Electronic_EDI,2023-11-12,2023-11-12,2023-11-12,2023-11-30,Auto_Adjudicated,18,1170319307,1587454801,101YP2500X,Psychologist Clinical,22,In_Network,Z00.121,,00006001954,,1,Medicare_Advantage,MA_PPO,39,M,0.4967,,,97.76,77.33,41.61,17.32,8.0,10.4,20.43,0.0,0.0,0,,0.1422,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000000773,MBR00000233,Medical_Professional,Paid,Electronic_EDI,2023-10-25,2023-10-25,2023-10-25,2023-11-03,Auto_Adjudicated,9,1950560596,1196833348,225100000X,Physical Therapist,24,In_Network,M54.5,,99233,,0,Medicare_Advantage,MA_PPO,87,M,0.8034,,,284.98,228.69,176.36,5.24,3.0,44.09,56.29,0.0,0.0,0,,0.0398,none,0,1,0,0,0,1.6e-05,0,0,,P4P
CLM0000000774,MBR00000172,Medical_Professional,Paid,Electronic_EDI,2023-01-27,2023-01-27,2023-01-27,2023-02-11,Manual_Review,15,1429653002,1878874025,207Q00000X,Family Medicine,21,In_Network,E78.5,Z00.01,99392,,0,Medicaid_MCO,MCO,50,F,0.2787,,,375.72,301.74,301.74,0.0,0.0,0.0,73.98,0.0,0.0,0,,0.0747,none,0,1,0,0,0,2.8e-05,0,0,,FFS
CLM0000000775,MBR00000097,Medical_Professional,Paid,Electronic_EDI,2023-02-13,2023-02-13,2023-02-13,2023-03-09,Auto_Adjudicated,24,1426424205,1878017518,207RN0300X,Nephrology,71,In_Network,I10,M17.11|OTHER,74178,,0,Commercial,EPO,34,M,1.3765,,,280.13,207.64,0.0,207.64,0.0,0.0,72.49,0.0,0.0,0,,0.1232,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000000776,MBR00000011,Pharmacy,Paid,Electronic_EDI,2023-08-09,2023-08-09,2023-08-09,2023-08-25,Auto_Adjudicated,16,1122148537,1473869105,207R00000X,Internal Medicine,23,In_Network,E78.5,,00071015523,,3,Medicare_Advantage,SNP,35,F,1.0833,,,79.96,54.36,28.9,1.24,17.0,7.22,25.6,0.0,0.0,0,,0.0272,none,0,1,0,0,0,3e-06,0,0,,FFS
CLM0000000777,MBR00000244,Pharmacy,Paid,Electronic_EDI,2023-02-06,2023-02-06,2023-02-06,2023-03-02,Auto_Adjudicated,24,1898658234,1810068286,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,,00006001954,,1,Commercial,PPO,52,M,0.6677,,,973.47,627.54,421.51,89.66,11.0,105.38,345.93,0.0,0.0,1,DME Fraud,1.0,provider_specialty_mismatch|temporal_clustering|high_volume_same_code|impossible_service_combo|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,3.9e-05,0,1,,Shared_Savings
CLM0000000778,MBR00000076,Medical_Professional,Denied,Electronic_EDI,2023-04-01,2023-04-01,2023-04-01,2023-04-16,Manual_Review,15,1084831484,1029818813,207RE0101X,Endocrinology,22,Out_of_Network,Z00.00,Z00.01,73721,,0,Commercial,HMO,26,M,2.1785,97,Authorization,1058.28,896.28,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0761,none,0,1,0,1,0,0.0,1,0,,Shared_Savings
CLM0000000779,MBR00000187,Medical_Professional,Paid,Electronic_EDI,2023-12-17,2023-12-17,2023-12-17,2023-12-28,Auto_Adjudicated,11,1210349885,1029818813,207R00000X,Internal Medicine,11,In_Network,F32.9,,99222,,0,Medicaid_MCO,MCO,36,F,1.191,,,466.05,235.89,232.89,0.0,3.0,0.0,230.16,0.0,0.0,0,,0.0192,none,0,1,0,0,0,2.2e-05,0,0,,FFS
CLM0000000780,MBR00000166,Dental,Denied,Paper,2023-11-23,2023-11-23,2023-11-23,2023-12-20,Auto_Adjudicated,27,1133265917,1148659045,207RE0101X,Endocrinology,31,In_Network,E78.5,I10|Z23,D0120,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,2,Eligibility,1575.45,1129.76,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1772,high_oop_waiver,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000781,MBR00000002,Pharmacy,Paid,Electronic_EDI,2023-04-02,2023-04-02,2023-04-02,2023-04-30,Manual_Review,28,1556072255,1829216053,207RN0300X,Nephrology,24,In_Network,M47.816,E11.65|G43.909,00078043215,,2,Commercial,PPO,42,F,0.9012,,,217.96,83.36,12.52,49.72,18.0,3.13,134.6,0.0,0.0,0,,0.0314,none,0,1,0,0,0,1e-06,0,1,IET_Initiation_Substance_Use,FFS
CLM0000000782,MBR00000299,Medical_Institutional,Paid,Electronic_EDI,2023-07-13,2023-07-13,2023-07-16,2023-07-20,Auto_Adjudicated,7,1832660692,1789540567,2084P0800X,Psychiatry,22,In_Network,J06.9,E11.65|E11.9,revenue_code:0110,,0,Medicaid_MCO,MCO,74,F,0.8833,,,5523.86,2175.9,2173.9,0.0,2.0,0.0,3347.96,0.0,0.0,0,,0.0717,none,0,1,0,0,0,0.000201,0,0,,P4P
CLM0000000783,MBR00000242,Medical_Institutional,Paid,Provider_Portal,2023-07-13,2023-07-13,2023-07-15,2023-07-27,Manual_Review,14,1389116733,1049766043,207RN0300X,Nephrology,11,In_Network,J06.9,OTHER,revenue_code:0120,,0,Medicaid_MCO,MLTSS,75,F,0.7104,,,13453.42,8644.33,8642.33,0.0,2.0,0.0,4809.09,0.0,0.0,0,,0.1035,benford_violation,0,1,1,0,0,0.0008,0,0,,FFS
CLM0000000784,MBR00000151,Behavioral_Health,Paid,Provider_Portal,2023-04-05,2023-04-05,2023-04-05,2023-04-29,Auto_Adjudicated,24,1592228076,1365397818,208600000X,Surgery General,31,In_Network,Z00.00,E78.5|OTHER,71250,,0,Medicare_Advantage,MA_HMO,77,M,0.8709,,,200.18,155.85,108.28,14.5,6.0,27.07,44.33,0.0,0.0,0,,0.0979,none,0,1,0,0,0,1e-05,0,0,,Shared_Savings
CLM0000000785,MBR00000202,Pharmacy,Paid,Electronic_EDI,2023-03-26,2023-03-26,2023-03-26,2023-04-03,Auto_Adjudicated,8,1873731689,1747935894,207RP1001X,Pulmonary Disease,31,In_Network,OTHER,F41.1,00069420020,,2,Commercial,PPO,87,F,0.6213,,,189.93,152.14,0.0,152.14,0.0,0.0,37.79,0.0,0.0,0,,0.098,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000786,MBR00000146,Vision,Paid,Electronic_EDI,2023-06-06,2023-06-06,2023-06-06,2023-06-29,Auto_Adjudicated,23,1556434733,1912895973,208600000X,Surgery General,22,In_Network,N39.0,Z00.00|F41.1,92012,,0,Medicaid_MCO,MCO,24,M,0.6484,,,400.75,145.78,141.78,0.0,4.0,0.0,254.97,94.05,37.32,0,,0.044,none,0,1,0,0,0,1.3e-05,0,0,,P4P
CLM0000000787,MBR00000218,Medical_Professional,Paid,Electronic_EDI,2023-08-04,2023-08-04,2023-08-04,2023-08-31,Auto_Adjudicated,27,1092800235,1649705287,207V00000X,Obstetrics & Gynecology,23,In_Network,Z00.00,R05.9,99283,,0,Commercial,HDHP_HSA,11,F,0.4964,,,424.37,208.86,31.77,169.15,0.0,7.94,215.51,22.09,4.85,0,,0.0927,impossible_service_combo,0,1,0,1,0,3e-06,0,0,SPD_Spirometry_Testing,Shared_Savings
CLM0000000788,MBR00000042,Medical_Professional,Paid,Electronic_EDI,2023-10-16,2023-10-16,2023-10-16,2023-10-24,Manual_Review,8,1274357072,1049766043,2084P0800X,Psychiatry,11,Emergency,M25.511,OTHER,90847,,0,Commercial,HMO,78,F,1.1448,,,159.75,124.24,80.67,3.4,20.0,20.17,35.51,0.0,0.0,0,,0.0086,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000000789,MBR00000139,Medical_Professional,Paid,Paper,2023-10-29,2023-10-29,2023-10-29,2023-11-03,Auto_Adjudicated,5,1466922283,1704466150,207RN0300X,Nephrology,21,Out_of_Network,OTHER,I25.10|OTHER,99396,,0,Commercial,PPO,74,M,1.7701,,,507.64,317.43,83.04,192.63,21.0,20.76,190.21,0.0,0.0,0,,0.0758,none,0,1,0,0,0,8e-06,1,0,,Shared_Savings
CLM0000000790,MBR00000106,Dental,Paid,Electronic_EDI,2023-01-08,2023-01-08,2023-01-08,2023-02-06,Auto_Adjudicated,29,1477762002,1473869105,207RC0000X,Cardiovascular Disease,71,In_Network,F32.9,Z12.11|E11.9,D2140,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,412.45,178.5,120.41,21.98,6.0,30.1,233.95,0.0,0.0,0,,0.0698,none,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000000791,MBR00000143,Pharmacy,Denied,Paper,2023-08-24,2023-08-24,2023-08-24,2023-09-23,Auto_Adjudicated,30,1733777382,1884259357,207RN0300X,Nephrology,24,Out_of_Network,OTHER,K21.0,00310075090,,2,Commercial,POS,85,M,1.6078,170,Medical_Necessity,113.76,65.79,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1398,none,0,1,0,0,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000000792,MBR00000140,Medical_Professional,Paid,Electronic_EDI,2023-08-10,2023-08-10,2023-08-10,2023-09-05,Clinical_Review,26,1264432433,1811797489,207RC0000X,Cardiovascular Disease,11,In_Network,E11.9,G47.33|Z00.01|Z79.4,99232,,0,Medicare_Advantage,MA_HMO,7,M,1.3997,,,404.18,300.89,230.43,0.85,12.0,57.61,103.29,0.0,0.0,0,,0.1324,controlled_substance_high_volume,0,1,0,0,0,2.1e-05,0,0,MMA_Medication_Management,FFS
CLM0000000793,MBR00000045,Behavioral_Health,Paid,Provider_Portal,2023-01-17,2023-01-17,2023-01-17,2023-02-05,Auto_Adjudicated,19,1661091022,1774401124,2086S0122X,Orthopedic Surgery,22,In_Network,OTHER,Z12.11,99391,,0,Commercial,HMO,78,F,1.0658,,,130.11,96.1,37.27,17.51,32.0,9.32,34.01,0.0,0.0,0,,0.1072,high_volume_same_code,0,1,0,1,0,3e-06,0,0,HBD_Hemoglobin_A1c_Testing,Shared_Savings
CLM0000000794,MBR00000294,Vision,Paid,Electronic_EDI,2023-10-27,2023-10-27,2023-10-27,2023-10-30,Auto_Adjudicated,3,1797494973,1123879500,207RP1001X,Pulmonary Disease,21,Out_of_Network,OTHER,OTHER,92014,,0,Medicare_Advantage,MA_HMO,8,M,0.6878,,,169.5,132.12,81.24,12.58,18.0,20.31,37.38,0.0,0.0,0,,0.0369,none,0,1,0,0,0,8e-06,1,0,,FFS
CLM0000000795,MBR00000005,Medical_Professional,Paid,Provider_Portal,2023-08-02,2023-08-02,2023-08-02,2023-08-30,Auto_Adjudicated,28,1377412382,1860951128,246ZN0300X,Neuropsychology,11,In_Network,N39.0,E78.5,99204,,0,Medicare_Advantage,MA_PPO,8,M,0.566,,,475.46,171.51,117.68,19.41,5.0,29.42,303.95,0.0,0.0,0,,0.0574,none,0,1,0,0,0,1.1e-05,0,0,,Capitation
CLM0000000796,MBR00000004,Medical_Institutional,Paid,Electronic_EDI,2023-09-16,2023-09-16,2023-09-16,2023-09-22,Auto_Adjudicated,6,1069440570,1994275960,207RN0300X,Nephrology,81,In_Network,J20.9,K21.0|M17.11,revenue_code:0200,,0,Medicare_Advantage,MA_PPO,68,M,1.23,,,12746.15,6427.4,5057.36,52.69,53.0,1264.34,6318.75,0.0,0.0,0,,0.1214,unusual_service_frequency,0,1,1,1,0,0.000468,0,0,,Shared_Savings
CLM0000000797,MBR00000118,Pharmacy,Paid,Electronic_EDI,2023-08-26,2023-08-26,2023-08-26,2023-09-01,Auto_Adjudicated,6,1944105498,1804282800,207R00000X,Internal Medicine,11,In_Network,Z00.01,OTHER|Z00.00|E11.9,00078043215,,1,Medicaid_MCO,MCO,69,M,1.2773,,,630.88,316.44,315.44,0.0,1.0,0.0,314.44,250.05,49.87,0,,0.041,none,0,1,0,0,0,2.9e-05,0,0,,FFS
CLM0000000798,MBR00000185,Medical_Professional,Denied,Electronic_EDI,2023-05-01,2023-05-01,2023-05-01,2023-05-23,Auto_Adjudicated,22,1102590784,1690197969,246ZN0300X,Neuropsychology,21,In_Network,I10,Z00.01|OTHER,99284,,0,Medicaid_MCO,MCO,73,M,1.5417,97,Authorization,198.68,95.27,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0875,billing_spike_recent,0,1,0,0,0,0.0,0,0,BCS_Breast_Cancer_Screening,Bundled_Payment
CLM0000000799,MBR00000056,Pharmacy,Denied,Electronic_EDI,2023-03-14,2023-03-14,2023-03-14,2023-03-26,Auto_Adjudicated,12,1905691248,1282319940,207RG0100X,Gastroenterology,31,In_Network,Z23,I10,00310075090,,1,Commercial,EPO,74,F,1.3941,1,Authorization,227.24,129.13,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1299,none,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000000800,MBR00000162,Medical_Professional,Denied,Electronic_EDI,2023-05-16,2023-05-16,2023-05-16,2023-06-12,Auto_Adjudicated,27,1988579666,1252125670,207RN0300X,Nephrology,11,In_Network,OTHER,OTHER,97110,,0,Medicaid_MCO,MLTSS,84,F,1.324,97,Coding_Error,852.49,475.03,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0905,billing_spike_recent,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000801,MBR00000212,Dental,Paid,Electronic_EDI,2023-10-01,2023-10-01,2023-10-01,2023-10-28,Auto_Adjudicated,27,1853233709,1300957944,101YP2500X,Psychologist Clinical,21,In_Network,E11.9,N39.0,D0120,,0,Commercial,HMO,57,F,2.5456,,,446.51,245.55,169.94,15.12,18.0,42.49,200.96,0.0,0.0,0,,0.0903,none,0,1,0,1,0,1.6e-05,0,0,,Shared_Savings
CLM0000000802,MBR00000028,Pharmacy,Paid,Electronic_EDI,2023-08-17,2023-08-17,2023-08-17,2023-09-11,Auto_Adjudicated,25,1887363539,1942423230,207RP1001X,Pulmonary Disease,23,In_Network,F32.9,OTHER|M54.5,59148001506,,1,Commercial,HMO,3,F,2.116,,,295.76,167.98,0.0,167.98,0.0,0.0,127.78,0.0,0.0,0,,0.1477,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000803,MBR00000296,Dental,Paid,Electronic_EDI,2023-08-14,2023-08-14,2023-08-14,2023-09-09,Clinical_Review,26,1231231881,1728466420,207RN0300X,Nephrology,21,In_Network,Z00.00,F32.9|OTHER|Z00.01,D4341,,0,Commercial,HMO,83,F,1.4969,,,461.14,233.37,44.31,146.98,31.0,11.08,227.77,29.96,9.59,0,,0.1664,upcoding_pattern,0,1,0,0,0,4e-06,0,0,POD_Persistence_of_Beta_Blocker,FFS
CLM0000000804,MBR00000106,Pharmacy,Paid,Provider_Portal,2023-02-16,2023-02-16,2023-02-16,2023-03-05,Clinical_Review,17,1682685390,1995553359,2084P0800X,Psychiatry,21,In_Network,M54.5,F33.0|OTHER,00078043215,,1,Medicare_Advantage,MA_PPO,69,M,1.7254,,,182.78,153.64,89.74,35.47,6.0,22.43,29.14,0.0,0.0,0,,0.2052,temporal_clustering|service_date_weekend,0,2,0,0,0,8e-06,0,0,,FFS
CLM0000000805,MBR00000191,Medical_Professional,Paid,Electronic_EDI,2023-01-04,2023-01-04,2023-01-04,2023-01-31,Auto_Adjudicated,27,1451464799,1287935251,208600000X,Surgery General,22,In_Network,Z12.11,I10,99231,,0,Commercial,POS,85,F,0.9729,,,106.06,67.38,4.53,23.72,38.0,1.13,38.68,0.0,0.0,0,,0.0598,unusual_service_frequency,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000806,MBR00000034,Medical_Professional,Denied,Electronic_EDI,2023-08-28,2023-08-28,2023-08-28,2023-09-25,Auto_Adjudicated,28,1192302048,1054984734,2084P0800X,Psychiatry,71,In_Network,OTHER,OTHER,27130,,0,Medicare_Advantage,MA_HMO,35,M,0.7712,2,Medical_Necessity,32959.91,19175.57,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1967,temporal_clustering,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000807,MBR00000210,Pharmacy,Paid,Paper,2023-12-08,2023-12-08,2023-12-08,2023-12-17,Auto_Adjudicated,9,1981853293,1144950506,207RG0100X,Gastroenterology,32,In_Network,E11.9,E78.5,00006001954,,3,Medicare_Advantage,SNP,49,M,0.6952,,,26.95,12.66,0.0,11.59,1.07,0.0,14.29,0.0,0.0,0,,0.003,none,0,1,0,0,0,0.0,0,1,AWV_Annual_Wellness_Visit,FFS
CLM0000000808,MBR00000251,Medical_Professional,Paid,Electronic_EDI,2023-05-09,2023-05-09,2023-05-09,2023-05-22,Auto_Adjudicated,13,1618564043,1878017518,246ZN0300X,Neuropsychology,11,In_Network,Z00.01,E11.9,99395,,0,Commercial,PPO,65,M,0.7737,,,151.1,72.19,5.36,52.5,13.0,1.34,78.91,3.45,1.37,0,,0.0766,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000809,MBR00000032,Pharmacy,Paid,Electronic_EDI,2023-06-09,2023-06-09,2023-06-09,2023-06-28,Auto_Adjudicated,19,1918359820,1157814306,246ZN0300X,Neuropsychology,22,In_Network,Z00.00,I10|H52.4|Z00.00,00071015523,,1,Medicaid_MCO,FFS_Medicaid,87,M,0.4839,,,102.43,74.74,72.74,0.0,2.0,0.0,27.69,0.0,0.0,0,,0.1443,none,0,1,0,0,0,7e-06,0,0,HBD_Hemoglobin_A1c_Testing,Bundled_Payment
CLM0000000810,MBR00000038,Medical_Professional,Paid,Electronic_EDI,2023-12-10,2023-12-10,2023-12-10,2024-01-05,Manual_Review,26,1388566092,1469881892,207RN0300X,Nephrology,23,In_Network,N39.0,,83036,,0,Commercial,EPO,46,M,1.1295,,,1223.18,682.16,419.61,119.65,38.0,104.9,541.02,0.0,0.0,0,,0.1378,none,0,1,0,0,0,3.9e-05,0,0,FLU_Flu_Vaccination,Shared_Savings
CLM0000000811,MBR00000088,Medical_Professional,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-25,2023-04-06,Auto_Adjudicated,12,1130461876,1321680994,207RN0300X,Nephrology,21,In_Network,N39.0,Z23|M47.816,99397,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,,,352.25,180.64,0.0,178.98,1.66,0.0,171.61,0.0,0.0,1,Prescription Drug Diversion,0.9292,unusual_service_frequency|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|unbundling_pattern|npi_mismatch|high_oop_waiver,1,5,0,0,0,0.0,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000000812,MBR00000004,Medical_Institutional,Paid,Provider_Portal,2023-07-07,2023-07-07,2023-07-09,2023-07-15,Auto_Adjudicated,8,1042080259,1004714954,207RG0100X,Gastroenterology,11,In_Network,E11.9,I10,revenue_code:0200,,0,Medicare_Advantage,MA_PPO,68,M,1.23,,,3444.54,1526.01,1162.43,19.97,53.0,290.61,1918.53,0.0,0.0,0,,0.1635,phantom_billing_indicator,0,1,0,0,0,0.000108,0,0,,FFS
CLM0000000813,MBR00000297,Pharmacy,Paid,Electronic_EDI,2023-01-31,2023-01-31,2023-01-31,2023-02-10,Auto_Adjudicated,10,1108756266,1007652766,207Q00000X,Family Medicine,22,In_Network,E78.5,E11.9|I10,00169751112,,1,Commercial,HMO,88,M,1.5311,,,74.68,63.26,20.61,10.5,27.0,5.15,11.42,0.0,0.0,0,,0.1623,upcoding_pattern,0,1,0,0,0,2e-06,0,1,,FFS
CLM0000000814,MBR00000180,Medical_Institutional,Denied,Electronic_EDI,2023-04-05,2023-04-05,2023-04-08,2023-04-29,Manual_Review,24,1519736600,1522426351,207RN0300X,Nephrology,21,In_Network,M54.5,Z00.00|F32.9|F41.1,revenue_code:0360,248,0,Medicare_Advantage,MA_PPO,72,F,1.1909,22,Network,1583.29,840.65,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0257,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000815,MBR00000183,Medical_Institutional,Paid,Electronic_EDI,2023-05-15,2023-05-15,2023-05-17,2023-05-31,Auto_Adjudicated,16,1673449362,1297948643,207R00000X,Internal Medicine,65,In_Network,Z00.00,OTHER,revenue_code:0360,,0,Commercial,PPO,51,M,0.8463,,,4275.11,1908.13,1314.11,208.49,57.0,328.53,2366.98,0.0,0.0,0,,0.1991,high_oop_waiver,0,1,0,0,0,0.000122,0,0,BPD_BP_Declined,FFS
CLM0000000816,MBR00000291,Medical_Institutional,Denied,Electronic_EDI,2023-09-04,2023-09-04,2023-09-07,2023-09-12,Auto_Adjudicated,8,1424416273,1433350836,207R00000X,Internal Medicine,11,Emergency,OTHER,G43.909,revenue_code:0120,,0,Commercial,PPO,78,M,1.4773,96,COB,6790.61,4881.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1025,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,,P4P
CLM0000000817,MBR00000249,Pharmacy,Paid,Electronic_EDI,2023-04-21,2023-04-21,2023-04-21,2023-05-13,Auto_Adjudicated,22,1048378959,1704466150,207R00000X,Internal Medicine,11,In_Network,OTHER,,59148001506,,2,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,581.09,465.76,300.65,6.27,30.0,128.85,115.33,0.0,0.0,0,,0.0407,none,0,1,0,0,0,2.8e-05,0,0,FLU_Flu_Vaccination,Shared_Savings
CLM0000000818,MBR00000242,Medical_Institutional,Paid,Provider_Portal,2023-06-15,2023-06-15,2023-06-18,2023-07-05,Manual_Review,20,1466922283,1007652766,207V00000X,Obstetrics & Gynecology,65,In_Network,M54.5,,revenue_code:0300,,0,Medicaid_MCO,MLTSS,75,F,0.7104,,,30756.76,22401.03,22399.03,0.0,2.0,0.0,8355.73,17940.51,3588.77,0,,0.0713,high_oop_waiver,0,1,1,0,0,0.002073,0,0,,Capitation
CLM0000000819,MBR00000106,Medical_Institutional,Denied,Electronic_EDI,2023-04-17,2023-04-17,2023-04-19,2023-05-03,Clinical_Review,16,1706046899,1809122260,207Q00000X,Family Medicine,65,In_Network,I25.10,OTHER,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,96,Network,14872.47,7973.37,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1787,upcoding_pattern,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000820,MBR00000106,Medical_Institutional,Paid,Paper,2023-02-20,2023-02-20,2023-02-21,2023-03-11,Auto_Adjudicated,19,1469009511,1321680994,2086S0122X,Orthopedic Surgery,21,Out_of_Network,M54.5,Z00.121,revenue_code:0300,193,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,9068.33,6495.99,5143.27,31.9,35.0,1285.82,2572.34,0.0,0.0,0,,0.0691,none,0,1,1,0,0,0.000476,0,0,,FFS
CLM0000000821,MBR00000091,Medical_Institutional,Paid,Provider_Portal,2023-10-12,2023-10-12,2023-10-13,2023-10-19,Auto_Adjudicated,7,1878453830,1972530373,207RG0100X,Gastroenterology,24,In_Network,Z00.00,OTHER,revenue_code:0210,,0,Commercial,PPO,13,F,1.2451,,,23882.78,12169.18,9498.62,261.9,34.0,2374.66,11713.6,0.0,0.0,0,,0.1477,none,0,1,1,0,0,0.000879,0,0,COA_Care_Transitions,FFS
CLM0000000822,MBR00000109,Medical_Professional,Paid,Electronic_EDI,2023-08-30,2023-08-30,2023-08-30,2023-09-05,Manual_Review,6,1514646292,1452088018,207V00000X,Obstetrics & Gynecology,31,In_Network,J44.1,E78.5,20610,,0,Commercial,HMO,8,F,0.5723,,,1584.31,940.79,641.11,101.4,38.0,160.28,643.52,0.0,0.0,0,,0.126,none,0,1,0,0,0,5.9e-05,0,0,KED_ESRD_Patients,Capitation
CLM0000000823,MBR00000117,Pharmacy,Paid,Electronic_EDI,2023-08-20,2023-08-20,2023-08-20,2023-09-14,Auto_Adjudicated,25,1478458171,1662516615,207RN0300X,Nephrology,11,In_Network,F10.10,,59148001506,,1,Medicaid_MCO,MLTSS,72,F,0.8628,,,107.29,43.04,39.04,0.0,4.0,0.0,64.25,0.0,0.0,0,,0.1127,billing_spike_recent,0,1,0,1,0,4e-06,0,0,,FFS
CLM0000000824,MBR00000044,Medical_Professional,Denied,Electronic_EDI,2023-07-29,2023-07-29,2023-07-29,2023-08-19,Auto_Adjudicated,21,1976612978,1339359594,2084P0800X,Psychiatry,23,In_Network,J06.9,I10|Z12.11,97110,,0,Commercial,PPO,29,M,0.7512,96,Duplicate,443.15,218.36,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1697,upcoding_pattern,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000000825,MBR00000112,Dental,Paid,Electronic_EDI,2023-02-17,2023-02-17,2023-02-17,2023-03-19,Auto_Adjudicated,30,1506426842,1164525386,207RG0100X,Gastroenterology,24,In_Network,E11.9,F41.1|OTHER,D0150,,0,Medicare_Advantage,MA_HMO,18,M,1.01,,,270.17,163.21,102.34,29.29,6.0,25.58,106.96,70.0,23.45,0,,0.0143,none,0,1,0,0,0,9e-06,0,0,PPC_Prenatal_Care,Capitation
CLM0000000826,MBR00000139,Pharmacy,Paid,Electronic_EDI,2023-07-04,2023-07-04,2023-07-04,2023-08-02,Auto_Adjudicated,29,1924450526,1469697158,2084P0800X,Psychiatry,21,In_Network,E78.5,J20.9|OTHER|E78.5,16590051660,,3,Commercial,PPO,74,M,1.7701,,,44.94,17.38,0.0,17.38,0.0,0.0,27.56,0.0,0.0,0,,0.1217,none,0,1,0,0,0,0.0,0,1,AWV_Annual_Wellness_Visit,Capitation
CLM0000000827,MBR00000098,Medical_Institutional,Paid,Paper,2023-09-12,2023-09-12,2023-09-15,2023-09-23,Auto_Adjudicated,11,1331829614,1829216053,207RP1001X,Pulmonary Disease,71,In_Network,J06.9,,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,7,M,0.511,,,35685.59,25585.54,20419.82,20.76,40.0,5104.96,10100.05,0.0,0.0,0,,0.12,none,0,1,1,1,0,0.00189,0,0,,FFS
CLM0000000828,MBR00000052,Pharmacy,Partially_Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-27,2023-07-11,Auto_Adjudicated,14,1972755666,1321680994,207RG0100X,Gastroenterology,81,In_Network,F32.9,I25.10,00169751112,,2,Commercial,PPO,0,F,1.325,18,Medical_Necessity,112.87,62.81,0.0,44.56,0.0,0.0,68.31,0.0,0.0,0,,0.1054,service_date_weekend,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000829,MBR00000118,Pharmacy,Denied,Electronic_EDI,2023-09-17,2023-09-17,2023-09-17,2023-10-13,Auto_Adjudicated,26,1658382624,1510751265,2086S0122X,Orthopedic Surgery,22,In_Network,Z00.121,,00169751112,,1,Medicaid_MCO,MCO,69,M,1.2773,3,Network,142.81,87.84,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0576,none,0,1,0,0,0,0.0,0,1,,Bundled_Payment
CLM0000000830,MBR00000148,Medical_Professional,Paid,Electronic_EDI,2023-04-29,2023-04-29,2023-04-29,2023-04-30,Auto_Adjudicated,1,1813729693,1513198866,2084P0800X,Psychiatry,11,Emergency,E11.9,R05.9|I10|OTHER,12001,,0,Commercial,EPO,51,F,0.6534,,,1801.11,1044.26,564.85,305.2,33.0,141.21,756.85,0.0,0.0,0,,0.0186,none,0,1,0,0,0,5.2e-05,0,0,,Bundled_Payment
CLM0000000831,MBR00000212,Pharmacy,Partially_Paid,Electronic_EDI,2023-07-04,2023-07-04,2023-07-04,2023-07-30,Auto_Adjudicated,26,1083045036,1588993671,207Q00000X,Family Medicine,65,In_Network,C50.911,M79.3,00071015523,,3,Commercial,HMO,57,F,2.5456,3,Medical_Necessity,116.9,82.46,0.0,50.89,0.0,0.0,66.01,0.0,0.0,0,,0.1253,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000832,MBR00000211,Behavioral_Health,Paid,Paper,2023-05-17,2023-05-17,2023-05-17,2023-05-23,Auto_Adjudicated,6,1658382624,1274911960,207RN0300X,Nephrology,22,In_Network,OTHER,I10|Z23|M79.3,71046,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,,,414.33,276.8,211.5,0.42,12.0,52.88,137.53,0.0,0.0,0,,0.0732,benford_violation,0,1,0,0,0,2e-05,0,0,,FFS
CLM0000000833,MBR00000061,Medical_Professional,Paid,Paper,2023-12-24,2023-12-24,2023-12-24,2024-01-01,Clinical_Review,8,1788188920,1297948643,207RN0300X,Nephrology,11,In_Network,I10,H52.4|Z23,97140,,0,Commercial,PPO,66,M,2.3575,,,191.19,134.31,0.0,134.31,0.0,0.0,56.88,0.0,0.0,0,,0.055,none,0,1,0,0,0,0.0,0,0,IET_Initiation_Substance_Use,FFS
CLM0000000834,MBR00000012,Medical_Professional,Paid,Electronic_EDI,2023-03-06,2023-03-06,2023-03-06,2023-03-21,Auto_Adjudicated,15,1111846258,1301869102,208600000X,Surgery General,24,In_Network,M17.11,,10060,,0,Commercial,HMO,84,M,1.3904,,,962.93,448.86,332.59,5.12,28.0,83.15,514.07,0.0,0.0,0,,0.0873,none,0,1,0,1,0,3.1e-05,0,0,CBP_Controlling_BP,Capitation
CLM0000000835,MBR00000096,Medical_Institutional,Paid,Electronic_EDI,2023-04-12,2023-04-12,2023-04-16,2023-05-04,Auto_Adjudicated,22,1943769986,1540743888,207Q00000X,Family Medicine,23,In_Network,J06.9,F10.10,revenue_code:0210,,0,Medicaid_MCO,MCO,62,M,0.7948,,,8036.44,5335.52,5330.52,0.0,5.0,0.0,2700.92,0.0,0.0,0,,0.1033,none,0,1,1,0,0,0.000493,0,0,,FFS
CLM0000000836,MBR00000050,Medical_Institutional,Paid,Electronic_EDI,2023-09-02,2023-09-02,2023-09-04,2023-09-13,Auto_Adjudicated,11,1334227781,1020312030,207RN0300X,Nephrology,11,Out_of_Network,J44.1,E78.5,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,12,F,0.8486,,,2896.34,1768.21,1384.87,4.12,33.0,346.22,1128.13,0.0,0.0,0,,0.0847,none,0,1,0,1,0,0.000128,1,0,SPC_Statin_Therapy,FFS
CLM0000000837,MBR00000125,Medical_Institutional,Paid,Electronic_EDI,2023-01-21,2023-01-21,2023-01-23,2023-02-19,Auto_Adjudicated,29,1478783612,1390802135,225100000X,Physical Therapist,11,In_Network,OTHER,M54.5,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,4318.67,1672.12,1299.07,3.28,45.0,324.77,2646.55,952.18,256.15,0,,0.0298,none,0,1,0,1,0,0.00012,0,0,,Capitation
CLM0000000838,MBR00000295,Medical_Institutional,Paid,Electronic_EDI,2023-07-04,2023-07-04,2023-07-08,2023-07-28,Auto_Adjudicated,24,1102040918,1354265777,225100000X,Physical Therapist,31,In_Network,OTHER,Z00.00|F41.1|I10,revenue_code:0210,,0,Commercial,HDHP_HSA,78,F,0.8618,,,13616.3,5143.79,4080.17,43.58,0.0,1020.04,8472.51,0.0,0.0,0,,0.2007,unusual_service_frequency,0,2,0,0,0,0.000378,0,0,,FFS
CLM0000000839,MBR00000056,Pharmacy,Denied,Electronic_EDI,2023-01-11,2023-01-11,2023-01-11,2023-02-03,Auto_Adjudicated,23,1145498455,1274911960,207RN0300X,Nephrology,81,In_Network,K21.0,,59148001506,,4,Commercial,EPO,74,F,1.3941,3,Duplicate,83.51,53.49,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0684,none,0,1,0,0,0,0.0,0,0,DDE_Diabetes_Short_Term_Complications,Capitation
CLM0000000840,MBR00000101,Medical_Professional,Paid,Electronic_EDI,2023-07-09,2023-07-09,2023-07-09,2023-08-02,Auto_Adjudicated,24,1887322427,1354265777,207R00000X,Internal Medicine,21,In_Network,Z00.121,N18.3|OTHER,27130,,0,Commercial,PPO,83,M,0.3627,,,23534.69,15109.84,12070.04,0.29,22.0,3017.51,8424.85,9303.3,1639.72,0,,0.1473,none,0,1,1,0,0,0.001117,0,0,,Shared_Savings
CLM0000000841,MBR00000213,Medical_Institutional,Paid,Electronic_EDI,2023-04-26,2023-04-26,2023-04-27,2023-04-27,Clinical_Review,1,1871417879,1144950506,207R00000X,Internal Medicine,11,Out_of_Network,M17.11,,revenue_code:0450,,0,Commercial,PPO,17,M,1.5857,,,6135.59,4517.89,3410.88,211.29,43.0,852.72,1617.7,0.0,0.0,0,,0.1267,none,0,1,0,0,0,0.000316,1,0,,Shared_Savings
CLM0000000842,MBR00000156,Dental,Paid,Electronic_EDI,2023-03-10,2023-03-10,2023-03-10,2023-04-04,Manual_Review,25,1946657989,1831337866,2084P0800X,Psychiatry,21,In_Network,OTHER,OTHER|Z12.11,D0150,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,132.46,97.02,66.96,0.32,13.0,16.74,35.44,0.0,0.0,0,,0.1214,none,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000000843,MBR00000013,Medical_Professional,Denied,Electronic_EDI,2023-06-28,2023-06-28,2023-06-28,2023-07-17,Auto_Adjudicated,19,1055095309,1040061910,207Q00000X,Family Medicine,22,In_Network,OTHER,,99283,,0,Commercial,PPO,64,F,1.428,50,Eligibility,454.73,262.76,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1814,unusual_service_frequency,0,1,0,1,0,0.0,0,0,,FFS
CLM0000000844,MBR00000051,Medical_Institutional,Paid,Paper,2023-04-29,2023-04-29,2023-05-03,2023-05-05,Auto_Adjudicated,6,1080383191,1691162131,207RC0000X,Cardiovascular Disease,11,In_Network,C50.911,H52.4,revenue_code:0300,,0,Medicare_Advantage,MA_PPO,17,F,1.0695,,,15640.49,8828.14,7037.69,7.02,24.0,1759.42,6812.35,0.0,0.0,0,,0.0443,none,0,1,1,0,0,0.000651,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000000845,MBR00000282,Medical_Professional,Paid,Electronic_EDI,2023-01-29,2023-01-29,2023-01-29,2023-02-22,Auto_Adjudicated,24,1618564043,1365397818,207RP1001X,Pulmonary Disease,22,In_Network,Z00.00,OTHER|N39.0,99283,,0,Medicare_Advantage,MA_HMO,16,M,0.7304,,,113.67,61.87,3.62,39.34,18.0,0.91,51.8,0.0,0.0,0,,0.0153,none,0,1,0,0,0,0.0,0,0,W30_Well_Child_Visit,FFS
CLM0000000846,MBR00000031,Medical_Professional,Paid,Electronic_EDI,2023-07-11,2023-07-11,2023-07-11,2023-07-15,Auto_Adjudicated,4,1326896487,1649705287,207Q00000X,Family Medicine,11,In_Network,E11.9,J06.9,99213,,0,Commercial,PPO,71,M,0.6746,,,388.12,318.76,215.66,33.18,16.0,53.92,69.36,0.0,0.0,0,,0.0694,none,0,1,0,0,0,2e-05,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000000847,MBR00000188,Medical_Institutional,Denied,Electronic_EDI,2023-07-23,2023-07-23,2023-07-24,2023-08-11,Clinical_Review,19,1528602428,1020312030,207RP1001X,Pulmonary Disease,31,In_Network,OTHER,I10|OTHER|E78.5,revenue_code:0450,,0,Commercial,HMO,8,F,1.5853,PR-1,Duplicate,13395.0,9305.15,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0247,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000848,MBR00000235,Medical_Professional,Paid,Electronic_EDI,2023-08-26,2023-08-26,2023-08-26,2023-09-13,Manual_Review,18,1176378924,1469697158,225100000X,Physical Therapist,31,In_Network,Z00.00,E78.5|I48.91,97140,,0,Commercial,HDHP_HSA,85,F,1.4308,,,480.52,252.02,0.0,252.02,0.0,0.0,228.5,0.0,0.0,0,,0.096,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000849,MBR00000081,Pharmacy,Paid,Electronic_EDI,2023-11-20,2023-11-20,2023-11-20,2023-11-21,Auto_Adjudicated,1,1220710861,1691162131,101YP2500X,Psychologist Clinical,24,Out_of_Network,M17.11,,16590051660,,1,Medicare_Advantage,SNP,66,F,2.159,,,131.55,92.3,54.74,18.88,5.0,13.68,39.25,0.0,0.0,0,,0.1018,none,0,1,0,1,0,5e-06,1,0,,Capitation
CLM0000000850,MBR00000213,Medical_Institutional,Paid,Electronic_EDI,2023-09-10,2023-09-10,2023-09-11,2023-09-22,Auto_Adjudicated,12,1319616460,1220755708,101YP2500X,Psychologist Clinical,11,In_Network,N18.3,OTHER,revenue_code:0120,,0,Commercial,PPO,17,M,1.5857,,,40096.38,24861.3,19803.22,64.27,43.0,4950.81,15235.08,0.0,0.0,0,,0.0218,none,0,1,1,0,0,0.001833,0,0,,FFS
CLM0000000851,MBR00000054,Dental,Paid,Electronic_EDI,2023-10-14,2023-10-14,2023-10-14,2023-10-18,Auto_Adjudicated,4,1340676357,1995553359,207RN0300X,Nephrology,23,In_Network,OTHER,E11.9,D3310,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,,,423.86,270.38,210.43,6.34,1.0,52.61,153.48,0.0,0.0,0,,0.1107,none,0,1,0,0,0,1.9e-05,0,0,,P4P
CLM0000000852,MBR00000089,Dental,Paid,Electronic_EDI,2023-08-21,2023-08-21,2023-08-21,2023-09-19,Auto_Adjudicated,29,1567711165,1297948643,207RP1001X,Pulmonary Disease,21,In_Network,OTHER,,D7140,,0,Commercial,PPO,14,M,0.5668,,,805.47,650.35,380.05,141.28,34.0,95.01,155.12,0.0,0.0,0,,0.0774,provider_specialty_mismatch,0,1,0,0,0,3.5e-05,0,0,,Capitation
CLM0000000853,MBR00000099,Medical_Professional,Paid,Electronic_EDI,2023-08-30,2023-08-30,2023-08-30,2023-09-24,Auto_Adjudicated,25,1390393668,1301833092,207Q00000X,Family Medicine,21,In_Network,Z00.00,,99387,,0,Commercial,HMO,10,F,0.7843,,,355.2,232.02,14.81,198.51,15.0,3.7,123.18,0.0,0.0,0,,0.1171,billing_spike_recent,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000000854,MBR00000299,Medical_Professional,Paid,Electronic_EDI,2023-10-12,2023-10-12,2023-10-12,2023-11-11,Clinical_Review,30,1650193199,1388050552,207RE0101X,Endocrinology,23,In_Network,K57.30,,99284,,0,Medicaid_MCO,MCO,74,F,0.8833,,,314.89,252.9,250.9,0.0,2.0,0.0,61.99,0.0,0.0,0,,0.0624,impossible_service_combo,0,1,0,0,0,2.3e-05,0,0,,Bundled_Payment
CLM0000000855,MBR00000065,Dental,Paid,Electronic_EDI,2023-08-26,2023-08-26,2023-08-26,2023-09-10,Auto_Adjudicated,15,1482771601,1741177636,207RN0300X,Nephrology,31,In_Network,OTHER,E13.9|K21.0,D2391,,0,Commercial,HDHP_HSA,63,M,0.7795,,,222.2,136.66,0.0,136.66,0.0,0.0,85.54,0.0,0.0,0,,0.0725,billing_spike_recent,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000000856,MBR00000040,Medical_Professional,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-10,Auto_Adjudicated,10,1389534304,1469881892,207RE0101X,Endocrinology,31,In_Network,Z00.01,E78.5|N39.0|OTHER,90837,,0,Medicare_Advantage,MA_HMO,66,F,0.6755,,,725.91,532.16,406.32,10.26,14.0,101.58,193.75,0.0,0.0,0,,0.0209,none,0,1,0,0,0,3.8e-05,0,0,,Capitation
CLM0000000857,MBR00000279,Medical_Professional,Denied,Electronic_EDI,2023-09-20,2023-09-20,2023-09-20,2023-10-19,Auto_Adjudicated,29,1983779639,1020312030,207RN0300X,Nephrology,11,In_Network,F41.1,,99203,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,5,Medical_Necessity,466.51,286.45,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0927,controlled_substance_high_volume,0,1,0,1,0,0.0,0,0,,FFS
CLM0000000858,MBR00000051,Medical_Professional,Paid,Electronic_EDI,2023-12-13,2023-12-13,2023-12-13,2023-12-23,Auto_Adjudicated,10,1893327624,1148659045,208600000X,Surgery General,23,In_Network,R05.9,Z00.01|Z00.00,99281,,0,Medicare_Advantage,MA_PPO,17,F,1.0695,,,291.6,184.51,111.63,30.97,14.0,27.91,107.09,0.0,0.0,0,,0.1481,none,0,1,0,0,0,1e-05,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000000859,MBR00000265,Pharmacy,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-27,2023-07-10,Auto_Adjudicated,13,1577859682,1509799493,207RN0300X,Nephrology,11,In_Network,J06.9,,00169751112,,1,Commercial,PPO,84,F,0.7969,,,847.31,478.82,192.17,213.61,25.0,48.04,368.49,0.0,0.0,0,,0.097,none,0,1,0,0,0,1.8e-05,0,0,,Bundled_Payment
CLM0000000860,MBR00000193,Medical_Professional,Paid,Paper,2023-03-23,2023-03-23,2023-03-23,2023-03-28,Auto_Adjudicated,5,1213747973,1498781755,207RN0300X,Nephrology,23,In_Network,Z12.11,OTHER,99212,,0,Commercial,PPO,11,M,0.5266,,,466.17,316.41,184.17,56.2,30.0,46.04,149.76,0.0,0.0,0,,0.1582,high_oop_waiver,0,1,0,0,0,1.7e-05,0,0,,Shared_Savings
CLM0000000861,MBR00000173,Medical_Professional,Paid,Electronic_EDI,2023-05-25,2023-05-25,2023-05-25,2023-06-19,Auto_Adjudicated,25,1932483309,1643323506,225100000X,Physical Therapist,21,In_Network,Z00.01,,99387,,0,Medicare_Advantage,PFFS,23,F,1.0279,,,153.8,59.04,15.66,25.47,14.0,3.91,94.76,9.86,3.74,0,,0.0374,none,0,1,0,0,0,1e-06,0,0,,Bundled_Payment
CLM0000000862,MBR00000221,Medical_Institutional,Paid,Electronic_EDI,2023-01-06,2023-01-06,2023-01-07,2023-01-10,Auto_Adjudicated,4,1356562955,1842149518,207V00000X,Obstetrics & Gynecology,24,Out_of_Network,OTHER,,revenue_code:0100,,0,Commercial,HDHP_HSA,28,M,1.6683,,,7756.21,5364.56,3959.65,415.0,0.0,989.91,2391.65,0.0,0.0,0,,0.0272,none,0,1,0,0,0,0.000367,1,0,SPD_Spirometry_Testing,Shared_Savings
CLM0000000863,MBR00000213,Pharmacy,Paid,Electronic_EDI,2023-04-21,2023-04-21,2023-04-21,2023-04-23,Auto_Adjudicated,2,1309817189,1867626800,207V00000X,Obstetrics & Gynecology,65,In_Network,E11.9,OTHER,00085163102,,1,Commercial,PPO,17,M,1.5857,,,308.47,188.48,0.0,188.48,0.0,0.0,119.99,0.0,0.0,0,,0.1251,none,0,1,0,0,0,0.0,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000000864,MBR00000034,Medical_Professional,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-12-10,Auto_Adjudicated,25,1252009836,1469642907,207RG0100X,Gastroenterology,11,In_Network,K21.0,N39.0|I10,99386,,0,Medicare_Advantage,MA_HMO,35,M,0.7712,,,130.49,92.97,31.19,46.98,7.0,7.8,37.52,0.0,0.0,0,,0.0515,none,0,1,0,0,0,3e-06,0,0,AWV_Annual_Wellness_Visit,Bundled_Payment
CLM0000000865,MBR00000300,Pharmacy,Denied,Electronic_EDI,2023-02-05,2023-02-05,2023-02-05,2023-03-03,Auto_Adjudicated,26,1810800968,1128148362,208600000X,Surgery General,32,Out_of_Network,M17.11,Z00.00,00310075090,,3,Commercial,PPO,64,F,1.0393,3,Eligibility,163.99,58.26,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1468,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000866,MBR00000285,Medical_Institutional,Paid,Provider_Portal,2023-11-15,2023-11-15,2023-11-15,2023-12-11,Auto_Adjudicated,26,1232573801,1179350099,208600000X,Surgery General,24,In_Network,Z00.01,I10|E78.5,revenue_code:0250,,0,Commercial,HDHP_HSA,56,M,0.9226,,,8754.77,4339.75,3350.36,151.79,0.0,837.59,4415.02,0.0,0.0,1,Upcoding,1.0,outlier_billing_amount|geographic_mismatch|provider_specialty_mismatch|impossible_service_combo|service_date_weekend|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,0.00031,0,0,,Capitation
CLM0000000867,MBR00000272,Medical_Institutional,Denied,Electronic_EDI,2023-07-21,2023-07-21,2023-07-23,2023-08-16,Manual_Review,26,1007266616,1354265777,101YP2500X,Psychologist Clinical,22,In_Network,K21.0,,revenue_code:0370,,0,Medicare_Advantage,MA_HMO,15,M,0.8525,50,Coding_Error,5221.23,3307.7,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.071,impossible_service_combo,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000000868,MBR00000185,Medical_Professional,Paid,Electronic_EDI,2023-04-25,2023-04-25,2023-04-25,2023-04-30,Auto_Adjudicated,5,1253087808,1765164601,2084P0800X,Psychiatry,22,Out_of_Network,I10,E13.9,81001,,0,Medicaid_MCO,MCO,73,M,1.5417,,,1358.81,790.8,787.8,0.0,3.0,0.0,568.01,0.0,0.0,0,,0.1471,none,0,1,0,0,0,7.3e-05,1,0,,FFS
CLM0000000869,MBR00000160,Medical_Professional,Paid,Electronic_EDI,2023-06-19,2023-06-19,2023-06-19,2023-06-30,Auto_Adjudicated,11,1887363539,1408846353,207RE0101X,Endocrinology,21,In_Network,E11.9,,27130,,0,Commercial,HMO,73,M,1.9608,,,12603.04,5099.76,3918.29,178.9,23.0,979.57,7503.28,0.0,0.0,0,,0.1369,none,0,1,0,0,0,0.000363,0,0,,FFS
CLM0000000870,MBR00000163,Medical_Professional,Paid,Electronic_EDI,2023-11-12,2023-11-12,2023-11-12,2023-12-05,Auto_Adjudicated,23,1298243993,1527857018,207Q00000X,Family Medicine,11,Out_of_Network,J06.9,,99385,,0,Medicaid_MCO,MCO,21,F,0.9607,,,390.38,147.13,143.13,0.0,4.0,0.0,243.25,0.0,0.0,0,,0.0443,none,0,1,0,1,0,1.3e-05,1,0,,P4P
CLM0000000871,MBR00000005,Dental,Paid,Electronic_EDI,2023-02-12,2023-02-12,2023-02-12,2023-02-22,Auto_Adjudicated,10,1732726112,1179350099,207Q00000X,Family Medicine,11,In_Network,F41.1,Z00.01,D7140,,0,Medicare_Advantage,MA_PPO,8,M,0.566,,,142.85,78.83,36.26,28.51,5.0,9.06,64.02,0.0,0.0,0,,0.0096,none,0,1,0,0,0,3e-06,0,0,,Shared_Savings
CLM0000000872,MBR00000154,Medical_Professional,Denied,Provider_Portal,2023-07-23,2023-07-23,2023-07-23,2023-08-16,Auto_Adjudicated,24,1474985672,1291071007,207RN0300X,Nephrology,23,In_Network,K21.0,,99202,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,1,Medical_Necessity,240.43,134.19,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0823,none,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,Capitation
CLM0000000873,MBR00000186,Vision,Paid,Electronic_EDI,2023-04-07,2023-04-07,2023-04-07,2023-05-05,Auto_Adjudicated,28,1396168768,1896197144,207RE0101X,Endocrinology,11,In_Network,Z00.00,I10|N40.0,92012,,0,Commercial,PPO,65,M,1.6983,,,147.67,79.73,41.89,15.37,12.0,10.47,67.94,32.64,7.65,0,,0.1836,upcoding_pattern,0,1,0,0,0,4e-06,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000000874,MBR00000196,Medical_Professional,Paid,Electronic_EDI,2023-07-14,2023-07-14,2023-07-14,2023-08-12,Auto_Adjudicated,29,1379875145,1473869105,207RN0300X,Nephrology,22,Out_of_Network,J06.9,E78.5,71250,,0,Commercial,PPO,16,F,1.6015,,,1498.67,1228.32,876.93,109.15,23.0,219.23,270.35,0.0,0.0,0,,0.1222,none,0,1,0,0,0,8.1e-05,1,0,,Bundled_Payment
CLM0000000875,MBR00000105,Medical_Professional,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-10,2023-11-03,Auto_Adjudicated,24,1887363539,1579331190,207Q00000X,Family Medicine,32,Out_of_Network,Z00.00,E11.9,97035,,0,Commercial,HMO,74,M,1.1834,,,378.0,171.18,0.0,171.18,0.0,0.0,206.82,0.0,0.0,0,,0.152,benford_violation|impossible_service_combo,0,1,0,1,0,0.0,1,0,,Shared_Savings
CLM0000000876,MBR00000144,Medical_Institutional,Paid,Electronic_EDI,2023-11-27,2023-11-27,2023-11-28,2023-12-21,Auto_Adjudicated,24,1110312325,1789540567,207RN0300X,Nephrology,23,In_Network,E78.5,,revenue_code:0370,,0,Commercial,HDHP_HSA,56,F,2.5926,,,11093.65,7851.92,5767.04,643.12,0.0,1441.76,3241.73,0.0,0.0,0,,0.0591,none,0,1,1,0,0,0.000534,0,0,,Capitation
CLM0000000877,MBR00000188,Pharmacy,Paid,Electronic_EDI,2023-04-02,2023-04-02,2023-04-02,2023-04-20,Auto_Adjudicated,18,1208538971,1774401124,208600000X,Surgery General,11,In_Network,Z00.01,,00071015523,,1,Commercial,HMO,8,F,1.5853,,,238.53,105.15,54.65,11.84,25.0,13.66,133.38,0.0,0.0,0,,0.0243,none,0,1,0,0,0,5e-06,0,1,,FFS
CLM0000000878,MBR00000135,Medical_Professional,Paid,Provider_Portal,2023-08-27,2023-08-27,2023-08-27,2023-08-30,Manual_Review,3,1272115456,1509799493,246ZN0300X,Neuropsychology,24,In_Network,I10,I25.10,81001,,0,Commercial,PPO,58,F,2.2702,,,385.47,143.54,81.23,5.0,37.0,20.31,241.93,0.0,0.0,0,,0.1366,none,0,1,0,0,0,8e-06,0,0,,Shared_Savings
CLM0000000879,MBR00000292,Medical_Professional,Denied,Electronic_EDI,2023-06-02,2023-06-02,2023-06-02,2023-06-16,Auto_Adjudicated,14,1470105939,1738617370,246ZN0300X,Neuropsychology,11,In_Network,M17.11,,99221,,0,Medicare_Advantage,MA_HMO,4,M,1.1779,5,Medical_Necessity,153.64,101.5,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0104,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000880,MBR00000208,Medical_Institutional,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-07-01,2023-07-29,Auto_Adjudicated,29,1850379080,1788579687,207V00000X,Obstetrics & Gynecology,24,In_Network,OTHER,,revenue_code:0360,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,14181.58,10943.27,8710.25,1.46,54.0,2177.56,3238.31,0.0,0.0,0,,0.1154,none,0,1,1,0,0,0.000806,0,0,,FFS
CLM0000000881,MBR00000001,Medical_Professional,Paid,Electronic_EDI,2023-02-27,2023-02-27,2023-02-27,2023-03-27,Auto_Adjudicated,28,1594587354,1312595355,101YP2500X,Psychologist Clinical,11,In_Network,E11.9,,12001,,0,Commercial,EPO,73,M,0.6527,,,168.07,86.57,0.0,86.57,0.0,0.0,81.5,0.0,0.0,0,,0.0658,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000000882,MBR00000008,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-11-04,2023-11-04,2023-11-07,2023-11-12,Auto_Adjudicated,8,1220710861,1884259357,101YP2500X,Psychologist Clinical,11,Out_of_Network,L70.0,Z00.00|Z79.4|E78.5,revenue_code:0110,,0,Medicaid_MCO,MCO,74,M,0.8375,16,Medical_Necessity,40145.87,24952.44,18519.96,0.0,3.0,0.0,21622.91,0.0,0.0,0,,0.0312,none,0,1,1,0,0,0.001714,0,0,,FFS
CLM0000000883,MBR00000206,Pharmacy,Denied,Electronic_EDI,2023-03-02,2023-03-02,2023-03-02,2023-03-25,Manual_Review,23,1461820376,1304018750,207RG0100X,Gastroenterology,65,In_Network,Z00.00,K21.0,16590051660,,1,Medicaid_MCO,MLTSS,21,M,1.4038,22,Duplicate,161.36,107.33,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0221,none,0,1,0,1,0,0.0,0,1,,FFS
CLM0000000884,MBR00000131,Medical_Professional,Paid,Electronic_EDI,2023-01-15,2023-01-15,2023-01-15,2023-01-25,Auto_Adjudicated,10,1133265917,1810068286,2086S0122X,Orthopedic Surgery,11,Out_of_Network,J06.9,,99231,,0,Commercial,EPO,15,F,0.9228,,,133.98,91.69,0.0,91.69,0.0,0.0,42.29,0.0,0.0,0,,0.1348,none,0,1,0,0,0,0.0,0,0,DDE_Diabetes_Short_Term_Complications,Capitation
CLM0000000885,MBR00000251,Pharmacy,Denied,Electronic_EDI,2023-09-29,2023-09-29,2023-09-29,2023-10-12,Auto_Adjudicated,13,1356408757,1433350836,225100000X,Physical Therapist,11,In_Network,Z23,Z79.4,59148001506,,2,Commercial,PPO,65,M,0.7737,256,Coding_Error,145.66,94.94,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0687,impossible_service_combo,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000886,MBR00000055,Medical_Professional,Denied,Electronic_EDI,2023-05-26,2023-05-26,2023-05-26,2023-06-15,Clinical_Review,20,1898865801,1144950506,101YP2500X,Psychologist Clinical,11,In_Network,Z00.01,E11.9|OTHER,99221,,0,Commercial,PPO,68,F,1.2896,5,Medical_Necessity,373.79,298.45,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0786,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000000887,MBR00000004,Dental,Paid,Electronic_EDI,2023-01-24,2023-01-24,2023-01-24,2023-02-08,Auto_Adjudicated,15,1897701389,1390802135,208600000X,Surgery General,21,In_Network,Z79.4,,D2391,,0,Medicare_Advantage,MA_PPO,68,M,1.23,,,214.37,94.64,41.88,34.29,8.0,10.47,119.73,0.0,0.0,0,,0.0644,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000000888,MBR00000124,Behavioral_Health,Paid,Electronic_EDI,2023-09-02,2023-09-02,2023-09-02,2023-09-21,Auto_Adjudicated,19,1522998767,1020312030,207RN0300X,Nephrology,31,Out_of_Network,I10,,27447,,0,Commercial,EPO,40,F,0.4583,,,83.31,60.04,0.0,60.04,0.0,0.0,23.27,0.0,0.0,0,,0.0569,phantom_billing_indicator,0,1,0,0,0,0.0,1,0,,Bundled_Payment
CLM0000000889,MBR00000215,Pharmacy,Paid,Electronic_EDI,2023-04-13,2023-04-13,2023-04-13,2023-04-16,Auto_Adjudicated,3,1267286378,1942423230,207RN0300X,Nephrology,11,In_Network,OTHER,OTHER|F41.1|E78.5,00006001954,,1,ACA_Marketplace,ACA_Silver,69,M,0.8895,,,163.08,134.29,0.0,134.29,0.0,0.0,28.79,0.0,0.0,0,,0.0265,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000890,MBR00000293,Behavioral_Health,Paid,Provider_Portal,2023-12-17,2023-12-17,2023-12-17,2023-12-26,Auto_Adjudicated,9,1210349885,1391074619,101YP2500X,Psychologist Clinical,11,In_Network,J44.1,Z00.01|OTHER,99204,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,321.89,168.93,104.4,27.43,11.0,26.1,152.96,0.0,0.0,0,,0.0592,none,0,1,0,1,0,1e-05,0,0,CBP_Controlling_BP,Capitation
CLM0000000891,MBR00000267,Pharmacy,Paid,Provider_Portal,2023-12-19,2023-12-19,2023-12-19,2024-01-13,Auto_Adjudicated,25,1905691248,1867626800,207RC0000X,Cardiovascular Disease,32,In_Network,K29.70,I10,00078043215,,3,Medicare_Advantage,MA_HMO,26,F,0.2859,,,216.89,160.31,106.59,11.07,16.0,26.65,56.58,0.0,0.0,0,,0.0586,none,0,1,0,0,0,1e-05,0,1,,P4P
CLM0000000892,MBR00000150,Medical_Professional,Denied,Electronic_EDI,2023-07-17,2023-07-17,2023-07-17,2023-08-05,Manual_Review,19,1466922283,1105871325,207Q00000X,Family Medicine,11,In_Network,I10,,27130,,0,Medicare_Advantage,MA_HMO,1,F,0.2444,16,COB,23862.74,15677.46,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0972,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000893,MBR00000241,Medical_Professional,Paid,Electronic_EDI,2023-06-20,2023-06-20,2023-06-20,2023-07-16,Auto_Adjudicated,26,1769163673,1860951128,2086S0122X,Orthopedic Surgery,11,Out_of_Network,M54.5,,99223,,0,Medicare_Advantage,MA_HMO,77,M,1.2169,,,451.76,220.49,152.11,13.35,17.0,38.03,231.27,0.0,0.0,0,,0.1296,none,0,1,0,0,0,1.4e-05,1,0,CBP_Controlling_BP,FFS
CLM0000000894,MBR00000022,Medical_Professional,Denied,Electronic_EDI,2023-06-09,2023-06-09,2023-06-09,2023-07-08,Auto_Adjudicated,29,1735391772,1177602659,101YP2500X,Psychologist Clinical,11,In_Network,Z87.891,M54.5|E78.5,97140,,0,Medicare_Advantage,MA_HMO,34,M,0.9472,2,Duplicate,1968.51,1087.39,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1265,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000895,MBR00000171,Medical_Institutional,Paid,Provider_Portal,2023-08-06,2023-08-06,2023-08-08,2023-08-17,Auto_Adjudicated,11,1594322174,1938465393,207RN0300X,Nephrology,65,In_Network,F32.9,Z00.00|E11.9,revenue_code:0300,,0,Commercial,PPO,27,F,0.819,,,1062.72,837.7,331.81,357.94,65.0,82.95,225.02,0.0,0.0,0,,0.0588,none,0,1,0,0,0,3.1e-05,0,0,,Capitation
CLM0000000896,MBR00000279,Medical_Institutional,Paid,Electronic_EDI,2023-11-23,2023-11-23,2023-11-23,2023-12-01,Manual_Review,8,1898865801,1297948643,2086S0122X,Orthopedic Surgery,22,In_Network,Z79.4,I48.91,revenue_code:0300,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,,,3642.4,2150.6,1682.68,17.25,30.0,420.67,1491.8,0.0,0.0,0,,0.1899,billing_spike_recent,0,1,0,0,0,0.000156,0,0,DAE_Drug_Alcohol_Dependence,FFS
CLM0000000897,MBR00000126,Medical_Institutional,Paid,Electronic_EDI,2023-08-19,2023-08-19,2023-08-19,2023-08-29,Auto_Adjudicated,10,1549436467,1564691686,207R00000X,Internal Medicine,22,In_Network,Z23,,revenue_code:0370,,0,Medicaid_MCO,MLTSS,48,F,0.637,,,13957.28,6931.07,6925.07,0.0,6.0,0.0,7026.21,5893.24,921.37,0,,0.1451,none,0,1,1,0,0,0.000641,0,0,,Shared_Savings
CLM0000000898,MBR00000291,Pharmacy,Paid,Electronic_EDI,2023-02-05,2023-02-05,2023-02-05,2023-02-23,Auto_Adjudicated,18,1633089013,1587454801,246ZN0300X,Neuropsychology,22,In_Network,I50.9,,00169751112,,3,Commercial,PPO,78,M,1.4773,,,224.66,190.57,53.32,109.92,14.0,13.33,34.09,0.0,0.0,0,,0.1495,none,0,1,0,0,0,5e-06,0,1,,Capitation
CLM0000000899,MBR00000068,Medical_Institutional,Denied,Provider_Portal,2023-03-12,2023-03-12,2023-03-16,2023-03-20,Auto_Adjudicated,8,1891821845,1318978078,225100000X,Physical Therapist,22,In_Network,M79.3,E11.9|OTHER,revenue_code:0360,,0,Medicare_Advantage,MA_HMO,28,F,0.8494,PR-1,Authorization,2977.09,1491.25,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0922,none,0,1,0,0,0,0.0,0,0,COL_Colorectal_Cancer_Screening,P4P
CLM0000000900,MBR00000032,Medical_Professional,Paid,Electronic_EDI,2023-08-14,2023-08-14,2023-08-14,2023-08-26,Auto_Adjudicated,12,1402833352,1575884274,207RP1001X,Pulmonary Disease,24,In_Network,M54.5,Z23,12001,,0,Medicaid_MCO,FFS_Medicaid,87,M,0.4839,,,375.95,139.51,137.51,0.0,2.0,0.0,236.44,0.0,0.0,0,,0.1144,none,0,1,0,0,0,1.3e-05,0,0,,Shared_Savings
CLM0000000901,MBR00000160,Medical_Professional,Paid,Electronic_EDI,2023-05-13,2023-05-13,2023-05-13,2023-05-19,Auto_Adjudicated,6,1780111559,1304018750,207R00000X,Internal Medicine,65,In_Network,OTHER,Z00.01,99204,,0,Commercial,HMO,73,M,1.9608,,,1530.86,688.35,519.66,15.78,23.0,129.91,842.51,0.0,0.0,1,Identity Theft,1.0,temporal_clustering|high_volume_same_code|benford_violation|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,4.8e-05,0,0,ACR_Urine_Protein,Shared_Savings
CLM0000000902,MBR00000274,Behavioral_Health,Paid,Electronic_EDI,2023-06-22,2023-06-22,2023-06-22,2023-07-04,Clinical_Review,12,1617763056,1133410177,207R00000X,Internal Medicine,23,In_Network,L70.0,OTHER,47562,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,244.4,203.63,138.0,31.13,0.0,34.5,40.77,0.0,0.0,0,,0.0805,none,0,1,0,0,0,1.3e-05,0,0,,P4P
CLM0000000903,MBR00000099,Medical_Professional,Paid,Electronic_EDI,2023-05-24,2023-05-24,2023-05-24,2023-06-22,Clinical_Review,29,1310400164,1649705287,207RN0300X,Nephrology,31,In_Network,Z00.00,Z79.4|N18.3,81001,,0,Commercial,HMO,10,F,0.7843,,,2276.86,1150.87,834.04,93.32,15.0,208.51,1125.99,0.0,0.0,0,,0.1794,unusual_service_frequency|diagnosis_procedure_mismatch|controlled_substance_high_volume,0,1,0,0,0,7.7e-05,0,0,,Capitation
CLM0000000904,MBR00000236,Medical_Professional,Denied,Electronic_EDI,2023-08-02,2023-08-02,2023-08-02,2023-08-15,Auto_Adjudicated,13,1059948944,1938465393,207R00000X,Internal Medicine,11,In_Network,Z00.00,I10,84443,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,256,Duplicate,694.3,541.88,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0238,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000000905,MBR00000053,Medical_Professional,Paid,Electronic_EDI,2023-03-24,2023-03-24,2023-03-24,2023-04-16,Manual_Review,23,1897146144,1938465393,207R00000X,Internal Medicine,22,Out_of_Network,N40.0,,71250,,0,Medicaid_MCO,MLTSS,74,F,0.9277,,,1127.93,886.54,886.54,0.0,0.0,0.0,241.39,0.0,0.0,0,,0.0966,none,0,1,0,0,0,8.2e-05,1,0,BPD_BP_Declined,P4P
CLM0000000906,MBR00000219,Behavioral_Health,Paid,Electronic_EDI,2023-01-27,2023-01-27,2023-01-27,2023-02-09,Auto_Adjudicated,13,1636337876,1157814306,225100000X,Physical Therapist,22,In_Network,Z79.4,F33.0|OTHER|M17.11,99222,,0,Medicare_Advantage,MA_HMO,84,M,0.9513,,,292.7,105.61,58.04,33.06,0.0,14.51,187.09,0.0,0.0,0,,0.063,none,0,1,0,0,0,5e-06,0,0,,Shared_Savings
CLM0000000907,MBR00000168,Medical_Professional,Paid,Electronic_EDI,2023-03-26,2023-03-26,2023-03-26,2023-04-09,Auto_Adjudicated,14,1990849102,1029818813,2086S0122X,Orthopedic Surgery,11,In_Network,OTHER,,33510,,0,Commercial,HMO,76,M,1.2791,,,513.79,368.48,46.51,282.34,28.0,11.63,145.31,0.0,0.0,0,,0.0867,unbundling_pattern,0,1,0,0,0,4e-06,0,0,,Shared_Savings
CLM0000000908,MBR00000055,Medical_Institutional,Paid,Electronic_EDI,2023-08-28,2023-08-28,2023-08-29,2023-09-17,Auto_Adjudicated,20,1324272690,1912895973,207V00000X,Obstetrics & Gynecology,11,In_Network,I50.9,K21.0,revenue_code:0370,,0,Commercial,PPO,68,F,1.2896,,,8424.39,5237.44,3985.91,181.05,74.0,996.48,3186.95,0.0,0.0,0,,0.1269,temporal_clustering,0,1,0,0,0,0.000369,0,0,,FFS
CLM0000000909,MBR00000212,Medical_Professional,Paid,Electronic_EDI,2023-08-07,2023-08-07,2023-08-07,2023-08-11,Auto_Adjudicated,4,1957378066,1894215172,207RG0100X,Gastroenterology,11,In_Network,E11.9,,33510,,0,Commercial,HMO,57,F,2.5456,,,1486.38,984.52,760.58,15.8,18.0,190.14,501.86,671.6,58.44,0,,0.1753,duplicate_claim_indicator,0,1,0,0,0,7e-05,0,0,,FFS
CLM0000000910,MBR00000211,Medical_Professional,Paid,Electronic_EDI,2023-10-18,2023-10-18,2023-10-18,2023-10-29,Auto_Adjudicated,11,1201027197,1267212691,2084P0800X,Psychiatry,11,Out_of_Network,Z00.00,OTHER|Z00.00,99203,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,,,278.87,158.55,116.46,0.97,12.0,29.12,120.32,0.0,0.0,0,,0.1326,none,0,1,0,0,0,1.1e-05,1,0,,FFS
CLM0000000911,MBR00000158,Pharmacy,Paid,Electronic_EDI,2023-02-08,2023-02-08,2023-02-08,2023-02-13,Auto_Adjudicated,5,1124477249,1368666316,207RE0101X,Endocrinology,31,In_Network,N39.0,Z23,00006001954,,2,Commercial,HMO,65,M,1.5361,,,80.31,33.15,7.9,9.28,14.0,1.97,47.16,6.36,1.09,0,,0.1409,none,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000000912,MBR00000070,Medical_Institutional,Paid,Electronic_EDI,2023-02-20,2023-02-20,2023-02-21,2023-02-26,Auto_Adjudicated,6,1451464799,1450837722,2086S0122X,Orthopedic Surgery,11,In_Network,F41.1,,revenue_code:0200,,0,Commercial,POS,42,F,0.8468,,,31784.93,13326.99,10453.34,207.31,53.0,2613.34,18457.94,0.0,0.0,0,,0.0616,none,0,1,1,0,0,0.000968,0,0,,Capitation
CLM0000000913,MBR00000041,Pharmacy,Denied,Electronic_EDI,2023-02-16,2023-02-16,2023-02-16,2023-03-10,Auto_Adjudicated,22,1958981650,1197700958,207R00000X,Internal Medicine,22,Out_of_Network,OTHER,L70.0,00071015523,,3,Commercial,PPO,42,F,0.8283,18,Eligibility,18.34,6.66,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0021,none,0,1,0,0,0,0.0,0,1,,P4P
CLM0000000914,MBR00000291,Medical_Professional,Paid,Electronic_EDI,2023-07-22,2023-07-22,2023-07-22,2023-07-28,Auto_Adjudicated,6,1207676414,1473869105,207RN0300X,Nephrology,11,Out_of_Network,C50.911,J06.9,81001,,0,Commercial,PPO,78,M,1.4773,,,1962.11,943.23,638.01,131.72,14.0,159.5,1018.88,0.0,0.0,0,,0.0477,none,0,1,0,0,0,5.9e-05,1,0,,Shared_Savings
CLM0000000915,MBR00000195,Behavioral_Health,Denied,Electronic_EDI,2023-07-25,2023-07-25,2023-07-25,2023-08-01,Auto_Adjudicated,7,1313587359,1354959095,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,Z00.00,11200,,0,Commercial,PPO,13,F,0.5967,170,Timely_Filing,200.41,135.81,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.115,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000916,MBR00000240,Medical_Institutional,Paid,Electronic_EDI,2023-02-27,2023-02-27,2023-02-27,2023-03-17,Auto_Adjudicated,18,1913217838,1930040953,101YP2500X,Psychologist Clinical,11,In_Network,Z00.121,,revenue_code:0370,,0,Medicaid_MCO,MCO,9,F,0.386,,,12086.5,5930.38,5924.38,0.0,6.0,0.0,6156.12,0.0,0.0,0,,0.0631,none,0,1,1,0,0,0.000548,0,0,,Capitation
CLM0000000917,MBR00000207,Vision,Paid,Provider_Portal,2023-06-11,2023-06-11,2023-06-11,2023-06-22,Auto_Adjudicated,11,1564110057,1579331190,207RP1001X,Pulmonary Disease,11,In_Network,G47.33,,92012,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,291.87,157.55,157.55,0.0,0.0,0.0,134.32,128.88,17.3,0,,0.1046,none,0,1,0,0,0,1.5e-05,0,0,MMA_Medication_Management,FFS
CLM0000000918,MBR00000248,Medical_Professional,Partially_Paid,Electronic_EDI,2023-01-19,2023-01-19,2023-01-19,2023-01-23,Auto_Adjudicated,4,1700802848,1576271272,207RN0300X,Nephrology,22,In_Network,E11.65,Z00.01|I10|OTHER,27130,,0,Commercial,PPO,40,F,0.6665,256,Medical_Necessity,45688.85,29438.07,18443.86,31.45,16.0,4610.96,22586.58,0.0,0.0,0,,0.1057,none,0,1,1,0,0,0.001707,0,0,,Capitation
CLM0000000919,MBR00000052,Medical_Institutional,Paid,Electronic_EDI,2023-08-08,2023-08-08,2023-08-12,2023-09-06,Clinical_Review,29,1945264928,1825450791,207RN0300X,Nephrology,11,In_Network,I25.10,,revenue_code:0360,,0,Commercial,PPO,0,F,1.325,,,14036.5,9370.01,7170.99,330.27,76.0,1792.75,4666.49,0.0,0.0,0,,0.0137,none,0,1,1,1,0,0.000664,0,0,,Capitation
CLM0000000920,MBR00000154,Medical_Professional,Paid,Electronic_EDI,2023-07-24,2023-07-24,2023-07-24,2023-08-21,Auto_Adjudicated,28,1856989511,1577226132,207Q00000X,Family Medicine,21,In_Network,M17.11,F10.10,99213,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,276.84,216.05,165.09,9.69,0.0,41.27,60.79,0.0,0.0,0,,0.0716,none,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000000921,MBR00000198,Pharmacy,Paid,Electronic_EDI,2023-01-10,2023-01-10,2023-01-10,2023-01-28,Auto_Adjudicated,18,1667149552,1061113875,2084P0800X,Psychiatry,23,Out_of_Network,OTHER,,16590051660,,2,Medicaid_MCO,MCO,81,F,1.4199,,,84.02,44.55,42.55,0.0,2.0,0.0,39.47,0.0,0.0,0,,0.06,none,0,1,0,0,0,4e-06,1,0,,Capitation
CLM0000000922,MBR00000031,Pharmacy,Partially_Paid,Electronic_EDI,2023-02-01,2023-02-01,2023-02-01,2023-02-17,Auto_Adjudicated,16,1981853293,1300957944,207RG0100X,Gastroenterology,65,Out_of_Network,E11.9,OTHER|E11.9,00310075090,,1,Commercial,PPO,71,M,0.6746,256,Medical_Necessity,101.7,72.66,25.21,4.17,16.0,6.3,50.01,0.0,0.0,0,,0.1139,impossible_service_combo,0,1,0,0,0,2e-06,0,1,,FFS
CLM0000000923,MBR00000047,Medical_Institutional,Paid,Electronic_EDI,2023-09-11,2023-09-11,2023-09-12,2023-10-06,Auto_Adjudicated,25,1788188920,1140170394,207Q00000X,Family Medicine,22,In_Network,OTHER,J45.20,revenue_code:0370,,0,Commercial,PPO,37,M,0.565,,,21386.69,11176.78,8556.19,437.54,44.0,2139.05,10209.91,0.0,0.0,0,,0.1287,none,0,1,1,1,0,0.000792,0,0,KED_ESRD_Patients,Shared_Savings
CLM0000000924,MBR00000188,Medical_Professional,Paid,Electronic_EDI,2023-11-19,2023-11-19,2023-11-19,2023-12-19,Auto_Adjudicated,30,1377412382,1738617370,246ZN0300X,Neuropsychology,22,In_Network,E11.65,J06.9|OTHER,99203,,0,Commercial,HMO,8,F,1.5853,,,312.98,220.73,141.89,18.37,25.0,35.47,92.25,0.0,0.0,0,,0.2102,geographic_mismatch|billing_spike_recent,0,2,0,0,0,1.3e-05,0,0,,Bundled_Payment
CLM0000000925,MBR00000262,Medical_Professional,Paid,Electronic_EDI,2023-11-02,2023-11-02,2023-11-02,2023-11-06,Auto_Adjudicated,4,1080383191,1112696614,207RN0300X,Nephrology,22,In_Network,K21.0,M47.816,99285,,0,Medicare_Advantage,PFFS,77,F,1.7452,,,650.89,530.99,421.4,0.24,4.0,105.35,119.9,0.0,0.0,0,,0.1063,none,0,1,0,1,0,3.9e-05,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000000926,MBR00000196,Medical_Professional,Paid,Electronic_EDI,2023-07-23,2023-07-23,2023-07-23,2023-07-26,Auto_Adjudicated,3,1033622184,1965244699,207RG0100X,Gastroenterology,22,Out_of_Network,E11.9,OTHER,11200,,0,Commercial,PPO,16,F,1.6015,,,367.45,190.34,15.56,147.89,23.0,3.89,177.11,0.0,0.0,0,,0.1052,impossible_service_combo,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000000927,MBR00000012,Pharmacy,Paid,Electronic_EDI,2023-07-08,2023-07-08,2023-07-08,2023-07-18,Auto_Adjudicated,10,1159640414,1809122260,225100000X,Physical Therapist,22,In_Network,E78.5,Z00.121|Z00.00|Z87.891,00071012831,,2,Commercial,HMO,84,M,1.3904,,,71.51,42.74,0.0,42.74,0.0,0.0,28.77,0.0,0.0,0,,0.1561,duplicate_claim_indicator|diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000928,MBR00000293,Medical_Professional,Paid,Electronic_EDI,2023-10-18,2023-10-18,2023-10-18,2023-10-28,Manual_Review,10,1900781649,1581533104,207RP1001X,Pulmonary Disease,22,In_Network,I25.10,Z00.01|J20.9,99396,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,325.28,154.27,106.31,10.38,11.0,26.58,171.01,0.0,0.0,0,,0.1356,npi_mismatch|diagnosis_procedure_mismatch,0,1,0,0,0,1e-05,0,0,,Bundled_Payment
CLM0000000929,MBR00000044,Medical_Professional,Denied,Provider_Portal,2023-10-29,2023-10-29,2023-10-29,2023-11-25,Auto_Adjudicated,27,1208538971,1177602659,207RC0000X,Cardiovascular Disease,22,Out_of_Network,I10,I10|F41.1,90853,,0,Commercial,PPO,29,M,0.7512,16,Medical_Necessity,612.27,374.29,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0023,none,0,1,0,1,0,0.0,1,0,SPD_Spirometry_Testing,Bundled_Payment
CLM0000000930,MBR00000073,Medical_Professional,Paid,Electronic_EDI,2023-11-22,2023-11-22,2023-11-22,2023-12-08,Auto_Adjudicated,16,1014482814,1128148362,207RE0101X,Endocrinology,24,In_Network,Z00.00,OTHER|E78.5,90837,,0,Commercial,POS,79,M,1.1768,,,280.9,171.0,0.0,171.0,0.0,0.0,109.9,0.0,0.0,0,,0.1851,unusual_service_frequency,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000931,MBR00000293,Medical_Professional,Denied,Paper,2023-05-24,2023-05-24,2023-05-24,2023-06-18,Auto_Adjudicated,25,1443292773,1287472731,2086S0122X,Orthopedic Surgery,21,In_Network,E78.5,I10,99385,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,1,Network,216.0,163.31,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0834,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,ACR_Urine_Protein,FFS
CLM0000000932,MBR00000227,Behavioral_Health,Paid,Electronic_EDI,2023-06-20,2023-06-20,2023-06-20,2023-07-11,Clinical_Review,21,1727787144,1013600387,101YP2500X,Psychologist Clinical,11,In_Network,M54.5,M54.5,99204,,0,Medicare_Advantage,MA_PPO,2,F,0.7835,,,312.94,231.8,174.13,0.14,14.0,43.53,81.14,153.19,12.18,0,,0.1071,npi_mismatch,0,1,0,0,0,1.6e-05,0,0,,Shared_Savings
CLM0000000933,MBR00000283,Medical_Professional,Paid,Electronic_EDI,2023-01-29,2023-01-29,2023-01-29,2023-02-20,Auto_Adjudicated,22,1017424540,1672803287,207RG0100X,Gastroenterology,23,In_Network,OTHER,I10,99395,,0,Medicare_Advantage,MA_HMO,21,M,0.5294,,,144.7,80.62,39.45,17.31,14.0,9.86,64.08,0.0,0.0,0,,0.0504,none,0,1,0,0,0,4e-06,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000000934,MBR00000239,Vision,Denied,Electronic_EDI,2023-03-04,2023-03-04,2023-03-04,2023-04-02,Clinical_Review,29,1119083414,1938465393,207RP1001X,Pulmonary Disease,24,In_Network,I25.10,I10|M47.816,V2103,,0,Commercial,HMO,1,F,1.1193,256,Duplicate,434.79,189.52,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Medically Unnecessary Services,0.9702,provider_specialty_mismatch|benford_violation|impossible_service_combo|billing_spike_recent|upcoding_pattern|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch,1,5,0,0,0,0.0,0,0,,FFS
CLM0000000935,MBR00000194,Pharmacy,Paid,Electronic_EDI,2023-05-16,2023-05-16,2023-05-16,2023-06-03,Manual_Review,18,1099247356,1005335812,246ZN0300X,Neuropsychology,24,Out_of_Network,Z23,Z87.891|N39.0|E78.5,00085163102,,2,Commercial,PPO,77,M,0.9783,,,102.19,48.71,0.0,48.71,0.0,0.0,53.48,0.0,0.0,0,,0.106,none,0,1,0,0,0,0.0,1,1,,FFS
CLM0000000936,MBR00000088,Medical_Institutional,Paid,Electronic_EDI,2023-10-18,2023-10-18,2023-10-21,2023-11-11,Auto_Adjudicated,24,1269720844,1894215172,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,N39.0,revenue_code:0360,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,,,24499.39,14724.61,10237.13,10.15,90.0,4387.34,9774.78,0.0,0.0,0,,0.1762,unbundling_pattern,0,1,1,0,0,0.000948,0,0,,FFS
CLM0000000937,MBR00000104,Medical_Institutional,Paid,Electronic_EDI,2023-06-10,2023-06-10,2023-06-12,2023-06-19,Manual_Review,9,1611521069,1301833092,207R00000X,Internal Medicine,23,In_Network,J06.9,OTHER,revenue_code:0250,,0,Medicaid_MCO,MCO,87,F,1.2297,,,7280.62,6079.13,6078.13,0.0,1.0,0.0,1201.49,0.0,0.0,0,,0.1446,provider_specialty_mismatch|controlled_substance_high_volume,0,1,1,0,0,0.000563,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000000938,MBR00000287,Pharmacy,Paid,Electronic_EDI,2023-07-30,2023-07-30,2023-07-30,2023-08-07,Clinical_Review,8,1893886964,1287472731,207V00000X,Obstetrics & Gynecology,81,In_Network,OTHER,,16590051660,,1,Commercial,PPO,4,M,0.7685,,,663.86,457.72,241.1,130.34,26.0,60.28,206.14,0.0,0.0,0,,0.0598,none,0,1,0,0,0,2.2e-05,0,0,,P4P
CLM0000000939,MBR00000259,Pharmacy,Paid,Electronic_EDI,2023-11-07,2023-11-07,2023-11-07,2023-11-25,Manual_Review,18,1338575285,1267212691,207V00000X,Obstetrics & Gynecology,11,In_Network,OTHER,Z12.11|Z23,00310075090,,4,Medicare_Advantage,MA_PPO,5,M,1.6554,,,78.14,37.8,18.47,7.71,7.0,4.62,40.34,0.0,0.0,0,,0.0148,none,0,1,0,0,0,2e-06,0,0,PPC_Prenatal_Care,Bundled_Payment
CLM0000000940,MBR00000113,Medical_Professional,Paid,Paper,2023-06-20,2023-06-20,2023-06-20,2023-07-18,Auto_Adjudicated,28,1256824549,1291071007,207RE0101X,Endocrinology,22,In_Network,E13.9,F41.1|I10,99214,,0,Medicaid_MCO,MLTSS,29,F,1.1621,,,336.03,284.35,283.35,0.0,1.0,0.0,51.68,0.0,0.0,0,,0.1071,geographic_mismatch,0,1,0,0,0,2.6e-05,0,0,,FFS
CLM0000000941,MBR00000118,Dental,Paid,Electronic_EDI,2023-05-01,2023-05-01,2023-05-01,2023-05-03,Manual_Review,2,1995916350,1004714954,207RP1001X,Pulmonary Disease,11,In_Network,N39.0,E11.9|E13.9|I10,D7140,,0,Medicaid_MCO,MCO,69,M,1.2773,,,341.67,262.33,261.33,0.0,1.0,0.0,79.34,0.0,0.0,0,,0.1069,none,0,1,0,0,0,2.4e-05,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000000942,MBR00000093,Medical_Professional,Paid,Electronic_EDI,2023-09-20,2023-09-20,2023-09-20,2023-10-06,Auto_Adjudicated,16,1133265917,1672803287,207RC0000X,Cardiovascular Disease,24,Out_of_Network,OTHER,N18.3,84443,,0,Medicare_Advantage,MA_HMO,43,F,0.6162,,,651.46,372.25,259.36,29.05,19.0,64.84,279.21,0.0,0.0,0,,0.0772,none,0,1,0,1,0,2.4e-05,0,0,,FFS
CLM0000000943,MBR00000103,Medical_Professional,Paid,Electronic_EDI,2023-04-24,2023-04-24,2023-04-24,2023-05-01,Auto_Adjudicated,7,1369267360,1942423230,207RC0000X,Cardiovascular Disease,21,In_Network,M54.5,Z12.11|M54.5,99397,,0,Medicaid_MCO,MCO,24,M,0.4785,,,81.77,56.59,55.59,0.0,1.0,0.0,25.18,0.0,0.0,0,,0.1414,none,0,1,0,0,0,5e-06,0,0,,Shared_Savings
CLM0000000944,MBR00000259,Medical_Institutional,Paid,Electronic_EDI,2023-05-20,2023-05-20,2023-05-24,2023-06-16,Auto_Adjudicated,27,1453331651,1301869102,225100000X,Physical Therapist,24,In_Network,J06.9,,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,4469.27,1821.62,1426.99,1.89,36.0,356.75,2647.65,0.0,0.0,0,,0.1321,none,0,1,0,0,0,0.000132,0,0,,FFS
CLM0000000945,MBR00000004,Pharmacy,Partially_Paid,Paper,2023-11-15,2023-11-15,2023-11-15,2023-12-01,Auto_Adjudicated,16,1323379997,1447186817,207Q00000X,Family Medicine,11,In_Network,E11.9,J20.9,00078043215,,3,Medicare_Advantage,MA_PPO,68,M,1.23,4,Medical_Necessity,157.44,132.49,23.86,45.3,8.0,5.96,74.32,0.0,0.0,0,,0.0181,none,0,1,0,1,0,2e-06,0,0,,Shared_Savings
CLM0000000946,MBR00000136,Medical_Professional,Paid,Electronic_EDI,2023-06-06,2023-06-06,2023-06-06,2023-06-08,Auto_Adjudicated,2,1327415110,1164525386,207V00000X,Obstetrics & Gynecology,11,In_Network,E78.5,E11.9,99212,,0,Commercial,POS,2,F,1.2611,,,104.59,45.03,0.0,45.03,0.0,0.0,59.56,0.0,0.0,0,,0.0759,none,0,1,0,0,0,0.0,0,0,AWV_Annual_Wellness_Visit,Capitation
CLM0000000947,MBR00000286,Medical_Professional,Paid,Electronic_EDI,2023-04-01,2023-04-01,2023-04-01,2023-04-02,Manual_Review,1,1338575285,1765164601,246ZN0300X,Neuropsychology,11,In_Network,I10,M54.5,20610,,0,Medicare_Advantage,PFFS,40,F,1.2751,,,84.0,65.21,26.98,28.49,3.0,6.74,18.79,0.0,0.0,0,,0.0643,none,0,1,0,0,0,2e-06,0,0,HBD_Hemoglobin_A1c_Testing,P4P
CLM0000000948,MBR00000165,Medical_Professional,Paid,Electronic_EDI,2023-10-27,2023-10-27,2023-10-27,2023-11-16,Auto_Adjudicated,20,1211612843,1811797489,207RG0100X,Gastroenterology,11,In_Network,OTHER,N39.0,99386,,0,ACA_Marketplace,ACA_Bronze,55,M,0.9775,,,151.02,88.84,0.0,88.84,0.0,0.0,62.18,0.0,0.0,0,,0.091,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000949,MBR00000140,Medical_Institutional,Paid,Electronic_EDI,2023-08-19,2023-08-19,2023-08-21,2023-08-26,Auto_Adjudicated,7,1706476585,1321680994,208600000X,Surgery General,31,In_Network,Z00.00,,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,7,M,1.3997,,,16256.53,11773.22,9361.97,15.76,55.0,2340.49,4483.31,0.0,0.0,0,,0.1154,none,0,1,1,0,0,0.000867,0,0,BPD_BP_Declined,FFS
CLM0000000950,MBR00000099,Medical_Professional,Paid,Electronic_EDI,2023-10-03,2023-10-03,2023-10-03,2023-10-05,Auto_Adjudicated,2,1469009511,1144950506,207RN0300X,Nephrology,11,In_Network,Z23,R05.9|OTHER,97110,,0,Commercial,HMO,10,F,0.7843,,,907.81,467.16,177.85,229.85,15.0,44.46,440.65,0.0,0.0,0,,0.0951,none,0,1,0,0,0,1.6e-05,0,0,,Capitation
CLM0000000951,MBR00000023,Dental,Paid,Electronic_EDI,2023-04-28,2023-04-28,2023-04-28,2023-05-03,Auto_Adjudicated,5,1976612978,1540743888,207Q00000X,Family Medicine,11,In_Network,J06.9,OTHER,D2140,,0,Medicare_Advantage,MA_PPO,87,M,1.084,,,167.97,101.53,46.38,28.56,15.0,11.59,66.44,0.0,0.0,0,,0.124,impossible_service_combo,0,1,0,0,0,4e-06,0,0,SPD_Spirometry_Testing,FFS
CLM0000000952,MBR00000070,Medical_Professional,Paid,Electronic_EDI,2023-10-08,2023-10-08,2023-10-08,2023-10-13,Auto_Adjudicated,5,1231231881,1170002937,207R00000X,Internal Medicine,31,In_Network,Z12.11,,99385,,0,Commercial,POS,42,F,0.8468,,,253.18,164.06,0.0,164.06,0.0,0.0,89.12,0.0,0.0,0,,0.0147,none,0,1,0,0,0,0.0,0,0,MMA_Medication_Management,Bundled_Payment
CLM0000000953,MBR00000028,Vision,Paid,Provider_Portal,2023-12-08,2023-12-08,2023-12-08,2023-12-19,Auto_Adjudicated,11,1879212418,1157814306,207V00000X,Obstetrics & Gynecology,21,In_Network,OTHER,F41.1|Z00.00,V2100,,0,Commercial,HMO,3,F,2.116,,,346.07,192.56,0.0,192.56,0.0,0.0,153.51,0.0,0.0,0,,0.1239,none,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000000954,MBR00000038,Pharmacy,Paid,Electronic_EDI,2023-02-28,2023-02-28,2023-02-28,2023-03-22,Auto_Adjudicated,22,1568777164,1187669363,2086S0122X,Orthopedic Surgery,22,In_Network,OTHER,,00169751112,,1,Commercial,EPO,46,M,1.1295,,,519.58,302.86,180.69,38.99,38.0,45.17,216.72,0.0,0.0,0,,0.1043,none,0,1,0,0,0,1.7e-05,0,0,,Shared_Savings
CLM0000000955,MBR00000052,Pharmacy,Paid,Electronic_EDI,2023-03-10,2023-03-10,2023-03-10,2023-04-05,Auto_Adjudicated,26,1624242487,1774401124,2084P0800X,Psychiatry,11,In_Network,G47.33,,59148001506,,1,Commercial,PPO,0,F,1.325,,,503.66,422.01,271.09,51.15,32.0,67.77,81.65,0.0,0.0,0,,0.1396,none,0,1,0,0,0,2.5e-05,0,0,,Capitation
CLM0000000956,MBR00000096,Vision,Paid,Electronic_EDI,2023-07-22,2023-07-22,2023-07-22,2023-08-07,Auto_Adjudicated,16,1887322427,1469642907,207RN0300X,Nephrology,65,In_Network,E13.9,I10,V2320,,0,Medicaid_MCO,MCO,62,M,0.7948,,,441.61,254.7,252.7,0.0,2.0,0.0,186.91,0.0,0.0,0,,0.0747,none,0,1,0,0,0,2.3e-05,0,0,,P4P
CLM0000000957,MBR00000004,Medical_Professional,Paid,Electronic_EDI,2023-09-17,2023-09-17,2023-09-17,2023-10-16,Auto_Adjudicated,29,1007266616,1774401124,207R00000X,Internal Medicine,22,In_Network,OTHER,,99283,,0,Medicare_Advantage,MA_PPO,68,M,1.23,,,213.82,92.0,42.29,31.14,8.0,10.57,121.82,0.0,0.0,0,,0.1841,impossible_service_combo|unbundling_pattern,0,1,0,0,0,4e-06,0,0,,P4P
CLM0000000958,MBR00000288,Medical_Institutional,Paid,Electronic_EDI,2023-01-01,2023-01-01,2023-01-05,2023-01-25,Auto_Adjudicated,24,1954226809,1811797489,207R00000X,Internal Medicine,11,In_Network,Z12.11,Z00.00|I10,revenue_code:0120,,0,Commercial,HMO,36,M,0.8408,,,11479.39,6810.04,5238.53,183.88,78.0,1309.63,4669.35,0.0,0.0,0,,0.0118,none,0,1,1,0,0,0.000485,0,0,,FFS
CLM0000000959,MBR00000038,Medical_Professional,Paid,Paper,2023-07-17,2023-07-17,2023-07-17,2023-07-22,Auto_Adjudicated,5,1855186422,1945682535,207RN0300X,Nephrology,23,In_Network,K21.0,Z00.00|N40.0,97035,,0,Commercial,EPO,46,M,1.1295,,,683.25,548.37,340.75,84.43,38.0,85.19,134.88,0.0,0.0,0,,0.0905,none,0,1,0,0,0,3.2e-05,0,0,,FFS
CLM0000000960,MBR00000121,Medical_Professional,Denied,Electronic_EDI,2023-02-15,2023-02-15,2023-02-15,2023-03-10,Manual_Review,23,1373899620,1728466420,225100000X,Physical Therapist,21,In_Network,E11.9,J20.9|Z00.00,80053,,0,Medicare_Advantage,MA_PPO,58,M,1.226,1,Timely_Filing,558.56,266.06,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.11,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000000961,MBR00000266,Medical_Professional,Paid,Electronic_EDI,2023-12-18,2023-12-18,2023-12-18,2023-12-25,Auto_Adjudicated,7,1642333103,1396850418,207RN0300X,Nephrology,21,In_Network,E11.9,F33.0,99213,,0,Commercial,EPO,14,M,1.075,,,140.68,70.71,0.0,70.71,0.0,0.0,69.97,0.0,0.0,0,,0.0265,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000962,MBR00000033,Pharmacy,Paid,Electronic_EDI,2023-09-18,2023-09-18,2023-09-18,2023-10-17,Auto_Adjudicated,29,1994365754,1804282800,207R00000X,Internal Medicine,21,In_Network,OTHER,OTHER,00169751112,,3,Medicare_Advantage,PFFS,31,F,0.821,,,570.11,276.34,206.53,13.18,5.0,51.63,293.77,0.0,0.0,0,,0.0998,none,0,1,0,0,0,1.9e-05,0,0,CDC_BP_Control,Bundled_Payment
CLM0000000963,MBR00000149,Pharmacy,Paid,Electronic_EDI,2023-12-23,2023-12-23,2023-12-23,2024-01-18,Auto_Adjudicated,26,1375680589,1965244699,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,Z00.00|I10,50458085930,,2,Commercial,PPO,42,F,0.5458,,,254.47,136.39,0.0,136.39,0.0,0.0,118.08,0.0,0.0,0,,0.0131,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000964,MBR00000254,Medical_Professional,Denied,Provider_Portal,2023-03-20,2023-03-20,2023-03-20,2023-03-22,Manual_Review,2,1816378991,1132693989,207R00000X,Internal Medicine,22,In_Network,F32.9,F32.9|Z00.00,90834,,0,Commercial,PPO,22,F,0.9285,CO-45,Medical_Necessity,1195.1,700.6,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0971,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000965,MBR00000168,Pharmacy,Paid,Electronic_EDI,2023-10-12,2023-10-12,2023-10-12,2023-10-18,Manual_Review,6,1457568950,1860951128,208600000X,Surgery General,11,In_Network,Z00.00,Z00.00,00071015523,,2,Commercial,HMO,76,M,1.2791,,,305.32,157.95,0.0,157.95,0.0,0.0,147.37,0.0,0.0,0,,0.161,impossible_service_combo|unbundling_pattern,0,1,0,0,0,0.0,0,1,,P4P
CLM0000000966,MBR00000064,Medical_Professional,Partially_Paid,Electronic_EDI,2023-05-18,2023-05-18,2023-05-18,2023-06-01,Clinical_Review,14,1682685390,1469642907,207RG0100X,Gastroenterology,24,In_Network,J45.20,I25.10,82947,,0,Medicare_Advantage,SNP,73,M,1.0644,5,Medical_Necessity,479.9,212.71,109.88,0.75,10.0,27.47,331.79,0.0,0.0,0,,0.0871,none,0,1,0,0,0,1e-05,0,0,,Shared_Savings
CLM0000000967,MBR00000215,Medical_Professional,Paid,Paper,2023-02-07,2023-02-07,2023-02-07,2023-03-02,Auto_Adjudicated,23,1269185915,1013600387,207R00000X,Internal Medicine,11,In_Network,OTHER,,71250,,0,ACA_Marketplace,ACA_Silver,69,M,0.8895,,,227.61,118.32,0.0,118.32,0.0,0.0,109.29,0.0,0.0,0,,0.0652,impossible_service_combo,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000968,MBR00000202,Medical_Professional,Paid,Electronic_EDI,2023-06-22,2023-06-22,2023-06-22,2023-07-09,Auto_Adjudicated,17,1496340237,1188760037,225100000X,Physical Therapist,23,In_Network,OTHER,,99213,,0,Commercial,PPO,87,F,0.6213,,,407.55,227.23,0.0,227.23,0.0,0.0,180.32,0.0,0.0,0,,0.0172,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000969,MBR00000114,Medical_Institutional,Denied,Paper,2023-06-18,2023-06-18,2023-06-21,2023-06-21,Auto_Adjudicated,3,1804302686,1774401124,207RP1001X,Pulmonary Disease,11,In_Network,N40.0,,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,1,Timely_Filing,22257.53,13237.83,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0857,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000000970,MBR00000014,Medical_Institutional,Paid,Electronic_EDI,2023-06-29,2023-06-29,2023-07-01,2023-07-18,Auto_Adjudicated,19,1637260822,1978943761,225100000X,Physical Therapist,22,In_Network,R05.9,E11.65|OTHER,revenue_code:0360,,0,Commercial,HMO,77,M,2.8513,,,15574.13,10554.51,8250.98,205.79,35.0,2062.74,5019.62,0.0,0.0,0,,0.0082,none,0,1,1,1,0,0.000764,0,0,,FFS
CLM0000000971,MBR00000003,Medical_Professional,Denied,Electronic_EDI,2023-11-03,2023-11-03,2023-11-03,2023-11-23,Auto_Adjudicated,20,1567711165,1527857018,207RG0100X,Gastroenterology,22,In_Network,Z00.01,Z00.00,90837,,0,Commercial,PPO,79,F,1.3879,50,Network,2932.7,2110.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0149,none,0,1,0,1,0,0.0,0,0,W30_Well_Child_Visit,Shared_Savings
CLM0000000972,MBR00000247,Medical_Professional,Paid,Electronic_EDI,2023-04-11,2023-04-11,2023-04-11,2023-05-09,Auto_Adjudicated,28,1956107350,1860951128,101YP2500X,Psychologist Clinical,23,Out_of_Network,Z00.01,OTHER|Z00.00,99283,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,210.96,160.95,112.62,15.18,5.0,28.15,50.01,0.0,0.0,0,,0.2661,benford_violation|billing_spike_recent|upcoding_pattern,0,2,0,0,0,1e-05,1,0,SPC_Statin_Therapy,FFS
CLM0000000973,MBR00000102,Medical_Institutional,Paid,Electronic_EDI,2023-08-18,2023-08-18,2023-08-20,2023-08-26,Auto_Adjudicated,8,1207523397,1007652766,2086S0122X,Orthopedic Surgery,24,Out_of_Network,E78.5,M54.5,revenue_code:0450,,0,Commercial,POS,68,M,1.6864,,,9040.49,4298.59,3219.49,209.23,65.0,804.87,4741.9,0.0,0.0,0,,0.0538,none,0,1,0,1,0,0.000298,1,0,,FFS
CLM0000000974,MBR00000043,Pharmacy,Paid,Electronic_EDI,2023-03-13,2023-03-13,2023-03-13,2023-03-15,Auto_Adjudicated,2,1495592428,1831337866,207Q00000X,Family Medicine,22,In_Network,E11.65,Z00.00,00071015523,,1,Commercial,PPO,68,F,0.4593,,,212.36,139.65,0.0,139.65,0.0,0.0,72.71,0.0,0.0,0,,0.1242,high_volume_same_code,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000975,MBR00000159,Medical_Professional,Paid,Electronic_EDI,2023-11-12,2023-11-12,2023-11-12,2023-12-05,Auto_Adjudicated,23,1661091022,1513198866,207Q00000X,Family Medicine,32,In_Network,OTHER,E11.9,71046,,0,Commercial,PPO,70,F,1.2009,,,458.94,202.83,129.95,26.39,14.0,32.49,256.11,0.0,0.0,0,,0.1397,none,0,1,0,0,0,1.2e-05,0,0,,Bundled_Payment
CLM0000000976,MBR00000277,Pharmacy,Paid,Electronic_EDI,2023-06-14,2023-06-14,2023-06-14,2023-07-06,Manual_Review,22,1856989511,1972530373,207RC0000X,Cardiovascular Disease,71,Out_of_Network,OTHER,,00071015523,,2,Medicaid_MCO,MCO,30,M,1.8495,,,149.18,98.46,95.46,0.0,3.0,0.0,50.72,0.0,0.0,0,,0.2066,geographic_mismatch|unbundling_pattern,0,2,0,0,0,9e-06,0,0,BPD_BP_Declined,Capitation
CLM0000000977,MBR00000003,Medical_Institutional,Paid,Paper,2023-10-14,2023-10-14,2023-10-17,2023-10-30,Manual_Review,16,1211372728,1738617370,207R00000X,Internal Medicine,81,In_Network,M54.5,OTHER|I10|E11.9,revenue_code:0370,,0,Commercial,PPO,79,F,1.3879,,,30392.51,24603.36,19642.2,0.61,50.0,4910.55,5789.15,0.0,0.0,0,,0.0657,none,0,1,1,0,0,0.001818,0,0,MMA_Medication_Management,Shared_Savings
CLM0000000978,MBR00000015,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-04-07,2023-04-07,2023-04-10,2023-04-28,Auto_Adjudicated,21,1253087808,1625992541,246ZN0300X,Neuropsychology,21,In_Network,J06.9,N18.3,revenue_code:0300,247,0,Medicaid_MCO,MCO,43,F,0.3775,170,Medical_Necessity,6700.41,5263.76,3123.89,0.0,4.0,0.0,3572.52,0.0,0.0,0,,0.1685,high_oop_waiver,0,1,0,0,0,0.000289,0,0,,Shared_Savings
CLM0000000979,MBR00000132,Medical_Professional,Paid,Provider_Portal,2023-04-23,2023-04-23,2023-04-23,2023-04-29,Manual_Review,6,1324142620,1144950506,101YP2500X,Psychologist Clinical,11,In_Network,M54.5,Z00.00|N18.3,99397,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,,,209.58,137.07,104.24,0.78,6.0,26.06,72.51,0.0,0.0,0,,0.1457,none,0,1,0,0,0,1e-05,0,0,,Capitation
CLM0000000980,MBR00000200,Vision,Denied,Electronic_EDI,2023-12-19,2023-12-19,2023-12-19,2023-12-23,Manual_Review,4,1501282310,1415734567,207RP1001X,Pulmonary Disease,23,In_Network,N39.0,,92014,,0,Commercial,HDHP_HSA,29,M,0.8011,3,Authorization,373.75,182.5,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0935,none,0,1,0,0,0,0.0,0,0,SPD_Spirometry_Testing,FFS
CLM0000000981,MBR00000146,Medical_Institutional,Denied,Electronic_EDI,2023-03-12,2023-03-12,2023-03-15,2023-03-25,Auto_Adjudicated,13,1231231881,1356856197,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,OTHER,revenue_code:0370,,0,Medicaid_MCO,MCO,24,M,0.6484,2,Medical_Necessity,3658.74,1534.71,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1249,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000000982,MBR00000272,Medical_Professional,Denied,Electronic_EDI,2023-07-21,2023-07-21,2023-07-21,2023-08-17,Auto_Adjudicated,27,1719850506,1365397818,101YP2500X,Psychologist Clinical,24,In_Network,OTHER,Z00.00,97010,,0,Medicare_Advantage,MA_HMO,15,M,0.8525,PR-1,Medical_Necessity,613.78,351.67,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.197,billing_spike_recent,0,1,0,1,0,0.0,0,0,,FFS
CLM0000000983,MBR00000013,Dental,Denied,Electronic_EDI,2023-04-26,2023-04-26,2023-04-26,2023-05-12,Clinical_Review,16,1327415110,1274911960,207RN0300X,Nephrology,11,Emergency,OTHER,Z00.00,D0150,,0,Commercial,PPO,64,F,1.428,96,Eligibility,322.89,177.37,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0069,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000000984,MBR00000106,Pharmacy,Paid,Electronic_EDI,2023-05-21,2023-05-21,2023-05-21,2023-06-10,Auto_Adjudicated,20,1175448241,1747596016,225100000X,Physical Therapist,24,In_Network,N39.0,Z23,00078043215,,3,Medicare_Advantage,MA_PPO,69,M,1.7254,,,297.16,204.26,130.52,35.11,6.0,32.63,92.9,0.0,0.0,0,,0.0922,none,0,1,0,0,0,1.2e-05,0,1,,Capitation
CLM0000000985,MBR00000111,Pharmacy,Paid,Electronic_EDI,2023-09-07,2023-09-07,2023-09-07,2023-10-07,Auto_Adjudicated,30,1666911728,1319611206,207RG0100X,Gastroenterology,11,In_Network,G47.33,OTHER,59148001506,,2,Medicare_Advantage,MA_PPO,44,M,0.7462,,,342.27,137.99,87.62,12.47,16.0,21.9,204.28,0.0,0.0,0,,0.066,none,0,1,0,0,0,8e-06,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000000986,MBR00000106,Pharmacy,Paid,Provider_Portal,2023-10-08,2023-10-08,2023-10-08,2023-10-18,Auto_Adjudicated,10,1211372728,1354265777,208600000X,Surgery General,32,In_Network,OTHER,OTHER|F41.1,50458085930,,3,Medicare_Advantage,MA_PPO,69,M,1.7254,,,158.39,59.09,36.19,7.85,6.0,9.05,99.3,0.0,0.0,0,,0.1775,controlled_substance_high_volume,0,1,0,0,0,3e-06,0,0,,FFS
CLM0000000987,MBR00000151,Medical_Professional,Paid,Electronic_EDI,2023-06-22,2023-06-22,2023-06-22,2023-07-07,Auto_Adjudicated,15,1495592428,1132693989,207RN0300X,Nephrology,23,In_Network,I50.9,Z23,71250,,0,Medicare_Advantage,MA_HMO,77,M,0.8709,,,612.06,436.28,330.32,17.38,6.0,82.58,175.78,255.49,40.66,0,,0.1341,none,0,1,0,0,0,3.1e-05,0,0,,Capitation
CLM0000000988,MBR00000235,Pharmacy,Paid,Electronic_EDI,2023-08-18,2023-08-18,2023-08-18,2023-09-08,Auto_Adjudicated,21,1627776731,1419347445,207RP1001X,Pulmonary Disease,11,In_Network,I10,,00069420020,,2,Commercial,HDHP_HSA,85,F,1.4308,,,175.0,113.91,0.0,113.91,0.0,0.0,61.09,0.0,0.0,0,,0.0296,none,0,1,0,0,0,0.0,0,0,BCS_Breast_Cancer_Screening,Bundled_Payment
CLM0000000989,MBR00000100,Medical_Professional,Denied,Electronic_EDI,2023-01-16,2023-01-16,2023-01-16,2023-01-21,Auto_Adjudicated,5,1944105498,1741177636,225100000X,Physical Therapist,22,In_Network,M54.5,,17000,,0,ACA_Marketplace,ACA_Gold,87,M,1.435,256,Network,523.95,276.13,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.159,temporal_clustering,0,1,0,0,0,0.0,0,0,,FFS
CLM0000000990,MBR00000218,Dental,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-25,2023-04-07,Manual_Review,13,1218294278,1061113875,207RP1001X,Pulmonary Disease,22,In_Network,Z00.00,OTHER|Z00.121|I10,D0120,,0,Commercial,HDHP_HSA,11,F,0.4964,,,759.85,548.8,0.0,548.8,0.0,0.0,211.05,0.0,0.0,0,,0.1019,none,0,1,0,0,0,0.0,0,0,AWV_Annual_Wellness_Visit,Shared_Savings
CLM0000000991,MBR00000046,Medical_Professional,Paid,Electronic_EDI,2023-09-24,2023-09-24,2023-09-24,2023-10-11,Auto_Adjudicated,17,1990849102,1809122260,2084P0800X,Psychiatry,32,In_Network,Z00.01,,99396,,0,Commercial,HMO,76,F,0.9613,,,359.84,205.72,97.59,48.74,35.0,24.4,154.12,0.0,0.0,0,,0.1069,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000000992,MBR00000169,Medical_Professional,Denied,Electronic_EDI,2023-08-28,2023-08-28,2023-08-28,2023-09-07,Auto_Adjudicated,10,1026612378,1986847322,207R00000X,Internal Medicine,22,In_Network,F41.1,N40.0,17000,,0,Commercial,EPO,30,M,1.4348,PR-1,Coding_Error,1577.08,1176.28,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0251,none,0,1,0,0,0,0.0,0,0,AWV_Annual_Wellness_Visit,FFS
CLM0000000993,MBR00000119,Medical_Institutional,Paid,Electronic_EDI,2023-01-17,2023-01-17,2023-01-17,2023-01-24,Clinical_Review,7,1389116733,1320546364,101YP2500X,Psychologist Clinical,22,In_Network,K29.70,,revenue_code:0450,,0,Commercial,POS,42,M,0.4987,,,5451.02,4190.65,3006.5,387.53,45.0,751.62,1260.37,0.0,0.0,0,,0.0535,none,0,1,0,0,0,0.000278,0,0,,Bundled_Payment
CLM0000000994,MBR00000164,Pharmacy,Paid,Electronic_EDI,2023-11-16,2023-11-16,2023-11-16,2023-11-30,Auto_Adjudicated,14,1667149552,1300957944,207RN0300X,Nephrology,21,In_Network,I10,OTHER,00071012831,,3,ACA_Marketplace,ACA_Silver,3,F,0.7155,,,489.76,354.23,131.99,126.67,39.0,56.57,135.53,0.0,0.0,0,,0.112,none,0,1,0,0,0,1.2e-05,0,0,,P4P
CLM0000000995,MBR00000033,Medical_Institutional,Paid,Electronic_EDI,2023-05-27,2023-05-27,2023-05-28,2023-06-23,Manual_Review,27,1487261286,1469642907,207R00000X,Internal Medicine,23,In_Network,M54.5,OTHER,revenue_code:0450,,0,Medicare_Advantage,PFFS,31,F,0.821,,,13362.82,10911.6,8664.41,41.08,40.0,2166.1,2451.22,0.0,0.0,0,,0.1242,none,0,1,1,0,0,0.000802,0,0,KED_ESRD_Patients,P4P
CLM0000000996,MBR00000289,Pharmacy,Denied,Electronic_EDI,2023-04-20,2023-04-20,2023-04-20,2023-05-03,Clinical_Review,13,1727787144,1419347445,207RP1001X,Pulmonary Disease,11,In_Network,J06.9,L70.0|OTHER|I10,00003014960,,1,Commercial,POS,51,M,1.0534,97,Timely_Filing,311.16,120.11,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1268,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000000997,MBR00000274,Medical_Professional,Paid,Paper,2023-06-15,2023-06-15,2023-06-15,2023-07-11,Manual_Review,26,1771383741,1005335812,246ZN0300X,Neuropsychology,81,In_Network,OTHER,J20.9,99232,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,107.8,44.56,11.01,30.8,0.0,2.75,63.24,7.76,1.7,0,,0.0947,unusual_service_frequency,0,1,0,1,0,1e-06,0,0,,Capitation
CLM0000000998,MBR00000247,Medical_Professional,Paid,Paper,2023-05-22,2023-05-22,2023-05-22,2023-06-12,Manual_Review,21,1373899620,1622950074,207RG0100X,Gastroenterology,22,In_Network,I10,,97010,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,2029.26,1513.15,1206.21,0.38,5.0,301.55,516.11,0.0,0.0,0,,0.2194,provider_specialty_mismatch|controlled_substance_high_volume,0,2,0,0,0,0.000112,0,0,,FFS
CLM0000000999,MBR00000270,Medical_Institutional,Paid,Paper,2023-06-30,2023-06-30,2023-07-02,2023-07-04,Clinical_Review,4,1924450526,1061149198,207RN0300X,Nephrology,31,In_Network,Z00.00,OTHER,revenue_code:0250,,0,Commercial,POS,1,F,1.6363,,,17838.19,12746.86,9908.88,284.77,76.0,2477.22,5091.33,0.0,0.0,0,,0.0095,none,0,1,1,0,0,0.000917,0,0,,FFS
CLM0000001000,MBR00000046,Medical_Professional,Paid,Electronic_EDI,2023-02-28,2023-02-28,2023-02-28,2023-03-28,Auto_Adjudicated,28,1838794554,1228356980,207RC0000X,Cardiovascular Disease,24,In_Network,F33.0,,33510,,0,Commercial,HMO,76,F,0.9613,,,2396.1,1349.17,996.12,69.02,35.0,249.03,1046.93,884.32,65.21,0,,0.1042,none,0,1,0,0,0,9.2e-05,0,0,,FFS
CLM0000001001,MBR00000156,Pharmacy,Paid,Electronic_EDI,2023-02-19,2023-02-19,2023-02-19,2023-03-09,Clinical_Review,18,1156265220,1625992541,101YP2500X,Psychologist Clinical,11,In_Network,N39.0,Z79.4|OTHER|Z00.00,00071015523,,1,Medicare_Advantage,MA_PPO,66,F,1.8933,,,438.09,270.02,177.42,35.24,13.0,44.36,168.07,0.0,0.0,0,,0.0962,phantom_billing_indicator,0,1,0,0,0,1.6e-05,0,1,,Capitation
CLM0000001002,MBR00000100,Vision,Paid,Electronic_EDI,2023-12-22,2023-12-22,2023-12-22,2024-01-09,Auto_Adjudicated,18,1111846258,1447657873,2084P0800X,Psychiatry,11,In_Network,Z00.00,E11.9,V2320,,0,ACA_Marketplace,ACA_Gold,87,M,1.435,,,100.6,45.46,0.0,45.46,0.0,0.0,55.14,0.0,0.0,0,,0.1207,none,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,Shared_Savings
CLM0000001003,MBR00000269,Pharmacy,Paid,Electronic_EDI,2023-09-26,2023-09-26,2023-09-26,2023-10-17,Auto_Adjudicated,21,1376791933,1291071007,225100000X,Physical Therapist,11,In_Network,OTHER,E11.9|Z00.00,59148001506,,2,Commercial,EPO,10,F,0.718,,,608.03,316.42,220.15,10.24,31.0,55.04,291.61,0.0,0.0,0,,0.1269,none,0,1,0,1,0,2e-05,0,1,TRC_Transition_of_Care,FFS
CLM0000001004,MBR00000059,Medical_Institutional,Denied,Electronic_EDI,2023-05-10,2023-05-10,2023-05-12,2023-05-12,Manual_Review,2,1602370875,1938465393,208600000X,Surgery General,11,In_Network,Z23,F33.0|Z23,revenue_code:0300,,0,Medicare_Advantage,SNP,12,F,1.266,96,Duplicate,14198.09,5520.72,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0458,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001005,MBR00000068,Medical_Institutional,Paid,Electronic_EDI,2023-11-01,2023-11-01,2023-11-01,2023-11-09,Auto_Adjudicated,8,1866366547,1811797489,207RN0300X,Nephrology,11,In_Network,J20.9,,revenue_code:0300,,0,Medicare_Advantage,MA_HMO,28,F,0.8494,,,21383.76,7850.38,6247.54,0.95,40.0,1561.89,13533.38,0.0,0.0,0,,0.1798,unbundling_pattern,0,1,1,0,0,0.000578,0,0,CDC_BP_Control,Capitation
CLM0000001006,MBR00000205,Dental,Paid,Electronic_EDI,2023-10-13,2023-10-13,2023-10-13,2023-11-06,Auto_Adjudicated,24,1451464799,1177602659,207RE0101X,Endocrinology,31,In_Network,I50.9,E11.9|G43.909|K57.30,D3310,,0,Medicaid_MCO,MCO,1,F,0.9425,,,484.48,329.16,328.16,0.0,1.0,0.0,155.32,0.0,0.0,0,,0.1644,high_volume_same_code|billing_spike_recent,0,1,0,0,0,3e-05,0,0,,Shared_Savings
CLM0000001007,MBR00000027,Pharmacy,Paid,Electronic_EDI,2023-09-08,2023-09-08,2023-09-08,2023-09-27,Auto_Adjudicated,19,1995916350,1564691686,207RP1001X,Pulmonary Disease,22,In_Network,Z00.00,Z00.00|K21.0|F10.10,00310075090,,4,Medicare_Advantage,MA_HMO,45,M,0.6886,,,166.33,107.51,85.52,0.61,0.0,21.38,58.82,0.0,0.0,0,,0.124,upcoding_pattern,0,1,0,0,0,8e-06,0,0,COA_Care_Transitions,FFS
CLM0000001008,MBR00000214,Pharmacy,Denied,Electronic_EDI,2023-09-16,2023-09-16,2023-09-16,2023-09-28,Auto_Adjudicated,12,1641660170,1368666316,207V00000X,Obstetrics & Gynecology,22,In_Network,I10,Z00.01|OTHER,00006001954,,1,Commercial,HDHP_HSA,76,M,1.7526,2,Eligibility,130.24,91.21,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1404,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001009,MBR00000083,Medical_Professional,Paid,Provider_Portal,2023-12-08,2023-12-08,2023-12-08,2023-12-22,Auto_Adjudicated,14,1542851144,1898471307,207RE0101X,Endocrinology,22,Out_of_Network,F32.9,F33.0,90837,,0,Commercial,PPO,76,M,0.6621,,,1065.2,578.07,176.16,338.87,19.0,44.04,487.13,0.0,0.0,0,,0.1298,none,0,1,0,1,0,1.6e-05,0,0,,FFS
CLM0000001010,MBR00000196,Pharmacy,Paid,Electronic_EDI,2023-10-27,2023-10-27,2023-10-27,2023-11-15,Auto_Adjudicated,19,1091395764,1791502603,207RG0100X,Gastroenterology,11,Out_of_Network,I10,N40.0|E78.5,50458085930,,1,Commercial,PPO,16,F,1.6015,,,92.5,69.61,0.0,69.61,0.0,0.0,22.89,0.0,0.0,0,,0.1285,none,0,1,0,0,0,0.0,0,0,BCS_Breast_Cancer_Screening,Bundled_Payment
CLM0000001011,MBR00000263,Medical_Professional,Paid,Electronic_EDI,2023-04-03,2023-04-03,2023-04-03,2023-04-18,Manual_Review,15,1838794554,1878017518,208600000X,Surgery General,21,In_Network,Z00.01,,12001,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,,,662.98,356.91,241.06,36.59,19.0,60.26,306.07,189.31,28.32,0,,0.1438,impossible_service_combo,0,1,0,0,0,2.2e-05,0,0,,P4P
CLM0000001012,MBR00000184,Pharmacy,Paid,Electronic_EDI,2023-09-18,2023-09-18,2023-09-18,2023-10-02,Manual_Review,14,1886549972,1847196500,207RP1001X,Pulmonary Disease,11,In_Network,M54.5,I48.91|I10|OTHER,00071012831,,4,Medicaid_MCO,MLTSS,30,M,2.8302,,,552.49,278.45,276.45,0.0,2.0,0.0,274.04,0.0,0.0,0,,0.0352,none,0,1,0,1,0,2.6e-05,0,0,CDC_HbA1c_Poor_Control,Capitation
CLM0000001013,MBR00000064,Dental,Paid,Electronic_EDI,2023-02-27,2023-02-27,2023-02-27,2023-03-16,Auto_Adjudicated,17,1201027197,1887266184,207Q00000X,Family Medicine,32,In_Network,Z23,,D1110,,0,Medicare_Advantage,SNP,73,M,1.0644,,,168.38,109.29,78.49,1.18,10.0,19.62,59.09,0.0,0.0,0,,0.0874,none,0,1,0,0,0,7e-06,0,0,,Capitation
CLM0000001014,MBR00000014,Dental,Denied,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-09,Auto_Adjudicated,9,1654042271,1005335812,207R00000X,Internal Medicine,23,In_Network,OTHER,E11.9|E78.5,D7140,,0,Commercial,HMO,77,M,2.8513,1,Timely_Filing,310.62,193.47,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0613,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001015,MBR00000013,Medical_Professional,Denied,Paper,2023-01-25,2023-01-25,2023-01-25,2023-02-12,Manual_Review,18,1014995735,1538261819,207RG0100X,Gastroenterology,11,In_Network,J44.1,I50.9|J06.9,99386,,0,Commercial,PPO,64,F,1.428,170,COB,502.12,357.11,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0819,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000001016,MBR00000027,Pharmacy,Paid,Electronic_EDI,2023-03-02,2023-03-02,2023-03-02,2023-03-23,Auto_Adjudicated,21,1485543430,1040061910,101YP2500X,Psychologist Clinical,23,In_Network,OTHER,M54.5|Z00.00|OTHER,00069420020,,1,Medicare_Advantage,MA_HMO,45,M,0.6886,,,93.55,54.18,25.28,22.57,0.0,6.32,39.37,0.0,0.0,0,,0.1089,npi_mismatch,0,1,0,1,0,2e-06,0,1,,FFS
CLM0000001017,MBR00000175,Medical_Professional,Paid,Electronic_EDI,2023-09-17,2023-09-17,2023-09-17,2023-10-09,Auto_Adjudicated,22,1115589144,1972530373,207R00000X,Internal Medicine,22,Out_of_Network,F32.9,F32.9|Z12.11,97140,,0,Commercial,PPO,14,F,1.5785,,,170.94,140.82,68.56,45.12,10.0,17.14,30.12,0.0,0.0,0,,0.1295,none,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000001018,MBR00000110,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-05-14,2023-05-14,2023-05-14,2023-06-02,Auto_Adjudicated,19,1505049857,1903401648,207Q00000X,Family Medicine,11,In_Network,F32.9,E11.9|J20.9,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,83,F,1.127,16,Medical_Necessity,2016.24,1199.45,577.77,8.71,53.0,144.44,1232.32,0.0,0.0,0,,0.0245,none,0,1,0,0,0,5.3e-05,0,0,,Capitation
CLM0000001019,MBR00000076,Pharmacy,Paid,Electronic_EDI,2023-02-28,2023-02-28,2023-02-28,2023-03-14,Auto_Adjudicated,14,1641660170,1151295616,207RE0101X,Endocrinology,11,In_Network,M54.5,E11.65|Z00.00,59148001506,,1,Commercial,HMO,26,M,2.1785,,,123.57,44.26,0.0,33.53,10.73,0.0,79.31,0.0,0.0,0,,0.1319,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000001020,MBR00000068,Medical_Institutional,Paid,Electronic_EDI,2023-12-18,2023-12-18,2023-12-20,2024-01-07,Auto_Adjudicated,20,1135745665,1951488764,207Q00000X,Family Medicine,11,In_Network,Z00.01,Z00.01,revenue_code:0210,,0,Medicare_Advantage,MA_HMO,28,F,0.8494,,,54635.19,34910.85,27884.2,15.6,40.0,6971.05,19724.34,0.0,0.0,0,,0.1602,outlier_billing_amount,0,1,1,0,0,0.002581,0,0,CDC_BP_Control,Capitation
CLM0000001021,MBR00000287,Medical_Professional,Paid,Electronic_EDI,2023-12-03,2023-12-03,2023-12-03,2023-12-25,Manual_Review,22,1888245409,1112696614,207RE0101X,Endocrinology,24,In_Network,I10,,99212,,0,Commercial,PPO,4,M,0.7685,,,191.22,139.78,9.68,101.68,26.0,2.42,51.44,0.0,0.0,0,,0.1137,impossible_service_combo,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000001022,MBR00000036,Pharmacy,Paid,Electronic_EDI,2023-03-24,2023-03-24,2023-03-24,2023-04-03,Auto_Adjudicated,10,1713343912,1865266296,207RG0100X,Gastroenterology,31,In_Network,Z00.00,N18.3|E78.5|OTHER,00078043215,,1,Commercial,EPO,17,M,2.0136,,,142.96,85.75,0.0,60.8,24.95,0.0,57.21,0.0,0.0,0,,0.1336,none,0,1,0,0,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,Bundled_Payment
CLM0000001023,MBR00000097,Pharmacy,Paid,Electronic_EDI,2023-08-03,2023-08-03,2023-08-03,2023-08-18,Auto_Adjudicated,15,1593056613,1829216053,207RN0300X,Nephrology,22,In_Network,Z87.891,E78.5,00003014960,,4,Commercial,EPO,34,M,1.3765,,,187.81,94.58,0.0,94.58,0.0,0.0,93.23,0.0,0.0,0,,0.0211,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001024,MBR00000144,Medical_Institutional,Denied,Electronic_EDI,2023-04-16,2023-04-16,2023-04-18,2023-05-07,Auto_Adjudicated,21,1080383191,1368666316,207RP1001X,Pulmonary Disease,11,In_Network,J06.9,I10|Z00.00,revenue_code:0360,,0,Commercial,HDHP_HSA,56,F,2.5926,5,Network,32473.01,20302.18,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0399,none,0,1,0,0,0,0.0,0,0,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000001025,MBR00000001,Medical_Institutional,Paid,Provider_Portal,2023-10-16,2023-10-16,2023-10-19,2023-11-05,Auto_Adjudicated,20,1590338573,1301833092,208600000X,Surgery General,21,In_Network,Z00.00,E13.9,revenue_code:0450,193,0,Commercial,EPO,73,M,0.6527,,,25951.31,17846.33,14140.02,128.3,43.0,3535.01,8104.98,0.0,0.0,0,,0.1075,unbundling_pattern,0,1,1,0,0,0.001309,0,0,,FFS
CLM0000001026,MBR00000277,Pharmacy,Denied,Provider_Portal,2023-09-04,2023-09-04,2023-09-04,2023-09-19,Auto_Adjudicated,15,1415701059,1574982369,207RC0000X,Cardiovascular Disease,21,In_Network,M25.511,E78.5,16590051660,,1,Medicaid_MCO,MCO,30,M,1.8495,50,Timely_Filing,159.21,105.59,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1927,controlled_substance_high_volume,0,1,0,1,0,0.0,0,0,,FFS
CLM0000001027,MBR00000029,Medical_Institutional,Paid,Electronic_EDI,2023-06-06,2023-06-06,2023-06-06,2023-06-14,Auto_Adjudicated,8,1907932706,1825450791,207V00000X,Obstetrics & Gynecology,11,In_Network,E78.5,E78.5,revenue_code:0100,,0,Medicaid_MCO,MCO,13,F,0.9053,,,20582.17,11397.28,11394.28,0.0,3.0,0.0,9184.89,0.0,0.0,0,,0.197,npi_mismatch,0,1,1,0,0,0.001055,0,0,,FFS
CLM0000001028,MBR00000203,Medical_Professional,Paid,Electronic_EDI,2023-12-01,2023-12-01,2023-12-01,2023-12-29,Auto_Adjudicated,28,1397401856,1354959095,101YP2500X,Psychologist Clinical,22,In_Network,OTHER,Z00.01|Z00.00|E11.9,99205,,0,Commercial,PPO,49,F,0.3046,,,475.93,257.44,86.04,129.88,20.0,21.51,218.49,0.0,0.0,0,,0.0021,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000001029,MBR00000187,Medical_Institutional,Paid,Electronic_EDI,2023-09-21,2023-09-21,2023-09-24,2023-10-08,Auto_Adjudicated,17,1135745665,1662516615,207RE0101X,Endocrinology,11,In_Network,OTHER,,revenue_code:0300,,0,Medicaid_MCO,MCO,36,F,1.191,,,2729.13,2061.21,2054.21,0.0,7.0,0.0,667.92,0.0,0.0,0,,0.1095,none,0,1,0,0,0,0.00019,0,0,,Bundled_Payment
CLM0000001030,MBR00000240,Pharmacy,Paid,Electronic_EDI,2023-02-24,2023-02-24,2023-02-24,2023-03-13,Auto_Adjudicated,17,1508520529,1415734567,207V00000X,Obstetrics & Gynecology,11,Emergency,M54.5,Z12.11,00310075090,,1,Medicaid_MCO,MCO,9,F,0.386,,,133.16,64.02,62.02,0.0,2.0,0.0,69.14,42.16,14.64,0,,0.1167,none,0,1,0,0,0,6e-06,0,1,,FFS
CLM0000001031,MBR00000194,Medical_Professional,Denied,Electronic_EDI,2023-06-09,2023-06-09,2023-06-09,2023-06-24,Clinical_Review,15,1793406356,1694343357,2084P0800X,Psychiatry,22,In_Network,E11.9,,71046,,0,Commercial,PPO,77,M,0.9783,2,Timely_Filing,280.48,152.12,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0847,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,,P4P
CLM0000001032,MBR00000226,Medical_Professional,Paid,Electronic_EDI,2023-10-25,2023-10-25,2023-10-25,2023-11-17,Clinical_Review,23,1356408757,1297948643,2084P0800X,Psychiatry,11,In_Network,OTHER,G47.33,99396,,0,Medicare_Advantage,MA_PPO,84,M,1.0796,,,194.71,132.63,97.83,0.35,10.0,24.46,62.08,0.0,0.0,0,,0.1116,none,0,1,0,0,0,9e-06,0,0,CDC_BP_Control,P4P
CLM0000001033,MBR00000133,Dental,Paid,Electronic_EDI,2023-07-13,2023-07-13,2023-07-13,2023-07-23,Auto_Adjudicated,10,1264432433,1977073565,2086S0122X,Orthopedic Surgery,23,In_Network,OTHER,Z00.01,D0120,,0,Medicaid_MCO,MCO,57,M,0.9592,,,516.97,288.1,287.1,0.0,1.0,0.0,228.87,0.0,0.0,0,,0.0426,none,0,1,0,1,0,2.7e-05,0,0,,Capitation
CLM0000001034,MBR00000152,Dental,Paid,Provider_Portal,2023-02-05,2023-02-05,2023-02-05,2023-03-06,Auto_Adjudicated,29,1728728765,1510751265,207RC0000X,Cardiovascular Disease,24,In_Network,OTHER,,D0150,,0,Commercial,HMO,82,F,1.2506,,,170.33,93.42,2.36,73.47,17.0,0.59,76.91,0.0,0.0,0,,0.086,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001035,MBR00000208,Medical_Institutional,Paid,Electronic_EDI,2023-10-05,2023-10-05,2023-10-06,2023-10-07,Manual_Review,2,1887322427,1007652766,207RC0000X,Cardiovascular Disease,22,In_Network,Z00.00,J06.9|OTHER,revenue_code:0200,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,95908.54,39553.71,31591.93,9.8,54.0,7897.98,56354.83,0.0,0.0,0,,0.0986,outlier_billing_amount,0,1,1,0,0,0.002924,0,0,,FFS
CLM0000001036,MBR00000170,Pharmacy,Paid,Electronic_EDI,2023-06-22,2023-06-22,2023-06-22,2023-06-23,Auto_Adjudicated,1,1965812565,1995553359,207Q00000X,Family Medicine,81,Out_of_Network,J44.1,K57.30|OTHER,59148001506,,1,Medicare_Advantage,MA_PPO,86,M,1.7691,,,304.96,185.1,133.72,14.95,3.0,33.43,119.86,0.0,0.0,0,,0.0958,none,0,1,0,0,0,1.2e-05,1,1,,P4P
CLM0000001037,MBR00000157,Vision,Denied,Electronic_EDI,2023-03-27,2023-03-27,2023-03-27,2023-04-12,Auto_Adjudicated,16,1147937670,1538261819,207RG0100X,Gastroenterology,23,In_Network,E78.5,Z00.00|Z23,V2100,,0,Medicare_Advantage,MA_HMO,26,F,0.9164,4,COB,209.03,176.53,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0965,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001038,MBR00000062,Medical_Institutional,Paid,Electronic_EDI,2023-10-20,2023-10-20,2023-10-22,2023-11-15,Auto_Adjudicated,26,1661091022,1994275960,225100000X,Physical Therapist,24,In_Network,Z12.11,E11.9|OTHER,revenue_code:0110,,0,Commercial,HMO,46,F,0.5516,,,10660.6,8293.42,6533.34,93.74,33.0,1633.34,2367.18,0.0,0.0,0,,0.0046,none,0,1,1,0,0,0.000605,0,0,HBD_Hemoglobin_A1c_Testing,Shared_Savings
CLM0000001039,MBR00000080,Medical_Professional,Denied,Electronic_EDI,2023-11-14,2023-11-14,2023-11-14,2023-11-15,Auto_Adjudicated,1,1331829614,1287472731,208600000X,Surgery General,23,Out_of_Network,Z00.01,,99205,,0,Commercial,HDHP_HSA,74,M,0.5935,1,Network,147.04,109.1,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1364,none,0,1,0,0,0,0.0,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000001040,MBR00000113,Medical_Institutional,Paid,Electronic_EDI,2023-07-30,2023-07-30,2023-08-03,2023-08-20,Auto_Adjudicated,21,1466922283,1672803287,207RP1001X,Pulmonary Disease,24,In_Network,I48.91,OTHER,revenue_code:0100,,0,Medicaid_MCO,MLTSS,29,F,1.1621,,,3182.98,1885.81,1879.81,0.0,6.0,0.0,1297.17,0.0,0.0,0,,0.0339,none,0,1,0,0,0,0.000174,0,0,MMA_Medication_Management,FFS
CLM0000001041,MBR00000003,Dental,Paid,Electronic_EDI,2023-09-15,2023-09-15,2023-09-15,2023-09-27,Auto_Adjudicated,12,1558692441,1930040953,101YP2500X,Psychologist Clinical,21,In_Network,N39.0,E11.65|M54.5,D7140,,0,Commercial,PPO,79,F,1.3879,,,277.74,211.45,147.36,2.25,25.0,36.84,66.29,0.0,0.0,0,,0.119,phantom_billing_indicator|controlled_substance_high_volume,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000001042,MBR00000132,Pharmacy,Paid,Electronic_EDI,2023-03-28,2023-03-28,2023-03-28,2023-03-29,Clinical_Review,1,1218294278,1114756459,207RN0300X,Nephrology,21,In_Network,OTHER,J20.9|OTHER,00085163102,,1,Medicare_Advantage,MA_PPO,84,F,1.3018,,,512.75,413.47,325.85,0.16,6.0,81.46,99.28,0.0,0.0,0,,0.0969,provider_specialty_mismatch,0,1,0,0,0,3e-05,0,1,,FFS
CLM0000001043,MBR00000002,Medical_Professional,Paid,Electronic_EDI,2023-09-26,2023-09-26,2023-09-26,2023-10-08,Auto_Adjudicated,12,1478458171,1930040953,207RE0101X,Endocrinology,21,In_Network,Z00.01,I25.10|OTHER,83036,,0,Commercial,PPO,42,F,0.9012,,,242.78,111.44,36.37,47.97,18.0,9.09,131.34,0.0,0.0,0,,0.0343,none,0,1,0,0,0,3e-06,0,0,,Capitation
CLM0000001044,MBR00000170,Dental,Partially_Paid,Electronic_EDI,2023-11-21,2023-11-21,2023-11-21,2023-12-11,Auto_Adjudicated,20,1315569619,1942423230,207RN0300X,Nephrology,22,In_Network,OTHER,E13.9,D1110,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,256,Medical_Necessity,733.44,438.8,231.18,27.43,3.0,57.8,414.03,0.0,0.0,0,,0.1054,unbundling_pattern,0,1,0,1,0,2.1e-05,0,0,,FFS
CLM0000001045,MBR00000208,Pharmacy,Paid,Provider_Portal,2023-03-27,2023-03-27,2023-03-27,2023-04-16,Auto_Adjudicated,20,1899326088,1903401648,2084P0800X,Psychiatry,21,In_Network,J06.9,Z00.01|OTHER,00006001954,,1,Medicare_Advantage,MA_HMO,66,M,2.1466,,,155.15,120.76,77.93,17.35,6.0,19.48,34.39,0.0,0.0,0,,0.1407,none,0,1,0,1,0,7e-06,0,1,COL_Colorectal_Cancer_Screening,FFS
CLM0000001046,MBR00000169,Medical_Institutional,Denied,Electronic_EDI,2023-12-05,2023-12-05,2023-12-06,2023-12-31,Auto_Adjudicated,26,1736809698,1746676564,101YP2500X,Psychologist Clinical,81,In_Network,OTHER,E11.9|OTHER,revenue_code:0360,,0,Commercial,EPO,30,M,1.4348,PR-1,Eligibility,14875.22,11318.58,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.04,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001047,MBR00000206,Behavioral_Health,Paid,Electronic_EDI,2023-02-02,2023-02-02,2023-02-02,2023-03-04,Auto_Adjudicated,30,1713741288,1576271272,225100000X,Physical Therapist,22,In_Network,K57.30,M54.5,99233,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,228.18,180.65,179.65,0.0,1.0,0.0,47.53,125.65,36.81,0,,0.1017,controlled_substance_high_volume,0,1,0,0,0,1.7e-05,0,0,,FFS
CLM0000001048,MBR00000001,Pharmacy,Paid,Electronic_EDI,2023-06-10,2023-06-10,2023-06-10,2023-06-12,Auto_Adjudicated,2,1145860509,1930040953,207Q00000X,Family Medicine,21,In_Network,Z00.01,,00078043215,,1,Commercial,EPO,73,M,0.6527,,,334.46,277.28,0.0,277.28,0.0,0.0,57.18,0.0,0.0,0,,0.1421,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001049,MBR00000017,Pharmacy,Paid,Electronic_EDI,2023-01-27,2023-01-27,2023-01-27,2023-02-22,Auto_Adjudicated,26,1331903993,1884259357,225100000X,Physical Therapist,22,In_Network,OTHER,E11.65|E78.5,00085163102,,2,Commercial,PPO,55,F,0.6174,,,896.37,442.43,277.38,56.71,39.0,69.34,453.94,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|unusual_service_frequency|high_volume_same_code|benford_violation|service_date_weekend|upcoding_pattern|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,2.6e-05,0,1,,Capitation
CLM0000001050,MBR00000207,Vision,Paid,Electronic_EDI,2023-06-10,2023-06-10,2023-06-10,2023-06-11,Auto_Adjudicated,1,1878057972,1220755708,207RE0101X,Endocrinology,24,In_Network,E11.65,Z00.00|OTHER,V2115,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,361.3,232.19,232.19,0.0,0.0,0.0,129.11,0.0,0.0,0,,0.1401,none,0,1,0,0,0,2.1e-05,0,0,,Bundled_Payment
CLM0000001051,MBR00000237,Medical_Professional,Paid,Paper,2023-08-21,2023-08-21,2023-08-21,2023-09-20,Auto_Adjudicated,30,1808451151,1894215172,2086S0122X,Orthopedic Surgery,24,In_Network,I10,N40.0|OTHER,99214,,0,Commercial,PPO,45,M,0.7983,,,536.55,230.53,148.33,20.12,25.0,37.08,306.02,0.0,0.0,0,,0.0286,none,0,1,0,0,0,1.4e-05,0,0,,Bundled_Payment
CLM0000001052,MBR00000212,Pharmacy,Paid,Provider_Portal,2023-11-09,2023-11-09,2023-11-09,2023-12-03,Auto_Adjudicated,24,1356408757,1123879500,207RN0300X,Nephrology,23,In_Network,I10,,00006001954,,2,Commercial,HMO,57,F,2.5456,,,345.23,211.52,0.0,199.91,11.61,0.0,133.71,0.0,0.0,0,,0.0534,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001053,MBR00000197,Medical_Professional,Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-23,2023-03-24,Auto_Adjudicated,29,1594322174,1767402068,207R00000X,Internal Medicine,11,In_Network,OTHER,,90837,,0,Medicare_Advantage,MA_HMO,59,M,1.1414,,,486.75,188.19,130.71,11.8,13.0,32.68,298.56,0.0,0.0,0,,0.0264,none,0,1,0,0,0,1.2e-05,0,0,,Capitation
CLM0000001054,MBR00000209,Dental,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-11-18,Auto_Adjudicated,3,1039678579,1304018750,207Q00000X,Family Medicine,32,In_Network,OTHER,I25.10|I10,D1110,,0,Medicare_Advantage,MA_HMO,10,F,0.5199,,,311.34,174.28,118.57,24.06,2.0,29.64,137.06,0.0,0.0,0,,0.0451,none,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000001055,MBR00000216,Dental,Paid,Electronic_EDI,2023-12-25,2023-12-25,2023-12-25,2023-12-28,Auto_Adjudicated,3,1253087808,1829216053,208600000X,Surgery General,65,In_Network,I25.10,,D3310,,0,Medicare_Advantage,MA_HMO,71,F,0.7117,,,193.64,118.19,83.18,4.21,10.0,20.8,75.45,0.0,0.0,0,,0.0029,none,0,1,0,0,0,8e-06,0,0,,P4P
CLM0000001056,MBR00000213,Pharmacy,Paid,Electronic_EDI,2023-01-24,2023-01-24,2023-01-24,2023-02-23,Manual_Review,30,1317654726,1012893364,207V00000X,Obstetrics & Gynecology,32,In_Network,I10,I10,59148001506,,1,Commercial,PPO,17,M,1.5857,,,770.59,537.96,340.41,84.44,28.0,85.1,232.63,0.0,0.0,0,,0.0067,none,0,1,0,0,0,3.2e-05,0,0,,FFS
CLM0000001057,MBR00000216,Pharmacy,Paid,Electronic_EDI,2023-12-12,2023-12-12,2023-12-12,2023-12-21,Manual_Review,9,1887698203,1574982369,207V00000X,Obstetrics & Gynecology,23,In_Network,J06.9,Z12.11,59148001506,,2,Medicare_Advantage,MA_HMO,71,F,0.7117,,,230.01,105.21,71.12,6.31,10.0,17.78,124.8,0.0,0.0,0,,0.0161,none,0,1,0,0,0,7e-06,0,0,,Capitation
CLM0000001058,MBR00000023,Pharmacy,Paid,Electronic_EDI,2023-11-22,2023-11-22,2023-11-22,2023-12-04,Auto_Adjudicated,12,1727787144,1025886739,101YP2500X,Psychologist Clinical,11,In_Network,E11.9,,50458085930,,5,Medicare_Advantage,MA_PPO,87,M,1.084,,,58.57,46.2,0.0,33.93,12.27,0.0,12.37,0.0,0.0,0,,0.0647,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001059,MBR00000019,Medical_Professional,Paid,Electronic_EDI,2023-01-11,2023-01-11,2023-01-11,2023-01-20,Auto_Adjudicated,9,1838794554,1049766043,207RE0101X,Endocrinology,71,Emergency,N18.3,M54.5,99214,,0,Commercial,PPO,77,M,0.6521,,,183.99,66.93,0.0,66.93,0.0,0.0,117.06,0.0,0.0,0,,0.0099,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001060,MBR00000114,Medical_Institutional,Paid,Electronic_EDI,2023-01-23,2023-01-23,2023-01-24,2023-01-28,Auto_Adjudicated,5,1923937825,1874728994,207RG0100X,Gastroenterology,11,In_Network,Z23,,revenue_code:0120,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,10450.97,6869.77,5453.28,33.17,20.0,1363.32,3581.2,0.0,0.0,0,,0.1364,none,0,1,1,0,0,0.000505,0,0,TRC_Transition_of_Care,Bundled_Payment
CLM0000001061,MBR00000160,Medical_Professional,Denied,Electronic_EDI,2023-09-18,2023-09-18,2023-09-18,2023-09-21,Auto_Adjudicated,3,1484613641,1825450791,207RC0000X,Cardiovascular Disease,11,In_Network,Z12.11,,99396,,0,Commercial,HMO,73,M,1.9608,3,Authorization,547.75,441.64,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0848,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001062,MBR00000224,Pharmacy,Denied,Paper,2023-05-31,2023-05-31,2023-05-31,2023-06-05,Auto_Adjudicated,5,1019263018,1055872102,208600000X,Surgery General,23,Out_of_Network,OTHER,Z23|E11.9|OTHER,00071015523,,1,Medicaid_MCO,MCO,86,F,1.3289,4,Eligibility,154.49,120.93,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0171,none,0,1,0,0,0,0.0,1,1,,FFS
CLM0000001063,MBR00000106,Medical_Institutional,Paid,Provider_Portal,2023-04-04,2023-04-04,2023-04-05,2023-04-30,Auto_Adjudicated,26,1905691248,1355732274,2086S0122X,Orthopedic Surgery,22,In_Network,OTHER,Z00.01,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,20665.47,12649.85,10084.55,9.16,35.0,2521.14,8015.62,0.0,0.0,0,,0.084,provider_specialty_mismatch,0,1,1,0,0,0.000933,0,0,SPD_Spirometry_Testing,FFS
CLM0000001064,MBR00000086,Medical_Institutional,Paid,Electronic_EDI,2023-05-26,2023-05-26,2023-05-29,2023-05-27,Manual_Review,1,1269185915,1408846353,208600000X,Surgery General,24,In_Network,E11.9,K29.70|E11.65|F33.0,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,8,M,0.5427,,,6307.6,2658.99,2108.55,0.3,23.0,527.14,3648.61,0.0,0.0,0,,0.1279,none,0,1,0,0,0,0.000195,0,0,BCS_Breast_Cancer_Screening,P4P
CLM0000001065,MBR00000231,Medical_Professional,Paid,Provider_Portal,2023-05-03,2023-05-03,2023-05-03,2023-05-30,Auto_Adjudicated,27,1906448800,1903401648,207RC0000X,Cardiovascular Disease,23,In_Network,Z23,OTHER,99231,,0,ACA_Marketplace,ACA_Silver,12,M,0.6456,,,386.44,154.12,0.0,154.12,0.0,0.0,232.32,0.0,0.0,0,,0.0599,npi_mismatch,0,1,0,1,0,0.0,0,0,SPC_Statin_Therapy,Capitation
CLM0000001066,MBR00000077,Medical_Institutional,Paid,Electronic_EDI,2023-12-17,2023-12-17,2023-12-21,2023-12-24,Auto_Adjudicated,7,1324084461,1354959095,207RC0000X,Cardiovascular Disease,11,Out_of_Network,N39.0,I50.9|E78.5,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,27,F,0.9229,,,38706.0,27322.76,21822.23,6.97,38.0,5455.56,11383.24,14924.08,5167.4,0,,0.0398,none,0,1,1,0,0,0.00202,1,0,,Shared_Savings
CLM0000001067,MBR00000245,Medical_Institutional,Paid,Electronic_EDI,2023-03-28,2023-03-28,2023-03-30,2023-04-16,Manual_Review,19,1550698436,1004714954,225100000X,Physical Therapist,23,In_Network,E11.9,,revenue_code:0120,,0,Medicaid_MCO,MCO,60,F,0.7502,,,24425.72,10072.65,10071.65,0.0,1.0,0.0,14353.07,0.0,0.0,0,,0.0739,impossible_service_combo,0,1,1,0,0,0.000932,0,0,TRC_Transition_of_Care,FFS
CLM0000001068,MBR00000056,Behavioral_Health,Paid,Electronic_EDI,2023-02-01,2023-02-01,2023-02-01,2023-02-09,Manual_Review,8,1288855406,1513198866,101YP2500X,Psychologist Clinical,31,In_Network,Z23,,27447,,0,Commercial,EPO,74,F,1.3941,,,64.4,24.46,0.0,24.46,0.0,0.0,39.94,0.0,0.0,0,,0.0061,none,0,1,0,1,0,0.0,0,0,PPC_Prenatal_Care,FFS
CLM0000001069,MBR00000113,Dental,Denied,Paper,2023-10-26,2023-10-26,2023-10-26,2023-11-22,Auto_Adjudicated,27,1089569577,1825450791,207R00000X,Internal Medicine,31,Out_of_Network,Z00.00,,D2391,,0,Medicaid_MCO,MLTSS,29,F,1.1621,16,COB,319.38,183.35,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1017,none,0,1,0,0,0,0.0,1,0,,FFS
CLM0000001070,MBR00000128,Medical_Institutional,Denied,Electronic_EDI,2023-10-29,2023-10-29,2023-10-29,2023-10-31,Auto_Adjudicated,2,1557212800,1938465393,207RE0101X,Endocrinology,11,Emergency,Z00.00,,revenue_code:0370,,0,Commercial,PPO,13,F,1.4203,22,Timely_Filing,4631.89,2049.54,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0353,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001071,MBR00000094,Pharmacy,Partially_Paid,Electronic_EDI,2023-11-17,2023-11-17,2023-11-17,2023-12-09,Auto_Adjudicated,22,1956215244,1574982369,101YP2500X,Psychologist Clinical,21,In_Network,OTHER,E78.5|OTHER|F41.1,00071012831,,2,Commercial,POS,36,F,0.3997,50,Medical_Necessity,307.96,232.06,0.0,137.34,0.0,0.0,170.62,0.0,0.0,0,,0.0488,none,0,1,0,0,0,0.0,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000001072,MBR00000002,Medical_Professional,Paid,Electronic_EDI,2023-12-15,2023-12-15,2023-12-15,2024-01-13,Auto_Adjudicated,29,1793630905,1012893364,207R00000X,Internal Medicine,11,In_Network,J06.9,Z87.891,99284,,0,Commercial,PPO,42,F,0.9012,,,290.01,180.09,114.26,19.26,18.0,28.57,109.92,0.0,0.0,0,,0.0491,none,0,1,0,0,0,1.1e-05,0,0,,P4P
CLM0000001073,MBR00000074,Medical_Professional,Paid,Electronic_EDI,2023-01-15,2023-01-15,2023-01-15,2023-01-29,Manual_Review,14,1826567270,1887266184,207V00000X,Obstetrics & Gynecology,24,In_Network,C50.911,Z12.11,99283,,0,Medicare_Advantage,MA_PPO,21,F,0.8719,,,658.93,512.36,362.01,40.85,19.0,90.5,146.57,0.0,0.0,0,,0.1098,none,0,1,0,0,0,3.4e-05,0,0,,FFS
CLM0000001074,MBR00000106,Medical_Institutional,Paid,Electronic_EDI,2023-10-04,2023-10-04,2023-10-08,2023-10-18,Auto_Adjudicated,14,1159268684,1738617370,207RN0300X,Nephrology,23,In_Network,Z00.01,K29.70,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,8897.62,4846.79,3847.8,2.05,35.0,961.95,4050.83,0.0,0.0,0,,0.0687,none,0,1,0,0,0,0.000356,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000001075,MBR00000100,Pharmacy,Denied,Electronic_EDI,2023-04-07,2023-04-07,2023-04-07,2023-04-12,Auto_Adjudicated,5,1097563011,1965244699,101YP2500X,Psychologist Clinical,22,In_Network,I50.9,,00071012831,,4,ACA_Marketplace,ACA_Gold,87,M,1.435,170,Timely_Filing,190.8,154.73,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1423,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000001076,MBR00000232,Medical_Professional,Paid,Electronic_EDI,2023-06-01,2023-06-01,2023-06-01,2023-06-28,Auto_Adjudicated,27,1421421733,1105733833,207RN0300X,Nephrology,11,Out_of_Network,R05.9,Z23|F41.1|OTHER,99203,,0,Medicaid_MCO,MCO,40,M,1.1083,,,263.27,220.79,218.79,0.0,2.0,0.0,42.48,0.0,0.0,0,,0.0969,none,0,1,0,0,0,2e-05,0,0,,Capitation
CLM0000001077,MBR00000014,Medical_Professional,Paid,Provider_Portal,2023-06-11,2023-06-11,2023-06-11,2023-07-10,Auto_Adjudicated,29,1972755666,1746676564,207RN0300X,Nephrology,24,Out_of_Network,OTHER,F41.1|E11.9,99203,,0,Commercial,HMO,77,M,2.8513,,,401.07,251.13,0.0,251.13,0.0,0.0,149.94,0.0,0.0,0,,0.0938,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000001078,MBR00000124,Medical_Institutional,Paid,Electronic_EDI,2023-12-20,2023-12-20,2023-12-20,2024-01-04,Auto_Adjudicated,15,1882720848,1616762819,207Q00000X,Family Medicine,24,In_Network,E11.9,,revenue_code:0370,,0,Commercial,EPO,40,F,0.4583,,,5005.16,2219.97,1457.36,340.26,58.0,364.34,2785.19,0.0,0.0,0,,0.1097,impossible_service_combo,0,1,0,0,0,0.000135,0,0,,Shared_Savings
CLM0000001079,MBR00000012,Medical_Professional,Denied,Electronic_EDI,2023-07-07,2023-07-07,2023-07-07,2023-07-28,Manual_Review,21,1929402739,1588993671,207RC0000X,Cardiovascular Disease,22,In_Network,J20.9,N39.0,27447,,0,Commercial,HMO,84,M,1.3904,96,Duplicate,8937.83,3367.19,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1346,none,0,1,0,0,0,0.0,0,0,AWV_Annual_Wellness_Visit,Shared_Savings
CLM0000001080,MBR00000281,Medical_Institutional,Denied,Electronic_EDI,2023-03-21,2023-03-21,2023-03-23,2023-04-13,Auto_Adjudicated,23,1654042271,1128148362,207RN0300X,Nephrology,11,In_Network,OTHER,,revenue_code:0210,,0,Medicare_Advantage,MA_HMO,3,M,0.8531,96,Medical_Necessity,7227.85,5848.31,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0373,none,0,1,0,1,0,0.0,0,0,AWV_Annual_Wellness_Visit,Bundled_Payment
CLM0000001081,MBR00000235,Medical_Institutional,Paid,Electronic_EDI,2023-02-01,2023-02-01,2023-02-01,2023-02-12,Auto_Adjudicated,11,1930591083,1228356980,207RE0101X,Endocrinology,22,In_Network,E11.9,Z00.00|E78.5,revenue_code:0360,,0,Commercial,HDHP_HSA,85,F,1.4308,,,20311.63,12279.46,9411.97,514.5,0.0,2352.99,8032.17,0.0,0.0,0,,0.0845,none,0,1,1,0,0,0.000871,0,0,,Shared_Savings
CLM0000001082,MBR00000296,Vision,Denied,Electronic_EDI,2023-07-31,2023-07-31,2023-07-31,2023-08-01,Clinical_Review,1,1721465780,1027261156,208600000X,Surgery General,65,In_Network,I10,N18.3,92014,,0,Commercial,HMO,83,F,1.4969,3,Coding_Error,470.76,212.27,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1492,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001083,MBR00000275,Medical_Professional,Paid,Electronic_EDI,2023-10-25,2023-10-25,2023-10-25,2023-10-29,Auto_Adjudicated,4,1909649019,1978943761,207R00000X,Internal Medicine,22,Emergency,J06.9,Z00.00|F32.9|J44.1,99233,,0,Medicare_Advantage,MA_PPO,67,M,0.8169,,,267.27,143.62,92.95,12.43,15.0,23.24,123.65,0.0,0.0,0,,0.0377,none,0,1,0,0,0,9e-06,0,0,,Capitation
CLM0000001084,MBR00000100,Medical_Professional,Partially_Paid,Provider_Portal,2023-09-13,2023-09-13,2023-09-13,2023-10-10,Manual_Review,27,1435110996,1163639177,207Q00000X,Family Medicine,24,In_Network,OTHER,E11.9|I50.9|OTHER,97010,,0,ACA_Marketplace,ACA_Gold,87,M,1.435,4,Medical_Necessity,983.44,801.93,389.32,28.67,12.0,97.33,456.12,0.0,0.0,0,,0.0625,none,0,1,0,0,0,3.6e-05,0,0,HBD_Hemoglobin_A1c_Testing,Bundled_Payment
CLM0000001085,MBR00000206,Medical_Professional,Paid,Electronic_EDI,2023-12-02,2023-12-02,2023-12-02,2023-12-26,Manual_Review,24,1469822310,1151295616,207RG0100X,Gastroenterology,11,In_Network,I10,,99284,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,360.96,299.75,298.75,0.0,1.0,0.0,61.21,0.0,0.0,0,,0.0354,none,0,1,0,0,0,2.8e-05,0,0,,P4P
CLM0000001086,MBR00000097,Medical_Professional,Denied,Electronic_EDI,2023-01-16,2023-01-16,2023-01-16,2023-01-19,Auto_Adjudicated,3,1344162462,1728466420,207RC0000X,Cardiovascular Disease,21,In_Network,Z00.01,,83036,,0,Commercial,EPO,34,M,1.3765,18,Timely_Filing,624.35,282.89,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1177,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000001087,MBR00000270,Pharmacy,Paid,Paper,2023-05-25,2023-05-25,2023-05-25,2023-06-19,Auto_Adjudicated,25,1190787795,1867389043,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,M54.5|E11.9,16590051660,,2,Commercial,POS,1,F,1.6363,,,168.67,101.65,0.0,101.65,0.0,0.0,67.02,0.0,0.0,0,,0.1326,high_volume_same_code,0,1,0,0,0,0.0,0,1,HBD_Hemoglobin_A1c_Testing,P4P
CLM0000001088,MBR00000130,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-08-08,2023-08-08,2023-08-08,2023-09-04,Auto_Adjudicated,27,1706065807,1355732274,246ZN0300X,Neuropsychology,21,Out_of_Network,Z12.11,OTHER,revenue_code:0250,871,0,Medicare_Advantage,MA_PPO,58,M,1.3394,CO-45,Medical_Necessity,23835.7,17950.06,8208.33,25.93,24.0,2052.08,13525.36,0.0,0.0,0,,0.1695,duplicate_claim_indicator,0,1,1,0,0,0.00076,1,0,,Capitation
CLM0000001089,MBR00000119,Medical_Professional,Paid,Electronic_EDI,2023-11-04,2023-11-04,2023-11-04,2023-11-21,Auto_Adjudicated,17,1210349885,1209882852,207RG0100X,Gastroenterology,11,In_Network,I10,OTHER,33510,,0,Commercial,POS,42,M,0.4987,,,2484.69,1767.02,1263.58,171.55,16.0,315.89,717.67,0.0,0.0,0,,0.1253,benford_violation,0,1,0,0,0,0.000117,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000001090,MBR00000276,Vision,Paid,Electronic_EDI,2023-04-23,2023-04-23,2023-04-23,2023-05-07,Auto_Adjudicated,14,1389116733,1133410177,207RE0101X,Endocrinology,22,Emergency,E11.65,OTHER,92012,,0,Commercial,POS,38,M,0.8085,,,458.88,311.03,0.0,298.4,12.63,0.0,147.85,0.0,0.0,0,,0.0807,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001091,MBR00000250,Pharmacy,Paid,Electronic_EDI,2023-08-31,2023-08-31,2023-08-31,2023-09-30,Auto_Adjudicated,30,1591624417,1788579687,246ZN0300X,Neuropsychology,21,In_Network,Z00.00,Z00.00,00003014960,,1,Commercial,PPO,41,M,0.9245,,,471.19,360.12,0.0,360.12,0.0,0.0,111.07,0.0,0.0,0,,0.0397,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001092,MBR00000293,Medical_Professional,Paid,Electronic_EDI,2023-03-16,2023-03-16,2023-03-16,2023-04-12,Auto_Adjudicated,27,1627776731,1527857018,101YP2500X,Psychologist Clinical,31,In_Network,Z23,OTHER,90837,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,2709.03,2051.78,1617.37,19.06,11.0,404.34,657.25,0.0,0.0,0,,0.0558,none,0,1,0,0,0,0.00015,0,0,,FFS
CLM0000001093,MBR00000020,Medical_Professional,Paid,Electronic_EDI,2023-08-01,2023-08-01,2023-08-01,2023-08-13,Auto_Adjudicated,12,1789174420,1689327034,208600000X,Surgery General,21,Out_of_Network,Z00.00,OTHER|M54.5|F33.0,99223,,0,Medicare_Advantage,MA_PPO,63,F,0.7119,,,197.5,128.86,85.3,16.23,6.0,21.33,68.64,0.0,0.0,0,,0.1322,none,0,1,0,0,0,8e-06,1,0,HBD_Hemoglobin_A1c_Testing,Bundled_Payment
CLM0000001094,MBR00000076,Pharmacy,Denied,Electronic_EDI,2023-10-06,2023-10-06,2023-10-06,2023-10-21,Auto_Adjudicated,15,1832660692,1842149518,208600000X,Surgery General,11,In_Network,E11.65,I10,00310075090,,1,Commercial,HMO,26,M,2.1785,4,Medical_Necessity,315.49,187.89,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0772,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001095,MBR00000095,Pharmacy,Denied,Electronic_EDI,2023-10-22,2023-10-22,2023-10-22,2023-11-20,Auto_Adjudicated,29,1379875145,1650774392,207RP1001X,Pulmonary Disease,11,In_Network,F33.0,Z23,00169751112,,1,Commercial,HMO,28,M,0.5827,CO-45,Eligibility,577.08,438.17,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0309,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001096,MBR00000134,Vision,Paid,Paper,2023-06-12,2023-06-12,2023-06-12,2023-07-10,Auto_Adjudicated,28,1522998767,1209882852,207RC0000X,Cardiovascular Disease,11,In_Network,Z00.00,,V2320,,0,Medicare_Advantage,MA_PPO,33,M,1.115,,,693.85,507.81,354.65,51.5,13.0,88.66,186.04,0.0,0.0,1,Unbundling,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|high_volume_same_code|benford_violation|unbundling_pattern|phantom_billing_indicator|controlled_substance_high_volume,1,5,0,0,0,3.3e-05,0,0,,Capitation
CLM0000001097,MBR00000144,Medical_Professional,Paid,Electronic_EDI,2023-06-19,2023-06-19,2023-06-19,2023-07-08,Auto_Adjudicated,19,1929402739,1577226132,225100000X,Physical Therapist,23,In_Network,M17.11,N18.3|Z00.01|OTHER,71250,,0,Commercial,HDHP_HSA,56,F,2.5926,,,372.12,166.72,0.0,166.72,0.0,0.0,205.4,0.0,0.0,0,,0.1301,temporal_clustering,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001098,MBR00000091,Pharmacy,Paid,Electronic_EDI,2023-11-13,2023-11-13,2023-11-13,2023-12-03,Auto_Adjudicated,20,1008470017,1144950506,207R00000X,Internal Medicine,23,In_Network,OTHER,OTHER,59148001506,,2,Commercial,PPO,13,F,1.2451,,,664.74,400.42,150.5,188.29,24.0,37.63,264.32,0.0,0.0,0,,0.1603,service_date_weekend,0,1,0,0,0,1.4e-05,0,0,CBP_Controlling_BP,Capitation
CLM0000001099,MBR00000235,Medical_Professional,Paid,Electronic_EDI,2023-07-16,2023-07-16,2023-07-16,2023-08-08,Manual_Review,23,1231954359,1694343357,207RN0300X,Nephrology,22,In_Network,Z12.11,OTHER,17000,,0,Commercial,HDHP_HSA,85,F,1.4308,,,1381.24,892.24,394.64,398.95,0.0,98.66,489.0,0.0,0.0,1,Date of Service Falsification,0.9943,outlier_billing_amount|unusual_service_frequency|high_volume_same_code|benford_violation|impossible_service_combo|service_date_weekend|upcoding_pattern|phantom_billing_indicator|controlled_substance_high_volume,1,5,0,1,0,3.7e-05,0,0,,Bundled_Payment
CLM0000001100,MBR00000069,Medical_Professional,Paid,Electronic_EDI,2023-05-06,2023-05-06,2023-05-06,2023-05-15,Clinical_Review,9,1923332120,1804282800,207V00000X,Obstetrics & Gynecology,31,Out_of_Network,OTHER,,99284,,0,Medicare_Advantage,MA_PPO,2,M,0.5765,,,282.74,235.46,167.3,18.33,8.0,41.83,47.28,0.0,0.0,0,,0.0075,none,0,1,0,0,0,1.5e-05,0,0,TRC_Transition_of_Care,Shared_Savings
CLM0000001101,MBR00000207,Pharmacy,Paid,Electronic_EDI,2023-04-09,2023-04-09,2023-04-09,2023-05-07,Auto_Adjudicated,28,1262622669,1461075342,207R00000X,Internal Medicine,11,In_Network,OTHER,I10|I50.9|OTHER,00078043215,,2,Medicaid_MCO,MLTSS,11,F,1.6522,,,602.46,354.83,354.83,0.0,0.0,0.0,247.63,0.0,0.0,0,,0.1918,benford_violation|service_date_weekend,0,1,0,0,0,3.3e-05,0,0,AWV_Annual_Wellness_Visit,Capitation
CLM0000001102,MBR00000257,Pharmacy,Paid,Electronic_EDI,2023-09-13,2023-09-13,2023-09-13,2023-09-22,Manual_Review,9,1059948944,1318978078,208600000X,Surgery General,22,In_Network,E11.9,I10,00085163102,,3,Medicaid_MCO,MCO,76,F,0.8322,,,392.39,190.99,189.99,0.0,1.0,0.0,201.4,0.0,0.0,0,,0.2301,high_volume_same_code|diagnosis_procedure_mismatch,0,2,0,0,0,1.8e-05,0,0,,FFS
CLM0000001103,MBR00000182,Medical_Professional,Paid,Electronic_EDI,2023-09-13,2023-09-13,2023-09-13,2023-10-08,Auto_Adjudicated,25,1855186422,1228356980,207RN0300X,Nephrology,11,In_Network,I25.10,M79.3|E11.9|E13.9,99383,,0,Commercial,HMO,82,F,0.8489,,,255.13,113.73,0.0,113.73,0.0,0.0,141.4,0.0,0.0,0,,0.0483,none,0,1,0,0,0,0.0,0,0,FUM_Follow_Up_ED_Mental_Health,Shared_Savings
CLM0000001104,MBR00000112,Medical_Professional,Paid,Electronic_EDI,2023-07-13,2023-07-13,2023-07-13,2023-08-07,Auto_Adjudicated,25,1331829614,1553094822,101YP2500X,Psychologist Clinical,11,In_Network,OTHER,,99215,,0,Medicare_Advantage,MA_HMO,18,M,1.01,,,441.64,360.33,273.52,12.42,6.0,68.38,81.31,0.0,0.0,0,,0.191,service_date_weekend,0,1,0,0,0,2.5e-05,0,0,,FFS
CLM0000001105,MBR00000059,Pharmacy,Paid,Electronic_EDI,2023-02-27,2023-02-27,2023-02-27,2023-03-08,Auto_Adjudicated,9,1918160357,1842149518,207V00000X,Obstetrics & Gynecology,21,In_Network,C50.911,R05.9,16590051660,,1,Medicare_Advantage,SNP,12,F,1.266,,,207.58,129.69,72.31,23.31,16.0,18.08,77.89,0.0,0.0,0,,0.08,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000001106,MBR00000042,Medical_Professional,Partially_Paid,Electronic_EDI,2023-02-27,2023-02-27,2023-02-27,2023-03-24,Auto_Adjudicated,25,1243052462,1252125670,2084P0800X,Psychiatry,23,Out_of_Network,OTHER,,27447,,0,Commercial,HMO,78,F,1.1448,97,Medical_Necessity,33137.34,15763.72,7806.94,8.74,20.0,1951.73,23349.92,0.0,0.0,0,,0.1064,service_date_weekend,0,1,1,0,0,0.000723,0,0,,FFS
CLM0000001107,MBR00000218,Medical_Professional,Paid,Electronic_EDI,2023-03-29,2023-03-29,2023-03-29,2023-04-25,Auto_Adjudicated,27,1826567270,1061113875,207RE0101X,Endocrinology,31,In_Network,E78.5,OTHER,43239,,0,Commercial,HDHP_HSA,11,F,0.4964,,,1679.61,941.91,744.51,11.28,0.0,186.13,737.7,0.0,0.0,0,,0.122,geographic_mismatch,0,1,0,0,0,6.9e-05,0,0,,P4P
CLM0000001108,MBR00000144,Medical_Professional,Paid,Electronic_EDI,2023-01-05,2023-01-05,2023-01-05,2023-01-20,Auto_Adjudicated,15,1026612378,1527857018,207RC0000X,Cardiovascular Disease,11,Out_of_Network,OTHER,F41.1|OTHER|I10,12001,,0,Commercial,HDHP_HSA,56,F,2.5926,,,1544.46,563.44,207.82,303.66,0.0,51.96,981.02,0.0,0.0,0,,0.2202,impossible_service_combo|diagnosis_procedure_mismatch,0,2,0,0,0,1.9e-05,0,0,,FFS
CLM0000001109,MBR00000014,Medical_Professional,Paid,Electronic_EDI,2023-06-22,2023-06-22,2023-06-22,2023-07-09,Auto_Adjudicated,17,1793406356,1068662623,2086S0122X,Orthopedic Surgery,21,In_Network,E11.9,M79.3,27447,,0,Commercial,HMO,77,M,2.8513,,,5378.18,1892.09,1256.64,283.29,38.0,314.16,3486.09,0.0,0.0,0,,0.014,none,0,1,0,1,0,0.000116,0,0,SPC_Statin_Therapy,Capitation
CLM0000001110,MBR00000296,Pharmacy,Paid,Electronic_EDI,2023-05-29,2023-05-29,2023-05-29,2023-06-14,Manual_Review,16,1340676357,1477113725,2086S0122X,Orthopedic Surgery,32,In_Network,M79.3,OTHER|F10.10,00003014960,,1,Commercial,HMO,83,F,1.4969,,,271.48,141.55,0.0,141.55,0.0,0.0,129.93,0.0,0.0,0,,0.0701,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001111,MBR00000199,Medical_Professional,Paid,Electronic_EDI,2023-05-19,2023-05-19,2023-05-19,2023-05-21,Clinical_Review,2,1803277343,1489993356,101YP2500X,Psychologist Clinical,24,In_Network,OTHER,OTHER|Z79.4,33510,,0,Medicaid_MCO,MLTSS,17,F,1.0776,,,1829.21,1287.4,1285.4,0.0,2.0,0.0,541.81,0.0,0.0,0,,0.0997,none,0,1,0,0,0,0.000119,0,0,TRC_Transition_of_Care,Shared_Savings
CLM0000001112,MBR00000253,Medical_Institutional,Denied,Provider_Portal,2023-12-02,2023-12-02,2023-12-06,2023-12-19,Auto_Adjudicated,17,1865750966,1301869102,207RP1001X,Pulmonary Disease,23,In_Network,J06.9,,revenue_code:0450,,0,Commercial,EPO,44,M,0.3882,22,Coding_Error,6283.77,4502.04,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0842,none,0,1,0,0,0,0.0,0,0,COL_Colorectal_Cancer_Screening,Bundled_Payment
CLM0000001113,MBR00000137,Pharmacy,Paid,Electronic_EDI,2023-03-28,2023-03-28,2023-03-28,2023-04-18,Manual_Review,21,1874109311,1728466420,208600000X,Surgery General,21,In_Network,J20.9,J20.9,16590051660,,2,Commercial,PPO,87,M,0.5201,,,883.91,311.53,225.0,5.28,25.0,56.25,572.38,0.0,0.0,0,,0.0746,none,0,1,0,0,0,2.1e-05,0,0,,FFS
CLM0000001114,MBR00000289,Medical_Professional,Paid,Electronic_EDI,2023-10-18,2023-10-18,2023-10-18,2023-11-04,Manual_Review,17,1888245409,1688513262,2084P0800X,Psychiatry,21,In_Network,E13.9,OTHER|M54.5,81001,,0,Commercial,POS,51,M,1.0534,,,1003.71,694.22,485.3,48.6,39.0,121.32,309.49,0.0,0.0,0,,0.0217,none,0,1,0,0,0,4.5e-05,0,0,TRC_Transition_of_Care,FFS
CLM0000001115,MBR00000061,Medical_Institutional,Paid,Electronic_EDI,2023-03-10,2023-03-10,2023-03-10,2023-03-25,Auto_Adjudicated,15,1424104563,1847196500,207RE0101X,Endocrinology,23,In_Network,OTHER,I48.91,revenue_code:0360,,0,Commercial,PPO,66,M,2.3575,,,28432.57,20737.71,16531.55,39.27,34.0,4132.89,7694.86,12110.94,3042.64,0,,0.1469,none,0,1,1,0,0,0.00153,0,0,CDC_HbA1c_Poor_Control,Bundled_Payment
CLM0000001116,MBR00000058,Medical_Professional,Paid,Paper,2023-08-08,2023-08-08,2023-08-08,2023-08-24,Auto_Adjudicated,16,1117755591,1867389043,207RP1001X,Pulmonary Disease,11,In_Network,K21.0,,90837,,0,Commercial,PPO,56,F,1.1626,,,1270.64,591.88,397.75,79.69,15.0,99.44,678.76,0.0,0.0,0,,0.0213,none,0,1,0,0,0,3.7e-05,0,0,PPC_Prenatal_Care,Capitation
CLM0000001117,MBR00000270,Pharmacy,Paid,Electronic_EDI,2023-11-06,2023-11-06,2023-11-06,2023-11-23,Auto_Adjudicated,17,1257723293,1450837722,207RC0000X,Cardiovascular Disease,22,In_Network,N18.3,M47.816|OTHER,00071015523,,3,Commercial,POS,1,F,1.6363,,,61.4,26.19,0.0,26.19,0.0,0.0,35.21,0.0,0.0,0,,0.0341,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000001118,MBR00000270,Pharmacy,Denied,Electronic_EDI,2023-10-28,2023-10-28,2023-10-28,2023-11-25,Auto_Adjudicated,28,1007414142,1040061910,207Q00000X,Family Medicine,11,In_Network,I10,F41.1,16590051660,,2,Commercial,POS,1,F,1.6363,256,Timely_Filing,399.13,280.61,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0888,upcoding_pattern,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001119,MBR00000154,Pharmacy,Denied,Electronic_EDI,2023-08-01,2023-08-01,2023-08-01,2023-08-14,Auto_Adjudicated,13,1898658234,1650774392,225100000X,Physical Therapist,22,In_Network,Z00.00,F41.1|Z00.00|OTHER,00069420020,,2,Medicare_Advantage,MA_HMO,54,F,1.9463,50,Coding_Error,267.07,169.27,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1026,none,0,1,0,0,0,0.0,0,1,,Bundled_Payment
CLM0000001120,MBR00000038,Medical_Professional,Denied,Electronic_EDI,2023-03-16,2023-03-16,2023-03-16,2023-03-23,Auto_Adjudicated,7,1647029816,1098360555,207Q00000X,Family Medicine,22,In_Network,Z00.00,Z12.11|J20.9,97140,,0,Commercial,EPO,46,M,1.1295,97,Medical_Necessity,475.04,260.5,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0862,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000001121,MBR00000097,Pharmacy,Denied,Electronic_EDI,2023-05-16,2023-05-16,2023-05-16,2023-05-18,Manual_Review,2,1375098560,1587454801,207RE0101X,Endocrinology,11,Out_of_Network,F32.9,E11.9,00078043215,,4,Commercial,EPO,34,M,1.3765,97,Timely_Filing,659.69,421.77,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1129,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000001122,MBR00000221,Medical_Institutional,Denied,Electronic_EDI,2023-06-02,2023-06-02,2023-06-06,2023-06-29,Clinical_Review,27,1403662694,1978943761,207V00000X,Obstetrics & Gynecology,21,In_Network,J20.9,F33.0,revenue_code:0110,292,0,Commercial,HDHP_HSA,28,M,1.6683,97,Medical_Necessity,2180.54,1646.63,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1118,duplicate_claim_indicator,0,1,0,0,1,0.0,0,0,,P4P
CLM0000001123,MBR00000254,Medical_Professional,Paid,Electronic_EDI,2023-10-31,2023-10-31,2023-10-31,2023-11-06,Auto_Adjudicated,6,1597649716,1972530373,207RC0000X,Cardiovascular Disease,11,In_Network,Z00.01,J06.9|I25.10,99395,,0,Commercial,PPO,22,F,0.9285,,,206.13,81.74,32.84,12.69,28.0,8.21,124.39,0.0,0.0,0,,0.0118,none,0,1,0,0,0,3e-06,0,0,,Capitation
CLM0000001124,MBR00000110,Medical_Professional,Paid,Electronic_EDI,2023-05-16,2023-05-16,2023-05-16,2023-05-29,Auto_Adjudicated,13,1990244466,1513198866,207RG0100X,Gastroenterology,24,In_Network,I10,H52.4|N18.3|Z00.00,17000,,0,Medicare_Advantage,MA_HMO,83,F,1.127,,,1797.89,1089.9,864.63,0.11,9.0,216.16,707.99,658.1,184.16,0,,0.0526,none,0,1,0,1,0,8e-05,0,0,BPD_BP_Declined,FFS
CLM0000001125,MBR00000018,Medical_Professional,Paid,Electronic_EDI,2023-10-24,2023-10-24,2023-10-24,2023-11-16,Auto_Adjudicated,23,1534538584,1140170394,207V00000X,Obstetrics & Gynecology,65,In_Network,E78.5,OTHER,71250,,0,Commercial,EPO,5,F,0.5555,,,1317.24,643.22,492.04,14.17,14.0,123.01,674.02,0.0,0.0,0,,0.0047,none,0,1,0,0,0,4.6e-05,0,0,BCS_Breast_Cancer_Screening,Capitation
CLM0000001126,MBR00000198,Medical_Professional,Paid,Electronic_EDI,2023-12-08,2023-12-08,2023-12-08,2023-12-14,Auto_Adjudicated,6,1175978429,1522426351,207R00000X,Internal Medicine,21,In_Network,OTHER,,99204,,0,Medicaid_MCO,MCO,81,F,1.4199,,,214.0,105.35,103.35,0.0,2.0,0.0,108.65,0.0,0.0,0,,0.0323,none,0,1,0,0,0,1e-05,0,0,DAE_Drug_Alcohol_Dependence,Shared_Savings
CLM0000001127,MBR00000216,Medical_Professional,Denied,Electronic_EDI,2023-02-09,2023-02-09,2023-02-09,2023-02-17,Auto_Adjudicated,8,1334227781,1473869105,208600000X,Surgery General,11,In_Network,Z00.01,,27130,,0,Medicare_Advantage,MA_HMO,71,F,0.7117,5,Duplicate,10934.15,8054.4,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.174,service_date_weekend,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000001128,MBR00000134,Vision,Denied,Provider_Portal,2023-12-02,2023-12-02,2023-12-02,2023-12-22,Auto_Adjudicated,20,1769163673,1765164601,246ZN0300X,Neuropsychology,65,In_Network,F41.1,E11.65,V2103,,0,Medicare_Advantage,MA_PPO,33,M,1.115,18,COB,258.23,174.24,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0779,none,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000001129,MBR00000175,Behavioral_Health,Paid,Electronic_EDI,2023-07-23,2023-07-23,2023-07-23,2023-08-11,Auto_Adjudicated,19,1101385540,1691162131,2084P0800X,Psychiatry,31,Out_of_Network,OTHER,E11.9,74177,,0,Commercial,PPO,14,F,1.5785,,,267.6,212.42,137.55,30.48,10.0,34.39,55.18,88.37,30.64,0,,0.0361,none,0,1,0,0,0,1.3e-05,1,0,HBD_Hemoglobin_A1c_Testing,Bundled_Payment
CLM0000001130,MBR00000297,Medical_Professional,Paid,Electronic_EDI,2023-08-04,2023-08-04,2023-08-04,2023-08-12,Auto_Adjudicated,8,1641660170,1365397818,207RG0100X,Gastroenterology,24,Out_of_Network,OTHER,M54.5,99392,,0,Commercial,HMO,88,M,1.5311,,,235.81,125.71,66.07,16.12,27.0,16.52,110.1,0.0,0.0,0,,0.0245,none,0,1,0,0,0,6e-06,1,0,,Shared_Savings
CLM0000001131,MBR00000076,Vision,Paid,Provider_Portal,2023-04-20,2023-04-20,2023-04-20,2023-05-07,Auto_Adjudicated,17,1433357203,1301869102,207V00000X,Obstetrics & Gynecology,21,In_Network,M47.816,,92012,,0,Commercial,HMO,26,M,2.1785,,,281.96,169.9,91.68,23.3,32.0,22.92,112.06,0.0,0.0,0,,0.0649,none,0,1,0,0,0,8e-06,0,0,,Shared_Savings
CLM0000001132,MBR00000172,Pharmacy,Denied,Electronic_EDI,2023-04-30,2023-04-30,2023-04-30,2023-05-22,Auto_Adjudicated,22,1034130209,1274911960,208600000X,Surgery General,11,Out_of_Network,E78.5,OTHER,00169751112,,4,Medicaid_MCO,MCO,50,F,0.2787,96,Duplicate,210.0,88.64,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0867,none,0,1,0,1,0,0.0,1,0,,Bundled_Payment
CLM0000001133,MBR00000184,Medical_Institutional,Paid,Electronic_EDI,2023-07-14,2023-07-14,2023-07-16,2023-07-21,Auto_Adjudicated,7,1797494973,1616762819,207V00000X,Obstetrics & Gynecology,81,In_Network,I10,OTHER|Z12.11|M54.5,revenue_code:0120,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,9824.76,7627.75,7627.75,0.0,0.0,0.0,2197.01,0.0,0.0,0,,0.133,none,0,1,1,1,0,0.000706,0,0,,Shared_Savings
CLM0000001134,MBR00000166,Vision,Paid,Electronic_EDI,2023-03-13,2023-03-13,2023-03-13,2023-03-27,Manual_Review,14,1067329999,1887266184,2086S0122X,Orthopedic Surgery,22,In_Network,I10,,92014,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,237.68,156.7,0.0,156.7,0.0,0.0,80.98,0.0,0.0,0,,0.083,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001135,MBR00000262,Pharmacy,Paid,Electronic_EDI,2023-09-15,2023-09-15,2023-09-15,2023-09-24,Auto_Adjudicated,9,1878057972,1356856197,207R00000X,Internal Medicine,21,In_Network,OTHER,OTHER|Z12.11,16590051660,,4,Medicare_Advantage,PFFS,77,F,1.7452,,,77.74,62.6,45.81,1.33,4.0,11.45,15.14,0.0,0.0,0,,0.1134,none,0,1,0,0,0,4e-06,0,0,BCS_Breast_Cancer_Screening,Shared_Savings
CLM0000001136,MBR00000182,Medical_Institutional,Paid,Electronic_EDI,2023-08-28,2023-08-28,2023-08-29,2023-09-26,Auto_Adjudicated,29,1477762002,1209882852,208600000X,Surgery General,24,In_Network,M54.5,,revenue_code:0450,,0,Commercial,HMO,82,F,0.8489,,,13139.68,8752.02,6718.28,320.16,34.0,1679.57,4387.66,0.0,0.0,0,,0.0135,none,0,1,1,0,0,0.000622,0,0,,Bundled_Payment
CLM0000001137,MBR00000156,Medical_Professional,Paid,Paper,2023-01-04,2023-01-04,2023-01-04,2023-01-16,Manual_Review,12,1049153238,1540743888,208600000X,Surgery General,23,In_Network,J06.9,Z87.891,71250,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,687.9,286.88,195.01,30.12,13.0,48.75,401.02,0.0,0.0,0,,0.2219,unusual_service_frequency|service_date_weekend|upcoding_pattern,0,2,0,0,0,1.8e-05,0,0,,FFS
CLM0000001138,MBR00000037,Medical_Professional,Paid,Electronic_EDI,2023-03-17,2023-03-17,2023-03-17,2023-04-12,Auto_Adjudicated,26,1706065807,1034732777,207RN0300X,Nephrology,11,In_Network,I10,N18.3|I10|M54.5,27130,,0,Medicaid_MCO,MLTSS,11,M,1.043,,,10212.26,6450.72,6449.72,0.0,1.0,0.0,3761.54,0.0,0.0,0,,0.0195,none,0,1,1,0,0,0.000597,0,0,,Capitation
CLM0000001139,MBR00000208,Dental,Paid,Electronic_EDI,2023-07-04,2023-07-04,2023-07-04,2023-07-31,Auto_Adjudicated,27,1133265917,1575884274,207RG0100X,Gastroenterology,81,In_Network,K21.0,,D4341,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,447.43,369.02,276.42,17.49,6.0,69.11,78.41,0.0,0.0,0,,0.0101,none,0,1,0,1,0,2.6e-05,0,0,,FFS
CLM0000001140,MBR00000041,Medical_Professional,Paid,Electronic_EDI,2023-09-24,2023-09-24,2023-09-24,2023-09-30,Auto_Adjudicated,6,1453331651,1228356980,207V00000X,Obstetrics & Gynecology,22,In_Network,J06.9,E11.9|I10,99221,,0,Commercial,PPO,42,F,0.8283,,,537.56,233.24,100.88,83.14,24.0,25.22,304.32,0.0,0.0,0,,0.148,none,0,1,0,0,0,9e-06,0,0,TRC_Transition_of_Care,FFS
CLM0000001141,MBR00000009,Medical_Professional,Paid,Electronic_EDI,2023-04-15,2023-04-15,2023-04-15,2023-05-14,Auto_Adjudicated,29,1170319307,1368666316,2084P0800X,Psychiatry,11,In_Network,J06.9,,99221,,0,Commercial,HMO,11,F,0.5327,,,307.98,158.33,90.38,10.35,35.0,22.6,149.65,0.0,0.0,0,,0.0682,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000001142,MBR00000152,Medical_Professional,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-11-17,Auto_Adjudicated,2,1415701059,1688513262,207RP1001X,Pulmonary Disease,11,Out_of_Network,Z00.00,Z23,99282,,0,Commercial,HMO,82,F,1.2506,,,369.8,248.83,43.84,177.03,17.0,10.96,120.97,0.0,0.0,0,,0.0205,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000001143,MBR00000171,Medical_Institutional,Paid,Electronic_EDI,2023-07-11,2023-07-11,2023-07-15,2023-07-23,Manual_Review,12,1513407277,1151295616,101YP2500X,Psychologist Clinical,22,In_Network,F32.9,,revenue_code:0250,,0,Commercial,PPO,27,F,0.819,,,32707.27,20762.02,16339.63,272.48,65.0,4084.91,11945.25,0.0,0.0,0,,0.0671,none,0,1,1,0,0,0.001512,0,0,,FFS
CLM0000001144,MBR00000300,Medical_Professional,Paid,Paper,2023-07-13,2023-07-13,2023-07-13,2023-07-18,Manual_Review,5,1788188920,1622950074,246ZN0300X,Neuropsychology,22,In_Network,Z00.01,E11.9,71046,,0,Commercial,PPO,64,F,1.0393,,,693.21,306.08,107.39,142.85,29.0,26.85,387.13,0.0,0.0,0,,0.0117,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000001145,MBR00000211,Vision,Denied,Electronic_EDI,2023-02-09,2023-02-09,2023-02-09,2023-02-11,Manual_Review,2,1699014308,1513198866,207RE0101X,Endocrinology,11,Out_of_Network,N39.0,Z00.00,92004,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,1,Eligibility,466.03,200.62,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0484,none,0,1,0,1,0,0.0,0,0,W30_Well_Child_Visit,Capitation
CLM0000001146,MBR00000255,Medical_Institutional,Paid,Electronic_EDI,2023-08-14,2023-08-14,2023-08-14,2023-08-31,Manual_Review,17,1396168768,1912895973,207RN0300X,Nephrology,22,In_Network,I50.9,E11.9|F33.0,revenue_code:0360,,0,Medicare_Advantage,MA_HMO,21,M,0.6945,,,1691.59,716.36,552.67,1.53,24.0,138.17,975.23,0.0,0.0,0,,0.0683,none,0,1,0,0,0,5.1e-05,0,0,,FFS
CLM0000001147,MBR00000109,Dental,Paid,Electronic_EDI,2023-10-21,2023-10-21,2023-10-21,2023-11-09,Auto_Adjudicated,19,1454203715,1175334579,2086S0122X,Orthopedic Surgery,21,In_Network,J20.9,,D3310,,0,Commercial,HMO,8,F,0.5723,,,246.86,152.52,0.0,142.75,9.77,0.0,94.34,0.0,0.0,0,,0.006,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000001148,MBR00000156,Medical_Institutional,Paid,Electronic_EDI,2023-03-17,2023-03-17,2023-03-20,2023-04-04,Auto_Adjudicated,18,1487261286,1197700958,207RP1001X,Pulmonary Disease,22,In_Network,I10,OTHER|F32.9,revenue_code:0450,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,4986.45,4019.49,3162.88,36.89,29.0,790.72,966.96,0.0,0.0,0,,0.0792,none,0,1,0,0,0,0.000293,0,0,W30_Well_Child_Visit,FFS
CLM0000001149,MBR00000293,Medical_Institutional,Paid,Electronic_EDI,2023-07-15,2023-07-15,2023-07-18,2023-07-28,Auto_Adjudicated,13,1928139578,1747596016,207RG0100X,Gastroenterology,81,In_Network,F33.0,,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,47818.86,28732.11,22942.23,22.32,32.0,5735.56,19086.75,0.0,0.0,0,,0.1341,outlier_billing_amount,0,1,1,0,0,0.002124,0,0,,Capitation
CLM0000001150,MBR00000132,Medical_Professional,Denied,Electronic_EDI,2023-01-03,2023-01-03,2023-01-03,2023-01-27,Auto_Adjudicated,24,1482771601,1282319940,207RN0300X,Nephrology,11,Out_of_Network,Z23,,10060,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,97,Network,1104.67,612.98,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0754,none,0,1,0,1,0,0.0,1,0,,P4P
CLM0000001151,MBR00000239,Medical_Professional,Denied,Paper,2023-03-17,2023-03-17,2023-03-17,2023-04-01,Auto_Adjudicated,15,1170319307,1319611206,207V00000X,Obstetrics & Gynecology,32,In_Network,J06.9,N18.3,99213,,0,Commercial,HMO,1,F,1.1193,22,Duplicate,162.9,74.07,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.044,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001152,MBR00000160,Dental,Paid,Electronic_EDI,2023-01-26,2023-01-26,2023-01-26,2023-02-12,Auto_Adjudicated,17,1641779816,1867389043,246ZN0300X,Neuropsychology,21,In_Network,I10,R05.9|OTHER,D2140,,0,Commercial,HMO,73,M,1.9608,,,210.11,166.61,93.68,26.51,23.0,23.42,43.5,0.0,0.0,0,,0.0934,none,0,1,0,0,0,9e-06,0,0,,Capitation
CLM0000001153,MBR00000070,Pharmacy,Denied,Electronic_EDI,2023-10-04,2023-10-04,2023-10-04,2023-10-18,Auto_Adjudicated,14,1046207613,1689327034,207Q00000X,Family Medicine,11,In_Network,OTHER,N18.3|J20.9,00071015523,,2,Commercial,POS,42,F,0.8468,PR-1,COB,66.43,56.02,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1203,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001154,MBR00000175,Medical_Institutional,Paid,Electronic_EDI,2023-12-24,2023-12-24,2023-12-25,2023-12-31,Auto_Adjudicated,7,1816378991,1579331190,207RE0101X,Endocrinology,11,In_Network,Z12.11,OTHER|F33.0,revenue_code:0210,,0,Commercial,PPO,14,F,1.5785,,,18031.65,12714.57,10092.55,50.89,48.0,2523.14,5317.08,0.0,0.0,0,,0.0015,none,0,1,1,0,0,0.000934,0,0,,Bundled_Payment
CLM0000001155,MBR00000067,Dental,Denied,Paper,2023-01-14,2023-01-14,2023-01-14,2023-02-03,Manual_Review,20,1590338573,1874728994,2086S0122X,Orthopedic Surgery,71,In_Network,F32.9,F32.9,D1110,,0,Medicaid_MCO,MCO,55,M,0.4175,5,Timely_Filing,423.81,257.59,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1173,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,CBP_Controlling_BP,Shared_Savings
CLM0000001156,MBR00000002,Pharmacy,Paid,Electronic_EDI,2023-09-10,2023-09-10,2023-09-10,2023-10-05,Auto_Adjudicated,25,1327415110,1860951128,2086S0122X,Orthopedic Surgery,11,In_Network,Z00.01,J45.20|E11.9|I50.9,00085163102,,1,Commercial,PPO,42,F,0.9012,,,141.86,114.43,33.11,55.05,18.0,8.28,27.43,0.0,0.0,0,,0.0451,none,0,1,0,1,0,3e-06,0,0,,P4P
CLM0000001157,MBR00000074,Medical_Professional,Denied,Electronic_EDI,2023-08-01,2023-08-01,2023-08-01,2023-08-11,Auto_Adjudicated,10,1147452455,1560230600,101YP2500X,Psychologist Clinical,11,In_Network,I50.9,,99282,,0,Medicare_Advantage,MA_PPO,21,F,0.8719,18,Duplicate,192.27,117.77,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0903,temporal_clustering,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001158,MBR00000060,Medical_Institutional,Paid,Electronic_EDI,2023-09-10,2023-09-10,2023-09-11,2023-09-24,Auto_Adjudicated,14,1770738194,1452088018,207RP1001X,Pulmonary Disease,21,In_Network,E78.5,OTHER|M79.3|I10,revenue_code:0100,682,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,13055.05,6823.84,3448.07,1077.05,0.0,2298.72,6231.21,0.0,0.0,0,,0.115,none,0,1,0,0,0,0.000319,0,0,,FFS
CLM0000001159,MBR00000118,Pharmacy,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-27,Manual_Review,27,1710617771,1005335812,208600000X,Surgery General,23,In_Network,K29.70,M17.11,00085163102,,3,Medicaid_MCO,MCO,69,M,1.2773,,,1562.87,693.11,692.11,0.0,1.0,0.0,869.76,0.0,0.0,0,,0.0845,none,0,1,0,1,0,6.4e-05,0,0,,Capitation
CLM0000001160,MBR00000270,Pharmacy,Paid,Electronic_EDI,2023-12-22,2023-12-22,2023-12-22,2023-12-29,Auto_Adjudicated,7,1319616460,1282319940,207V00000X,Obstetrics & Gynecology,21,In_Network,Z00.00,,00071015523,,2,Commercial,POS,1,F,1.6363,,,146.31,61.28,0.0,61.28,0.0,0.0,85.03,0.0,0.0,0,,0.0071,none,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000001161,MBR00000123,Medical_Professional,Paid,Electronic_EDI,2023-01-15,2023-01-15,2023-01-15,2023-01-28,Auto_Adjudicated,13,1637260822,1320546364,207R00000X,Internal Medicine,11,In_Network,M54.5,OTHER,99204,,0,ACA_Marketplace,ACA_Bronze,7,M,0.2444,,,527.93,303.3,0.0,303.3,0.0,0.0,224.63,0.0,0.0,0,,0.1039,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000001162,MBR00000254,Medical_Professional,Paid,Provider_Portal,2023-02-23,2023-02-23,2023-02-23,2023-03-04,Auto_Adjudicated,9,1888245409,1390802135,2084P0800X,Psychiatry,22,In_Network,I48.91,Z23,97140,,0,Commercial,PPO,22,F,0.9285,,,575.06,313.23,224.37,4.76,28.0,56.09,261.83,0.0,0.0,0,,0.0388,none,0,1,0,0,0,2.1e-05,0,0,,FFS
CLM0000001163,MBR00000168,Medical_Institutional,Paid,Electronic_EDI,2023-03-31,2023-03-31,2023-03-31,2023-04-11,Auto_Adjudicated,11,1006539337,1274911960,207Q00000X,Family Medicine,32,In_Network,Z12.11,OTHER,revenue_code:0370,,0,Commercial,HMO,76,M,1.2791,,,71452.4,32406.78,25648.1,270.66,76.0,6412.02,39045.62,0.0,0.0,1,Medically Unnecessary Services,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|impossible_service_combo|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,1,0,0,0.002374,0,0,LCS_Lung_Cancer_Screening,Shared_Savings
CLM0000001164,MBR00000003,Medical_Professional,Paid,Electronic_EDI,2023-10-08,2023-10-08,2023-10-08,2023-10-22,Auto_Adjudicated,14,1706018784,1320546364,207RC0000X,Cardiovascular Disease,32,In_Network,Z00.00,,97140,,0,Commercial,PPO,79,F,1.3879,,,692.37,418.34,311.0,4.58,25.0,77.75,274.03,0.0,0.0,0,,0.0198,none,0,1,0,1,0,2.9e-05,0,0,,FFS
CLM0000001165,MBR00000059,Medical_Professional,Paid,Electronic_EDI,2023-01-28,2023-01-28,2023-01-28,2023-02-25,Auto_Adjudicated,28,1086690796,1887266184,208600000X,Surgery General,81,Out_of_Network,OTHER,Z00.00,99284,,0,Medicare_Advantage,SNP,12,F,1.266,,,409.83,292.77,218.93,3.11,16.0,54.73,117.06,160.52,33.37,0,,0.0998,duplicate_claim_indicator,0,1,0,0,0,2e-05,0,0,,FFS
CLM0000001166,MBR00000281,Medical_Institutional,Paid,Electronic_EDI,2023-02-14,2023-02-14,2023-02-14,2023-02-15,Auto_Adjudicated,1,1900799244,1365397818,207Q00000X,Family Medicine,21,In_Network,OTHER,G47.33,revenue_code:0210,291,0,Medicare_Advantage,MA_HMO,3,M,0.8531,,,53452.5,35167.18,28108.06,2.1,30.0,7027.02,18285.32,24160.16,2025.07,1,Provider Impersonation,0.9409,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|temporal_clustering|billing_spike_recent|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,1,0,0,0.002602,0,0,,Bundled_Payment
CLM0000001167,MBR00000182,Medical_Institutional,Paid,Paper,2023-09-20,2023-09-20,2023-09-20,2023-10-01,Auto_Adjudicated,11,1816378991,1355732274,207RC0000X,Cardiovascular Disease,11,In_Network,Z12.11,E11.9|R05.9,revenue_code:0120,,0,Commercial,HMO,82,F,0.8489,,,11383.41,8384.93,6334.69,432.56,34.0,1583.67,2998.48,0.0,0.0,0,,0.1904,npi_mismatch,0,1,1,1,0,0.000586,0,0,CDC_BP_Control,P4P
CLM0000001168,MBR00000280,Medical_Professional,Partially_Paid,Provider_Portal,2023-05-31,2023-05-31,2023-05-31,2023-06-26,Auto_Adjudicated,26,1556434733,1068662623,225100000X,Physical Therapist,11,In_Network,F33.0,OTHER|I25.10|K21.0,74177,,0,Commercial,PPO,79,F,0.6697,18,Medical_Necessity,1128.1,851.26,32.07,563.1,35.0,8.02,489.91,0.0,0.0,0,,0.0836,duplicate_claim_indicator,0,1,0,0,0,3e-06,0,0,SPC_Statin_Therapy,Shared_Savings
CLM0000001169,MBR00000098,Medical_Institutional,Paid,Electronic_EDI,2023-09-11,2023-09-11,2023-09-13,2023-09-14,Auto_Adjudicated,3,1170319307,1358873132,246ZN0300X,Neuropsychology,32,In_Network,Z12.11,OTHER|F32.9|E11.65,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,7,M,0.511,,,58135.65,24297.63,19400.22,7.36,40.0,4850.05,33838.02,0.0,0.0,0,,0.1847,outlier_billing_amount,0,1,1,1,0,0.001796,0,0,,FFS
CLM0000001170,MBR00000212,Medical_Professional,Paid,Electronic_EDI,2023-05-12,2023-05-12,2023-05-12,2023-05-28,Auto_Adjudicated,16,1002224900,1842149518,207V00000X,Obstetrics & Gynecology,24,Emergency,J20.9,M54.5,99387,,0,Commercial,HMO,57,F,2.5456,,,148.52,125.64,0.0,125.64,0.0,0.0,22.88,0.0,0.0,0,,0.0481,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001171,MBR00000227,Medical_Professional,Paid,Electronic_EDI,2023-02-02,2023-02-02,2023-02-02,2023-02-07,Auto_Adjudicated,5,1155203600,1447186817,101YP2500X,Psychologist Clinical,23,In_Network,K29.70,J20.9,97110,,0,Medicare_Advantage,MA_PPO,2,F,0.7835,,,291.62,125.92,89.4,0.17,14.0,22.35,165.7,0.0,0.0,0,,0.0448,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000001172,MBR00000294,Pharmacy,Partially_Paid,Paper,2023-08-03,2023-08-03,2023-08-03,2023-08-20,Manual_Review,17,1647029816,1978943761,207Q00000X,Family Medicine,22,In_Network,Z79.4,N40.0|M17.11,00071012831,,2,Medicare_Advantage,MA_HMO,8,M,0.6878,22,Medical_Necessity,615.53,442.76,231.18,15.57,18.0,57.79,292.99,0.0,0.0,0,,0.1405,none,0,1,0,0,0,2.1e-05,0,1,,P4P
CLM0000001173,MBR00000006,Dental,Denied,Electronic_EDI,2023-02-09,2023-02-09,2023-02-09,2023-03-03,Clinical_Review,22,1887322427,1415734567,101YP2500X,Psychologist Clinical,22,In_Network,M54.5,E11.9|Z00.00,D4341,,0,Commercial,EPO,88,M,1.4365,1,Medical_Necessity,272.17,172.71,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1219,none,0,1,0,0,0,0.0,0,0,CCS_Cervical_Cancer_Screening,Bundled_Payment
CLM0000001174,MBR00000289,Medical_Professional,Paid,Provider_Portal,2023-06-21,2023-06-21,2023-06-21,2023-07-11,Auto_Adjudicated,20,1086690796,1132693989,2086S0122X,Orthopedic Surgery,22,In_Network,E11.9,E11.9|OTHER,84443,,0,Commercial,POS,51,M,1.0534,,,1692.12,1030.81,742.86,63.23,39.0,185.72,661.31,469.95,205.61,0,,0.0802,none,0,1,0,0,0,6.9e-05,0,0,,Bundled_Payment
CLM0000001175,MBR00000125,Dental,Paid,Electronic_EDI,2023-11-13,2023-11-13,2023-11-13,2023-11-30,Auto_Adjudicated,17,1866366547,1164525386,2084P0800X,Psychiatry,21,In_Network,J20.9,OTHER|E11.65,D0150,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,251.4,201.35,149.51,3.46,11.0,37.38,50.05,0.0,0.0,0,,0.0433,none,0,1,0,0,0,1.4e-05,0,0,,Capitation
CLM0000001176,MBR00000250,Dental,Paid,Electronic_EDI,2023-03-07,2023-03-07,2023-03-07,2023-03-30,Auto_Adjudicated,23,1327415110,1672803287,207RN0300X,Nephrology,22,In_Network,G47.33,OTHER,D0120,,0,Commercial,PPO,41,M,0.9245,,,284.32,211.75,0.0,211.75,0.0,0.0,72.57,0.0,0.0,0,,0.108,impossible_service_combo,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001177,MBR00000166,Medical_Institutional,Paid,Electronic_EDI,2023-03-14,2023-03-14,2023-03-16,2023-03-31,Auto_Adjudicated,17,1897146144,1977073565,208600000X,Surgery General,11,In_Network,I25.10,Z00.00|OTHER,revenue_code:0100,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,34152.64,12926.34,8390.56,872.82,67.0,3595.95,21226.3,0.0,0.0,0,,0.0495,none,0,1,1,0,0,0.000777,0,0,,Shared_Savings
CLM0000001178,MBR00000170,Behavioral_Health,Partially_Paid,Electronic_EDI,2023-12-07,2023-12-07,2023-12-07,2023-12-26,Auto_Adjudicated,19,1017424540,1209882852,207RP1001X,Pulmonary Disease,11,In_Network,I10,E78.5|I10,17000,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,16,Medical_Necessity,337.52,224.02,101.91,30.39,3.0,25.48,176.75,0.0,0.0,0,,0.1382,billing_spike_recent,0,1,0,0,0,9e-06,0,0,,Shared_Savings
CLM0000001179,MBR00000113,Medical_Professional,Paid,Electronic_EDI,2023-04-20,2023-04-20,2023-04-20,2023-04-23,Auto_Adjudicated,3,1496489953,1894215172,207RN0300X,Nephrology,11,In_Network,J06.9,,99395,,0,Medicaid_MCO,MLTSS,29,F,1.1621,,,168.81,100.84,99.84,0.0,1.0,0.0,67.97,0.0,0.0,0,,0.1018,none,0,1,0,0,0,9e-06,0,0,,P4P
CLM0000001180,MBR00000247,Medical_Professional,Paid,Electronic_EDI,2023-05-14,2023-05-14,2023-05-14,2023-05-15,Auto_Adjudicated,1,1147452455,1842149518,2086S0122X,Orthopedic Surgery,81,Out_of_Network,J45.20,E78.5,99285,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,401.11,223.32,159.78,18.6,5.0,39.94,177.79,0.0,0.0,0,,0.1299,none,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000001181,MBR00000081,Pharmacy,Paid,Electronic_EDI,2023-09-03,2023-09-03,2023-09-03,2023-09-08,Auto_Adjudicated,5,1207676414,1252125670,207R00000X,Internal Medicine,81,In_Network,I10,F41.1,00310075090,,1,Medicare_Advantage,SNP,66,F,2.159,,,116.3,42.67,22.1,10.04,5.0,5.53,73.63,0.0,0.0,0,,0.056,none,0,1,0,0,0,2e-06,0,1,,Shared_Savings
CLM0000001182,MBR00000153,Medical_Institutional,Denied,Electronic_EDI,2023-02-15,2023-02-15,2023-02-17,2023-03-04,Auto_Adjudicated,17,1543927384,1188760037,207RE0101X,Endocrinology,24,Emergency,OTHER,,revenue_code:0450,,0,Commercial,POS,12,F,0.6525,4,Timely_Filing,19827.44,15644.78,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0383,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001183,MBR00000169,Medical_Professional,Paid,Electronic_EDI,2023-01-22,2023-01-22,2023-01-22,2023-02-03,Auto_Adjudicated,12,1421421733,1025886739,207V00000X,Obstetrics & Gynecology,31,In_Network,F32.9,J44.1,99281,,0,Commercial,EPO,30,M,1.4348,,,306.88,157.6,20.36,110.16,22.0,5.09,149.28,0.0,0.0,0,,0.0808,none,0,1,0,1,0,2e-06,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000001184,MBR00000217,Medical_Professional,Denied,Electronic_EDI,2023-10-30,2023-10-30,2023-10-30,2023-11-10,Manual_Review,11,1734752728,1140170394,101YP2500X,Psychologist Clinical,11,In_Network,OTHER,Z00.00,99231,,0,ACA_Marketplace,ACA_Bronze,11,F,1.1619,2,Authorization,273.26,232.16,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0195,none,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,Bundled_Payment
CLM0000001185,MBR00000144,Medical_Professional,Partially_Paid,Electronic_EDI,2023-12-07,2023-12-07,2023-12-07,2023-12-21,Auto_Adjudicated,14,1119160702,1013600387,207RC0000X,Cardiovascular Disease,11,In_Network,J06.9,J06.9|Z87.891|M25.511,99385,,0,Commercial,HDHP_HSA,56,F,2.5926,PR-1,Medical_Necessity,218.67,165.65,0.0,107.91,0.0,0.0,110.76,0.0,0.0,0,,0.0626,none,0,1,0,0,0,0.0,0,0,COA_Care_Transitions,Capitation
CLM0000001186,MBR00000202,Medical_Professional,Paid,Electronic_EDI,2023-12-21,2023-12-21,2023-12-21,2024-01-20,Auto_Adjudicated,30,1205349488,1473869105,207V00000X,Obstetrics & Gynecology,11,In_Network,J06.9,E11.9|K57.30|Z79.4,43239,,0,Commercial,PPO,87,F,0.6213,,,219.93,165.26,0.0,165.26,0.0,0.0,54.67,0.0,0.0,0,,0.115,none,0,1,0,1,0,0.0,0,0,IET_Initiation_Substance_Use,Shared_Savings
CLM0000001187,MBR00000151,Medical_Professional,Paid,Electronic_EDI,2023-01-09,2023-01-09,2023-01-09,2023-01-21,Auto_Adjudicated,12,1943769986,1312595355,207Q00000X,Family Medicine,11,Out_of_Network,OTHER,F41.1,97110,,0,Medicare_Advantage,MA_HMO,77,M,0.8709,,,847.52,547.68,433.18,0.2,6.0,108.3,299.84,0.0,0.0,1,Phantom Billing,1.0,outlier_billing_amount|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|service_date_weekend|duplicate_claim_indicator|unbundling_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch,1,5,0,0,0,4e-05,1,0,W30_Well_Child_Visit,FFS
CLM0000001188,MBR00000196,Behavioral_Health,Paid,Electronic_EDI,2023-07-10,2023-07-10,2023-07-10,2023-07-24,Auto_Adjudicated,14,1147452455,1297948643,2086S0122X,Orthopedic Surgery,24,In_Network,E11.65,,99282,,0,Commercial,PPO,16,F,1.6015,,,182.59,139.65,0.0,139.65,0.0,0.0,42.94,0.0,0.0,0,,0.0971,unbundling_pattern,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001189,MBR00000200,Medical_Professional,Paid,Electronic_EDI,2023-11-01,2023-11-01,2023-11-01,2023-11-17,Auto_Adjudicated,16,1069440570,1433350836,246ZN0300X,Neuropsychology,11,In_Network,Z00.01,,99212,,0,Commercial,HDHP_HSA,29,M,0.8011,,,421.39,200.38,0.0,200.38,0.0,0.0,221.01,0.0,0.0,0,,0.0241,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000001190,MBR00000210,Pharmacy,Paid,Electronic_EDI,2023-10-31,2023-10-31,2023-10-31,2023-11-24,Auto_Adjudicated,24,1826043246,1842149518,2084P0800X,Psychiatry,71,In_Network,OTHER,J20.9|M17.11|Z23,00069420020,,1,Medicare_Advantage,SNP,49,M,0.6952,,,286.11,184.91,103.79,37.17,18.0,25.95,101.2,0.0,0.0,0,,0.0956,unusual_service_frequency,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000001191,MBR00000246,Medical_Professional,Paid,Electronic_EDI,2023-05-10,2023-05-10,2023-05-10,2023-06-02,Manual_Review,23,1769163673,1105733833,207RN0300X,Nephrology,23,In_Network,Z12.11,OTHER,99231,,0,Commercial,PPO,80,F,0.7925,,,196.37,126.01,0.0,126.01,0.0,0.0,70.36,0.0,0.0,0,,0.0044,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001192,MBR00000164,Medical_Professional,Paid,Electronic_EDI,2023-06-26,2023-06-26,2023-06-26,2023-07-26,Auto_Adjudicated,30,1630305772,1728466420,2084P0800X,Psychiatry,11,In_Network,C50.911,OTHER,97140,,0,ACA_Marketplace,ACA_Silver,3,F,0.7155,,,1537.64,869.45,492.38,127.05,39.0,211.02,668.19,0.0,0.0,0,,0.1269,benford_violation,0,1,0,1,0,4.6e-05,0,0,,FFS
CLM0000001193,MBR00000060,Dental,Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-23,2023-03-15,Auto_Adjudicated,20,1496340237,1498781755,225100000X,Physical Therapist,31,In_Network,I10,M79.3,D4341,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,470.21,297.85,0.0,297.85,0.0,0.0,172.36,0.0,0.0,0,,0.2199,npi_mismatch|high_oop_waiver,0,2,0,0,0,0.0,0,0,,FFS
CLM0000001194,MBR00000201,Medical_Professional,Paid,Electronic_EDI,2023-02-19,2023-02-19,2023-02-19,2023-03-20,Auto_Adjudicated,29,1550698436,1577226132,207RP1001X,Pulmonary Disease,31,In_Network,OTHER,,99385,,0,Medicare_Advantage,MA_PPO,74,M,1.1575,,,407.09,296.33,223.63,10.8,6.0,55.91,110.76,0.0,0.0,0,,0.0145,none,0,1,0,0,0,2.1e-05,0,0,,P4P
CLM0000001195,MBR00000024,Medical_Professional,Denied,Electronic_EDI,2023-05-16,2023-05-16,2023-05-16,2023-06-04,Manual_Review,19,1893886964,1112696614,207RN0300X,Nephrology,22,In_Network,OTHER,E78.5,85025,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,96,Duplicate,345.13,153.08,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0358,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001196,MBR00000068,Pharmacy,Denied,Electronic_EDI,2023-03-24,2023-03-24,2023-03-24,2023-04-10,Auto_Adjudicated,17,1658382624,1105733833,207RE0101X,Endocrinology,11,In_Network,Z12.11,OTHER|Z00.01,00310075090,,1,Medicare_Advantage,MA_HMO,28,F,0.8494,4,Eligibility,850.1,712.5,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.147,none,0,1,0,0,0,0.0,0,1,SPC_Statin_Therapy,FFS
CLM0000001197,MBR00000235,Medical_Professional,Denied,Electronic_EDI,2023-12-16,2023-12-16,2023-12-16,2024-01-02,Auto_Adjudicated,17,1321381114,1020312030,225100000X,Physical Therapist,21,In_Network,I10,OTHER|E11.65,99284,,0,Commercial,HDHP_HSA,85,F,1.4308,CO-45,Medical_Necessity,381.51,222.98,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0682,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001198,MBR00000136,Medical_Professional,Denied,Electronic_EDI,2023-01-29,2023-01-29,2023-01-29,2023-02-13,Manual_Review,15,1379875145,1542515060,2086S0122X,Orthopedic Surgery,22,In_Network,E11.65,C50.911,97110,,0,Commercial,POS,2,F,1.2611,22,Duplicate,2103.4,1464.86,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0979,benford_violation,0,1,0,0,0,0.0,0,0,ACR_Urine_Protein,P4P
CLM0000001199,MBR00000154,Vision,Denied,Electronic_EDI,2023-07-09,2023-07-09,2023-07-09,2023-07-16,Auto_Adjudicated,7,1567711165,1296566243,2084P0800X,Psychiatry,24,In_Network,I10,,V2103,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,2,Coding_Error,219.41,176.25,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0242,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001200,MBR00000297,Medical_Institutional,Paid,Electronic_EDI,2023-07-19,2023-07-19,2023-07-22,2023-07-30,Auto_Adjudicated,11,1356331863,1068662623,207V00000X,Obstetrics & Gynecology,11,In_Network,K21.0,,revenue_code:0300,,0,Commercial,HMO,88,M,1.5311,,,2632.26,2196.02,1718.46,8.94,39.0,429.62,436.24,0.0,0.0,0,,0.1979,duplicate_claim_indicator,0,1,0,0,0,0.000159,0,0,,FFS
CLM0000001201,MBR00000074,Pharmacy,Paid,Electronic_EDI,2023-01-22,2023-01-22,2023-01-22,2023-02-10,Clinical_Review,19,1871417879,1811797489,207R00000X,Internal Medicine,32,In_Network,F33.0,,00071012831,,1,Medicare_Advantage,MA_PPO,21,F,0.8719,,,94.89,61.04,7.1,33.17,19.0,1.77,33.85,0.0,0.0,0,,0.0398,none,0,1,0,0,0,1e-06,0,1,,FFS
CLM0000001202,MBR00000006,Medical_Professional,Paid,Electronic_EDI,2023-06-08,2023-06-08,2023-06-08,2023-06-27,Auto_Adjudicated,19,1484613641,1619587398,207RC0000X,Cardiovascular Disease,11,In_Network,I10,Z23,99222,,0,Commercial,EPO,88,M,1.4365,,,506.76,420.48,303.49,8.12,33.0,75.87,86.28,0.0,0.0,0,,0.0955,none,0,1,0,0,0,2.8e-05,0,0,SPD_Spirometry_Testing,Shared_Savings
CLM0000001203,MBR00000035,Medical_Professional,Denied,Electronic_EDI,2023-12-05,2023-12-05,2023-12-05,2023-12-10,Auto_Adjudicated,5,1199465234,1391074619,208600000X,Surgery General,81,In_Network,OTHER,,99215,,0,ACA_Marketplace,ACA_Platinum,46,M,0.6598,2,Eligibility,171.17,109.19,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1574,benford_violation,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001204,MBR00000076,Medical_Institutional,Paid,Electronic_EDI,2023-02-09,2023-02-09,2023-02-10,2023-03-06,Auto_Adjudicated,25,1866366547,1187669363,207RN0300X,Nephrology,11,In_Network,Z87.891,J06.9,revenue_code:0110,,0,Commercial,HMO,26,M,2.1785,,,52414.83,25029.92,19955.18,45.95,40.0,4988.79,27384.91,0.0,0.0,0,,0.2054,outlier_billing_amount,0,2,1,0,0,0.001847,0,0,,P4P
CLM0000001205,MBR00000213,Pharmacy,Paid,Electronic_EDI,2023-02-21,2023-02-21,2023-02-21,2023-03-15,Auto_Adjudicated,22,1154652946,1197700958,207V00000X,Obstetrics & Gynecology,31,Out_of_Network,J06.9,E11.9,16590051660,,2,Commercial,PPO,17,M,1.5857,,,113.37,70.95,0.0,70.95,0.0,0.0,42.42,0.0,0.0,0,,0.1319,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,P4P
CLM0000001206,MBR00000229,Medical_Professional,Paid,Electronic_EDI,2023-03-01,2023-03-01,2023-03-01,2023-03-17,Manual_Review,16,1638309014,1983760474,2084P0800X,Psychiatry,11,In_Network,Z23,Z00.01,99222,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,365.81,149.65,91.16,21.7,14.0,22.79,216.16,0.0,0.0,0,,0.0745,none,0,1,0,0,0,8e-06,0,0,,Shared_Savings
CLM0000001207,MBR00000170,Dental,Paid,Provider_Portal,2023-01-20,2023-01-20,2023-01-20,2023-02-03,Auto_Adjudicated,14,1141106555,1321680994,208600000X,Surgery General,24,In_Network,OTHER,,D7140,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,440.01,313.69,224.47,30.1,3.0,56.12,126.32,0.0,0.0,0,,0.1222,service_date_weekend|unbundling_pattern,0,1,0,0,0,2.1e-05,0,0,ACR_Urine_Protein,FFS
CLM0000001208,MBR00000079,Pharmacy,Paid,Electronic_EDI,2023-11-14,2023-11-14,2023-11-14,2023-12-01,Auto_Adjudicated,17,1396168768,1164525386,207RN0300X,Nephrology,31,In_Network,F32.9,M54.5,00169751112,,1,Medicaid_MCO,MLTSS,55,F,0.5016,,,157.94,73.79,69.79,0.0,4.0,0.0,84.15,0.0,0.0,0,,0.1744,phantom_billing_indicator,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000001209,MBR00000159,Medical_Institutional,Paid,Electronic_EDI,2023-01-17,2023-01-17,2023-01-20,2023-02-04,Manual_Review,18,1220235547,1068662623,207RN0300X,Nephrology,21,In_Network,OTHER,E78.5|N39.0,revenue_code:0100,682,0,Commercial,PPO,70,F,1.2009,,,10415.52,5807.83,4561.19,35.35,71.0,1140.3,4607.69,0.0,0.0,0,,0.0024,none,0,1,0,0,0,0.000422,0,0,,FFS
CLM0000001210,MBR00000005,Medical_Institutional,Paid,Electronic_EDI,2023-04-11,2023-04-11,2023-04-14,2023-04-24,Clinical_Review,13,1260336577,1896197144,207RN0300X,Nephrology,11,Out_of_Network,Z00.00,,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,8,M,0.566,,,5640.56,3036.06,2386.77,31.6,21.0,596.69,2604.5,0.0,0.0,0,,0.1079,none,0,1,0,0,0,0.000221,0,0,,FFS
CLM0000001211,MBR00000202,Medical_Institutional,Paid,Electronic_EDI,2023-10-24,2023-10-24,2023-10-28,2023-11-19,Manual_Review,26,1216417633,1325999602,2084P0800X,Psychiatry,81,In_Network,E78.5,OTHER,revenue_code:0250,,0,Commercial,PPO,87,F,0.6213,,,79834.72,37362.99,29588.35,347.55,30.0,7397.09,42471.73,0.0,0.0,0,,0.0836,outlier_billing_amount,0,1,1,0,0,0.002739,0,0,,Bundled_Payment
CLM0000001212,MBR00000184,Pharmacy,Paid,Electronic_EDI,2023-12-24,2023-12-24,2023-12-24,2023-12-29,Auto_Adjudicated,5,1263063839,1105733833,207RP1001X,Pulmonary Disease,81,In_Network,M17.11,Z00.01,16590051660,,3,Medicaid_MCO,MLTSS,30,M,2.8302,,,306.07,217.31,215.31,0.0,2.0,0.0,88.76,0.0,0.0,0,,0.0586,none,0,1,0,0,0,2e-05,0,1,,Shared_Savings
CLM0000001213,MBR00000007,Medical_Professional,Paid,Electronic_EDI,2023-02-24,2023-02-24,2023-02-24,2023-03-08,Auto_Adjudicated,12,1887698203,1188760037,225100000X,Physical Therapist,24,In_Network,I10,I48.91|E78.5,99232,,0,Commercial,HDHP_HSA,72,F,0.7578,,,133.67,68.1,0.0,68.1,0.0,0.0,65.57,0.0,0.0,0,,0.0996,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001214,MBR00000243,Dental,Paid,Electronic_EDI,2023-05-10,2023-05-10,2023-05-10,2023-05-22,Manual_Review,12,1513407277,1978943761,207V00000X,Obstetrics & Gynecology,21,In_Network,J06.9,M79.3|Z79.4|K29.70,D2391,,0,Medicaid_MCO,MCO,21,M,0.4834,,,169.21,138.9,134.9,0.0,4.0,0.0,30.31,0.0,0.0,0,,0.1023,none,0,1,0,0,0,1.2e-05,0,0,,Bundled_Payment
CLM0000001215,MBR00000224,Medical_Institutional,Paid,Electronic_EDI,2023-03-06,2023-03-06,2023-03-09,2023-03-09,Auto_Adjudicated,3,1888245409,1007652766,207R00000X,Internal Medicine,11,In_Network,N39.0,Z00.00|E11.9,revenue_code:0210,,0,Medicaid_MCO,MCO,86,F,1.3289,,,22053.52,7792.08,7783.08,0.0,9.0,0.0,14261.44,0.0,0.0,0,,0.127,provider_specialty_mismatch,0,1,1,0,0,0.00072,0,0,,FFS
CLM0000001216,MBR00000097,Vision,Paid,Electronic_EDI,2023-03-11,2023-03-11,2023-03-11,2023-03-14,Auto_Adjudicated,3,1419204214,1874728994,207V00000X,Obstetrics & Gynecology,21,In_Network,E78.5,OTHER|J06.9,92002,,0,Commercial,EPO,34,M,1.3765,,,299.41,172.68,0.0,172.68,0.0,0.0,126.73,0.0,0.0,0,,0.052,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001217,MBR00000188,Vision,Paid,Electronic_EDI,2023-12-05,2023-12-05,2023-12-05,2024-01-01,Manual_Review,27,1175978429,1402472115,207RG0100X,Gastroenterology,23,In_Network,I10,F33.0|M54.5,92014,,0,Commercial,HMO,8,F,1.5853,,,121.42,70.68,0.0,66.04,4.64,0.0,50.74,0.0,0.0,0,,0.1052,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001218,MBR00000181,Medical_Professional,Paid,Electronic_EDI,2023-05-02,2023-05-02,2023-05-02,2023-05-26,Auto_Adjudicated,24,1267286378,1330485436,101YP2500X,Psychologist Clinical,11,In_Network,E78.5,F41.1|K21.0|I10,97010,,0,Commercial,PPO,82,F,1.0432,,,4253.11,2731.61,2072.24,113.31,28.0,518.06,1521.5,0.0,0.0,0,,0.106,none,0,1,0,0,0,0.000192,0,0,,Bundled_Payment
CLM0000001219,MBR00000045,Medical_Professional,Paid,Electronic_EDI,2023-08-08,2023-08-08,2023-08-08,2023-08-19,Auto_Adjudicated,11,1453331651,1068662623,225100000X,Physical Therapist,11,In_Network,Z00.01,J06.9|I10,99386,,0,Commercial,HMO,78,F,1.0658,,,74.64,30.6,0.0,5.11,25.49,0.0,44.04,0.0,0.0,0,,0.1387,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001220,MBR00000060,Medical_Institutional,Paid,Electronic_EDI,2023-02-26,2023-02-26,2023-02-26,2023-03-06,Auto_Adjudicated,8,1756856314,1616762819,207RG0100X,Gastroenterology,65,In_Network,E11.9,E78.5,revenue_code:0120,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,9006.37,7028.64,3911.02,510.28,0.0,2607.35,1977.73,0.0,0.0,0,,0.115,temporal_clustering,0,1,0,0,0,0.000362,0,0,,FFS
CLM0000001221,MBR00000204,Medical_Institutional,Denied,Electronic_EDI,2023-04-13,2023-04-13,2023-04-15,2023-04-26,Auto_Adjudicated,13,1878453830,1301869102,207V00000X,Obstetrics & Gynecology,23,In_Network,Z00.00,Z23|OTHER,revenue_code:0110,,0,Commercial,HMO,12,M,0.8716,97,Coding_Error,13887.79,6402.75,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1542,geographic_mismatch|phantom_billing_indicator,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,Shared_Savings
CLM0000001222,MBR00000282,Pharmacy,Paid,Electronic_EDI,2023-05-10,2023-05-10,2023-05-10,2023-06-01,Auto_Adjudicated,22,1928139578,1177602659,207RC0000X,Cardiovascular Disease,23,Out_of_Network,OTHER,E11.9,00169751112,,1,Medicare_Advantage,MA_HMO,16,M,0.7304,,,116.99,63.34,9.75,33.15,18.0,2.44,53.65,0.0,0.0,0,,0.1096,none,0,1,0,0,0,1e-06,0,0,,P4P
CLM0000001223,MBR00000173,Medical_Professional,Denied,Electronic_EDI,2023-07-30,2023-07-30,2023-07-30,2023-08-08,Auto_Adjudicated,9,1618546650,1289435414,225100000X,Physical Therapist,71,In_Network,I10,E11.9|OTHER|I10,83036,,0,Medicare_Advantage,PFFS,23,F,1.0279,96,COB,1305.84,825.66,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.163,unusual_service_frequency,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000001224,MBR00000170,Medical_Institutional,Paid,Electronic_EDI,2023-11-20,2023-11-20,2023-11-23,2023-11-22,Auto_Adjudicated,2,1756856314,1282319940,2086S0122X,Orthopedic Surgery,22,In_Network,Z00.00,,revenue_code:0450,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,21659.23,7631.94,6060.76,9.99,46.0,1515.19,14027.29,0.0,0.0,0,,0.0116,none,0,1,1,0,0,0.000561,0,0,,FFS
CLM0000001225,MBR00000192,Vision,Paid,Electronic_EDI,2023-03-29,2023-03-29,2023-03-29,2023-04-11,Auto_Adjudicated,13,1112402001,1903401648,207RG0100X,Gastroenterology,21,In_Network,OTHER,,V2115,,0,Medicaid_MCO,MCO,22,F,1.1739,,,322.9,213.53,213.53,0.0,0.0,0.0,109.37,0.0,0.0,0,,0.196,service_date_weekend,0,1,0,0,0,2e-05,0,0,,Shared_Savings
CLM0000001226,MBR00000138,Behavioral_Health,Partially_Paid,Electronic_EDI,2023-08-20,2023-08-20,2023-08-20,2023-09-07,Manual_Review,18,1929402739,1319611206,207RN0300X,Nephrology,65,In_Network,OTHER,,99387,,0,Commercial,HDHP_HSA,47,M,0.996,18,Medical_Necessity,228.01,102.99,0.0,53.22,0.0,0.0,174.79,0.0,0.0,0,,0.094,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001227,MBR00000014,Medical_Professional,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-27,2023-07-13,Manual_Review,16,1426424205,1995553359,207Q00000X,Family Medicine,81,In_Network,E78.5,OTHER|M54.5,71046,,0,Commercial,HMO,77,M,2.8513,,,1046.64,764.29,467.1,142.41,38.0,116.78,282.35,0.0,0.0,0,,0.0999,none,0,1,0,0,0,4.3e-05,0,0,,Capitation
CLM0000001228,MBR00000126,Behavioral_Health,Paid,Provider_Portal,2023-10-13,2023-10-13,2023-10-13,2023-10-19,Auto_Adjudicated,6,1274357072,1809122260,2084P0800X,Psychiatry,11,In_Network,OTHER,M54.5,99213,,0,Medicaid_MCO,MLTSS,48,F,0.637,,,212.83,105.09,103.09,0.0,2.0,0.0,107.74,0.0,0.0,0,,0.0567,high_volume_same_code,0,1,0,0,0,1e-05,0,0,,Bundled_Payment
CLM0000001229,MBR00000273,Medical_Professional,Paid,Electronic_EDI,2023-05-01,2023-05-01,2023-05-01,2023-05-27,Auto_Adjudicated,26,1175978429,1649705287,207RG0100X,Gastroenterology,21,In_Network,OTHER,Z12.11|K21.0,10060,,0,ACA_Marketplace,ACA_Bronze,4,M,1.3569,,,249.48,162.35,0.0,162.35,0.0,0.0,87.13,0.0,0.0,0,,0.0099,none,0,1,0,0,0,0.0,0,0,CCS_Cervical_Cancer_Screening,Bundled_Payment
CLM0000001230,MBR00000239,Medical_Institutional,Denied,Paper,2023-06-02,2023-06-02,2023-06-02,2023-06-21,Auto_Adjudicated,19,1683650935,1510751265,2086S0122X,Orthopedic Surgery,21,In_Network,K29.70,Z23,revenue_code:0300,871,0,Commercial,HMO,1,F,1.1193,1,Eligibility,32612.33,19564.76,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0388,none,0,1,0,0,0,0.0,0,0,MPT_Annual_Monitoring,Bundled_Payment
CLM0000001231,MBR00000279,Medical_Professional,Paid,Electronic_EDI,2023-08-12,2023-08-12,2023-08-12,2023-09-03,Auto_Adjudicated,22,1295273693,1025886739,207RP1001X,Pulmonary Disease,11,In_Network,J44.1,Z12.11,99214,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,,,721.64,570.5,424.76,30.55,9.0,106.19,151.14,0.0,0.0,0,,0.0904,none,0,1,0,0,0,3.9e-05,0,0,,P4P
CLM0000001232,MBR00000049,Medical_Institutional,Partially_Paid,Paper,2023-06-09,2023-06-09,2023-06-09,2023-07-08,Auto_Adjudicated,29,1466922283,1865266296,207V00000X,Obstetrics & Gynecology,11,In_Network,I25.10,OTHER|M47.816,revenue_code:0110,,0,Medicare_Advantage,PFFS,67,M,0.978,5,Medical_Necessity,14732.04,7778.5,4091.41,6.37,51.0,1022.85,9560.41,0.0,0.0,0,,0.064,none,0,1,0,0,0,0.000379,0,0,TRC_Transition_of_Care,P4P
CLM0000001233,MBR00000156,Medical_Professional,Paid,Electronic_EDI,2023-09-30,2023-09-30,2023-09-30,2023-10-16,Auto_Adjudicated,16,1403662694,1774401124,207Q00000X,Family Medicine,11,In_Network,OTHER,OTHER,99382,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,317.06,190.62,115.32,33.47,13.0,28.83,126.44,0.0,0.0,0,,0.0946,duplicate_claim_indicator,0,1,0,1,0,1.1e-05,0,0,FUH_Follow_Up_Hospitalization,Shared_Savings
CLM0000001234,MBR00000176,Medical_Professional,Paid,Electronic_EDI,2023-01-05,2023-01-05,2023-01-05,2023-01-23,Clinical_Review,18,1637260822,1144950506,207RN0300X,Nephrology,23,In_Network,F32.9,OTHER,99283,,0,Commercial,POS,4,M,0.8792,,,295.54,182.51,45.29,104.9,21.0,11.32,113.03,0.0,0.0,0,,0.1021,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000001235,MBR00000064,Medical_Professional,Paid,Electronic_EDI,2023-05-06,2023-05-06,2023-05-06,2023-05-29,Auto_Adjudicated,23,1183801932,1903401648,208600000X,Surgery General,11,In_Network,OTHER,Z23|OTHER,11200,,0,Medicare_Advantage,SNP,73,M,1.0644,,,285.74,115.83,84.64,0.03,10.0,21.16,169.91,0.0,0.0,0,,0.0231,none,0,1,0,0,0,8e-06,0,0,,Shared_Savings
CLM0000001236,MBR00000061,Dental,Paid,Electronic_EDI,2023-03-04,2023-03-04,2023-03-04,2023-03-28,Manual_Review,24,1133265917,1878874025,2084P0800X,Psychiatry,32,In_Network,Z00.01,,D2140,,0,Commercial,PPO,66,M,2.3575,,,275.41,171.18,36.34,112.76,13.0,9.08,104.23,0.0,0.0,0,,0.0056,none,0,1,0,0,0,3e-06,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000001237,MBR00000231,Medical_Institutional,Paid,Electronic_EDI,2023-02-21,2023-02-21,2023-02-21,2023-03-19,Auto_Adjudicated,26,1083045036,1140170394,207Q00000X,Family Medicine,22,In_Network,Z87.891,F32.9,revenue_code:0100,,0,ACA_Marketplace,ACA_Silver,12,M,0.6456,,,27978.0,16634.66,11329.05,375.31,75.0,4855.31,11343.34,0.0,0.0,0,,0.0308,none,0,1,1,0,0,0.001049,0,0,COL_Colorectal_Cancer_Screening,Shared_Savings
CLM0000001238,MBR00000199,Pharmacy,Denied,Provider_Portal,2023-01-20,2023-01-20,2023-01-20,2023-02-11,Auto_Adjudicated,22,1869706360,1705448933,207Q00000X,Family Medicine,21,Out_of_Network,OTHER,,00071015523,,2,Medicaid_MCO,MLTSS,17,F,1.0776,22,Coding_Error,247.68,107.86,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0758,none,0,1,0,0,0,0.0,1,1,,Capitation
CLM0000001239,MBR00000192,Pharmacy,Denied,Electronic_EDI,2023-05-08,2023-05-08,2023-05-08,2023-05-10,Manual_Review,2,1957378066,1831337866,207RN0300X,Nephrology,24,In_Network,Z00.00,J44.1,00085163102,,2,Medicaid_MCO,MCO,22,F,1.1739,96,Eligibility,798.26,527.54,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1901,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001240,MBR00000082,Medical_Professional,Paid,Electronic_EDI,2023-03-20,2023-03-20,2023-03-20,2023-03-31,Clinical_Review,11,1049153238,1447186817,246ZN0300X,Neuropsychology,23,In_Network,E78.5,H52.4|I25.10,99285,,0,Medicare_Advantage,MA_HMO,39,F,0.5376,,,437.6,265.06,189.29,25.44,3.0,47.32,172.54,0.0,0.0,0,,0.1231,none,0,1,0,0,0,1.8e-05,0,0,,FFS
CLM0000001241,MBR00000156,Medical_Professional,Paid,Electronic_EDI,2023-09-30,2023-09-30,2023-09-30,2023-10-18,Manual_Review,18,1945264928,1005335812,101YP2500X,Psychologist Clinical,24,In_Network,OTHER,,97035,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,541.6,227.79,149.4,28.03,13.0,37.35,313.81,0.0,0.0,0,,0.078,none,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000001242,MBR00000007,Medical_Professional,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-14,Auto_Adjudicated,14,1331829614,1688513262,246ZN0300X,Neuropsychology,32,In_Network,H52.4,,99387,,0,Commercial,HDHP_HSA,72,F,0.7578,,,422.22,280.4,45.64,223.35,0.0,11.41,141.82,0.0,0.0,0,,0.1778,billing_spike_recent,0,1,0,0,0,4e-06,0,0,,P4P
CLM0000001243,MBR00000040,Medical_Institutional,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-10,2023-10-12,Auto_Adjudicated,2,1526973051,1447657873,101YP2500X,Psychologist Clinical,24,In_Network,H52.4,M17.11|Z00.00,revenue_code:0200,,0,Medicare_Advantage,MA_HMO,66,F,0.6755,,,11483.59,6715.99,5341.0,7.74,32.0,1335.25,4767.6,0.0,0.0,0,,0.1205,unbundling_pattern,0,1,1,0,0,0.000494,0,0,,FFS
CLM0000001244,MBR00000159,Vision,Paid,Electronic_EDI,2023-11-14,2023-11-14,2023-11-14,2023-11-23,Auto_Adjudicated,9,1734752728,1738617370,225100000X,Physical Therapist,24,In_Network,OTHER,OTHER|Z00.00,92012,,0,Commercial,PPO,70,F,1.2009,,,132.44,106.31,56.36,21.85,14.0,14.09,26.13,0.0,0.0,0,,0.2039,billing_spike_recent,0,2,0,0,0,5e-06,0,0,,P4P
CLM0000001245,MBR00000098,Medical_Professional,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-10,2023-10-20,Auto_Adjudicated,10,1584745499,1318978078,207RG0100X,Gastroenterology,24,In_Network,Z00.01,Z00.01,11200,,0,Medicare_Advantage,MA_HMO,7,M,0.511,,,1500.84,929.48,720.02,10.46,19.0,180.0,571.36,0.0,0.0,0,,0.1327,none,0,1,0,1,0,6.7e-05,0,0,,Shared_Savings
CLM0000001246,MBR00000292,Pharmacy,Paid,Electronic_EDI,2023-06-01,2023-06-01,2023-06-01,2023-06-03,Manual_Review,2,1101385540,1312595355,207R00000X,Internal Medicine,21,Emergency,I50.9,Z00.00,16590051660,,4,Medicare_Advantage,MA_HMO,4,M,1.1779,,,304.64,143.74,88.61,29.98,3.0,22.15,160.9,0.0,0.0,0,,0.1431,none,0,1,0,0,0,8e-06,0,0,,Capitation
CLM0000001247,MBR00000144,Pharmacy,Paid,Paper,2023-12-16,2023-12-16,2023-12-16,2024-01-08,Auto_Adjudicated,23,1952322604,1055872102,2084P0800X,Psychiatry,23,In_Network,M79.3,,50458085930,,2,Commercial,HDHP_HSA,56,F,2.5926,,,2135.36,1538.39,801.15,536.95,0.0,200.29,596.97,0.0,0.0,0,,0.1079,none,0,1,0,0,0,7.4e-05,0,0,TRC_Transition_of_Care,Capitation
CLM0000001248,MBR00000025,Dental,Paid,Electronic_EDI,2023-05-19,2023-05-19,2023-05-19,2023-05-31,Auto_Adjudicated,12,1267286378,1643323506,207RN0300X,Nephrology,22,In_Network,E11.9,,D2140,,0,Commercial,POS,74,M,1.3309,,,277.71,156.05,0.0,156.05,0.0,0.0,121.66,0.0,0.0,0,,0.1522,benford_violation,0,1,0,0,0,0.0,0,0,MPT_Annual_Monitoring,Capitation
CLM0000001249,MBR00000006,Medical_Professional,Paid,Electronic_EDI,2023-10-24,2023-10-24,2023-10-24,2023-11-17,Auto_Adjudicated,24,1907932706,1282319940,2084P0800X,Psychiatry,81,In_Network,E11.9,F33.0,97035,,0,Commercial,EPO,88,M,1.4365,,,1207.75,926.74,684.35,38.3,33.0,171.09,281.01,0.0,0.0,0,,0.053,none,0,1,0,0,0,6.3e-05,0,0,HBD_Hemoglobin_A1c_Testing,Capitation
CLM0000001250,MBR00000213,Vision,Paid,Paper,2023-03-03,2023-03-03,2023-03-03,2023-03-30,Auto_Adjudicated,27,1170319307,1747935894,207RN0300X,Nephrology,22,In_Network,R05.9,M54.5,92014,,0,Commercial,PPO,17,M,1.5857,,,479.9,276.06,157.37,51.35,28.0,39.34,203.84,0.0,0.0,1,DME Fraud,1.0,outlier_billing_amount|geographic_mismatch|temporal_clustering|high_volume_same_code|benford_violation|service_date_weekend|billing_spike_recent|upcoding_pattern|npi_mismatch|high_oop_waiver,1,5,0,0,0,1.5e-05,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000001251,MBR00000054,Medical_Institutional,Denied,Electronic_EDI,2023-12-14,2023-12-14,2023-12-18,2024-01-10,Manual_Review,27,1046207613,1706603847,207Q00000X,Family Medicine,11,In_Network,R05.9,OTHER|J44.1,revenue_code:0370,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,PR-1,Coding_Error,112129.11,51064.41,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2012,outlier_billing_amount,0,2,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001252,MBR00000059,Medical_Institutional,Paid,Electronic_EDI,2023-04-19,2023-04-19,2023-04-20,2023-05-17,Auto_Adjudicated,28,1133265917,1810068286,2084P0800X,Psychiatry,22,Emergency,J44.1,OTHER,revenue_code:0100,,0,Medicare_Advantage,SNP,12,F,1.266,,,2148.81,1287.64,988.98,18.42,33.0,247.24,861.17,0.0,0.0,0,,0.022,none,0,1,0,0,0,9.2e-05,0,0,,Shared_Savings
CLM0000001253,MBR00000134,Pharmacy,Paid,Paper,2023-08-14,2023-08-14,2023-08-14,2023-08-29,Auto_Adjudicated,15,1064567615,1878874025,2084P0800X,Psychiatry,21,In_Network,F32.9,,00071015523,,1,Medicare_Advantage,MA_PPO,33,M,1.115,,,196.83,79.06,14.63,47.78,13.0,3.66,117.77,0.0,0.0,0,,0.0796,controlled_substance_high_volume,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000001254,MBR00000081,Medical_Professional,Paid,Electronic_EDI,2023-05-08,2023-05-08,2023-05-08,2023-05-16,Auto_Adjudicated,8,1218947226,1728466420,246ZN0300X,Neuropsychology,22,In_Network,E13.9,I10,97110,,0,Medicare_Advantage,SNP,66,F,2.159,,,6314.13,3455.07,2746.96,16.37,5.0,686.74,2859.06,0.0,0.0,1,Identity Theft,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|benford_violation|impossible_service_combo|service_date_weekend|billing_spike_recent|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,0.000254,0,0,,FFS
CLM0000001255,MBR00000184,Pharmacy,Denied,Electronic_EDI,2023-03-24,2023-03-24,2023-03-24,2023-03-27,Manual_Review,3,1344162462,1625992541,207RN0300X,Nephrology,22,In_Network,M54.5,Z23|F33.0,50458085930,,1,Medicaid_MCO,MLTSS,30,M,2.8302,PR-1,Eligibility,134.43,85.07,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0793,impossible_service_combo,0,1,0,1,0,0.0,0,0,,FFS
CLM0000001256,MBR00000151,Medical_Institutional,Denied,Electronic_EDI,2023-04-29,2023-04-29,2023-04-29,2023-05-18,Auto_Adjudicated,19,1664872214,1574982369,207R00000X,Internal Medicine,71,In_Network,E11.9,I10,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,77,M,0.8709,170,COB,30912.83,20360.78,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0153,none,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,FFS
CLM0000001257,MBR00000035,Pharmacy,Paid,Electronic_EDI,2023-08-07,2023-08-07,2023-08-07,2023-08-11,Clinical_Review,4,1111846258,1874728994,2086S0122X,Orthopedic Surgery,11,In_Network,J44.1,Z12.11|Z00.121,00006001954,,1,ACA_Marketplace,ACA_Platinum,46,M,0.6598,,,77.12,41.5,0.0,41.5,0.0,0.0,35.62,0.0,0.0,0,,0.1436,controlled_substance_high_volume,0,1,0,0,0,0.0,0,1,BCS_Breast_Cancer_Screening,FFS
CLM0000001258,MBR00000232,Dental,Paid,Electronic_EDI,2023-02-10,2023-02-10,2023-02-10,2023-02-18,Auto_Adjudicated,8,1376791933,1649705287,225100000X,Physical Therapist,81,In_Network,F33.0,K57.30,D2140,,0,Medicaid_MCO,MCO,40,M,1.1083,,,464.64,198.97,196.97,0.0,2.0,0.0,265.67,0.0,0.0,0,,0.1,none,0,1,0,0,0,1.8e-05,0,0,,FFS
CLM0000001259,MBR00000135,Medical_Institutional,Paid,Electronic_EDI,2023-03-13,2023-03-13,2023-03-15,2023-03-21,Auto_Adjudicated,8,1771383741,1831337866,2086S0122X,Orthopedic Surgery,24,Out_of_Network,OTHER,,revenue_code:0250,,0,Commercial,PPO,58,F,2.2702,,,6698.23,3416.58,2685.58,0.61,59.0,671.39,3281.65,0.0,0.0,0,,0.0986,none,0,1,0,0,0,0.000249,1,0,,P4P
CLM0000001260,MBR00000184,Medical_Professional,Paid,Electronic_EDI,2023-11-27,2023-11-27,2023-11-27,2023-12-06,Manual_Review,9,1413983739,1390802135,101YP2500X,Psychologist Clinical,11,In_Network,Z23,OTHER|E11.65,99395,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,587.19,354.93,352.93,0.0,2.0,0.0,232.26,276.06,64.94,0,,0.0778,none,0,1,0,1,0,3.3e-05,0,0,,FFS
CLM0000001261,MBR00000002,Medical_Professional,Paid,Electronic_EDI,2023-01-31,2023-01-31,2023-01-31,2023-02-12,Auto_Adjudicated,12,1156265220,1354265777,207R00000X,Internal Medicine,11,In_Network,OTHER,E11.9,99284,,0,Commercial,PPO,42,F,0.9012,,,576.81,359.4,252.2,26.15,18.0,63.05,217.41,0.0,0.0,0,,0.0802,high_volume_same_code,0,1,0,1,0,2.3e-05,0,0,,Bundled_Payment
CLM0000001262,MBR00000186,Dental,Denied,Electronic_EDI,2023-09-17,2023-09-17,2023-09-17,2023-09-27,Auto_Adjudicated,10,1324272690,1788579687,207RN0300X,Nephrology,65,In_Network,OTHER,,D3310,,0,Commercial,PPO,65,M,1.6983,16,COB,285.89,220.29,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0567,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001263,MBR00000088,Medical_Institutional,Paid,Electronic_EDI,2023-04-19,2023-04-19,2023-04-20,2023-05-05,Auto_Adjudicated,16,1193571728,1020312030,225100000X,Physical Therapist,24,In_Network,Z23,OTHER,revenue_code:0110,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,,,1029.02,387.5,0.0,387.5,0.0,0.0,641.52,0.0,0.0,0,,0.1623,impossible_service_combo,0,1,0,0,0,0.0,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000001264,MBR00000154,Dental,Paid,Provider_Portal,2023-04-25,2023-04-25,2023-04-25,2023-05-24,Auto_Adjudicated,29,1594587354,1469642907,207RG0100X,Gastroenterology,11,Out_of_Network,J20.9,OTHER|F41.1,D0150,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,519.52,321.14,255.24,2.09,0.0,63.81,198.38,0.0,0.0,0,,0.1004,billing_spike_recent,0,1,0,0,0,2.4e-05,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000001265,MBR00000093,Medical_Professional,Paid,Electronic_EDI,2023-05-11,2023-05-11,2023-05-11,2023-05-31,Auto_Adjudicated,20,1510562885,1625992541,207RN0300X,Nephrology,22,In_Network,OTHER,Z00.01,97010,,0,Medicare_Advantage,MA_HMO,43,F,0.6162,,,1469.54,650.47,479.08,32.62,19.0,119.77,819.07,0.0,0.0,0,,0.0229,none,0,1,0,0,0,4.4e-05,0,0,,FFS
CLM0000001266,MBR00000299,Medical_Institutional,Paid,Electronic_EDI,2023-05-18,2023-05-18,2023-05-22,2023-06-08,Auto_Adjudicated,21,1793630905,1209882852,225100000X,Physical Therapist,11,In_Network,M54.5,E78.5,revenue_code:0100,,0,Medicaid_MCO,MCO,74,F,0.8833,,,21868.12,17312.93,17310.93,0.0,2.0,0.0,4555.19,0.0,0.0,0,,0.1022,high_volume_same_code,0,1,1,1,0,0.001602,0,0,HBD_Hemoglobin_A1c_Testing,P4P
CLM0000001267,MBR00000073,Dental,Denied,Electronic_EDI,2023-09-12,2023-09-12,2023-09-12,2023-09-17,Auto_Adjudicated,5,1252009836,1304018750,2084P0800X,Psychiatry,23,In_Network,F10.10,M25.511,D7140,,0,Commercial,POS,79,M,1.1768,1,Coding_Error,483.85,335.21,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.017,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001268,MBR00000276,Pharmacy,Paid,Electronic_EDI,2023-10-16,2023-10-16,2023-10-16,2023-10-20,Auto_Adjudicated,4,1990244466,1040061910,207RN0300X,Nephrology,11,In_Network,I25.10,Z00.00|M54.5,59148001506,,3,Commercial,POS,38,M,0.8085,,,249.22,120.95,62.44,7.9,35.0,15.61,128.27,0.0,0.0,0,,0.0382,none,0,1,0,1,0,6e-06,0,1,MPT_Annual_Monitoring,FFS
CLM0000001269,MBR00000277,Medical_Professional,Paid,Electronic_EDI,2023-05-11,2023-05-11,2023-05-11,2023-05-17,Auto_Adjudicated,6,1736809698,1365397818,207RN0300X,Nephrology,21,In_Network,Z23,Z12.11|OTHER,74177,,0,Medicaid_MCO,MCO,30,M,1.8495,,,565.09,361.97,358.97,0.0,3.0,0.0,203.12,0.0,0.0,0,,0.0649,none,0,1,0,0,0,3.3e-05,0,0,,FFS
CLM0000001270,MBR00000133,Medical_Professional,Denied,Electronic_EDI,2023-03-03,2023-03-03,2023-03-03,2023-03-29,Auto_Adjudicated,26,1673449362,1763260577,2084P0800X,Psychiatry,21,In_Network,OTHER,K21.0|N39.0,99284,,0,Medicaid_MCO,MCO,57,M,0.9592,22,Coding_Error,204.94,160.44,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0881,none,0,1,0,0,0,0.0,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000001271,MBR00000096,Dental,Paid,Electronic_EDI,2023-01-02,2023-01-02,2023-01-02,2023-01-08,Auto_Adjudicated,6,1490172833,1972530373,207RN0300X,Nephrology,22,In_Network,I10,,D4341,,0,Medicaid_MCO,MCO,62,M,0.7948,,,388.9,164.42,162.42,0.0,2.0,0.0,224.48,0.0,0.0,0,,0.1619,npi_mismatch,0,1,0,0,0,1.5e-05,0,0,ACR_Urine_Protein,Capitation
CLM0000001272,MBR00000121,Pharmacy,Partially_Paid,Electronic_EDI,2023-09-18,2023-09-18,2023-09-18,2023-10-18,Auto_Adjudicated,30,1946657989,1763260577,2084P0800X,Psychiatry,11,In_Network,Z00.00,I50.9,00071015523,,1,Medicare_Advantage,MA_PPO,58,M,1.226,2,Medical_Necessity,165.59,84.24,28.44,5.49,18.0,7.11,106.56,0.0,0.0,0,,0.1003,none,0,1,0,0,0,3e-06,0,1,,Capitation
CLM0000001273,MBR00000297,Medical_Institutional,Paid,Paper,2023-11-26,2023-11-26,2023-11-26,2023-12-19,Manual_Review,23,1526973051,1220755708,207V00000X,Obstetrics & Gynecology,23,In_Network,E11.9,OTHER|J06.9,revenue_code:0200,,0,Commercial,HMO,88,M,1.5311,,,24964.85,14704.65,11708.29,30.29,39.0,2927.07,10260.2,0.0,0.0,0,,0.0188,none,0,1,1,0,0,0.001084,0,0,MMA_Medication_Management,FFS
CLM0000001274,MBR00000185,Medical_Institutional,Denied,Electronic_EDI,2023-01-13,2023-01-13,2023-01-17,2023-02-07,Auto_Adjudicated,25,1699014308,1297948643,246ZN0300X,Neuropsychology,24,In_Network,OTHER,,revenue_code:0120,,0,Medicaid_MCO,MCO,73,M,1.5417,256,Duplicate,6223.34,2952.6,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0741,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001275,MBR00000166,Medical_Professional,Partially_Paid,Electronic_EDI,2023-07-31,2023-07-31,2023-07-31,2023-08-10,Auto_Adjudicated,10,1159268684,1747596016,207RP1001X,Pulmonary Disease,23,In_Network,J06.9,,99214,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,50,Medical_Necessity,239.72,99.89,0.0,70.32,0.0,0.0,169.4,0.0,0.0,0,,0.0203,none,0,1,0,0,0,0.0,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000001276,MBR00000011,Medical_Institutional,Denied,Electronic_EDI,2023-03-20,2023-03-20,2023-03-21,2023-03-25,Manual_Review,5,1556434733,1148612764,207Q00000X,Family Medicine,65,In_Network,E13.9,I10|Z00.01|F41.1,revenue_code:0210,,0,Medicare_Advantage,SNP,35,F,1.0833,22,COB,14341.38,6388.9,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0442,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001277,MBR00000255,Medical_Professional,Paid,Electronic_EDI,2023-03-17,2023-03-17,2023-03-17,2023-03-23,Auto_Adjudicated,6,1923937825,1112696614,207V00000X,Obstetrics & Gynecology,24,Out_of_Network,E11.9,I10|OTHER,47562,,0,Medicare_Advantage,MA_HMO,21,M,0.6945,,,412.81,212.97,148.66,9.15,18.0,37.16,199.84,0.0,0.0,0,,0.2766,benford_violation|unbundling_pattern|controlled_substance_high_volume,0,2,0,1,0,1.4e-05,1,0,,Shared_Savings
CLM0000001278,MBR00000025,Medical_Professional,Denied,Electronic_EDI,2023-10-25,2023-10-25,2023-10-25,2023-11-20,Auto_Adjudicated,26,1721465780,1312595355,208600000X,Surgery General,11,In_Network,F41.1,Z00.00|OTHER|M54.5,90853,,0,Commercial,POS,74,M,1.3309,1,Network,264.64,193.15,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1141,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,FUH_Follow_Up_Hospitalization,P4P
CLM0000001279,MBR00000014,Pharmacy,Paid,Paper,2023-04-01,2023-04-01,2023-04-01,2023-04-14,Auto_Adjudicated,13,1513278494,1896197144,207R00000X,Internal Medicine,11,In_Network,N39.0,Z00.121,16590051660,,2,Commercial,HMO,77,M,2.8513,,,327.95,275.95,57.39,166.22,38.0,14.35,52.0,0.0,0.0,0,,0.2049,diagnosis_procedure_mismatch,0,2,0,0,0,5e-06,0,0,,Bundled_Payment
CLM0000001280,MBR00000085,Medical_Professional,Paid,Electronic_EDI,2023-04-20,2023-04-20,2023-04-20,2023-05-03,Auto_Adjudicated,13,1789174420,1510751265,207RN0300X,Nephrology,23,In_Network,E11.9,,74177,,0,Medicare_Advantage,SNP,2,M,0.7823,,,280.33,128.31,70.09,25.7,15.0,17.52,152.02,47.32,16.95,0,,0.137,none,0,1,0,0,0,6e-06,0,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000001281,MBR00000146,Pharmacy,Denied,Electronic_EDI,2023-02-14,2023-02-14,2023-02-14,2023-02-22,Auto_Adjudicated,8,1677021292,1027261156,101YP2500X,Psychologist Clinical,23,In_Network,Z12.11,,00071015523,,5,Medicaid_MCO,MCO,24,M,0.6484,5,Authorization,227.13,171.86,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.05,none,0,1,0,0,0,0.0,0,1,,Bundled_Payment
CLM0000001282,MBR00000271,Medical_Institutional,Paid,Electronic_EDI,2023-11-21,2023-11-21,2023-11-22,2023-12-02,Auto_Adjudicated,11,1147937670,1288028182,2084P0800X,Psychiatry,81,In_Network,E78.5,OTHER|Z00.01,revenue_code:0210,,0,Medicaid_MCO,MCO,4,F,0.6696,,,21272.36,12186.57,12177.57,0.0,9.0,0.0,9085.79,0.0,0.0,0,,0.0992,none,0,1,1,1,0,0.001127,0,0,,FFS
CLM0000001283,MBR00000234,Medical_Professional,Paid,Electronic_EDI,2023-11-22,2023-11-22,2023-11-22,2023-12-04,Manual_Review,12,1232573801,1005335812,207RG0100X,Gastroenterology,11,In_Network,Z00.01,OTHER|M25.511,43239,,0,Medicare_Advantage,MA_HMO,59,M,0.395,,,1889.07,772.12,609.83,9.84,0.0,152.46,1116.95,0.0,0.0,0,,0.0594,none,0,1,0,1,0,5.6e-05,0,0,,FFS
CLM0000001284,MBR00000061,Medical_Professional,Paid,Electronic_EDI,2023-11-24,2023-11-24,2023-11-24,2023-12-17,Auto_Adjudicated,23,1231231881,1419347445,207RC0000X,Cardiovascular Disease,11,In_Network,K21.0,F32.9,99395,,0,Commercial,PPO,66,M,2.3575,,,933.58,605.93,363.0,139.18,13.0,90.75,327.65,0.0,0.0,0,,0.0975,none,0,1,0,0,0,3.4e-05,0,0,,FFS
CLM0000001285,MBR00000118,Medical_Professional,Paid,Electronic_EDI,2023-03-24,2023-03-24,2023-03-24,2023-04-18,Manual_Review,25,1474985672,1972530373,225100000X,Physical Therapist,31,In_Network,E11.65,Z79.4,11200,,0,Medicaid_MCO,MCO,69,M,1.2773,,,1755.99,958.05,957.05,0.0,1.0,0.0,797.94,0.0,0.0,0,,0.0249,none,0,1,0,0,0,8.9e-05,0,0,,Bundled_Payment
CLM0000001286,MBR00000230,Pharmacy,Paid,Electronic_EDI,2023-03-09,2023-03-09,2023-03-09,2023-03-24,Auto_Adjudicated,15,1376791933,1477113725,246ZN0300X,Neuropsychology,32,In_Network,Z00.01,J06.9|M54.5,00310075090,,3,Commercial,HMO,9,M,0.4087,,,110.91,55.86,0.0,55.86,0.0,0.0,55.05,0.0,0.0,0,,0.0003,none,0,1,0,0,0,0.0,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000001287,MBR00000160,Dental,Paid,Electronic_EDI,2023-12-04,2023-12-04,2023-12-04,2023-12-15,Auto_Adjudicated,11,1869706360,1527857018,207RC0000X,Cardiovascular Disease,22,In_Network,J06.9,,D0150,,0,Commercial,HMO,73,M,1.9608,,,311.08,166.65,28.93,107.49,23.0,7.23,144.43,0.0,0.0,0,,0.1017,none,0,1,0,0,0,3e-06,0,0,,FFS
CLM0000001288,MBR00000055,Pharmacy,Paid,Electronic_EDI,2023-08-09,2023-08-09,2023-08-09,2023-08-23,Manual_Review,14,1631060535,1831337866,207RG0100X,Gastroenterology,22,Out_of_Network,F32.9,,59148001506,,2,Commercial,PPO,68,F,1.2896,,,248.43,150.51,59.64,65.96,10.0,14.91,97.92,45.3,11.72,0,,0.039,none,0,1,0,0,0,6e-06,0,0,COA_Care_Transitions,P4P
CLM0000001289,MBR00000126,Pharmacy,Paid,Electronic_EDI,2023-04-05,2023-04-05,2023-04-05,2023-04-11,Auto_Adjudicated,6,1532359759,1509799493,225100000X,Physical Therapist,31,In_Network,OTHER,Z00.00|N39.0|Z00.01,50458085930,,2,Medicaid_MCO,MLTSS,48,F,0.637,,,185.65,111.28,109.28,0.0,2.0,0.0,74.37,0.0,0.0,0,,0.1396,provider_specialty_mismatch|high_oop_waiver,0,1,0,0,0,1e-05,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000001290,MBR00000186,Dental,Paid,Provider_Portal,2023-01-17,2023-01-17,2023-01-17,2023-01-20,Manual_Review,3,1484438840,1880530717,225100000X,Physical Therapist,22,In_Network,N18.3,I10,D0150,,0,Commercial,PPO,65,M,1.6983,,,407.59,223.39,22.85,182.83,12.0,5.71,184.2,0.0,0.0,0,,0.127,upcoding_pattern,0,1,0,0,0,2e-06,0,0,,Capitation
CLM0000001291,MBR00000293,Pharmacy,Paid,Paper,2023-10-14,2023-10-14,2023-10-14,2023-10-21,Auto_Adjudicated,7,1797494973,1325999602,207RG0100X,Gastroenterology,24,In_Network,OTHER,Z00.01|Z79.4,00071012831,,2,Medicare_Advantage,MA_HMO,84,F,2.8513,,,528.39,213.46,150.32,14.56,11.0,37.58,314.93,0.0,0.0,0,,0.1679,unusual_service_frequency,0,1,0,0,0,1.4e-05,0,0,,Capitation
CLM0000001292,MBR00000197,Medical_Institutional,Paid,Electronic_EDI,2023-10-15,2023-10-15,2023-10-17,2023-10-16,Auto_Adjudicated,1,1886549972,1148659045,207RG0100X,Gastroenterology,71,Out_of_Network,N39.0,I50.9|Z00.121|OTHER,revenue_code:0200,,0,Medicare_Advantage,MA_HMO,59,M,1.1414,,,14735.92,8968.01,7138.35,9.08,36.0,1784.59,5767.91,0.0,0.0,0,,0.0238,none,0,1,1,0,0,0.000661,0,0,FUH_Follow_Up_Hospitalization,Bundled_Payment
CLM0000001293,MBR00000006,Pharmacy,Paid,Electronic_EDI,2023-01-04,2023-01-04,2023-01-04,2023-01-06,Manual_Review,2,1810800968,1706603847,2086S0122X,Orthopedic Surgery,11,In_Network,OTHER,OTHER|E11.9,00003014960,,1,Commercial,EPO,88,M,1.4365,,,404.65,323.43,193.11,49.05,33.0,48.28,81.22,0.0,0.0,0,,0.0428,none,0,1,0,0,0,1.8e-05,0,1,PCR_Plan_All_Cause_Readmission,P4P
CLM0000001294,MBR00000208,Medical_Institutional,Paid,Electronic_EDI,2023-06-21,2023-06-21,2023-06-25,2023-06-29,Auto_Adjudicated,8,1263063839,1765164601,207RC0000X,Cardiovascular Disease,11,In_Network,Z00.01,J06.9,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,4733.37,2593.46,2019.84,14.66,54.0,504.96,2139.91,0.0,0.0,0,,0.0223,none,0,1,0,0,0,0.000187,0,0,BPD_BP_Declined,Capitation
CLM0000001295,MBR00000078,Medical_Professional,Paid,Electronic_EDI,2023-06-23,2023-06-23,2023-06-23,2023-07-21,Manual_Review,28,1454749898,1765164601,207Q00000X,Family Medicine,71,Out_of_Network,E11.65,E11.65,99203,,0,Commercial,EPO,65,F,1.3174,,,373.78,232.08,0.0,232.08,0.0,0.0,141.7,0.0,0.0,0,,0.0081,none,0,1,0,1,0,0.0,0,0,ACR_Urine_Protein,P4P
CLM0000001296,MBR00000260,Pharmacy,Denied,Electronic_EDI,2023-06-16,2023-06-16,2023-06-16,2023-06-22,Auto_Adjudicated,6,1147937670,1827839595,207RN0300X,Nephrology,21,Out_of_Network,J06.9,Z00.00,00310075090,,4,Medicare_Advantage,SNP,59,M,0.3786,170,Network,50.92,33.97,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1686,benford_violation|billing_spike_recent,0,1,0,0,0,0.0,1,0,,Capitation
CLM0000001297,MBR00000121,Pharmacy,Paid,Electronic_EDI,2023-05-13,2023-05-13,2023-05-13,2023-06-03,Auto_Adjudicated,21,1231231881,1004714954,207RE0101X,Endocrinology,11,In_Network,L70.0,E11.9|OTHER|Z23,16590051660,,2,Medicare_Advantage,MA_PPO,58,M,1.226,,,474.96,268.01,195.3,5.88,18.0,48.83,206.95,0.0,0.0,0,,0.0704,none,0,1,0,0,0,1.8e-05,0,1,,Capitation
CLM0000001298,MBR00000061,Medical_Professional,Paid,Electronic_EDI,2023-04-28,2023-04-28,2023-04-28,2023-05-03,Auto_Adjudicated,5,1220235547,1148659045,225100000X,Physical Therapist,22,In_Network,OTHER,,97110,,0,Commercial,PPO,66,M,2.3575,,,609.08,455.29,216.77,171.33,13.0,54.19,153.79,0.0,0.0,0,,0.0987,high_oop_waiver,0,1,0,0,0,2e-05,0,0,,FFS
CLM0000001299,MBR00000144,Vision,Paid,Electronic_EDI,2023-05-01,2023-05-01,2023-05-01,2023-05-15,Auto_Adjudicated,14,1648123576,1220755708,246ZN0300X,Neuropsychology,22,In_Network,N40.0,F41.1|H52.4,V2100,,0,Commercial,HDHP_HSA,56,F,2.5926,,,147.02,53.94,0.0,53.94,0.0,0.0,93.08,0.0,0.0,0,,0.1184,none,0,1,0,0,0,0.0,0,0,POD_Persistence_of_Beta_Blocker,FFS
CLM0000001300,MBR00000079,Medical_Professional,Denied,Electronic_EDI,2023-11-27,2023-11-27,2023-11-27,2023-12-16,Auto_Adjudicated,19,1451464799,1860951128,207RN0300X,Nephrology,11,In_Network,Z00.01,OTHER|K57.30,90837,,0,Medicaid_MCO,MLTSS,55,F,0.5016,5,Duplicate,570.03,233.01,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0986,upcoding_pattern,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001301,MBR00000074,Pharmacy,Paid,Electronic_EDI,2023-12-23,2023-12-23,2023-12-23,2024-01-09,Auto_Adjudicated,17,1379875145,1354959095,2084P0800X,Psychiatry,23,In_Network,F33.0,M54.5,00310075090,,3,Medicare_Advantage,MA_PPO,21,F,0.8719,,,283.0,102.9,50.7,20.52,19.0,12.68,180.1,0.0,0.0,0,,0.0657,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000001302,MBR00000172,Vision,Paid,Electronic_EDI,2023-02-10,2023-02-10,2023-02-10,2023-03-06,Auto_Adjudicated,24,1327415110,1473869105,207RN0300X,Nephrology,11,In_Network,J45.20,R05.9|Z00.01,92004,,0,Medicaid_MCO,MCO,50,F,0.2787,,,157.64,129.14,129.14,0.0,0.0,0.0,28.5,82.51,36.55,0,,0.0284,none,0,1,0,0,0,1.2e-05,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000001303,MBR00000226,Medical_Professional,Paid,Electronic_EDI,2023-09-16,2023-09-16,2023-09-16,2023-09-24,Auto_Adjudicated,8,1658382624,1878874025,207RG0100X,Gastroenterology,11,In_Network,Z00.00,,73721,,0,Medicare_Advantage,MA_PPO,84,M,1.0796,,,374.14,149.11,110.82,0.59,10.0,27.7,225.03,98.45,9.91,0,,0.0694,none,0,1,0,0,0,1e-05,0,0,ACR_Urine_Protein,Bundled_Payment
CLM0000001304,MBR00000249,Dental,Paid,Electronic_EDI,2023-07-25,2023-07-25,2023-07-25,2023-08-17,Auto_Adjudicated,23,1590338573,1894215172,225100000X,Physical Therapist,11,In_Network,I10,,D1110,,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,291.3,219.97,0.0,199.85,20.12,0.0,71.33,0.0,0.0,0,,0.0103,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001305,MBR00000126,Pharmacy,Denied,Provider_Portal,2023-04-02,2023-04-02,2023-04-02,2023-04-15,Auto_Adjudicated,13,1756856314,1406199453,207RG0100X,Gastroenterology,22,In_Network,K57.30,,00169751112,,1,Medicaid_MCO,MLTSS,48,F,0.637,2,Eligibility,376.78,149.83,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1136,none,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000001306,MBR00000021,Pharmacy,Paid,Electronic_EDI,2023-03-08,2023-03-08,2023-03-08,2023-03-22,Auto_Adjudicated,14,1375098560,1390802135,207RG0100X,Gastroenterology,31,In_Network,M54.5,OTHER,00078043215,,1,Commercial,POS,72,M,0.6126,,,38.66,22.0,0.0,22.0,0.0,0.0,16.66,0.0,0.0,0,,0.1174,none,0,1,0,0,0,0.0,0,1,,Bundled_Payment
CLM0000001307,MBR00000149,Vision,Paid,Electronic_EDI,2023-09-28,2023-09-28,2023-09-28,2023-10-08,Auto_Adjudicated,10,1067329999,1325999602,207RN0300X,Nephrology,22,In_Network,Z00.00,,V2100,,0,Commercial,PPO,42,F,0.5458,,,368.32,229.04,0.0,229.04,0.0,0.0,139.28,0.0,0.0,0,,0.0632,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001308,MBR00000136,Pharmacy,Paid,Electronic_EDI,2023-05-11,2023-05-11,2023-05-11,2023-06-10,Auto_Adjudicated,30,1331829614,1469642907,225100000X,Physical Therapist,31,In_Network,OTHER,E78.5,00069420020,,5,Commercial,POS,2,F,1.2611,,,157.8,117.44,0.0,117.44,0.0,0.0,40.36,0.0,0.0,0,,0.0914,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000001309,MBR00000061,Medical_Institutional,Paid,Electronic_EDI,2023-02-16,2023-02-16,2023-02-17,2023-03-13,Auto_Adjudicated,25,1658382624,1581533104,2084P0800X,Psychiatry,11,In_Network,OTHER,Z12.11,revenue_code:0360,,0,Commercial,PPO,66,M,2.3575,,,34134.78,14612.15,11631.52,38.75,34.0,2907.88,19522.63,0.0,0.0,0,,0.0459,none,0,1,1,0,0,0.001077,0,0,,FFS
CLM0000001310,MBR00000272,Pharmacy,Paid,Electronic_EDI,2023-12-14,2023-12-14,2023-12-14,2023-12-28,Auto_Adjudicated,14,1793630905,1577226132,207RE0101X,Endocrinology,21,In_Network,Z12.11,,00078043215,,2,Medicare_Advantage,MA_HMO,15,M,0.8525,,,266.62,179.96,96.05,44.9,15.0,24.01,86.66,0.0,0.0,0,,0.0532,none,0,1,0,0,0,9e-06,0,1,,FFS
CLM0000001311,MBR00000293,Medical_Institutional,Paid,Electronic_EDI,2023-11-29,2023-11-29,2023-11-30,2023-12-22,Auto_Adjudicated,23,1874109311,1163639177,225100000X,Physical Therapist,21,In_Network,OTHER,,revenue_code:0300,682,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,44213.7,34674.01,27680.01,42.0,32.0,6920.0,9539.69,22125.99,4960.34,0,,0.1064,none,0,1,1,0,0,0.002562,0,0,,FFS
CLM0000001312,MBR00000014,Medical_Professional,Paid,Electronic_EDI,2023-05-31,2023-05-31,2023-05-31,2023-06-28,Auto_Adjudicated,28,1648123576,1704466150,207RC0000X,Cardiovascular Disease,24,In_Network,OTHER,OTHER|Z79.4,99284,,0,Commercial,HMO,77,M,2.8513,,,359.63,296.45,86.28,150.6,38.0,21.57,63.18,0.0,0.0,0,,0.1099,npi_mismatch,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000001313,MBR00000236,Medical_Professional,Paid,Provider_Portal,2023-06-03,2023-06-03,2023-06-03,2023-06-12,Auto_Adjudicated,9,1617763056,1867389043,207RN0300X,Nephrology,22,In_Network,E11.65,E78.5,97140,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,296.36,249.44,246.44,0.0,3.0,0.0,46.92,0.0,0.0,0,,0.0895,none,0,1,0,0,0,2.3e-05,0,0,,Capitation
CLM0000001314,MBR00000192,Medical_Professional,Paid,Electronic_EDI,2023-05-31,2023-05-31,2023-05-31,2023-06-10,Auto_Adjudicated,10,1901547390,1128148362,207RC0000X,Cardiovascular Disease,24,In_Network,I48.91,Z00.01|F41.1,43239,,0,Medicaid_MCO,MCO,22,F,1.1739,,,934.5,760.33,760.33,0.0,0.0,0.0,174.17,0.0,0.0,0,,0.1248,none,0,1,0,0,0,7e-05,0,0,,P4P
CLM0000001315,MBR00000081,Pharmacy,Paid,Provider_Portal,2023-03-10,2023-03-10,2023-03-10,2023-04-02,Auto_Adjudicated,23,1253087808,1688513262,246ZN0300X,Neuropsychology,21,In_Network,OTHER,J44.1|I50.9,00078043215,,2,Medicare_Advantage,SNP,66,F,2.159,,,286.65,150.18,105.77,12.96,5.0,26.44,136.47,0.0,0.0,0,,0.0798,none,0,1,0,0,0,1e-05,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000001316,MBR00000188,Vision,Paid,Electronic_EDI,2023-02-07,2023-02-07,2023-02-07,2023-02-16,Manual_Review,9,1732193518,1542515060,225100000X,Physical Therapist,65,In_Network,G43.909,I10|Z87.891,92002,,0,Commercial,HMO,8,F,1.5853,,,206.47,92.58,0.0,78.73,13.85,0.0,113.89,0.0,0.0,0,,0.1291,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001317,MBR00000039,Behavioral_Health,Paid,Electronic_EDI,2023-04-08,2023-04-08,2023-04-08,2023-04-11,Auto_Adjudicated,3,1804302686,1054984734,208600000X,Surgery General,31,In_Network,J06.9,J06.9|OTHER,99213,,0,Medicaid_MCO,MCO,20,F,0.5358,,,174.88,98.12,98.12,0.0,0.0,0.0,76.76,0.0,0.0,0,,0.0639,none,0,1,0,0,0,9e-06,0,0,COA_Care_Transitions,P4P
CLM0000001318,MBR00000022,Medical_Professional,Paid,Electronic_EDI,2023-05-19,2023-05-19,2023-05-19,2023-06-06,Auto_Adjudicated,18,1539066691,1867626800,207R00000X,Internal Medicine,65,In_Network,E11.9,R05.9|OTHER,99231,,0,Medicare_Advantage,MA_HMO,34,M,0.9472,,,87.55,39.98,2.75,20.54,16.0,0.69,47.57,0.0,0.0,0,,0.0691,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001319,MBR00000298,Medical_Institutional,Denied,Electronic_EDI,2023-02-25,2023-02-25,2023-02-28,2023-03-04,Manual_Review,7,1002224900,1365397818,207RE0101X,Endocrinology,11,In_Network,K21.0,Z00.00,revenue_code:0360,,0,Medicaid_MCO,MCO,75,M,0.8324,5,Eligibility,24965.0,20322.34,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1796,geographic_mismatch,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001320,MBR00000188,Medical_Institutional,Paid,Electronic_EDI,2023-01-13,2023-01-13,2023-01-16,2023-01-31,Manual_Review,18,1484613641,1175334579,207V00000X,Obstetrics & Gynecology,11,In_Network,I10,OTHER,revenue_code:0300,,0,Commercial,HMO,8,F,1.5853,,,11312.49,6560.08,5174.17,46.37,46.0,1293.54,4752.41,3631.53,1137.55,0,,0.2015,unbundling_pattern,0,2,1,0,0,0.000479,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000001321,MBR00000078,Medical_Professional,Paid,Provider_Portal,2023-12-01,2023-12-01,2023-12-01,2023-12-05,Auto_Adjudicated,4,1888245409,1447186817,2084P0800X,Psychiatry,22,In_Network,Z00.00,,99203,,0,Commercial,EPO,65,F,1.3174,,,218.21,110.18,0.0,82.29,27.89,0.0,108.03,0.0,0.0,0,,0.116,none,0,1,0,0,0,0.0,0,0,IET_Initiation_Substance_Use,FFS
CLM0000001322,MBR00000140,Medical_Institutional,Denied,Electronic_EDI,2023-11-12,2023-11-12,2023-11-13,2023-11-27,Manual_Review,15,1167433253,1741177636,207RN0300X,Nephrology,22,In_Network,F32.9,OTHER|M17.11|I25.10,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,7,M,1.3997,5,Authorization,5166.92,4185.3,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0561,none,0,1,0,1,0,0.0,0,0,IET_Initiation_Substance_Use,Capitation
CLM0000001323,MBR00000288,Medical_Professional,Denied,Electronic_EDI,2023-04-20,2023-04-20,2023-04-20,2023-04-28,Auto_Adjudicated,8,1526973051,1025886739,207RN0300X,Nephrology,24,Out_of_Network,M54.5,OTHER|Z00.121,99395,,0,Commercial,HMO,36,M,0.8408,5,Medical_Necessity,226.04,112.89,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1244,none,0,1,0,0,0,0.0,1,0,,FFS
CLM0000001324,MBR00000137,Vision,Paid,Electronic_EDI,2023-08-09,2023-08-09,2023-08-09,2023-08-25,Auto_Adjudicated,16,1879212418,1616762819,208600000X,Surgery General,11,In_Network,Z00.01,OTHER|E11.9,V2103,,0,Commercial,PPO,87,M,0.5201,,,360.44,215.67,143.06,11.84,25.0,35.77,144.77,123.44,12.23,0,,0.0513,none,0,1,0,0,0,1.3e-05,0,0,SPC_Statin_Therapy,FFS
CLM0000001325,MBR00000273,Medical_Professional,Paid,Electronic_EDI,2023-02-21,2023-02-21,2023-02-21,2023-02-28,Auto_Adjudicated,7,1403662694,1689327034,207RP1001X,Pulmonary Disease,22,In_Network,OTHER,E11.9,10060,,0,ACA_Marketplace,ACA_Bronze,4,M,1.3569,,,772.44,447.46,267.11,2.27,0.0,178.07,324.98,220.87,34.26,0,,0.1163,none,0,1,0,0,0,2.5e-05,0,0,,FFS
CLM0000001326,MBR00000262,Pharmacy,Paid,Electronic_EDI,2023-11-29,2023-11-29,2023-11-29,2023-12-07,Auto_Adjudicated,8,1216417633,1140170394,207Q00000X,Family Medicine,11,In_Network,I10,M17.11,00006001954,,2,Medicare_Advantage,PFFS,77,F,1.7452,,,145.15,111.65,85.26,1.07,4.0,21.32,33.5,0.0,0.0,0,,0.1068,none,0,1,0,1,0,8e-06,0,1,,Bundled_Payment
CLM0000001327,MBR00000108,Dental,Paid,Electronic_EDI,2023-10-19,2023-10-19,2023-10-19,2023-11-16,Auto_Adjudicated,28,1580443769,1622950074,207RC0000X,Cardiovascular Disease,22,In_Network,Z79.4,,D1110,,0,Medicaid_MCO,MCO,25,F,0.2795,,,174.38,103.3,103.3,0.0,0.0,0.0,71.08,0.0,0.0,0,,0.0263,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000001328,MBR00000207,Pharmacy,Paid,Electronic_EDI,2023-03-05,2023-03-05,2023-03-05,2023-04-04,Auto_Adjudicated,30,1113370285,1274911960,2084P0800X,Psychiatry,11,In_Network,E11.65,L70.0,00310075090,,2,Medicaid_MCO,MLTSS,11,F,1.6522,,,143.78,75.64,75.64,0.0,0.0,0.0,68.14,0.0,0.0,0,,0.291,geographic_mismatch|benford_violation|high_oop_waiver,0,2,0,0,0,7e-06,0,1,POD_Persistence_of_Beta_Blocker,FFS
CLM0000001329,MBR00000196,Medical_Professional,Paid,Provider_Portal,2023-03-18,2023-03-18,2023-03-18,2023-03-28,Auto_Adjudicated,10,1075661656,1447186817,207R00000X,Internal Medicine,65,In_Network,OTHER,E78.5,71250,,0,Commercial,PPO,16,F,1.6015,,,377.74,155.7,33.42,90.92,23.0,8.36,222.04,0.0,0.0,0,,0.2015,provider_specialty_mismatch,0,2,0,0,0,3e-06,0,0,SPC_Statin_Therapy,FFS
CLM0000001330,MBR00000227,Medical_Professional,Paid,Electronic_EDI,2023-04-30,2023-04-30,2023-04-30,2023-05-20,Clinical_Review,20,1175252466,1447657873,207Q00000X,Family Medicine,11,In_Network,E78.5,Z23|I10,99213,,0,Medicare_Advantage,MA_PPO,2,F,0.7835,,,258.07,159.93,116.52,0.28,14.0,29.13,98.14,0.0,0.0,0,,0.1143,high_oop_waiver,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000001331,MBR00000115,Behavioral_Health,Paid,Electronic_EDI,2023-02-03,2023-02-03,2023-02-03,2023-02-14,Manual_Review,11,1705084901,1140170394,207RG0100X,Gastroenterology,22,In_Network,E11.9,OTHER,90837,,0,Commercial,PPO,15,F,0.7398,,,308.27,210.49,0.0,210.49,0.0,0.0,97.78,0.0,0.0,0,,0.1069,none,0,1,0,0,0,0.0,0,0,KED_ESRD_Patients,Shared_Savings
CLM0000001332,MBR00000014,Medical_Professional,Paid,Electronic_EDI,2023-05-05,2023-05-05,2023-05-05,2023-05-11,Auto_Adjudicated,6,1638309014,1650774392,207Q00000X,Family Medicine,11,Emergency,Z79.4,J45.20,99205,,0,Commercial,HMO,77,M,2.8513,,,219.42,105.16,0.0,105.16,0.0,0.0,114.26,0.0,0.0,0,,0.1174,temporal_clustering,0,1,0,0,0,0.0,0,0,COA_Care_Transitions,Bundled_Payment
CLM0000001333,MBR00000054,Medical_Professional,Paid,Electronic_EDI,2023-08-28,2023-08-28,2023-08-28,2023-08-31,Auto_Adjudicated,3,1966338974,1330485436,207RE0101X,Endocrinology,11,In_Network,E11.65,Z00.00,90837,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,,,2170.07,1480.22,1181.43,2.43,1.0,295.36,689.85,0.0,0.0,0,,0.1036,none,0,1,0,1,0,0.000109,0,0,,Shared_Savings
CLM0000001334,MBR00000184,Behavioral_Health,Paid,Electronic_EDI,2023-09-18,2023-09-18,2023-09-18,2023-10-15,Auto_Adjudicated,27,1478783612,1447186817,207RG0100X,Gastroenterology,22,In_Network,OTHER,Z00.00|OTHER,99386,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,169.43,98.44,96.44,0.0,2.0,0.0,70.99,0.0,0.0,0,,0.08,none,0,1,0,1,0,9e-06,0,0,FLU_Flu_Vaccination,Capitation
CLM0000001335,MBR00000228,Pharmacy,Paid,Electronic_EDI,2023-01-03,2023-01-03,2023-01-03,2023-01-05,Auto_Adjudicated,2,1519595029,1287472731,207RE0101X,Endocrinology,11,In_Network,I10,Z12.11|N18.3,00071015523,,2,Commercial,PPO,55,F,0.7203,,,47.39,17.62,0.0,17.62,0.0,0.0,29.77,0.0,0.0,0,,0.0562,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000001336,MBR00000221,Pharmacy,Paid,Electronic_EDI,2023-05-07,2023-05-07,2023-05-07,2023-05-22,Manual_Review,15,1220710861,1027261156,207RE0101X,Endocrinology,22,In_Network,M54.5,OTHER|Z00.00,00071012831,,2,Commercial,HDHP_HSA,28,M,1.6683,,,156.18,58.1,0.0,58.1,0.0,0.0,98.08,0.0,0.0,0,,0.1383,service_date_weekend|unbundling_pattern,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001337,MBR00000176,Medical_Professional,Paid,Electronic_EDI,2023-10-26,2023-10-26,2023-10-26,2023-11-02,Auto_Adjudicated,7,1222934819,1368666316,207RN0300X,Nephrology,11,In_Network,Z00.00,Z79.4,20610,,0,Commercial,POS,4,M,0.8792,,,439.3,166.8,0.0,166.8,0.0,0.0,272.5,0.0,0.0,0,,0.0684,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,POD_Persistence_of_Beta_Blocker,Bundled_Payment
CLM0000001338,MBR00000026,Medical_Institutional,Paid,Electronic_EDI,2023-11-09,2023-11-09,2023-11-09,2023-12-02,Clinical_Review,23,1039678579,1764064254,207Q00000X,Family Medicine,23,In_Network,F10.10,OTHER,revenue_code:0100,,0,Medicaid_MCO,MCO,17,M,1.0686,,,269335.8,150195.19,150188.19,0.0,7.0,0.0,119140.61,0.0,0.0,0,,0.1996,outlier_billing_amount,0,1,1,1,0,0.013901,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000001339,MBR00000006,Pharmacy,Paid,Electronic_EDI,2023-07-22,2023-07-22,2023-07-22,2023-07-27,Auto_Adjudicated,5,1897231867,1860951128,207RN0300X,Nephrology,32,In_Network,M54.5,I10,00169751112,,4,Commercial,EPO,88,M,1.4365,,,128.66,97.78,24.37,34.32,33.0,6.09,30.88,0.0,0.0,0,,0.0968,none,0,1,0,0,0,2e-06,0,1,POD_Persistence_of_Beta_Blocker,FFS
CLM0000001340,MBR00000231,Medical_Professional,Paid,Electronic_EDI,2023-09-21,2023-09-21,2023-09-21,2023-10-09,Auto_Adjudicated,18,1673449362,1564691686,207V00000X,Obstetrics & Gynecology,24,In_Network,E11.9,,97140,,0,ACA_Marketplace,ACA_Silver,12,M,0.6456,,,229.67,117.39,0.0,117.39,0.0,0.0,112.28,0.0,0.0,0,,0.081,none,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000001341,MBR00000166,Medical_Professional,Paid,Electronic_EDI,2023-03-30,2023-03-30,2023-03-30,2023-04-10,Auto_Adjudicated,11,1513278494,1704466150,207R00000X,Internal Medicine,11,In_Network,N18.3,G47.33,81001,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,669.01,444.52,0.0,444.52,0.0,0.0,224.49,0.0,0.0,0,,0.0458,none,0,1,0,0,0,0.0,0,0,W30_Well_Child_Visit,Capitation
CLM0000001342,MBR00000232,Medical_Professional,Paid,Provider_Portal,2023-11-08,2023-11-08,2023-11-08,2023-11-24,Clinical_Review,16,1506426842,1187669363,207RP1001X,Pulmonary Disease,22,In_Network,E78.5,OTHER,99285,,0,Medicaid_MCO,MCO,40,M,1.1083,,,258.06,199.33,197.33,0.0,2.0,0.0,58.73,0.0,0.0,0,,0.0962,none,0,1,0,0,0,1.8e-05,0,0,AMR_Asthma_Medication_Ratio,Capitation
CLM0000001343,MBR00000052,Medical_Institutional,Paid,Electronic_EDI,2023-06-20,2023-06-20,2023-06-23,2023-06-26,Auto_Adjudicated,6,1826919173,1560230600,208600000X,Surgery General,11,In_Network,Z00.00,Z00.00|Z12.11,revenue_code:0210,,0,Commercial,PPO,0,F,1.325,,,4203.07,2647.67,1973.79,104.43,76.0,493.45,1555.4,0.0,0.0,0,,0.1142,diagnosis_procedure_mismatch,0,1,0,0,0,0.000183,0,0,CBP_Controlling_BP,FFS
CLM0000001344,MBR00000130,Medical_Professional,Paid,Electronic_EDI,2023-09-06,2023-09-06,2023-09-06,2023-09-10,Clinical_Review,4,1887322427,1164525386,207RN0300X,Nephrology,21,In_Network,E11.9,E11.9,99384,,0,Medicare_Advantage,MA_PPO,58,M,1.3394,,,335.15,272.07,199.59,18.58,4.0,49.9,63.08,0.0,0.0,0,,0.016,none,0,1,0,0,0,1.8e-05,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000001345,MBR00000277,Dental,Paid,Electronic_EDI,2023-04-05,2023-04-05,2023-04-05,2023-04-11,Auto_Adjudicated,6,1376791933,1029818813,207V00000X,Obstetrics & Gynecology,31,In_Network,OTHER,,D2140,,0,Medicaid_MCO,MCO,30,M,1.8495,,,491.58,247.33,244.33,0.0,3.0,0.0,244.25,0.0,0.0,0,,0.0694,none,0,1,0,0,0,2.3e-05,0,0,,FFS
CLM0000001346,MBR00000054,Medical_Professional,Paid,Provider_Portal,2023-03-04,2023-03-04,2023-03-04,2023-03-22,Manual_Review,18,1526973051,1358873132,207Q00000X,Family Medicine,11,In_Network,J44.1,Z00.00,99382,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,,,291.59,176.25,137.0,4.0,1.0,34.25,115.34,0.0,0.0,0,,0.0877,none,0,1,0,1,0,1.3e-05,0,0,SPC_Statin_Therapy,Capitation
CLM0000001347,MBR00000018,Medical_Professional,Paid,Electronic_EDI,2023-07-11,2023-07-11,2023-07-11,2023-07-31,Auto_Adjudicated,20,1886537420,1415734567,207RP1001X,Pulmonary Disease,11,In_Network,F32.9,Z00.01,99223,,0,Commercial,EPO,5,F,0.5555,,,245.03,152.53,110.57,0.32,14.0,27.64,92.5,0.0,0.0,0,,0.1374,npi_mismatch|high_oop_waiver,0,1,0,0,0,1e-05,0,0,MPT_Annual_Monitoring,Capitation
CLM0000001348,MBR00000194,Vision,Paid,Electronic_EDI,2023-07-07,2023-07-07,2023-07-07,2023-08-04,Auto_Adjudicated,28,1532359759,1408846353,208600000X,Surgery General,31,In_Network,F41.1,J06.9|I25.10,92002,,0,Commercial,PPO,77,M,0.9783,,,232.91,101.91,0.0,101.91,0.0,0.0,131.0,0.0,0.0,0,,0.0349,none,0,1,0,1,0,0.0,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000001349,MBR00000179,Vision,Paid,Paper,2023-07-25,2023-07-25,2023-07-25,2023-08-23,Auto_Adjudicated,29,1741980770,1179350099,207Q00000X,Family Medicine,21,In_Network,OTHER,OTHER|G47.33,V2320,,0,Medicare_Advantage,SNP,82,F,0.5266,,,205.02,122.96,78.94,7.29,17.0,19.73,82.06,0.0,0.0,0,,0.1376,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000001350,MBR00000289,Pharmacy,Paid,Electronic_EDI,2023-10-18,2023-10-18,2023-10-18,2023-11-10,Clinical_Review,23,1683650935,1402472115,207RN0300X,Nephrology,11,In_Network,Z00.00,,00006001954,,1,Commercial,POS,51,M,1.0534,,,64.58,43.67,0.0,43.67,0.0,0.0,20.91,0.0,0.0,0,,0.0508,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001351,MBR00000274,Vision,Paid,Electronic_EDI,2023-10-05,2023-10-05,2023-10-05,2023-10-06,Manual_Review,1,1451329728,1945682535,208600000X,Surgery General,71,In_Network,I10,OTHER,92012,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,588.33,235.22,162.24,32.41,0.0,40.56,353.11,0.0,0.0,0,,0.0999,none,0,1,0,0,0,1.5e-05,0,0,,Capitation
CLM0000001352,MBR00000220,Medical_Professional,Denied,Electronic_EDI,2023-04-19,2023-04-19,2023-04-19,2023-05-11,Clinical_Review,22,1267286378,1175334579,207R00000X,Internal Medicine,11,In_Network,OTHER,Z00.00,99202,,0,Commercial,HMO,38,M,0.7736,18,Network,947.27,635.47,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1194,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001353,MBR00000006,Medical_Institutional,Paid,Electronic_EDI,2023-06-17,2023-06-17,2023-06-21,2023-07-09,Auto_Adjudicated,22,1956107350,1607833568,2084P0800X,Psychiatry,24,In_Network,N39.0,Z23|OTHER,revenue_code:0450,,0,Commercial,EPO,88,M,1.4365,,,4761.94,2917.37,2272.85,15.31,61.0,568.21,1844.57,0.0,0.0,0,,0.0783,none,0,1,0,0,0,0.00021,0,0,,FFS
CLM0000001354,MBR00000148,Medical_Professional,Partially_Paid,Electronic_EDI,2023-01-31,2023-01-31,2023-01-31,2023-02-22,Auto_Adjudicated,22,1055717021,1560230600,207RN0300X,Nephrology,11,In_Network,OTHER,OTHER|F32.9,99283,,0,Commercial,EPO,51,F,0.6534,16,Medical_Necessity,207.16,110.95,0.0,74.51,0.0,0.0,132.65,0.0,0.0,0,,0.162,temporal_clustering|billing_spike_recent,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001355,MBR00000272,Medical_Institutional,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-13,2023-10-30,Auto_Adjudicated,20,1199465234,1685903362,208600000X,Surgery General,81,In_Network,E13.9,Z87.891,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,15,M,0.8525,,,4533.18,2451.08,1922.49,26.97,21.0,480.62,2082.1,0.0,0.0,0,,0.2343,benford_violation|service_date_weekend,0,2,0,0,0,0.000178,0,0,,FFS
CLM0000001356,MBR00000136,Pharmacy,Paid,Electronic_EDI,2023-02-18,2023-02-18,2023-02-18,2023-03-11,Auto_Adjudicated,21,1269185915,1985590322,2084P0800X,Psychiatry,24,In_Network,G43.909,OTHER|F33.0,00006001954,,1,Commercial,POS,2,F,1.2611,,,367.04,285.53,79.04,176.72,10.0,19.76,81.51,0.0,0.0,0,,0.1106,none,0,1,0,0,0,7e-06,0,0,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000001357,MBR00000292,Pharmacy,Paid,Electronic_EDI,2023-01-25,2023-01-25,2023-01-25,2023-02-12,Clinical_Review,18,1832660692,1300957944,207Q00000X,Family Medicine,11,In_Network,I25.10,,00078043215,,3,Medicare_Advantage,MA_HMO,4,M,1.1779,,,79.91,66.46,40.01,13.45,3.0,10.0,13.45,0.0,0.0,0,,0.0287,none,0,1,0,1,0,4e-06,0,0,,FFS
CLM0000001358,MBR00000194,Medical_Professional,Paid,Provider_Portal,2023-07-06,2023-07-06,2023-07-06,2023-07-25,Auto_Adjudicated,19,1735391772,1391074619,207Q00000X,Family Medicine,81,In_Network,Z00.00,OTHER|C50.911|Z00.01,90834,,0,Commercial,PPO,77,M,0.9783,,,1059.84,558.36,408.41,29.85,18.0,102.1,501.48,0.0,0.0,0,,0.1106,none,0,1,0,0,0,3.8e-05,0,0,AWV_Annual_Wellness_Visit,FFS
CLM0000001359,MBR00000034,Medical_Professional,Paid,Electronic_EDI,2023-11-27,2023-11-27,2023-11-27,2023-12-18,Manual_Review,21,1145498455,1432077493,207RN0300X,Nephrology,11,In_Network,OTHER,OTHER|E11.9,90837,,0,Medicare_Advantage,MA_HMO,35,M,0.7712,,,877.0,508.08,381.2,24.58,7.0,95.3,368.92,0.0,0.0,0,,0.1646,npi_mismatch,0,1,0,0,0,3.5e-05,0,0,,Bundled_Payment
CLM0000001360,MBR00000156,Behavioral_Health,Paid,Electronic_EDI,2023-05-16,2023-05-16,2023-05-16,2023-05-18,Auto_Adjudicated,2,1064567615,1577226132,207RN0300X,Nephrology,31,In_Network,N39.0,,99395,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,203.78,120.45,66.27,24.61,13.0,16.57,83.33,0.0,0.0,0,,0.1259,duplicate_claim_indicator,0,1,0,0,0,6e-06,0,0,FLU_Flu_Vaccination,Bundled_Payment
CLM0000001361,MBR00000207,Medical_Institutional,Paid,Electronic_EDI,2023-03-08,2023-03-08,2023-03-12,2023-03-24,Auto_Adjudicated,16,1905691248,1827839595,207RP1001X,Pulmonary Disease,23,In_Network,Z00.00,OTHER|Z00.00,revenue_code:0370,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,40804.77,27616.29,27610.29,0.0,6.0,0.0,13188.48,0.0,0.0,0,,0.1677,high_oop_waiver,0,1,1,0,0,0.002556,0,0,,Shared_Savings
CLM0000001362,MBR00000020,Medical_Professional,Paid,Electronic_EDI,2023-03-08,2023-03-08,2023-03-08,2023-03-12,Clinical_Review,4,1618546650,1741177636,2086S0122X,Orthopedic Surgery,11,Out_of_Network,E11.9,OTHER,74177,,0,Medicare_Advantage,MA_PPO,63,F,0.7119,,,508.83,239.36,174.93,14.7,6.0,43.73,269.47,0.0,0.0,0,,0.1541,unusual_service_frequency,0,1,0,0,0,1.6e-05,1,0,IET_Initiation_Substance_Use,Shared_Savings
CLM0000001363,MBR00000108,Medical_Professional,Paid,Electronic_EDI,2023-10-28,2023-10-28,2023-10-28,2023-11-25,Auto_Adjudicated,28,1995916350,1765164601,207R00000X,Internal Medicine,22,In_Network,J06.9,OTHER|E78.5|Z00.00,99386,,0,Medicaid_MCO,MCO,25,F,0.2795,,,280.32,148.09,148.09,0.0,0.0,0.0,132.23,0.0,0.0,0,,0.0382,none,0,1,0,1,0,1.4e-05,0,0,,P4P
CLM0000001364,MBR00000212,Medical_Professional,Paid,Electronic_EDI,2023-08-26,2023-08-26,2023-08-26,2023-09-25,Auto_Adjudicated,30,1327415110,1616762819,207RP1001X,Pulmonary Disease,11,In_Network,E78.5,OTHER,33510,,0,Commercial,HMO,57,F,2.5456,,,277.34,116.42,0.0,116.42,0.0,0.0,160.92,0.0,0.0,0,,0.1683,impossible_service_combo,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001365,MBR00000050,Medical_Institutional,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-28,2023-07-02,Auto_Adjudicated,5,1419204214,1148659045,101YP2500X,Psychologist Clinical,22,In_Network,Z00.00,N18.3,revenue_code:0200,,0,Medicare_Advantage,MA_PPO,12,F,0.8486,,,1333.35,472.07,347.76,4.37,33.0,86.94,861.28,0.0,0.0,0,,0.1179,none,0,1,0,1,0,3.2e-05,0,0,DAE_Drug_Alcohol_Dependence,Shared_Savings
CLM0000001366,MBR00000110,Medical_Institutional,Paid,Electronic_EDI,2023-11-29,2023-11-29,2023-12-03,2023-12-26,Auto_Adjudicated,27,1564110057,1469881892,246ZN0300X,Neuropsychology,22,In_Network,E78.5,N39.0,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,83,F,1.127,,,31154.87,13820.27,11011.85,2.46,53.0,2752.96,17334.6,0.0,0.0,0,,0.0382,none,0,1,1,0,0,0.001019,0,0,,Bundled_Payment
CLM0000001367,MBR00000206,Medical_Institutional,Paid,Electronic_EDI,2023-02-07,2023-02-07,2023-02-11,2023-02-22,Auto_Adjudicated,15,1253087808,1746676564,101YP2500X,Psychologist Clinical,21,In_Network,OTHER,,revenue_code:0370,291,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,6878.7,2562.65,2557.65,0.0,5.0,0.0,4316.05,0.0,0.0,0,,0.0476,none,0,1,0,0,0,0.000237,0,0,,Bundled_Payment
CLM0000001368,MBR00000229,Medical_Institutional,Paid,Electronic_EDI,2023-08-10,2023-08-10,2023-08-14,2023-08-31,Auto_Adjudicated,21,1231954359,1666461892,2086S0122X,Orthopedic Surgery,31,In_Network,J44.1,OTHER|Z00.00,revenue_code:0450,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,33978.2,16009.23,12749.84,17.93,54.0,3187.46,17968.97,0.0,0.0,0,,0.1072,none,0,1,1,0,0,0.00118,0,0,,FFS
CLM0000001369,MBR00000159,Medical_Institutional,Paid,Electronic_EDI,2023-05-10,2023-05-10,2023-05-14,2023-05-30,Auto_Adjudicated,20,1519736600,1564636990,2084P0800X,Psychiatry,65,Out_of_Network,M54.5,M17.11|H52.4,revenue_code:0100,,0,Commercial,PPO,70,F,1.2009,,,8739.28,4633.01,3646.36,4.05,71.0,911.59,4106.27,0.0,0.0,0,,0.0782,none,0,1,0,0,0,0.000338,0,0,SPD_Spirometry_Testing,Bundled_Payment
CLM0000001370,MBR00000290,Medical_Professional,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-25,2023-03-29,Auto_Adjudicated,4,1374847145,1450837722,207Q00000X,Family Medicine,22,In_Network,Z00.01,Z00.01,99205,,0,Commercial,PPO,9,M,0.5261,,,265.17,101.3,0.0,101.3,0.0,0.0,163.87,0.0,0.0,0,,0.0305,none,0,1,0,1,0,0.0,0,0,CDC_BP_Control,FFS
CLM0000001371,MBR00000279,Medical_Professional,Denied,Electronic_EDI,2023-11-26,2023-11-26,2023-11-26,2023-12-24,Auto_Adjudicated,28,1898865801,1774401124,207RG0100X,Gastroenterology,23,In_Network,M25.511,Z00.00|F33.0|J06.9,10060,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,22,Timely_Filing,750.85,623.31,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1315,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000001372,MBR00000144,Medical_Professional,Paid,Electronic_EDI,2023-12-10,2023-12-10,2023-12-10,2023-12-30,Auto_Adjudicated,20,1007414142,1985590322,208600000X,Surgery General,11,In_Network,F10.10,F41.1|F33.0|Z12.11,99386,,0,Commercial,HDHP_HSA,56,F,2.5926,,,213.81,89.25,0.0,89.25,0.0,0.0,124.56,0.0,0.0,0,,0.1314,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001373,MBR00000051,Dental,Denied,Electronic_EDI,2023-10-27,2023-10-27,2023-10-27,2023-11-11,Auto_Adjudicated,15,1874914200,1179350099,207RP1001X,Pulmonary Disease,81,In_Network,Z00.00,E11.9|I10,D0120,,0,Medicare_Advantage,MA_PPO,17,F,1.0695,CO-45,Network,132.79,103.33,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0348,none,0,1,0,0,0,0.0,0,0,CDC_BP_Control,Bundled_Payment
CLM0000001374,MBR00000228,Pharmacy,Partially_Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-23,2023-03-14,Auto_Adjudicated,19,1518661623,1040061910,207RN0300X,Nephrology,31,In_Network,OTHER,,00169751112,,2,Commercial,PPO,55,F,0.7203,1,Medical_Necessity,89.65,63.4,0.0,37.54,0.0,0.0,52.11,0.0,0.0,0,,0.1476,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001375,MBR00000076,Medical_Professional,Paid,Paper,2023-09-17,2023-09-17,2023-09-17,2023-10-17,Auto_Adjudicated,30,1326896487,1296566243,207RC0000X,Cardiovascular Disease,71,In_Network,E78.5,N40.0|I10,12001,,0,Commercial,HMO,26,M,2.1785,,,334.27,245.54,145.62,31.52,32.0,36.4,88.73,0.0,0.0,0,,0.1522,diagnosis_procedure_mismatch,0,1,0,0,0,1.3e-05,0,0,SPC_Statin_Therapy,FFS
CLM0000001376,MBR00000252,Medical_Institutional,Denied,Electronic_EDI,2023-05-09,2023-05-09,2023-05-10,2023-05-29,Auto_Adjudicated,20,1636337876,1061149198,207RG0100X,Gastroenterology,24,In_Network,E78.5,OTHER,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,80,M,0.7173,16,Duplicate,11643.26,5368.24,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.061,none,0,1,0,0,0,0.0,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000001377,MBR00000177,Medical_Institutional,Paid,Electronic_EDI,2023-05-17,2023-05-17,2023-05-17,2023-06-06,Auto_Adjudicated,20,1501282310,1114756459,2084P0800X,Psychiatry,21,In_Network,M54.5,Z00.00,revenue_code:0450,470,0,Commercial,HMO,42,F,1.2774,,,32792.64,26874.2,21286.42,189.18,77.0,5321.6,5918.44,0.0,0.0,0,,0.0239,none,0,1,1,0,0,0.00197,0,0,,FFS
CLM0000001378,MBR00000125,Medical_Institutional,Paid,Electronic_EDI,2023-03-11,2023-03-11,2023-03-14,2023-04-07,Auto_Adjudicated,27,1568777164,1581533104,2086S0122X,Orthopedic Surgery,11,In_Network,OTHER,M54.5|OTHER|Z00.01,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,6245.39,2904.67,2280.46,9.1,45.0,570.11,3340.72,0.0,0.0,0,,0.143,none,0,1,0,0,0,0.000211,0,0,,P4P
CLM0000001379,MBR00000168,Pharmacy,Paid,Electronic_EDI,2023-07-31,2023-07-31,2023-07-31,2023-08-21,Auto_Adjudicated,21,1454749898,1951488764,101YP2500X,Psychologist Clinical,22,In_Network,OTHER,,00310075090,,2,Commercial,HMO,76,M,1.2791,,,166.22,60.0,0.0,60.0,0.0,0.0,106.22,0.0,0.0,0,,0.0777,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000001380,MBR00000162,Behavioral_Health,Paid,Electronic_EDI,2023-11-04,2023-11-04,2023-11-04,2023-11-09,Clinical_Review,5,1403662694,1419347445,207RN0300X,Nephrology,11,In_Network,Z79.4,,99221,,0,Medicaid_MCO,MLTSS,84,F,1.324,,,247.9,105.88,104.88,0.0,1.0,0.0,142.02,0.0,0.0,0,,0.123,none,0,1,0,1,0,1e-05,0,0,,FFS
CLM0000001381,MBR00000279,Medical_Professional,Denied,Electronic_EDI,2023-03-25,2023-03-25,2023-03-25,2023-04-19,Clinical_Review,25,1002224900,1354959095,207R00000X,Internal Medicine,22,In_Network,F41.1,J44.1|E78.5,99214,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,97,COB,188.24,98.86,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0681,none,0,1,0,0,0,0.0,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000001382,MBR00000065,Medical_Institutional,Paid,Electronic_EDI,2023-07-12,2023-07-12,2023-07-15,2023-08-08,Auto_Adjudicated,27,1330688043,1510751265,207RG0100X,Gastroenterology,21,In_Network,M54.5,,revenue_code:0110,470,0,Commercial,HDHP_HSA,63,M,0.7795,,,16974.57,6624.6,4948.35,439.17,0.0,1237.09,10349.97,0.0,0.0,0,,0.0644,diagnosis_procedure_mismatch,0,1,0,0,0,0.000458,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000001383,MBR00000279,Medical_Institutional,Paid,Electronic_EDI,2023-08-21,2023-08-21,2023-08-24,2023-09-13,Auto_Adjudicated,23,1501282310,1540743888,207V00000X,Obstetrics & Gynecology,23,In_Network,J06.9,,revenue_code:0100,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,,,32308.85,24419.52,19506.16,6.83,30.0,4876.54,7889.33,0.0,0.0,0,,0.1134,none,0,1,1,0,0,0.001805,0,0,COA_Care_Transitions,Shared_Savings
CLM0000001384,MBR00000010,Medical_Institutional,Paid,Provider_Portal,2023-08-15,2023-08-15,2023-08-18,2023-08-20,Manual_Review,5,1462532026,1898471307,2084P0800X,Psychiatry,23,In_Network,M54.5,OTHER,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,44,F,1.4631,,,17100.34,10777.91,8568.45,27.34,40.0,2142.11,6322.43,0.0,0.0,0,,0.0235,none,0,1,1,0,0,0.000793,0,0,,Bundled_Payment
CLM0000001385,MBR00000226,Medical_Professional,Paid,Paper,2023-04-04,2023-04-04,2023-04-04,2023-04-20,Auto_Adjudicated,16,1490172833,1469697158,207V00000X,Obstetrics & Gynecology,11,In_Network,OTHER,E11.9|Z00.00,81001,,0,Medicare_Advantage,MA_PPO,84,M,1.0796,,,627.54,510.4,400.13,0.23,10.0,100.03,117.14,0.0,0.0,0,,0.0385,none,0,1,0,0,0,3.7e-05,0,0,,FFS
CLM0000001386,MBR00000277,Medical_Institutional,Paid,Electronic_EDI,2023-01-11,2023-01-11,2023-01-11,2023-01-13,Manual_Review,2,1874109311,1388050552,225100000X,Physical Therapist,24,In_Network,K57.30,N18.3,revenue_code:0100,,0,Medicaid_MCO,MCO,30,M,1.8495,,,5629.64,3623.96,3621.96,0.0,2.0,0.0,2005.68,0.0,0.0,0,,0.1469,none,0,1,0,1,0,0.000335,0,0,,FFS
CLM0000001387,MBR00000125,Medical_Professional,Paid,Electronic_EDI,2023-10-25,2023-10-25,2023-10-25,2023-11-18,Auto_Adjudicated,24,1520692162,1196833348,207RC0000X,Cardiovascular Disease,11,In_Network,Z23,Z12.11,99202,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,263.87,100.74,68.71,3.85,11.0,17.18,163.13,0.0,0.0,0,,0.1362,none,0,1,0,0,0,6e-06,0,0,HBD_Hemoglobin_A1c_Testing,Capitation
CLM0000001388,MBR00000023,Pharmacy,Paid,Electronic_EDI,2023-08-03,2023-08-03,2023-08-03,2023-09-01,Clinical_Review,29,1170319307,1105871325,207RN0300X,Nephrology,11,In_Network,OTHER,OTHER|Z00.01|F41.1,00071012831,,1,Medicare_Advantage,MA_PPO,87,M,1.084,,,98.56,60.93,20.11,20.79,15.0,5.03,37.63,0.0,0.0,0,,0.1069,geographic_mismatch,0,1,0,0,0,2e-06,0,0,,FFS
CLM0000001389,MBR00000238,Pharmacy,Paid,Electronic_EDI,2023-09-10,2023-09-10,2023-09-10,2023-09-12,Auto_Adjudicated,2,1402833352,1300957944,207V00000X,Obstetrics & Gynecology,21,In_Network,I10,Z00.01|Z00.00,50458085930,,1,Commercial,PPO,74,F,0.4382,,,112.58,43.83,0.0,43.83,0.0,0.0,68.75,0.0,0.0,0,,0.008,none,0,1,0,0,0,0.0,0,1,,Capitation
CLM0000001390,MBR00000252,Medical_Professional,Paid,Electronic_EDI,2023-07-10,2023-07-10,2023-07-10,2023-07-14,Auto_Adjudicated,4,1414670047,1297948643,246ZN0300X,Neuropsychology,11,In_Network,Z00.00,E11.9,99395,,0,Medicare_Advantage,MA_HMO,80,M,0.7173,,,263.42,215.85,132.9,34.72,15.0,33.23,47.57,0.0,0.0,0,,0.02,none,0,1,0,0,0,1.2e-05,0,0,,Capitation
CLM0000001391,MBR00000106,Behavioral_Health,Paid,Electronic_EDI,2023-05-19,2023-05-19,2023-05-19,2023-06-16,Auto_Adjudicated,28,1830816512,1140170394,225100000X,Physical Therapist,21,In_Network,J06.9,F41.1,99284,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,198.25,134.47,93.68,11.37,6.0,23.42,63.78,0.0,0.0,0,,0.0919,benford_violation,0,1,0,1,0,9e-06,0,0,,FFS
CLM0000001392,MBR00000159,Pharmacy,Paid,Electronic_EDI,2023-04-01,2023-04-01,2023-04-01,2023-04-25,Manual_Review,24,1901508637,1179350099,207RC0000X,Cardiovascular Disease,11,Emergency,OTHER,K21.0|OTHER,00006001954,,4,Commercial,PPO,70,F,1.2009,,,411.35,215.53,133.09,35.17,14.0,33.27,195.82,0.0,0.0,0,,0.1823,high_oop_waiver,0,1,0,0,0,1.2e-05,0,0,,Shared_Savings
CLM0000001393,MBR00000240,Medical_Institutional,Paid,Electronic_EDI,2023-08-25,2023-08-25,2023-08-28,2023-09-19,Auto_Adjudicated,25,1549436467,1788579687,207R00000X,Internal Medicine,11,Out_of_Network,Z00.00,,revenue_code:0360,,0,Medicaid_MCO,MCO,9,F,0.386,,,7069.3,4627.47,4621.47,0.0,6.0,0.0,2441.83,0.0,0.0,0,,0.196,geographic_mismatch,0,1,0,0,0,0.000428,0,0,,FFS
CLM0000001394,MBR00000060,Behavioral_Health,Paid,Electronic_EDI,2023-10-26,2023-10-26,2023-10-26,2023-11-02,Auto_Adjudicated,7,1878057972,1061113875,207Q00000X,Family Medicine,11,Out_of_Network,Z00.01,N39.0|E78.5|I10,90847,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,267.19,193.97,0.0,193.97,0.0,0.0,73.22,0.0,0.0,0,,0.0822,none,0,1,0,0,0,0.0,1,0,,Shared_Savings
CLM0000001395,MBR00000187,Pharmacy,Paid,Electronic_EDI,2023-04-27,2023-04-27,2023-04-27,2023-05-17,Auto_Adjudicated,20,1002224900,1228356980,207RC0000X,Cardiovascular Disease,22,In_Network,J06.9,,00003014960,,4,Medicaid_MCO,MCO,36,F,1.191,,,124.13,101.77,98.77,0.0,3.0,0.0,22.36,0.0,0.0,0,,0.0893,none,0,1,0,1,0,9e-06,0,0,,P4P
CLM0000001396,MBR00000135,Medical_Professional,Paid,Electronic_EDI,2023-01-09,2023-01-09,2023-01-09,2023-02-03,Clinical_Review,25,1898658234,1575884274,2084P0800X,Psychiatry,31,In_Network,OTHER,E11.65|I50.9,97010,,0,Commercial,PPO,58,F,2.2702,,,343.53,227.85,152.51,0.21,37.0,38.13,115.68,0.0,0.0,0,,0.0196,none,0,1,0,0,0,1.4e-05,0,0,,Bundled_Payment
CLM0000001397,MBR00000055,Medical_Institutional,Paid,Electronic_EDI,2023-02-25,2023-02-25,2023-02-27,2023-02-28,Clinical_Review,3,1213747973,1473869105,207RE0101X,Endocrinology,11,In_Network,J06.9,E11.9|Z79.4|OTHER,revenue_code:0360,,0,Commercial,PPO,68,F,1.2896,,,20715.43,14240.53,11232.34,126.11,74.0,2808.08,6474.9,0.0,0.0,0,,0.017,none,0,1,1,1,0,0.00104,0,0,,Capitation
CLM0000001398,MBR00000249,Medical_Institutional,Paid,Electronic_EDI,2023-07-27,2023-07-27,2023-07-27,2023-08-05,Auto_Adjudicated,9,1976304517,1688513262,246ZN0300X,Neuropsychology,21,In_Network,K57.30,,revenue_code:0120,871,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,17494.98,9631.94,6365.43,450.47,88.0,2728.04,7863.04,0.0,0.0,0,,0.015,none,0,1,1,0,0,0.000589,0,0,,Bundled_Payment
CLM0000001399,MBR00000102,Pharmacy,Denied,Electronic_EDI,2023-03-26,2023-03-26,2023-03-26,2023-04-04,Auto_Adjudicated,9,1464997678,1132693989,207RN0300X,Nephrology,11,In_Network,OTHER,,00310075090,,3,Commercial,POS,68,M,1.6864,18,Network,111.37,51.5,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0886,high_volume_same_code,0,1,0,0,0,0.0,0,0,COL_Colorectal_Cancer_Screening,Capitation
CLM0000001400,MBR00000282,Vision,Denied,Electronic_EDI,2023-10-20,2023-10-20,2023-10-20,2023-11-06,Manual_Review,17,1419204214,1209882852,2084P0800X,Psychiatry,11,In_Network,I50.9,,92014,,0,Medicare_Advantage,MA_HMO,16,M,0.7304,PR-1,Coding_Error,97.09,51.08,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Medically Unnecessary Services,0.9974,outlier_billing_amount|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|impossible_service_combo|service_date_weekend|billing_spike_recent|unbundling_pattern|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001401,MBR00000170,Medical_Institutional,Paid,Electronic_EDI,2023-04-08,2023-04-08,2023-04-12,2023-04-16,Auto_Adjudicated,8,1793406356,1469697158,207V00000X,Obstetrics & Gynecology,21,Out_of_Network,Z00.01,E11.9,revenue_code:0360,470,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,24152.26,16444.76,13102.58,20.54,46.0,3275.64,7707.5,0.0,0.0,0,,0.0341,none,0,1,1,0,0,0.001213,0,0,,Shared_Savings
CLM0000001402,MBR00000158,Medical_Professional,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-27,2023-07-08,Auto_Adjudicated,11,1774425033,1728466420,207RN0300X,Nephrology,22,In_Network,I10,OTHER,12001,,0,Commercial,HMO,65,M,1.5361,,,1458.16,1146.09,639.29,332.97,14.0,159.82,312.07,414.55,159.83,0,,0.1151,none,0,1,0,0,0,5.9e-05,0,0,,Shared_Savings
CLM0000001403,MBR00000134,Medical_Institutional,Paid,Electronic_EDI,2023-03-23,2023-03-23,2023-03-23,2023-03-31,Auto_Adjudicated,8,1201027197,1025886739,2086S0122X,Orthopedic Surgery,24,In_Network,E78.5,,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,33,M,1.115,,,35585.6,24295.36,19402.48,20.26,22.0,4850.62,11290.24,0.0,0.0,0,,0.1564,billing_spike_recent,0,1,1,0,0,0.001796,0,0,ACR_Urine_Protein,Capitation
CLM0000001404,MBR00000128,Pharmacy,Paid,Electronic_EDI,2023-06-13,2023-06-13,2023-06-13,2023-06-15,Auto_Adjudicated,2,1986485249,1133410177,207RN0300X,Nephrology,24,In_Network,OTHER,,00169751112,,1,Commercial,PPO,13,F,1.4203,,,182.13,150.84,0.0,150.84,0.0,0.0,31.29,0.0,0.0,0,,0.142,none,0,1,0,0,0,0.0,0,1,MPT_Annual_Monitoring,FFS
CLM0000001405,MBR00000243,Medical_Professional,Denied,Electronic_EDI,2023-09-01,2023-09-01,2023-09-01,2023-09-22,Auto_Adjudicated,21,1192302048,1477113725,207RN0300X,Nephrology,65,In_Network,OTHER,OTHER,99232,,0,Medicaid_MCO,MCO,21,M,0.4834,3,Timely_Filing,227.37,155.99,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1733,benford_violation,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001406,MBR00000201,Medical_Professional,Paid,Electronic_EDI,2023-10-13,2023-10-13,2023-10-13,2023-11-02,Auto_Adjudicated,20,1528834564,1564636990,207RE0101X,Endocrinology,65,In_Network,I10,,85025,,0,Medicare_Advantage,MA_PPO,74,M,1.1575,,,185.47,123.25,82.89,13.64,6.0,20.72,62.22,0.0,0.0,0,,0.2854,service_date_weekend|duplicate_claim_indicator|phantom_billing_indicator,0,2,0,0,0,8e-06,0,0,,Capitation
CLM0000001407,MBR00000228,Medical_Professional,Partially_Paid,Electronic_EDI,2023-09-23,2023-09-23,2023-09-23,2023-10-20,Auto_Adjudicated,27,1324272690,1898471307,101YP2500X,Psychologist Clinical,11,In_Network,Z12.11,OTHER|I10,99214,,0,Commercial,PPO,55,F,0.7203,97,Medical_Necessity,299.64,106.75,0.0,36.43,27.44,0.0,235.77,0.0,0.0,0,,0.0972,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001408,MBR00000133,Pharmacy,Paid,Electronic_EDI,2023-07-02,2023-07-02,2023-07-02,2023-07-20,Auto_Adjudicated,18,1891821845,1579331190,225100000X,Physical Therapist,11,In_Network,I10,Z00.00,00085163102,,1,Medicaid_MCO,MCO,57,M,0.9592,,,125.65,82.3,81.3,0.0,1.0,0.0,43.35,0.0,0.0,0,,0.0059,none,0,1,0,0,0,8e-06,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000001409,MBR00000081,Medical_Professional,Denied,Electronic_EDI,2023-06-14,2023-06-14,2023-06-14,2023-07-05,Manual_Review,21,1706018784,1321680994,207RC0000X,Cardiovascular Disease,22,In_Network,F32.9,,90834,,0,Medicare_Advantage,SNP,66,F,2.159,170,Timely_Filing,375.77,145.17,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2142,temporal_clustering|upcoding_pattern,0,2,0,0,0,0.0,0,0,,FFS
CLM0000001410,MBR00000026,Medical_Professional,Denied,Electronic_EDI,2023-04-27,2023-04-27,2023-04-27,2023-05-08,Auto_Adjudicated,11,1220235547,1287472731,207V00000X,Obstetrics & Gynecology,22,In_Network,J06.9,,80053,,0,Medicaid_MCO,MCO,17,M,1.0686,50,Coding_Error,251.1,153.44,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1099,none,0,1,0,0,0,0.0,0,0,W30_Well_Child_Visit,FFS
CLM0000001411,MBR00000229,Medical_Professional,Denied,Electronic_EDI,2023-12-21,2023-12-21,2023-12-21,2024-01-02,Auto_Adjudicated,12,1924450526,1325999602,246ZN0300X,Neuropsychology,22,Out_of_Network,OTHER,G43.909,85025,,0,Medicare_Advantage,PFFS,63,M,1.1626,1,Timely_Filing,316.0,203.23,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0025,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001412,MBR00000132,Medical_Institutional,Denied,Electronic_EDI,2023-09-21,2023-09-21,2023-09-22,2023-10-04,Auto_Adjudicated,13,1988579666,1388050552,246ZN0300X,Neuropsychology,22,In_Network,Z12.11,,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,5,Authorization,3573.64,2405.44,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1798,benford_violation,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,FFS
CLM0000001413,MBR00000156,Medical_Professional,Partially_Paid,Electronic_EDI,2023-11-16,2023-11-16,2023-11-16,2023-12-16,Auto_Adjudicated,30,1139362508,1289435414,2084P0800X,Psychiatry,81,In_Network,Z00.00,,99214,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,CO-45,Medical_Necessity,460.01,361.38,191.51,7.88,13.0,47.88,199.75,0.0,0.0,0,,0.0242,none,0,1,0,0,0,1.8e-05,0,0,,Shared_Savings
CLM0000001414,MBR00000144,Medical_Professional,Partially_Paid,Electronic_EDI,2023-09-23,2023-09-23,2023-09-23,2023-10-08,Auto_Adjudicated,15,1638309014,1365397818,207V00000X,Obstetrics & Gynecology,22,In_Network,N39.0,,20610,,0,Commercial,HDHP_HSA,56,F,2.5926,1,Medical_Necessity,1419.3,832.4,179.0,320.01,0.0,44.75,875.54,0.0,0.0,0,,0.1011,none,0,1,0,1,0,1.7e-05,0,0,,FFS
CLM0000001415,MBR00000135,Pharmacy,Paid,Provider_Portal,2023-02-01,2023-02-01,2023-02-01,2023-02-27,Auto_Adjudicated,26,1986485249,1179350099,207RC0000X,Cardiovascular Disease,65,Emergency,OTHER,Z12.11,00085163102,,3,Commercial,PPO,58,F,2.2702,,,99.4,58.69,12.56,5.99,37.0,3.14,40.71,0.0,0.0,0,,0.0537,none,0,1,0,0,0,1e-06,0,0,,Capitation
CLM0000001416,MBR00000204,Medical_Professional,Denied,Electronic_EDI,2023-04-06,2023-04-06,2023-04-06,2023-04-16,Auto_Adjudicated,10,1462532026,1579331190,207RE0101X,Endocrinology,81,In_Network,Z12.11,I10,99231,,0,Commercial,HMO,12,M,0.8716,CO-45,Authorization,516.52,322.49,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1464,none,0,1,0,1,0,0.0,0,0,TRC_Transition_of_Care,P4P
CLM0000001417,MBR00000184,Medical_Professional,Denied,Electronic_EDI,2023-06-15,2023-06-15,2023-06-15,2023-07-06,Auto_Adjudicated,21,1451329728,1650774392,207RE0101X,Endocrinology,22,In_Network,OTHER,K21.0,99204,,0,Medicaid_MCO,MLTSS,30,M,2.8302,4,COB,294.76,152.47,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1078,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001418,MBR00000293,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-04-23,2023-04-23,2023-04-24,2023-05-02,Manual_Review,9,1918578486,1163639177,207RN0300X,Nephrology,11,In_Network,Z23,J20.9|I10|Z00.00,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,16,Medical_Necessity,44985.2,21852.92,9943.12,30.29,32.0,2485.78,32494.0,0.0,0.0,0,,0.1166,none,0,1,1,0,0,0.00092,0,0,SPD_Spirometry_Testing,Bundled_Payment
CLM0000001419,MBR00000043,Medical_Professional,Paid,Electronic_EDI,2023-11-23,2023-11-23,2023-11-23,2023-12-05,Manual_Review,12,1591624417,1765164601,2084P0800X,Psychiatry,21,In_Network,E11.65,OTHER|F32.9,20610,,0,Commercial,PPO,68,F,0.4593,,,986.85,398.17,0.0,398.17,0.0,0.0,588.68,0.0,0.0,0,,0.0456,none,0,1,0,0,0,0.0,0,0,COL_Colorectal_Cancer_Screening,Capitation
CLM0000001420,MBR00000172,Medical_Professional,Partially_Paid,Electronic_EDI,2023-06-26,2023-06-26,2023-06-26,2023-07-22,Auto_Adjudicated,26,1042080259,1829216053,207RG0100X,Gastroenterology,21,In_Network,M17.11,,97140,,0,Medicaid_MCO,MCO,50,F,0.2787,22,Medical_Necessity,1011.8,778.96,525.59,0.0,0.0,0.0,486.21,0.0,0.0,0,,0.1194,service_date_weekend,0,1,0,0,0,4.9e-05,0,0,,FFS
CLM0000001421,MBR00000019,Medical_Institutional,Paid,Electronic_EDI,2023-03-21,2023-03-21,2023-03-24,2023-04-11,Auto_Adjudicated,21,1673449362,1690197969,225100000X,Physical Therapist,32,In_Network,OTHER,E11.9,revenue_code:0450,,0,Commercial,PPO,77,M,0.6521,,,14960.53,5548.5,4388.87,27.42,35.0,1097.22,9412.03,0.0,0.0,0,,0.1396,phantom_billing_indicator,0,1,0,0,0,0.000406,0,0,,FFS
CLM0000001422,MBR00000239,Medical_Professional,Paid,Electronic_EDI,2023-08-03,2023-08-03,2023-08-03,2023-08-18,Manual_Review,15,1826567270,1164525386,207V00000X,Obstetrics & Gynecology,81,In_Network,E11.65,OTHER|M54.5,33510,,0,Commercial,HMO,1,F,1.1193,,,915.92,769.91,452.1,185.79,19.0,113.02,146.01,0.0,0.0,1,Unbundling,0.8399,outlier_billing_amount|provider_specialty_mismatch|high_volume_same_code|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|high_oop_waiver,1,5,0,0,0,4.2e-05,0,0,,FFS
CLM0000001423,MBR00000184,Medical_Institutional,Denied,Electronic_EDI,2023-05-16,2023-05-16,2023-05-16,2023-05-29,Auto_Adjudicated,13,1630305772,1489434038,2086S0122X,Orthopedic Surgery,11,Out_of_Network,Z12.11,E78.5,revenue_code:0120,,0,Medicaid_MCO,MLTSS,30,M,2.8302,170,Duplicate,14429.63,7136.41,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1405,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001424,MBR00000135,Behavioral_Health,Paid,Electronic_EDI,2023-02-15,2023-02-15,2023-02-15,2023-03-11,Auto_Adjudicated,24,1506426842,1705448933,207RG0100X,Gastroenterology,11,In_Network,OTHER,,99283,,0,Commercial,PPO,58,F,2.2702,,,209.76,147.05,87.33,0.89,37.0,21.83,62.71,0.0,0.0,0,,0.0975,none,0,1,0,0,0,8e-06,0,0,,Bundled_Payment
CLM0000001425,MBR00000237,Medical_Institutional,Paid,Provider_Portal,2023-12-06,2023-12-06,2023-12-07,2023-12-11,Manual_Review,5,1310400164,1650774392,207RP1001X,Pulmonary Disease,31,Out_of_Network,Z00.00,L70.0|G43.909,revenue_code:0450,,0,Commercial,PPO,45,M,0.7983,,,124514.19,89107.45,71141.24,117.9,63.0,17785.31,35406.74,0.0,0.0,0,,0.1704,outlier_billing_amount,0,1,1,0,0,0.006585,1,0,,Capitation
CLM0000001426,MBR00000142,Medical_Institutional,Paid,Paper,2023-12-06,2023-12-06,2023-12-07,2024-01-01,Auto_Adjudicated,26,1177281088,1553094822,208600000X,Surgery General,22,In_Network,E78.5,,revenue_code:0250,,0,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,23519.36,12902.97,8514.34,658.63,81.0,3649.0,10616.39,0.0,0.0,0,,0.1114,none,0,1,1,0,0,0.000788,0,0,,Shared_Savings
CLM0000001427,MBR00000071,Dental,Paid,Electronic_EDI,2023-10-06,2023-10-06,2023-10-06,2023-10-25,Auto_Adjudicated,19,1900799244,1938465393,207Q00000X,Family Medicine,24,In_Network,E78.5,OTHER,D1110,,0,Commercial,EPO,19,F,0.5699,,,210.87,117.09,53.46,28.26,22.0,13.37,93.78,0.0,0.0,0,,0.197,high_oop_waiver,0,1,0,1,0,5e-06,0,0,SPC_Statin_Therapy,FFS
CLM0000001428,MBR00000144,Medical_Institutional,Paid,Electronic_EDI,2023-04-23,2023-04-23,2023-04-25,2023-05-03,Auto_Adjudicated,10,1419204214,1157814306,207V00000X,Obstetrics & Gynecology,21,In_Network,E11.65,Z00.00|Z79.4,revenue_code:0120,871,0,Commercial,HDHP_HSA,56,F,2.5926,,,11122.38,7217.52,5443.16,413.57,0.0,1360.79,3904.86,0.0,0.0,0,,0.0131,none,0,1,1,0,0,0.000504,0,0,,FFS
CLM0000001429,MBR00000022,Pharmacy,Denied,Electronic_EDI,2023-10-26,2023-10-26,2023-10-26,2023-11-16,Clinical_Review,21,1170319307,1365397818,207Q00000X,Family Medicine,11,In_Network,OTHER,E78.5|OTHER|Z00.00,00085163102,,1,Medicare_Advantage,MA_HMO,34,M,0.9472,16,COB,134.06,51.57,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.103,benford_violation,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001430,MBR00000272,Medical_Institutional,Denied,Electronic_EDI,2023-04-14,2023-04-14,2023-04-18,2023-05-14,Auto_Adjudicated,30,1747318937,1810068286,207RP1001X,Pulmonary Disease,11,In_Network,J20.9,F41.1|C50.911,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,15,M,0.8525,16,Medical_Necessity,11582.73,4181.02,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0212,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001431,MBR00000214,Medical_Institutional,Paid,Provider_Portal,2023-11-12,2023-11-12,2023-11-13,2023-11-23,Auto_Adjudicated,11,1627776731,1564636990,101YP2500X,Psychologist Clinical,11,In_Network,F32.9,M25.511|Z79.4|F32.9,revenue_code:0300,,0,Commercial,HDHP_HSA,76,M,1.7526,,,3686.17,2621.79,1728.26,461.46,0.0,432.07,1064.38,0.0,0.0,0,,0.1413,temporal_clustering|service_date_weekend,0,1,0,0,0,0.00016,0,0,,Capitation
CLM0000001432,MBR00000224,Vision,Paid,Electronic_EDI,2023-11-14,2023-11-14,2023-11-14,2023-11-26,Auto_Adjudicated,12,1026612378,1352413270,207RN0300X,Nephrology,21,Out_of_Network,Z00.00,OTHER,92012,,0,Medicaid_MCO,MCO,86,F,1.3289,,,440.78,268.76,265.76,0.0,3.0,0.0,172.02,0.0,0.0,0,,0.0514,none,0,1,0,0,0,2.5e-05,1,0,,Capitation
CLM0000001433,MBR00000263,Medical_Professional,Paid,Electronic_EDI,2023-03-03,2023-03-03,2023-03-03,2023-03-31,Clinical_Review,28,1429653002,1105871325,246ZN0300X,Neuropsychology,11,Out_of_Network,OTHER,I25.10,99222,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,,,229.79,195.13,110.41,38.12,19.0,27.6,34.66,0.0,0.0,0,,0.0274,none,0,1,0,0,0,1e-05,1,0,,Capitation
CLM0000001434,MBR00000235,Dental,Paid,Electronic_EDI,2023-04-24,2023-04-24,2023-04-24,2023-05-05,Auto_Adjudicated,11,1980039511,1220755708,208600000X,Surgery General,22,In_Network,M54.5,,D2391,,0,Commercial,HDHP_HSA,85,F,1.4308,,,1315.31,656.88,48.6,596.14,0.0,12.15,658.43,0.0,0.0,1,Duplicate Billing,0.906,unusual_service_frequency|benford_violation|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|npi_mismatch|controlled_substance_high_volume,1,5,0,1,0,4e-06,0,0,,FFS
CLM0000001435,MBR00000135,Medical_Institutional,Paid,Electronic_EDI,2023-09-09,2023-09-09,2023-09-10,2023-10-05,Manual_Review,26,1734752728,1649705287,2086S0122X,Orthopedic Surgery,24,In_Network,I10,N39.0,revenue_code:0120,,0,Commercial,PPO,58,F,2.2702,,,8390.89,4501.38,3551.74,2.71,59.0,887.93,3889.51,0.0,0.0,0,,0.0421,none,0,1,0,0,0,0.000329,0,0,,FFS
CLM0000001436,MBR00000036,Medical_Institutional,Denied,Electronic_EDI,2023-03-26,2023-03-26,2023-03-28,2023-04-22,Auto_Adjudicated,27,1636337876,1220755708,2086S0122X,Orthopedic Surgery,11,In_Network,OTHER,OTHER|K21.0,revenue_code:0300,,0,Commercial,EPO,17,M,2.0136,5,Timely_Filing,20468.03,13660.57,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.074,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001437,MBR00000118,Medical_Institutional,Paid,Electronic_EDI,2023-10-16,2023-10-16,2023-10-17,2023-11-03,Auto_Adjudicated,18,1788188920,1312595355,207RE0101X,Endocrinology,65,In_Network,OTHER,,revenue_code:0300,,0,Medicaid_MCO,MCO,69,M,1.2773,,,1860.58,1290.74,1285.74,0.0,5.0,0.0,569.84,0.0,0.0,0,,0.1809,high_volume_same_code,0,1,0,0,0,0.000119,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000001438,MBR00000282,Medical_Professional,Paid,Electronic_EDI,2023-09-01,2023-09-01,2023-09-01,2023-09-04,Auto_Adjudicated,3,1133514780,1540743888,101YP2500X,Psychologist Clinical,11,In_Network,M54.5,N18.3,27130,,0,Medicare_Advantage,MA_HMO,16,M,0.7304,,,35926.33,19514.48,15578.73,23.07,18.0,3894.68,16411.85,13872.84,1301.03,0,,0.0186,none,0,1,1,0,0,0.001442,0,0,,FFS
CLM0000001439,MBR00000287,Medical_Professional,Denied,Electronic_EDI,2023-03-23,2023-03-23,2023-03-23,2023-03-25,Auto_Adjudicated,2,1602370875,1447657873,207Q00000X,Family Medicine,23,In_Network,J20.9,M54.5|E11.9|F32.9,99204,,0,Commercial,PPO,4,M,0.7685,PR-1,Timely_Filing,583.89,239.97,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0773,benford_violation,0,1,0,0,0,0.0,0,0,MPT_Annual_Monitoring,Capitation
CLM0000001440,MBR00000226,Vision,Denied,Electronic_EDI,2023-10-06,2023-10-06,2023-10-06,2023-10-15,Auto_Adjudicated,9,1963647323,1690197969,101YP2500X,Psychologist Clinical,11,Emergency,OTHER,,V2320,,0,Medicare_Advantage,MA_PPO,84,M,1.0796,170,Duplicate,578.23,222.02,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0858,high_volume_same_code,0,1,0,0,0,0.0,0,0,MMA_Medication_Management,Bundled_Payment
CLM0000001441,MBR00000061,Medical_Institutional,Paid,Electronic_EDI,2023-01-16,2023-01-16,2023-01-20,2023-01-17,Manual_Review,1,1344162462,1887266184,101YP2500X,Psychologist Clinical,31,Out_of_Network,Z00.00,,revenue_code:0110,,0,Commercial,PPO,66,M,2.3575,,,6385.68,2240.58,1680.91,105.44,34.0,420.23,4145.1,0.0,0.0,0,,0.0088,none,0,1,0,0,0,0.000156,0,0,,Bundled_Payment
CLM0000001442,MBR00000060,Dental,Paid,Electronic_EDI,2023-05-18,2023-05-18,2023-05-18,2023-06-10,Auto_Adjudicated,23,1770738194,1622950074,101YP2500X,Psychologist Clinical,11,In_Network,OTHER,J06.9|Z00.00|F41.1,D7140,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,419.46,224.49,0.0,224.49,0.0,0.0,194.97,0.0,0.0,0,,0.0948,none,0,1,0,1,0,0.0,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000001443,MBR00000266,Medical_Professional,Paid,Electronic_EDI,2023-03-06,2023-03-06,2023-03-06,2023-03-26,Manual_Review,20,1135745665,1068662623,207Q00000X,Family Medicine,21,In_Network,M54.5,R05.9,11200,,0,Commercial,EPO,14,M,1.075,,,475.61,232.74,149.26,13.17,33.0,37.31,242.87,98.5,34.92,0,,0.1328,none,0,1,0,0,0,1.4e-05,0,0,MMA_Medication_Management,FFS
CLM0000001444,MBR00000045,Medical_Professional,Paid,Electronic_EDI,2023-01-01,2023-01-01,2023-01-01,2023-01-15,Clinical_Review,14,1593056613,1564691686,101YP2500X,Psychologist Clinical,81,Out_of_Network,F41.1,Z00.00|E11.65,90847,,0,Commercial,HMO,78,F,1.0658,,,229.67,82.85,20.04,25.8,32.0,5.01,146.82,0.0,0.0,0,,0.1557,provider_specialty_mismatch,0,1,0,0,0,2e-06,1,0,CDC_BP_Control,Bundled_Payment
CLM0000001445,MBR00000176,Medical_Professional,Partially_Paid,Electronic_EDI,2023-09-24,2023-09-24,2023-09-24,2023-10-19,Auto_Adjudicated,25,1299958874,1619587398,207RE0101X,Endocrinology,11,In_Network,Z00.00,,47562,,0,Commercial,POS,4,M,0.8792,256,Medical_Necessity,691.65,470.13,20.78,321.88,21.0,5.19,322.79,0.0,0.0,0,,0.1228,high_oop_waiver,0,1,0,0,0,2e-06,0,0,,FFS
CLM0000001446,MBR00000120,Medical_Professional,Paid,Electronic_EDI,2023-02-24,2023-02-24,2023-02-24,2023-03-01,Auto_Adjudicated,5,1263063839,1288028182,207RE0101X,Endocrinology,24,In_Network,Z00.00,,99385,,0,Commercial,PPO,62,F,1.0823,,,135.16,71.29,0.0,71.29,0.0,0.0,63.87,0.0,0.0,0,,0.1966,high_oop_waiver,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001447,MBR00000096,Medical_Institutional,Paid,Electronic_EDI,2023-09-07,2023-09-07,2023-09-08,2023-09-23,Auto_Adjudicated,16,1243349799,1432077493,207RG0100X,Gastroenterology,23,In_Network,Z00.01,,revenue_code:0110,,0,Medicaid_MCO,MCO,62,M,0.7948,,,20582.04,12812.25,12807.25,0.0,5.0,0.0,7769.79,0.0,0.0,0,,0.1553,controlled_substance_high_volume,0,1,1,0,0,0.001185,0,0,,Capitation
CLM0000001448,MBR00000201,Vision,Paid,Paper,2023-01-28,2023-01-28,2023-01-28,2023-02-08,Manual_Review,11,1793406356,1685903362,2084P0800X,Psychiatry,21,In_Network,M54.5,,V2100,,0,Medicare_Advantage,MA_PPO,74,M,1.1575,,,421.65,329.74,254.15,6.05,6.0,63.54,91.91,0.0,0.0,0,,0.1125,none,0,1,0,0,0,2.4e-05,0,0,,Shared_Savings
CLM0000001449,MBR00000291,Dental,Paid,Electronic_EDI,2023-11-17,2023-11-17,2023-11-17,2023-11-18,Auto_Adjudicated,1,1943769986,1809122260,101YP2500X,Psychologist Clinical,11,In_Network,OTHER,M54.5,D2391,,0,Commercial,PPO,78,M,1.4773,,,759.51,403.91,170.22,177.14,14.0,42.55,355.6,0.0,0.0,0,,0.0909,none,0,1,0,0,0,1.6e-05,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000001450,MBR00000229,Medical_Institutional,Paid,Electronic_EDI,2023-12-18,2023-12-18,2023-12-18,2024-01-02,Auto_Adjudicated,15,1145887050,1829216053,2086S0122X,Orthopedic Surgery,31,In_Network,M17.11,Z00.00|Z00.01,revenue_code:0210,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,19031.49,8720.13,6892.75,50.2,54.0,1723.19,10311.36,0.0,0.0,0,,0.0188,none,0,1,1,1,0,0.000638,0,0,,Capitation
CLM0000001451,MBR00000151,Medical_Professional,Paid,Electronic_EDI,2023-04-24,2023-04-24,2023-04-24,2023-04-29,Manual_Review,5,1360102160,1616762819,207R00000X,Internal Medicine,65,In_Network,M54.5,N40.0,99386,,0,Medicare_Advantage,MA_HMO,77,M,0.8709,,,227.68,111.35,70.44,17.3,6.0,17.61,116.33,0.0,0.0,0,,0.0596,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000001452,MBR00000138,Medical_Institutional,Paid,Electronic_EDI,2023-06-24,2023-06-24,2023-06-26,2023-06-26,Auto_Adjudicated,2,1897231867,1151295616,207RE0101X,Endocrinology,11,In_Network,K21.0,J20.9,revenue_code:0450,,0,Commercial,HDHP_HSA,47,M,0.996,,,10123.59,3744.19,2789.11,257.8,0.0,697.28,6379.4,0.0,0.0,0,,0.121,temporal_clustering,0,1,0,0,0,0.000258,0,0,,Capitation
CLM0000001453,MBR00000274,Medical_Institutional,Denied,Electronic_EDI,2023-08-12,2023-08-12,2023-08-12,2023-08-19,Auto_Adjudicated,7,1957378066,1029818813,207RN0300X,Nephrology,31,In_Network,E78.5,,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,16,Eligibility,13402.36,6200.26,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0851,geographic_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001454,MBR00000174,Pharmacy,Paid,Electronic_EDI,2023-07-31,2023-07-31,2023-07-31,2023-08-06,Auto_Adjudicated,6,1597649716,1728466420,207V00000X,Obstetrics & Gynecology,31,In_Network,F33.0,OTHER|K57.30,00071015523,,1,Medicare_Advantage,MA_HMO,85,M,0.3901,,,580.13,464.76,348.39,11.27,18.0,87.1,115.37,0.0,0.0,0,,0.0164,none,0,1,0,0,0,3.2e-05,0,0,AWV_Annual_Wellness_Visit,Shared_Savings
CLM0000001455,MBR00000154,Medical_Institutional,Paid,Electronic_EDI,2023-01-10,2023-01-10,2023-01-13,2023-01-29,Auto_Adjudicated,19,1899326088,1738617370,207RN0300X,Nephrology,22,In_Network,M17.11,,revenue_code:0370,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,45194.09,18661.17,14900.18,11.94,24.0,3725.05,26532.92,0.0,0.0,0,,0.0484,none,0,1,1,0,0,0.001379,0,0,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000001456,MBR00000203,Medical_Professional,Paid,Electronic_EDI,2023-12-18,2023-12-18,2023-12-18,2024-01-11,Auto_Adjudicated,24,1451464799,1898471307,207RE0101X,Endocrinology,24,In_Network,Z12.11,,99385,,0,Commercial,PPO,49,F,0.3046,,,268.47,138.33,14.78,99.85,20.0,3.7,130.14,0.0,0.0,0,,0.0794,none,0,1,0,0,0,1e-06,0,0,,Bundled_Payment
CLM0000001457,MBR00000075,Medical_Professional,Paid,Electronic_EDI,2023-12-02,2023-12-02,2023-12-02,2023-12-17,Auto_Adjudicated,15,1677021292,1804282800,207RG0100X,Gastroenterology,11,In_Network,E13.9,OTHER|E78.5|I25.10,99392,,0,Medicaid_MCO,MCO,5,M,1.0573,,,457.71,189.61,185.61,0.0,4.0,0.0,268.1,142.96,31.26,0,,0.0837,none,0,1,0,0,0,1.7e-05,0,0,,Shared_Savings
CLM0000001458,MBR00000019,Behavioral_Health,Paid,Electronic_EDI,2023-06-24,2023-06-24,2023-06-24,2023-07-14,Auto_Adjudicated,20,1147452455,1896197144,207RE0101X,Endocrinology,22,In_Network,Z12.11,E11.65|N39.0|OTHER,47562,,0,Commercial,PPO,77,M,0.6521,,,169.97,64.49,0.0,48.91,15.58,0.0,105.48,0.0,0.0,0,,0.1428,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001459,MBR00000258,Pharmacy,Paid,Electronic_EDI,2023-07-19,2023-07-19,2023-07-19,2023-07-23,Auto_Adjudicated,4,1727787144,1300957944,207R00000X,Internal Medicine,81,Out_of_Network,OTHER,,00003014960,,2,Commercial,EPO,9,F,0.5431,,,255.18,137.65,82.23,16.87,18.0,20.56,117.53,0.0,0.0,0,,0.1239,none,0,1,0,1,0,8e-06,1,0,,Shared_Savings
CLM0000001460,MBR00000183,Vision,Denied,Electronic_EDI,2023-03-03,2023-03-03,2023-03-03,2023-03-27,Auto_Adjudicated,24,1299958874,1930040953,207V00000X,Obstetrics & Gynecology,24,In_Network,J44.1,,V2100,,0,Commercial,PPO,51,M,0.8463,50,Coding_Error,235.11,178.99,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1705,benford_violation|high_oop_waiver,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001461,MBR00000052,Medical_Professional,Paid,Electronic_EDI,2023-09-26,2023-09-26,2023-09-26,2023-10-12,Auto_Adjudicated,16,1111846258,1114756459,246ZN0300X,Neuropsychology,11,In_Network,E11.9,N39.0,20610,,0,Commercial,PPO,0,F,1.325,,,771.03,284.56,157.15,56.12,32.0,39.29,486.47,0.0,0.0,0,,0.1602,unbundling_pattern,0,1,0,0,0,1.5e-05,0,0,,Capitation
CLM0000001462,MBR00000093,Medical_Institutional,Paid,Electronic_EDI,2023-07-04,2023-07-04,2023-07-08,2023-07-17,Auto_Adjudicated,13,1388662212,1540743888,207RN0300X,Nephrology,22,In_Network,I10,E78.5,revenue_code:0370,,0,Medicare_Advantage,MA_HMO,43,F,0.6162,,,5727.08,3968.26,3112.72,36.36,41.0,778.18,1758.82,0.0,0.0,0,,0.0547,none,0,1,0,0,0,0.000288,0,0,,FFS
CLM0000001463,MBR00000297,Medical_Professional,Paid,Electronic_EDI,2023-04-12,2023-04-12,2023-04-12,2023-05-09,Auto_Adjudicated,27,1231231881,1747596016,207RG0100X,Gastroenterology,11,In_Network,E78.5,Z87.891|E78.5,99205,,0,Commercial,HMO,88,M,1.5311,,,137.63,51.6,2.14,21.92,27.0,0.54,86.03,0.0,0.0,0,,0.1048,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001464,MBR00000188,Dental,Paid,Electronic_EDI,2023-04-21,2023-04-21,2023-04-21,2023-05-01,Auto_Adjudicated,10,1167433253,1685903362,208600000X,Surgery General,11,In_Network,OTHER,Z00.01,D0120,,0,Commercial,HMO,8,F,1.5853,,,165.7,118.13,52.59,27.39,25.0,13.15,47.57,0.0,0.0,0,,0.1215,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000001465,MBR00000188,Medical_Professional,Partially_Paid,Paper,2023-01-30,2023-01-30,2023-01-30,2023-02-13,Auto_Adjudicated,14,1231954359,1477113725,101YP2500X,Psychologist Clinical,11,In_Network,OTHER,,99285,,0,Commercial,HMO,8,F,1.5853,2,Medical_Necessity,374.78,312.08,94.25,24.63,25.0,23.56,207.34,0.0,0.0,0,,0.0522,none,0,1,0,0,0,9e-06,0,0,,Shared_Savings
CLM0000001466,MBR00000023,Pharmacy,Paid,Electronic_EDI,2023-10-11,2023-10-11,2023-10-11,2023-11-08,Auto_Adjudicated,28,1893886964,1746676564,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,J44.1,00078043215,,4,Medicare_Advantage,MA_PPO,87,M,1.084,,,73.81,36.03,0.0,36.03,0.0,0.0,37.78,0.0,0.0,0,,0.0977,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000001467,MBR00000293,Medical_Professional,Paid,Electronic_EDI,2023-01-23,2023-01-23,2023-01-23,2023-01-28,Auto_Adjudicated,5,1454749898,1564691686,2086S0122X,Orthopedic Surgery,22,In_Network,J45.20,,99204,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,236.09,136.65,69.46,38.83,11.0,17.36,99.44,0.0,0.0,0,,0.0832,none,0,1,0,0,0,6e-06,0,0,BPD_BP_Declined,FFS
CLM0000001468,MBR00000270,Medical_Professional,Paid,Electronic_EDI,2023-07-22,2023-07-22,2023-07-22,2023-08-07,Clinical_Review,16,1555292468,1765164601,207RE0101X,Endocrinology,11,Out_of_Network,OTHER,I10,85025,,0,Commercial,POS,1,F,1.6363,,,1212.27,756.35,476.77,148.39,12.0,119.19,455.92,0.0,0.0,0,,0.0558,none,0,1,0,1,0,4.4e-05,0,0,,Shared_Savings
CLM0000001469,MBR00000166,Medical_Professional,Paid,Electronic_EDI,2023-10-20,2023-10-20,2023-10-20,2023-11-07,Auto_Adjudicated,18,1597245892,1320546364,225100000X,Physical Therapist,24,In_Network,J06.9,N40.0,27130,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,39433.55,18288.01,12145.98,892.62,44.0,5205.42,21145.54,0.0,0.0,0,,0.1319,none,0,1,1,0,0,0.001124,0,0,DAE_Drug_Alcohol_Dependence,Bundled_Payment
CLM0000001470,MBR00000098,Medical_Institutional,Paid,Provider_Portal,2023-01-19,2023-01-19,2023-01-23,2023-02-10,Auto_Adjudicated,22,1567711165,1898471307,207Q00000X,Family Medicine,32,In_Network,F33.0,K21.0|OTHER|Z23,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,7,M,0.511,,,4970.1,1854.18,1440.15,13.99,40.0,360.04,3115.92,0.0,0.0,0,,0.0809,none,0,1,0,0,0,0.000133,0,0,,FFS
CLM0000001471,MBR00000207,Pharmacy,Paid,Electronic_EDI,2023-02-24,2023-02-24,2023-02-24,2023-03-24,Auto_Adjudicated,28,1369267360,1163639177,207V00000X,Obstetrics & Gynecology,22,In_Network,Z12.11,,59148001506,,2,Medicaid_MCO,MLTSS,11,F,1.6522,,,26.38,10.13,10.13,0.0,0.0,0.0,16.25,0.0,0.0,0,,0.0888,none,0,1,0,0,0,1e-06,0,0,,Capitation
CLM0000001472,MBR00000249,Behavioral_Health,Paid,Electronic_EDI,2023-10-01,2023-10-01,2023-10-01,2023-10-12,Manual_Review,11,1976612978,1040061910,207RE0101X,Endocrinology,11,Out_of_Network,OTHER,Z12.11,99281,,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,147.21,78.76,0.0,78.76,0.0,0.0,68.45,0.0,0.0,0,,0.0574,none,0,1,0,0,0,0.0,1,0,COA_Care_Transitions,P4P
CLM0000001473,MBR00000232,Medical_Institutional,Paid,Electronic_EDI,2023-10-23,2023-10-23,2023-10-27,2023-10-27,Auto_Adjudicated,4,1897231867,1433350836,2086S0122X,Orthopedic Surgery,81,In_Network,OTHER,,revenue_code:0200,,0,Medicaid_MCO,MCO,40,M,1.1083,,,14373.5,6514.61,6505.61,0.0,9.0,0.0,7858.89,0.0,0.0,0,,0.0823,temporal_clustering,0,1,1,0,0,0.000602,0,0,FLU_Flu_Vaccination,Capitation
CLM0000001474,MBR00000294,Medical_Institutional,Denied,Electronic_EDI,2023-01-30,2023-01-30,2023-02-01,2023-02-11,Auto_Adjudicated,12,1490172833,1388050552,101YP2500X,Psychologist Clinical,11,Out_of_Network,I48.91,K21.0|N40.0,revenue_code:0370,,0,Medicare_Advantage,MA_HMO,8,M,0.6878,97,Coding_Error,35472.89,21523.08,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Duplicate Billing,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|benford_violation|service_date_weekend|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.0,1,0,ACR_Urine_Protein,FFS
CLM0000001475,MBR00000188,Pharmacy,Paid,Paper,2023-04-06,2023-04-06,2023-04-06,2023-04-11,Auto_Adjudicated,5,1808451151,1522426351,207R00000X,Internal Medicine,22,Emergency,OTHER,I10,00003014960,,1,Commercial,HMO,8,F,1.5853,,,43.8,16.74,0.0,10.84,5.9,0.0,27.06,0.0,0.0,0,,0.0737,none,0,1,0,0,0,0.0,0,0,BPD_BP_Declined,Bundled_Payment
CLM0000001476,MBR00000102,Medical_Professional,Paid,Electronic_EDI,2023-08-06,2023-08-06,2023-08-06,2023-08-28,Auto_Adjudicated,22,1211612843,1055872102,207Q00000X,Family Medicine,11,In_Network,OTHER,,17000,,0,Commercial,POS,68,M,1.6864,,,344.3,238.78,0.0,238.78,0.0,0.0,105.52,0.0,0.0,0,,0.0669,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001477,MBR00000154,Pharmacy,Paid,Paper,2023-07-14,2023-07-14,2023-07-14,2023-08-01,Auto_Adjudicated,18,1664872214,1847196500,246ZN0300X,Neuropsychology,71,In_Network,Z00.01,,00069420020,,5,Medicare_Advantage,MA_HMO,54,F,1.9463,,,118.82,50.68,33.2,9.18,0.0,8.3,68.14,0.0,0.0,0,,0.0849,none,0,1,0,0,0,3e-06,0,1,,FFS
CLM0000001478,MBR00000242,Pharmacy,Denied,Electronic_EDI,2023-07-05,2023-07-05,2023-07-05,2023-07-28,Auto_Adjudicated,23,1006539337,1510751265,207RG0100X,Gastroenterology,21,In_Network,F41.1,J06.9|E78.5,00069420020,,2,Medicaid_MCO,MLTSS,75,F,0.7104,22,Timely_Filing,956.28,350.78,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1286,none,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000001479,MBR00000081,Medical_Institutional,Denied,Electronic_EDI,2023-04-05,2023-04-05,2023-04-08,2023-04-16,Manual_Review,11,1117755591,1402472115,208600000X,Surgery General,71,In_Network,L70.0,,revenue_code:0110,,0,Medicare_Advantage,SNP,66,F,2.159,3,Eligibility,13246.79,6305.06,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0809,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000001480,MBR00000073,Medical_Professional,Paid,Paper,2023-07-13,2023-07-13,2023-07-13,2023-08-11,Auto_Adjudicated,29,1733777382,1112696614,207RE0101X,Endocrinology,81,Emergency,N18.3,Z12.11,99222,,0,Commercial,POS,79,M,1.1768,,,387.26,268.25,183.55,5.82,33.0,45.89,119.01,0.0,0.0,0,,0.0212,none,0,1,0,1,0,1.7e-05,0,0,,FFS
CLM0000001481,MBR00000213,Medical_Professional,Paid,Electronic_EDI,2023-01-18,2023-01-18,2023-01-18,2023-02-14,Auto_Adjudicated,27,1642333103,1898471307,207RP1001X,Pulmonary Disease,71,Out_of_Network,J20.9,OTHER,99397,,0,Commercial,PPO,17,M,1.5857,,,485.34,197.67,19.84,144.87,28.0,4.96,287.67,0.0,0.0,0,,0.2043,impossible_service_combo,0,2,0,1,0,2e-06,1,0,,P4P
CLM0000001482,MBR00000139,Medical_Professional,Denied,Electronic_EDI,2023-11-10,2023-11-10,2023-11-10,2023-12-08,Manual_Review,28,1368580443,1068662623,207RE0101X,Endocrinology,24,In_Network,Z12.11,Z79.4|M17.11,33510,,0,Commercial,PPO,74,M,1.7701,16,Duplicate,474.51,349.77,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.012,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001483,MBR00000243,Vision,Denied,Electronic_EDI,2023-07-14,2023-07-14,2023-07-14,2023-08-05,Auto_Adjudicated,22,1617763056,1809122260,207RP1001X,Pulmonary Disease,24,In_Network,E11.9,I10|I25.10|OTHER,92012,,0,Medicaid_MCO,MCO,21,M,0.4834,97,Medical_Necessity,294.42,195.25,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0476,none,0,1,0,0,0,0.0,0,0,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000001484,MBR00000045,Medical_Institutional,Paid,Paper,2023-05-14,2023-05-14,2023-05-15,2023-05-20,Auto_Adjudicated,6,1956215244,1978943761,208600000X,Surgery General,71,In_Network,OTHER,,revenue_code:0120,,0,Commercial,HMO,78,F,1.0658,,,15068.46,7592.14,6011.17,22.18,56.0,1502.79,7476.32,0.0,0.0,0,,0.1267,none,0,1,1,0,0,0.000556,0,0,,Capitation
CLM0000001485,MBR00000106,Medical_Institutional,Denied,Electronic_EDI,2023-05-12,2023-05-12,2023-05-16,2023-05-17,Auto_Adjudicated,5,1033622184,1809122260,207RN0300X,Nephrology,11,In_Network,H52.4,J06.9,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,18,Timely_Filing,20709.32,8184.43,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.01,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000001486,MBR00000083,Medical_Institutional,Denied,Electronic_EDI,2023-05-13,2023-05-13,2023-05-13,2023-06-11,Auto_Adjudicated,29,1710668368,1157814306,207RP1001X,Pulmonary Disease,24,Emergency,N18.3,OTHER,revenue_code:0100,,0,Commercial,PPO,76,M,0.6621,1,Network,10688.65,8602.3,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.117,unusual_service_frequency,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001487,MBR00000207,Pharmacy,Paid,Electronic_EDI,2023-06-06,2023-06-06,2023-06-06,2023-07-03,Auto_Adjudicated,27,1002224900,1318978078,207V00000X,Obstetrics & Gynecology,11,In_Network,Z00.01,J06.9,00006001954,,3,Medicaid_MCO,MLTSS,11,F,1.6522,,,414.94,193.57,193.57,0.0,0.0,0.0,221.37,0.0,0.0,0,,0.142,none,0,1,0,0,0,1.8e-05,0,0,MMA_Medication_Management,FFS
CLM0000001488,MBR00000223,Medical_Professional,Partially_Paid,Provider_Portal,2023-03-11,2023-03-11,2023-03-11,2023-04-07,Manual_Review,27,1015411732,1301833092,207R00000X,Internal Medicine,21,In_Network,Z00.01,,80053,,0,Commercial,PPO,65,F,0.3534,18,Medical_Necessity,1407.29,937.62,368.43,1.67,13.0,92.11,932.08,0.0,0.0,0,,0.063,none,0,1,0,0,0,3.4e-05,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000001489,MBR00000142,Medical_Professional,Paid,Paper,2023-08-04,2023-08-04,2023-08-04,2023-08-24,Manual_Review,20,1528602428,1188760037,207RP1001X,Pulmonary Disease,21,In_Network,K21.0,,33510,,0,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,533.03,370.76,93.68,208.93,28.0,40.15,162.27,0.0,0.0,0,,0.0459,none,0,1,0,0,0,9e-06,0,0,FUM_Follow_Up_ED_Mental_Health,Bundled_Payment
CLM0000001490,MBR00000147,Pharmacy,Paid,Provider_Portal,2023-03-07,2023-03-07,2023-03-07,2023-04-02,Auto_Adjudicated,26,1097563011,1942423230,207RG0100X,Gastroenterology,81,In_Network,I10,I10|OTHER,00310075090,,2,Commercial,PPO,31,F,0.7098,,,330.37,203.48,0.0,203.48,0.0,0.0,126.89,0.0,0.0,0,,0.0719,high_oop_waiver,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001491,MBR00000041,Medical_Professional,Paid,Electronic_EDI,2023-04-23,2023-04-23,2023-04-23,2023-05-08,Auto_Adjudicated,15,1667149552,1774401124,2086S0122X,Orthopedic Surgery,21,In_Network,I10,E11.65,99221,,0,Commercial,PPO,42,F,0.8283,,,340.15,218.41,98.71,71.02,24.0,24.68,121.74,0.0,0.0,0,,0.1449,none,0,1,0,0,0,9e-06,0,0,,Bundled_Payment
CLM0000001492,MBR00000208,Medical_Professional,Partially_Paid,Electronic_EDI,2023-11-09,2023-11-09,2023-11-09,2023-11-14,Auto_Adjudicated,5,1374458552,1220755708,207V00000X,Obstetrics & Gynecology,22,In_Network,Z00.01,,27447,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,16,Medical_Necessity,116004.71,57783.97,28859.42,11.8,6.0,7214.86,79912.63,0.0,0.0,0,,0.1964,outlier_billing_amount|geographic_mismatch,0,1,1,0,0,0.002671,0,0,,FFS
CLM0000001493,MBR00000298,Medical_Institutional,Denied,Electronic_EDI,2023-07-22,2023-07-22,2023-07-22,2023-07-30,Manual_Review,8,1625939855,1688513262,207RP1001X,Pulmonary Disease,23,In_Network,M54.5,M17.11,revenue_code:0450,,0,Medicaid_MCO,MCO,75,M,0.8324,50,Duplicate,26882.65,17305.3,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0109,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001494,MBR00000229,Medical_Professional,Paid,Electronic_EDI,2023-11-21,2023-11-21,2023-11-21,2023-12-17,Manual_Review,26,1897146144,1177602659,207RE0101X,Endocrinology,23,In_Network,Z00.00,OTHER|M25.511,99281,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,339.65,258.77,176.34,24.34,14.0,44.09,80.88,0.0,0.0,0,,0.1079,none,0,1,0,0,0,1.6e-05,0,0,,FFS
CLM0000001495,MBR00000069,Vision,Paid,Paper,2023-08-25,2023-08-25,2023-08-25,2023-09-14,Auto_Adjudicated,20,1181941909,1267212691,208600000X,Surgery General,11,In_Network,L70.0,E13.9|I25.10|J20.9,92012,,0,Medicare_Advantage,MA_PPO,2,M,0.5765,,,210.64,155.53,106.37,14.57,8.0,26.59,55.11,0.0,0.0,0,,0.0986,none,0,1,0,0,0,1e-05,0,0,FUM_Follow_Up_ED_Mental_Health,Shared_Savings
CLM0000001496,MBR00000186,Pharmacy,Paid,Electronic_EDI,2023-10-09,2023-10-09,2023-10-09,2023-11-08,Auto_Adjudicated,30,1324084461,1705448933,207R00000X,Internal Medicine,22,In_Network,J44.1,J06.9|I10,00003014960,,1,Commercial,PPO,65,M,1.6983,,,78.68,36.31,0.0,36.31,0.0,0.0,42.37,0.0,0.0,0,,0.109,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000001497,MBR00000092,Behavioral_Health,Paid,Electronic_EDI,2023-02-02,2023-02-02,2023-02-02,2023-03-01,Auto_Adjudicated,27,1899326088,1132693989,207RN0300X,Nephrology,23,In_Network,M17.11,OTHER|Z00.00,17000,,0,Medicaid_MCO,MLTSS,68,F,1.3217,,,286.43,212.35,209.35,0.0,3.0,0.0,74.08,0.0,0.0,0,,0.0458,none,0,1,0,1,0,1.9e-05,0,0,,FFS
CLM0000001498,MBR00000010,Vision,Paid,Electronic_EDI,2023-07-01,2023-07-01,2023-07-01,2023-07-24,Auto_Adjudicated,23,1171387771,1039962073,207RC0000X,Cardiovascular Disease,65,In_Network,OTHER,OTHER|E78.5|E11.9,92014,,0,Medicare_Advantage,MA_HMO,44,F,1.4631,,,119.18,82.23,58.96,4.53,4.0,14.74,36.95,0.0,0.0,0,,0.0666,none,0,1,0,0,0,5e-06,0,0,,P4P
CLM0000001499,MBR00000056,Medical_Professional,Denied,Electronic_EDI,2023-05-06,2023-05-06,2023-05-06,2023-05-08,Auto_Adjudicated,2,1218947226,1039962073,246ZN0300X,Neuropsychology,71,In_Network,F41.1,Z00.00|J06.9,99204,,0,Commercial,EPO,74,F,1.3941,5,Coding_Error,630.65,358.29,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.114,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001500,MBR00000031,Medical_Professional,Paid,Electronic_EDI,2023-01-07,2023-01-07,2023-01-07,2023-01-13,Auto_Adjudicated,6,1688560518,1319611206,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,Z00.01,97140,,0,Commercial,PPO,71,M,0.6746,,,153.76,91.2,26.92,41.55,16.0,6.73,62.56,0.0,0.0,0,,0.0777,none,0,1,0,0,0,2e-06,0,0,,Shared_Savings
CLM0000001501,MBR00000060,Pharmacy,Paid,Electronic_EDI,2023-02-02,2023-02-02,2023-02-02,2023-02-14,Auto_Adjudicated,12,1597649716,1738617370,2086S0122X,Orthopedic Surgery,11,In_Network,I10,I10,50458085930,,3,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,79.01,48.05,0.0,48.05,0.0,0.0,30.96,0.0,0.0,0,,0.1033,none,0,1,0,0,0,0.0,0,0,DAE_Drug_Alcohol_Dependence,P4P
CLM0000001502,MBR00000236,Medical_Professional,Paid,Electronic_EDI,2023-03-10,2023-03-10,2023-03-10,2023-03-12,Auto_Adjudicated,2,1130461876,1432077493,2086S0122X,Orthopedic Surgery,23,In_Network,E78.5,E13.9|Z23|Z00.00,80053,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,1308.96,967.91,964.91,0.0,3.0,0.0,341.05,0.0,0.0,0,,0.1066,none,0,1,0,1,0,8.9e-05,0,0,,FFS
CLM0000001503,MBR00000092,Behavioral_Health,Paid,Electronic_EDI,2023-01-03,2023-01-03,2023-01-03,2023-02-01,Auto_Adjudicated,29,1207676414,1616762819,207RC0000X,Cardiovascular Disease,22,In_Network,M54.5,,43239,,0,Medicaid_MCO,MLTSS,68,F,1.3217,,,216.14,141.78,138.78,0.0,3.0,0.0,74.36,0.0,0.0,0,,0.1467,geographic_mismatch,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000001504,MBR00000222,Medical_Professional,Paid,Electronic_EDI,2023-06-07,2023-06-07,2023-06-07,2023-06-14,Clinical_Review,7,1108756266,1140170394,207RP1001X,Pulmonary Disease,24,In_Network,OTHER,M54.5,99231,,0,Commercial,PPO,48,F,0.6945,,,306.83,237.43,0.0,231.35,6.08,0.0,69.4,0.0,0.0,0,,0.1253,none,0,1,0,0,0,0.0,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000001505,MBR00000287,Medical_Institutional,Paid,Electronic_EDI,2023-01-19,2023-01-19,2023-01-23,2023-01-31,Auto_Adjudicated,12,1893327624,1406199453,2084P0800X,Psychiatry,31,Out_of_Network,OTHER,Z00.00|OTHER,revenue_code:0250,,0,Commercial,PPO,4,M,0.7685,,,6463.5,4913.91,3768.45,146.35,57.0,942.11,1549.59,0.0,0.0,0,,0.0784,provider_specialty_mismatch,0,1,0,0,0,0.000349,1,0,,Bundled_Payment
CLM0000001506,MBR00000173,Pharmacy,Paid,Electronic_EDI,2023-10-23,2023-10-23,2023-10-23,2023-11-13,Auto_Adjudicated,21,1564110057,1296566243,207RN0300X,Nephrology,11,In_Network,K21.0,,00006001954,,4,Medicare_Advantage,PFFS,23,F,1.0279,,,162.53,131.15,83.15,13.21,14.0,20.79,31.38,0.0,0.0,0,,0.1031,none,0,1,0,0,0,8e-06,0,0,TRC_Transition_of_Care,Capitation
CLM0000001507,MBR00000151,Dental,Paid,Provider_Portal,2023-08-01,2023-08-01,2023-08-01,2023-08-03,Auto_Adjudicated,2,1746688640,1061149198,246ZN0300X,Neuropsychology,32,In_Network,OTHER,OTHER|J06.9,D4341,,0,Medicare_Advantage,MA_HMO,77,M,0.8709,,,527.66,415.5,326.86,0.93,6.0,81.71,112.16,0.0,0.0,0,,0.1454,none,0,1,0,1,0,3e-05,0,0,POD_Persistence_of_Beta_Blocker,Capitation
CLM0000001508,MBR00000220,Medical_Institutional,Paid,Electronic_EDI,2023-12-12,2023-12-12,2023-12-13,2024-01-01,Auto_Adjudicated,20,1091271799,1012893364,225100000X,Physical Therapist,11,In_Network,E11.9,E11.9|Z00.01,revenue_code:0210,,0,Commercial,HMO,38,M,0.7736,,,14017.04,5052.43,3805.34,240.76,55.0,951.33,8964.61,0.0,0.0,1,Code Substitution,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|benford_violation|impossible_service_combo|service_date_weekend|billing_spike_recent|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch,1,5,0,0,0,0.000352,0,0,,Capitation
CLM0000001509,MBR00000028,Medical_Institutional,Paid,Electronic_EDI,2023-01-31,2023-01-31,2023-02-01,2023-02-04,Auto_Adjudicated,4,1881170383,1728466420,225100000X,Physical Therapist,81,In_Network,J44.1,Z87.891,revenue_code:0450,,0,Commercial,HMO,3,F,2.116,,,12057.31,6407.33,4728.39,417.84,79.0,1182.1,5649.98,3397.86,1188.07,0,,0.0765,none,0,1,0,0,0,0.000438,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000001510,MBR00000135,Medical_Professional,Paid,Paper,2023-01-29,2023-01-29,2023-01-29,2023-02-26,Manual_Review,28,1209940651,1662516615,207RN0300X,Nephrology,21,In_Network,I10,Z00.01|I50.9,99395,,0,Commercial,PPO,58,F,2.2702,,,244.54,131.27,72.45,3.71,37.0,18.11,113.27,0.0,0.0,0,,0.1675,provider_specialty_mismatch,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000001511,MBR00000154,Medical_Institutional,Paid,Electronic_EDI,2023-11-08,2023-11-08,2023-11-11,2023-11-29,Auto_Adjudicated,21,1330688043,1827839595,207RN0300X,Nephrology,31,In_Network,I25.10,,revenue_code:0360,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,23586.38,16356.08,13055.85,12.26,24.0,3263.96,7230.3,0.0,0.0,0,,0.0522,none,0,1,1,1,0,0.001208,0,0,,Shared_Savings
CLM0000001512,MBR00000248,Pharmacy,Paid,Electronic_EDI,2023-05-21,2023-05-21,2023-05-21,2023-06-01,Auto_Adjudicated,11,1850379080,1574982369,207RN0300X,Nephrology,11,In_Network,E11.9,E78.5|L70.0|Z12.11,00085163102,,3,Commercial,PPO,40,F,0.6665,,,259.95,164.65,0.0,164.65,0.0,0.0,95.3,0.0,0.0,0,,0.1844,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001513,MBR00000242,Medical_Institutional,Paid,Electronic_EDI,2023-09-30,2023-09-30,2023-10-01,2023-10-22,Manual_Review,22,1952322604,1978943761,101YP2500X,Psychologist Clinical,22,Out_of_Network,I25.10,,revenue_code:0250,,0,Medicaid_MCO,MLTSS,75,F,0.7104,,,17890.73,15122.18,15120.18,0.0,2.0,0.0,2768.55,0.0,0.0,1,Duplicate Billing,0.8379,unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|upcoding_pattern|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,1,0,0,0.0014,1,0,,FFS
CLM0000001514,MBR00000255,Pharmacy,Paid,Electronic_EDI,2023-03-10,2023-03-10,2023-03-10,2023-03-20,Auto_Adjudicated,10,1309817189,1433350836,101YP2500X,Psychologist Clinical,11,In_Network,K21.0,,00071012831,,1,Medicare_Advantage,MA_HMO,21,M,0.6945,,,463.32,305.41,221.11,11.02,18.0,55.28,157.91,0.0,0.0,0,,0.061,none,0,1,0,0,0,2e-05,0,1,MMA_Medication_Management,Shared_Savings
CLM0000001515,MBR00000207,Medical_Professional,Denied,Electronic_EDI,2023-01-04,2023-01-04,2023-01-04,2023-01-08,Auto_Adjudicated,4,1078576574,1765164601,207RN0300X,Nephrology,24,In_Network,E11.65,I10,99203,,0,Medicaid_MCO,MLTSS,11,F,1.6522,1,COB,176.43,111.77,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1077,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001516,MBR00000161,Medical_Professional,Paid,Electronic_EDI,2023-06-28,2023-06-28,2023-06-28,2023-06-29,Auto_Adjudicated,1,1428403730,1012893364,207RP1001X,Pulmonary Disease,71,In_Network,I10,E78.5|E13.9,84443,,0,Medicaid_MCO,MLTSS,9,F,0.8354,,,2253.43,1746.65,1742.65,0.0,4.0,0.0,506.78,0.0,0.0,0,,0.141,impossible_service_combo,0,1,0,0,0,0.000161,0,0,,Capitation
CLM0000001517,MBR00000247,Vision,Denied,Electronic_EDI,2023-07-25,2023-07-25,2023-07-25,2023-08-01,Auto_Adjudicated,7,1334227781,1994275960,225100000X,Physical Therapist,31,In_Network,M17.11,E13.9|J44.1,92002,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,97,Network,183.53,136.73,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1434,duplicate_claim_indicator|upcoding_pattern,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001518,MBR00000263,Medical_Professional,Denied,Electronic_EDI,2023-02-09,2023-02-09,2023-02-09,2023-03-03,Manual_Review,22,1683994149,1763260577,246ZN0300X,Neuropsychology,23,In_Network,M54.5,M54.5,71250,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,PR-1,Eligibility,776.56,334.09,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1445,none,0,1,0,0,0,0.0,0,0,ACR_Urine_Protein,FFS
CLM0000001519,MBR00000148,Medical_Institutional,Denied,Electronic_EDI,2023-01-04,2023-01-04,2023-01-07,2023-01-21,Manual_Review,17,1981853293,1643673796,101YP2500X,Psychologist Clinical,11,In_Network,I10,Z79.4|Z00.00,revenue_code:0360,,0,Commercial,EPO,51,F,0.6534,2,COB,21268.79,12590.65,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.045,none,0,1,0,0,0,0.0,0,0,IET_Initiation_Substance_Use,FFS
CLM0000001520,MBR00000296,Medical_Institutional,Paid,Electronic_EDI,2023-03-18,2023-03-18,2023-03-20,2023-03-27,Manual_Review,9,1520692162,1252125670,2084P0800X,Psychiatry,81,In_Network,M17.11,N18.3,revenue_code:0100,,0,Commercial,HMO,83,F,1.4969,,,10053.86,8504.32,6543.33,282.15,43.0,1635.83,1549.54,0.0,0.0,0,,0.0498,none,0,1,1,0,0,0.000606,0,0,,FFS
CLM0000001521,MBR00000263,Vision,Paid,Electronic_EDI,2023-02-09,2023-02-09,2023-02-09,2023-03-02,Manual_Review,21,1706065807,1827839595,2086S0122X,Orthopedic Surgery,21,In_Network,I10,OTHER|I10,92014,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,,,327.26,230.37,168.95,0.18,19.0,42.24,96.89,115.71,33.95,0,,0.1271,none,0,1,0,0,0,1.6e-05,0,0,,Capitation
CLM0000001522,MBR00000157,Medical_Professional,Denied,Electronic_EDI,2023-12-24,2023-12-24,2023-12-24,2024-01-05,Auto_Adjudicated,12,1769163673,1114756459,207V00000X,Obstetrics & Gynecology,23,In_Network,K21.0,,10060,,0,Medicare_Advantage,MA_HMO,26,F,0.9164,1,COB,533.36,192.95,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1248,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001523,MBR00000022,Medical_Professional,Paid,Electronic_EDI,2023-12-21,2023-12-21,2023-12-21,2023-12-26,Auto_Adjudicated,5,1299958874,1865266296,101YP2500X,Psychologist Clinical,11,In_Network,M54.5,OTHER|Z00.00|K57.30,99215,,0,Medicare_Advantage,MA_HMO,34,M,0.9472,,,720.09,274.18,194.31,15.29,16.0,48.58,445.91,0.0,0.0,0,,0.0356,none,0,1,0,0,0,1.8e-05,0,0,,FFS
CLM0000001524,MBR00000070,Dental,Paid,Provider_Portal,2023-01-06,2023-01-06,2023-01-06,2023-01-27,Manual_Review,21,1457568950,1643673796,101YP2500X,Psychologist Clinical,31,In_Network,J20.9,Z00.00|Z12.11,D0150,,0,Commercial,POS,42,F,0.8468,,,395.15,282.82,65.92,185.42,15.0,16.48,112.33,0.0,0.0,0,,0.0776,none,0,1,0,0,0,6e-06,0,0,FUM_Follow_Up_ED_Mental_Health,Capitation
CLM0000001525,MBR00000229,Pharmacy,Paid,Electronic_EDI,2023-06-14,2023-06-14,2023-06-14,2023-06-28,Auto_Adjudicated,14,1321381114,1765164601,207V00000X,Obstetrics & Gynecology,21,In_Network,F41.1,J20.9|E11.9,00003014960,,1,Medicare_Advantage,PFFS,63,M,1.1626,,,163.99,120.8,50.6,43.55,14.0,12.65,43.19,0.0,0.0,0,,0.1342,none,0,1,0,0,0,5e-06,0,1,,FFS
CLM0000001526,MBR00000035,Medical_Institutional,Paid,Electronic_EDI,2023-05-19,2023-05-19,2023-05-22,2023-06-08,Auto_Adjudicated,20,1637260822,1575884274,246ZN0300X,Neuropsychology,21,In_Network,I10,J06.9,revenue_code:0300,871,0,ACA_Marketplace,ACA_Platinum,46,M,0.6598,,,14949.94,11357.97,8921.53,138.05,68.0,2230.38,3591.97,0.0,0.0,0,,0.1684,service_date_weekend,0,1,1,0,1,0.000826,0,0,,Capitation
CLM0000001527,MBR00000144,Medical_Professional,Paid,Electronic_EDI,2023-01-10,2023-01-10,2023-01-10,2023-01-27,Auto_Adjudicated,17,1216417633,1128148362,2084P0800X,Psychiatry,11,In_Network,E78.5,OTHER|I10|J20.9,99383,,0,Commercial,HDHP_HSA,56,F,2.5926,,,493.19,244.78,0.0,244.78,0.0,0.0,248.41,0.0,0.0,0,,0.0857,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001528,MBR00000182,Medical_Institutional,Paid,Electronic_EDI,2023-08-28,2023-08-28,2023-08-28,2023-09-01,Manual_Review,4,1192302048,1489434038,207RP1001X,Pulmonary Disease,22,In_Network,E11.65,,revenue_code:0360,,0,Commercial,HMO,82,F,0.8489,,,45371.48,34166.29,27207.3,123.17,34.0,6801.82,11205.19,0.0,0.0,1,Phantom Billing,1.0,outlier_billing_amount|unusual_service_frequency|temporal_clustering|benford_violation|impossible_service_combo|service_date_weekend|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,1,0,0,0.002518,0,0,CDC_HbA1c_Poor_Control,Shared_Savings
CLM0000001529,MBR00000265,Vision,Denied,Electronic_EDI,2023-11-02,2023-11-02,2023-11-02,2023-11-04,Manual_Review,2,1736809698,1789540567,246ZN0300X,Neuropsychology,11,In_Network,OTHER,,V2115,,0,Commercial,PPO,84,F,0.7969,97,Duplicate,136.66,115.62,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0757,impossible_service_combo,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001530,MBR00000254,Pharmacy,Paid,Electronic_EDI,2023-08-08,2023-08-08,2023-08-08,2023-08-12,Auto_Adjudicated,4,1313587359,1747935894,225100000X,Physical Therapist,65,In_Network,Z00.00,OTHER,00169751112,,5,Commercial,PPO,22,F,0.9285,,,453.61,289.43,177.68,39.33,28.0,44.42,164.18,0.0,0.0,0,,0.0699,unusual_service_frequency,0,1,0,0,0,1.6e-05,0,0,,FFS
CLM0000001531,MBR00000224,Vision,Paid,Provider_Portal,2023-11-26,2023-11-26,2023-11-26,2023-12-03,Auto_Adjudicated,7,1424104563,1763260577,207R00000X,Internal Medicine,24,In_Network,Z00.01,E11.9|OTHER|I10,92012,,0,Medicaid_MCO,MCO,86,F,1.3289,,,333.6,216.49,213.49,0.0,3.0,0.0,117.11,139.66,44.43,0,,0.1244,temporal_clustering,0,1,0,0,0,2e-05,0,0,,FFS
CLM0000001532,MBR00000130,Behavioral_Health,Paid,Electronic_EDI,2023-08-17,2023-08-17,2023-08-17,2023-08-24,Auto_Adjudicated,7,1453331651,1274911960,207R00000X,Internal Medicine,71,In_Network,OTHER,F32.9|Z00.00|OTHER,17000,,0,Medicare_Advantage,MA_PPO,58,M,1.3394,,,176.08,83.13,45.32,22.49,4.0,11.33,92.95,0.0,0.0,0,,0.0802,none,0,1,0,0,0,4e-06,0,0,MPT_Annual_Monitoring,FFS
CLM0000001533,MBR00000045,Medical_Institutional,Paid,Electronic_EDI,2023-07-16,2023-07-16,2023-07-19,2023-08-13,Manual_Review,28,1966338974,1649705287,207RE0101X,Endocrinology,21,In_Network,J06.9,I10,revenue_code:0200,470,0,Commercial,HMO,78,F,1.0658,,,16102.12,7372.53,5852.73,0.62,56.0,1463.18,8729.59,0.0,0.0,0,,0.1901,billing_spike_recent|upcoding_pattern,0,1,1,0,0,0.000542,0,0,,P4P
CLM0000001534,MBR00000198,Medical_Institutional,Denied,Provider_Portal,2023-12-07,2023-12-07,2023-12-08,2023-12-31,Auto_Adjudicated,24,1139362508,1209882852,207R00000X,Internal Medicine,23,In_Network,E78.5,K21.0|I50.9,revenue_code:0450,,0,Medicaid_MCO,MCO,81,F,1.4199,96,Eligibility,41959.59,14851.02,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0359,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000001535,MBR00000056,Pharmacy,Paid,Electronic_EDI,2023-09-11,2023-09-11,2023-09-11,2023-10-08,Auto_Adjudicated,27,1267286378,1432077493,207RE0101X,Endocrinology,22,In_Network,E11.9,R05.9,00071015523,,4,Commercial,EPO,74,F,1.3941,,,318.94,145.92,0.0,145.92,0.0,0.0,173.02,0.0,0.0,0,,0.0711,none,0,1,0,1,0,0.0,0,1,COA_Care_Transitions,FFS
CLM0000001536,MBR00000169,Pharmacy,Paid,Electronic_EDI,2023-10-02,2023-10-02,2023-10-02,2023-10-17,Auto_Adjudicated,15,1260336577,1300957944,101YP2500X,Psychologist Clinical,65,In_Network,OTHER,,59148001506,,1,Commercial,EPO,30,M,1.4348,,,869.4,370.28,202.91,94.64,22.0,50.73,499.12,0.0,0.0,0,,0.2339,unusual_service_frequency|diagnosis_procedure_mismatch,0,2,0,1,0,1.9e-05,0,0,,FFS
CLM0000001537,MBR00000295,Pharmacy,Paid,Electronic_EDI,2023-10-08,2023-10-08,2023-10-08,2023-10-18,Auto_Adjudicated,10,1671999102,1049766043,207RP1001X,Pulmonary Disease,21,In_Network,M17.11,R05.9|Z00.00,00071015523,,1,Commercial,HDHP_HSA,78,F,0.8618,,,362.29,246.86,56.0,176.86,0.0,14.0,115.43,0.0,0.0,0,,0.0589,none,0,1,0,0,0,5e-06,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000001538,MBR00000166,Medical_Professional,Paid,Electronic_EDI,2023-01-12,2023-01-12,2023-01-12,2023-01-25,Auto_Adjudicated,13,1899326088,1649705287,207R00000X,Internal Medicine,21,In_Network,I10,,97012,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,168.41,62.4,0.0,62.4,0.0,0.0,106.01,0.0,0.0,0,,0.0907,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001539,MBR00000192,Vision,Denied,Electronic_EDI,2023-09-21,2023-09-21,2023-09-21,2023-10-18,Auto_Adjudicated,27,1039678579,1391074619,207RG0100X,Gastroenterology,21,In_Network,Z23,H52.4|I48.91,92002,,0,Medicaid_MCO,MCO,22,F,1.1739,16,Timely_Filing,525.98,438.79,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.123,high_oop_waiver,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,Bundled_Payment
CLM0000001540,MBR00000201,Pharmacy,Paid,Electronic_EDI,2023-09-26,2023-09-26,2023-09-26,2023-10-07,Auto_Adjudicated,11,1035707913,1140170394,101YP2500X,Psychologist Clinical,22,In_Network,E78.5,,16590051660,,4,Medicare_Advantage,MA_PPO,74,M,1.1575,,,71.22,57.69,40.91,0.55,6.0,10.23,13.53,26.55,8.54,1,Upcoding,1.0,outlier_billing_amount|unusual_service_frequency|temporal_clustering|high_volume_same_code|impossible_service_combo|service_date_weekend|duplicate_claim_indicator|unbundling_pattern|phantom_billing_indicator|npi_mismatch|high_oop_waiver,1,5,0,0,0,4e-06,0,0,,FFS
CLM0000001541,MBR00000248,Dental,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-27,2023-07-16,Auto_Adjudicated,19,1508520529,1706603847,246ZN0300X,Neuropsychology,32,In_Network,I10,,D1110,,0,Commercial,PPO,40,F,0.6665,,,595.26,302.22,71.59,196.73,16.0,17.9,293.04,0.0,0.0,0,,0.1131,controlled_substance_high_volume,0,1,0,0,0,7e-06,0,0,,Shared_Savings
CLM0000001542,MBR00000136,Medical_Institutional,Paid,Electronic_EDI,2023-07-22,2023-07-22,2023-07-24,2023-07-27,Auto_Adjudicated,5,1099247356,1005335812,246ZN0300X,Neuropsychology,11,Out_of_Network,OTHER,J20.9|L70.0,revenue_code:0300,,0,Commercial,POS,2,F,1.2611,,,54427.71,43864.63,34874.42,199.61,72.0,8718.6,10563.08,0.0,0.0,0,,0.1926,outlier_billing_amount,0,1,1,0,0,0.003228,1,0,,FFS
CLM0000001543,MBR00000154,Medical_Institutional,Denied,Electronic_EDI,2023-10-26,2023-10-26,2023-10-30,2023-11-25,Auto_Adjudicated,30,1154652946,1330485436,225100000X,Physical Therapist,23,In_Network,K21.0,Z00.00,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,5,Timely_Filing,17876.82,10534.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.01,none,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000001544,MBR00000055,Pharmacy,Paid,Paper,2023-02-20,2023-02-20,2023-02-20,2023-03-12,Manual_Review,20,1871348663,1105733833,207RN0300X,Nephrology,11,In_Network,E13.9,I10|Z00.00,00003014960,,3,Commercial,PPO,68,F,1.2896,,,226.32,176.47,54.61,98.21,10.0,13.65,49.85,0.0,0.0,0,,0.0175,none,0,1,0,0,0,5e-06,0,0,BPD_BP_Declined,Shared_Savings
CLM0000001545,MBR00000184,Pharmacy,Paid,Electronic_EDI,2023-07-09,2023-07-09,2023-07-09,2023-08-07,Auto_Adjudicated,29,1046058495,1587454801,225100000X,Physical Therapist,11,Out_of_Network,OTHER,M54.5|E11.9,00003014960,,2,Medicaid_MCO,MLTSS,30,M,2.8302,,,484.87,336.58,334.58,0.0,2.0,0.0,148.29,0.0,0.0,0,,0.1226,geographic_mismatch,0,1,0,0,0,3.1e-05,0,0,,Shared_Savings
CLM0000001546,MBR00000092,Medical_Professional,Denied,Electronic_EDI,2023-10-04,2023-10-04,2023-10-04,2023-10-13,Manual_Review,9,1706476585,1942423230,207RN0300X,Nephrology,71,In_Network,E11.9,,90834,,0,Medicaid_MCO,MLTSS,68,F,1.3217,18,Timely_Filing,285.21,113.07,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0912,service_date_weekend,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000001547,MBR00000156,Medical_Institutional,Paid,Electronic_EDI,2023-04-04,2023-04-04,2023-04-06,2023-04-23,Manual_Review,19,1012271279,1689327034,207RG0100X,Gastroenterology,24,In_Network,I10,I10|Z23,revenue_code:0200,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,12443.35,8793.44,7004.62,8.67,29.0,1751.15,3649.91,0.0,0.0,0,,0.011,none,0,1,1,0,0,0.000648,0,0,,Shared_Savings
CLM0000001548,MBR00000226,Pharmacy,Partially_Paid,Electronic_EDI,2023-04-05,2023-04-05,2023-04-05,2023-04-14,Auto_Adjudicated,9,1101385540,1020312030,207RC0000X,Cardiovascular Disease,71,In_Network,E78.5,,50458085930,,2,Medicare_Advantage,MA_PPO,84,M,1.0796,96,Medical_Necessity,149.75,100.32,35.53,1.5,10.0,8.88,93.85,0.0,0.0,0,,0.2587,impossible_service_combo|phantom_billing_indicator,0,2,0,0,0,3e-06,0,0,,FFS
CLM0000001549,MBR00000006,Behavioral_Health,Paid,Electronic_EDI,2023-01-02,2023-01-02,2023-01-02,2023-01-17,Auto_Adjudicated,15,1881358103,1791502603,225100000X,Physical Therapist,21,In_Network,N40.0,F33.0|J20.9,99391,,0,Commercial,EPO,88,M,1.4365,,,177.49,133.64,78.53,2.48,33.0,19.63,43.85,0.0,0.0,0,,0.1597,unbundling_pattern,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000001550,MBR00000169,Medical_Professional,Paid,Electronic_EDI,2023-04-23,2023-04-23,2023-04-23,2023-05-03,Auto_Adjudicated,10,1555292468,1114756459,207R00000X,Internal Medicine,24,In_Network,Z12.11,OTHER,71250,,0,Commercial,EPO,30,M,1.4348,,,435.93,319.48,166.54,89.31,22.0,41.63,116.45,0.0,0.0,0,,0.1065,benford_violation,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000001551,MBR00000055,Medical_Professional,Paid,Electronic_EDI,2023-05-09,2023-05-09,2023-05-09,2023-05-14,Manual_Review,5,1855186422,1747596016,207RN0300X,Nephrology,23,In_Network,F41.1,Z12.11,47562,,0,Commercial,PPO,68,F,1.2896,,,726.04,519.99,269.5,173.11,10.0,67.38,206.05,0.0,0.0,0,,0.1385,none,0,1,0,0,0,2.5e-05,0,0,TRC_Transition_of_Care,P4P
CLM0000001552,MBR00000087,Medical_Institutional,Paid,Electronic_EDI,2023-12-08,2023-12-08,2023-12-08,2023-12-22,Auto_Adjudicated,14,1495592428,1489993356,207RG0100X,Gastroenterology,22,Out_of_Network,Z00.00,Z23,revenue_code:0450,,0,Medicaid_MCO,MCO,70,F,0.9232,,,63624.41,42809.23,42806.23,0.0,3.0,0.0,20815.18,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|benford_violation|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,1,1,0,0.003962,0,0,,Bundled_Payment
CLM0000001553,MBR00000011,Medical_Professional,Paid,Electronic_EDI,2023-01-30,2023-01-30,2023-01-30,2023-02-15,Auto_Adjudicated,16,1333969109,1554490060,207RG0100X,Gastroenterology,11,In_Network,Z00.00,Z00.00|OTHER|N18.3,97010,,0,Medicare_Advantage,SNP,35,F,1.0833,,,532.52,414.9,317.87,0.56,17.0,79.47,117.62,0.0,0.0,0,,0.0331,none,0,1,0,0,0,2.9e-05,0,0,,FFS
CLM0000001554,MBR00000053,Medical_Professional,Paid,Electronic_EDI,2023-08-21,2023-08-21,2023-08-21,2023-08-26,Auto_Adjudicated,5,1147452455,1489993356,225100000X,Physical Therapist,11,Emergency,Z23,,99222,,0,Medicaid_MCO,MLTSS,74,F,0.9277,,,233.0,172.31,172.31,0.0,0.0,0.0,60.69,0.0,0.0,0,,0.1268,none,0,1,0,0,0,1.6e-05,0,0,PPC_Prenatal_Care,FFS
CLM0000001555,MBR00000297,Medical_Institutional,Paid,Electronic_EDI,2023-01-23,2023-01-23,2023-01-25,2023-02-04,Auto_Adjudicated,12,1994365754,1220755708,207R00000X,Internal Medicine,11,In_Network,I10,I10|K21.0|Z00.00,revenue_code:0210,,0,Commercial,HMO,88,M,1.5311,,,947.45,680.19,487.57,31.73,39.0,121.89,267.26,0.0,0.0,0,,0.2324,provider_specialty_mismatch|controlled_substance_high_volume,0,2,0,0,0,4.5e-05,0,0,,Shared_Savings
CLM0000001556,MBR00000300,Medical_Institutional,Denied,Electronic_EDI,2023-10-14,2023-10-14,2023-10-15,2023-10-17,Manual_Review,3,1594322174,1831337866,207RN0300X,Nephrology,24,Emergency,OTHER,OTHER,revenue_code:0120,,0,Commercial,PPO,64,F,1.0393,97,Authorization,44833.99,18440.17,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0198,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001557,MBR00000212,Medical_Institutional,Paid,Electronic_EDI,2023-06-18,2023-06-18,2023-06-20,2023-07-08,Manual_Review,20,1732726112,1163639177,207R00000X,Internal Medicine,24,In_Network,OTHER,,revenue_code:0200,,0,Commercial,HMO,57,F,2.5456,,,3534.9,2955.44,1953.49,445.57,68.0,488.37,579.46,0.0,0.0,0,,0.1519,phantom_billing_indicator,0,1,0,0,0,0.000181,0,0,,Shared_Savings
CLM0000001558,MBR00000184,Medical_Professional,Paid,Electronic_EDI,2023-06-02,2023-06-02,2023-06-02,2023-06-12,Manual_Review,10,1843445592,1898471307,207RP1001X,Pulmonary Disease,23,In_Network,OTHER,M54.5|OTHER,70553,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,909.84,716.95,714.95,0.0,2.0,0.0,192.89,0.0,0.0,0,,0.0024,none,0,1,0,0,0,6.6e-05,0,0,CBP_Controlling_BP,FFS
CLM0000001559,MBR00000229,Behavioral_Health,Paid,Electronic_EDI,2023-12-05,2023-12-05,2023-12-05,2023-12-08,Auto_Adjudicated,3,1592228076,1650774392,207RE0101X,Endocrinology,11,In_Network,F32.9,E78.5|J06.9,99396,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,254.66,157.32,103.96,13.37,14.0,25.99,97.34,0.0,0.0,0,,0.0213,none,0,1,0,1,0,1e-05,0,0,,FFS
CLM0000001560,MBR00000272,Medical_Institutional,Denied,Provider_Portal,2023-09-26,2023-09-26,2023-09-27,2023-10-12,Auto_Adjudicated,16,1331264469,1643673796,207V00000X,Obstetrics & Gynecology,24,Out_of_Network,E78.5,OTHER,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,15,M,0.8525,4,Network,29260.12,23408.12,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.069,none,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000001561,MBR00000159,Pharmacy,Paid,Electronic_EDI,2023-02-07,2023-02-07,2023-02-07,2023-03-05,Clinical_Review,26,1443292773,1489434038,207R00000X,Internal Medicine,11,In_Network,F41.1,,59148001506,,4,Commercial,PPO,70,F,1.2009,,,89.06,55.13,26.05,8.56,14.0,6.51,33.93,0.0,0.0,0,,0.0792,billing_spike_recent,0,1,0,1,0,2e-06,0,1,,FFS
CLM0000001562,MBR00000011,Medical_Professional,Paid,Provider_Portal,2023-04-06,2023-04-06,2023-04-06,2023-05-06,Auto_Adjudicated,30,1006539337,1887266184,207Q00000X,Family Medicine,32,In_Network,Z00.01,I10|OTHER,97110,,0,Medicare_Advantage,SNP,35,F,1.0833,,,971.53,607.34,470.87,1.75,17.0,117.72,364.19,0.0,0.0,0,,0.03,none,0,1,0,0,0,4.4e-05,0,0,,Shared_Savings
CLM0000001563,MBR00000210,Pharmacy,Paid,Provider_Portal,2023-04-09,2023-04-09,2023-04-09,2023-05-09,Auto_Adjudicated,30,1625939855,1402472115,101YP2500X,Psychologist Clinical,21,In_Network,OTHER,I10|F41.1,16590051660,,2,Medicare_Advantage,SNP,49,M,0.6952,,,662.32,510.79,383.64,13.24,18.0,95.91,151.53,0.0,0.0,0,,0.063,none,0,1,0,0,0,3.6e-05,0,1,FUH_Follow_Up_Hospitalization,Capitation
CLM0000001564,MBR00000296,Pharmacy,Paid,Electronic_EDI,2023-08-07,2023-08-07,2023-08-07,2023-08-13,Manual_Review,6,1832660692,1945682535,2086S0122X,Orthopedic Surgery,23,In_Network,I50.9,OTHER|I10,00169751112,,5,Commercial,HMO,83,F,1.4969,,,216.8,117.83,66.16,4.13,31.0,16.54,98.97,44.86,11.48,0,,0.0195,none,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000001565,MBR00000080,Medical_Professional,Paid,Electronic_EDI,2023-10-25,2023-10-25,2023-10-25,2023-11-01,Auto_Adjudicated,7,1124477249,1061113875,208600000X,Surgery General,11,In_Network,E78.5,Z00.00|E11.9,97110,,0,Commercial,HDHP_HSA,74,M,0.5935,,,352.01,249.84,0.0,249.84,0.0,0.0,102.17,0.0,0.0,0,,0.0788,geographic_mismatch,0,1,0,0,0,0.0,0,0,,P4P
CLM0000001566,MBR00000143,Pharmacy,Denied,Electronic_EDI,2023-08-17,2023-08-17,2023-08-17,2023-09-13,Auto_Adjudicated,27,1658382624,1164525386,2084P0800X,Psychiatry,21,In_Network,OTHER,E78.5,00003014960,,3,Commercial,POS,85,M,1.6078,2,Medical_Necessity,55.66,41.84,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1019,none,0,1,0,0,0,0.0,0,1,,P4P
CLM0000001567,MBR00000114,Pharmacy,Partially_Paid,Electronic_EDI,2023-05-25,2023-05-25,2023-05-25,2023-06-13,Auto_Adjudicated,19,1495592428,1164525386,225100000X,Physical Therapist,22,Out_of_Network,E11.9,Z23,00078043215,,3,Medicare_Advantage,MA_PPO,57,F,1.0712,50,Medical_Necessity,592.36,473.66,205.16,21.61,19.0,51.29,295.3,0.0,0.0,0,,0.0741,none,0,1,0,0,0,1.9e-05,0,1,,Shared_Savings
CLM0000001568,MBR00000125,Medical_Institutional,Denied,Electronic_EDI,2023-09-26,2023-09-26,2023-09-29,2023-10-13,Manual_Review,17,1059948944,1842149518,207RN0300X,Nephrology,22,In_Network,M25.511,J45.20|Z00.00,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,50,Network,8081.99,5359.79,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0585,none,0,1,0,0,0,0.0,0,0,FUH_Follow_Up_Hospitalization,Capitation
CLM0000001569,MBR00000212,Pharmacy,Paid,Electronic_EDI,2023-09-30,2023-09-30,2023-09-30,2023-10-25,Auto_Adjudicated,25,1950560596,1128148362,2086S0122X,Orthopedic Surgery,11,In_Network,Z23,,00169751112,,1,Commercial,HMO,57,F,2.5456,,,148.49,73.39,0.0,73.39,0.0,0.0,75.1,0.0,0.0,0,,0.1047,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001570,MBR00000120,Medical_Professional,Denied,Provider_Portal,2023-01-29,2023-01-29,2023-01-29,2023-01-31,Clinical_Review,2,1243349799,1296566243,207R00000X,Internal Medicine,22,In_Network,OTHER,I25.10,99204,,0,Commercial,PPO,62,F,1.0823,170,Network,991.33,734.64,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.03,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001571,MBR00000285,Medical_Institutional,Denied,Electronic_EDI,2023-07-14,2023-07-14,2023-07-15,2023-07-31,Auto_Adjudicated,17,1658382624,1938465393,207RG0100X,Gastroenterology,11,In_Network,OTHER,,revenue_code:0100,,0,Commercial,HDHP_HSA,56,M,0.9226,96,COB,27537.54,10909.74,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1168,phantom_billing_indicator,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000001572,MBR00000234,Behavioral_Health,Denied,Electronic_EDI,2023-09-13,2023-09-13,2023-09-13,2023-10-01,Auto_Adjudicated,18,1346717076,1004714954,207RE0101X,Endocrinology,65,In_Network,M54.5,G43.909|OTHER,11200,,0,Medicare_Advantage,MA_HMO,59,M,0.395,97,Timely_Filing,390.12,263.23,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1839,npi_mismatch|controlled_substance_high_volume,0,1,0,1,0,0.0,0,0,KED_ESRD_Patients,P4P
CLM0000001573,MBR00000009,Medical_Professional,Paid,Electronic_EDI,2023-08-05,2023-08-05,2023-08-05,2023-09-03,Auto_Adjudicated,29,1670125610,1767402068,207RN0300X,Nephrology,21,In_Network,J20.9,,71250,,0,Commercial,HMO,11,F,0.5327,,,2051.02,1443.54,687.14,549.61,35.0,171.79,607.48,0.0,0.0,0,,0.0273,none,0,1,0,0,0,6.4e-05,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000001574,MBR00000244,Medical_Professional,Paid,Electronic_EDI,2023-03-29,2023-03-29,2023-03-29,2023-04-13,Auto_Adjudicated,15,1145887050,1643323506,207RP1001X,Pulmonary Disease,22,In_Network,E11.9,OTHER|Z00.00,90853,,0,Commercial,PPO,52,M,0.6677,,,218.11,171.83,0.0,171.83,0.0,0.0,46.28,0.0,0.0,0,,0.0256,none,0,1,0,1,0,0.0,0,0,ACR_Urine_Protein,FFS
CLM0000001575,MBR00000228,Medical_Professional,Denied,Electronic_EDI,2023-02-27,2023-02-27,2023-02-27,2023-03-15,Auto_Adjudicated,16,1731980913,1304018750,101YP2500X,Psychologist Clinical,22,In_Network,OTHER,,99204,,0,Commercial,PPO,55,F,0.7203,2,Duplicate,603.14,330.27,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0871,none,0,1,0,0,0,0.0,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000001576,MBR00000158,Behavioral_Health,Paid,Paper,2023-04-15,2023-04-15,2023-04-15,2023-05-10,Auto_Adjudicated,25,1956107350,1945682535,207RE0101X,Endocrinology,24,In_Network,F41.1,I10|F10.10|E11.9,99203,,0,Commercial,HMO,65,M,1.5361,,,507.28,368.9,90.2,242.15,14.0,22.55,138.38,0.0,0.0,0,,0.1043,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000001577,MBR00000154,Medical_Professional,Paid,Electronic_EDI,2023-05-07,2023-05-07,2023-05-07,2023-05-16,Auto_Adjudicated,9,1633089013,1694343357,207Q00000X,Family Medicine,11,In_Network,OTHER,E11.9|OTHER,99204,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,224.02,141.65,104.33,11.23,0.0,26.08,82.37,0.0,0.0,0,,0.0755,none,0,1,0,0,0,1e-05,0,0,,Bundled_Payment
CLM0000001578,MBR00000250,Medical_Professional,Paid,Electronic_EDI,2023-11-27,2023-11-27,2023-11-27,2023-11-30,Auto_Adjudicated,3,1026612378,1607833568,208600000X,Surgery General,23,Out_of_Network,OTHER,F32.9,90832,,0,Commercial,PPO,41,M,0.9245,,,1100.34,730.81,540.4,31.31,24.0,135.1,369.53,0.0,0.0,0,,0.163,temporal_clustering|benford_violation,0,1,0,0,0,5e-05,1,0,,FFS
CLM0000001579,MBR00000134,Pharmacy,Paid,Electronic_EDI,2023-08-12,2023-08-12,2023-08-12,2023-08-27,Auto_Adjudicated,15,1374361443,1554490060,207RG0100X,Gastroenterology,65,In_Network,E78.5,,00003014960,,1,Medicare_Advantage,MA_PPO,33,M,1.115,,,390.33,270.3,170.61,44.03,13.0,42.65,120.03,0.0,0.0,0,,0.0243,none,0,1,0,0,0,1.6e-05,0,0,MMA_Medication_Management,Bundled_Payment
CLM0000001580,MBR00000051,Pharmacy,Paid,Electronic_EDI,2023-10-28,2023-10-28,2023-10-28,2023-11-16,Auto_Adjudicated,19,1946657989,1267212691,207RP1001X,Pulmonary Disease,22,In_Network,Z00.01,Z12.11,00078043215,,1,Medicare_Advantage,MA_PPO,17,F,1.0695,,,102.18,43.79,0.0,43.79,0.0,0.0,58.39,0.0,0.0,0,,0.1011,none,0,1,0,0,0,0.0,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000001581,MBR00000099,Medical_Institutional,Paid,Electronic_EDI,2023-01-10,2023-01-10,2023-01-12,2023-01-25,Auto_Adjudicated,15,1451329728,1591405274,101YP2500X,Psychologist Clinical,11,In_Network,F33.0,F32.9,revenue_code:0250,,0,Commercial,HMO,10,F,0.7843,,,27329.73,19675.64,15667.36,40.44,51.0,3916.84,7654.09,0.0,0.0,0,,0.014,none,0,1,1,0,0,0.00145,0,0,,Capitation
CLM0000001582,MBR00000081,Behavioral_Health,Paid,Electronic_EDI,2023-10-09,2023-10-09,2023-10-09,2023-10-31,Auto_Adjudicated,22,1683994149,1540743888,207RE0101X,Endocrinology,11,Out_of_Network,M54.5,E78.5|Z00.01,99213,,0,Medicare_Advantage,SNP,66,F,2.159,,,160.13,63.66,41.17,7.19,5.0,10.29,96.47,0.0,0.0,0,,0.2405,high_volume_same_code|billing_spike_recent,0,2,0,0,0,4e-06,1,0,,Shared_Savings
CLM0000001583,MBR00000202,Medical_Professional,Paid,Paper,2023-03-09,2023-03-09,2023-03-09,2023-03-17,Auto_Adjudicated,8,1172766349,1522426351,207RN0300X,Nephrology,71,In_Network,E78.5,OTHER|E78.5,90837,,0,Commercial,PPO,87,F,0.6213,,,3989.44,3339.4,2395.17,323.43,22.0,598.79,650.04,0.0,0.0,0,,0.1093,none,0,1,0,0,0,0.000222,0,0,,FFS
CLM0000001584,MBR00000056,Medical_Institutional,Paid,Electronic_EDI,2023-07-23,2023-07-23,2023-07-27,2023-07-24,Manual_Review,1,1803277343,1810068286,207RN0300X,Nephrology,11,In_Network,J20.9,M17.11|Z00.00,revenue_code:0360,,0,Commercial,EPO,74,F,1.3941,,,13879.37,5845.35,4621.74,21.17,47.0,1155.44,8034.02,0.0,0.0,0,,0.0794,none,0,1,0,0,0,0.000428,0,0,TRC_Transition_of_Care,Bundled_Payment
CLM0000001585,MBR00000191,Medical_Institutional,Denied,Electronic_EDI,2023-05-19,2023-05-19,2023-05-22,2023-06-12,Manual_Review,24,1700802848,1297948643,246ZN0300X,Neuropsychology,11,In_Network,J20.9,,revenue_code:0360,,0,Commercial,POS,85,F,0.9729,18,Eligibility,19991.05,16854.66,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0439,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001586,MBR00000144,Medical_Professional,Paid,Electronic_EDI,2023-11-07,2023-11-07,2023-11-07,2023-12-03,Auto_Adjudicated,26,1344162462,1763260577,225100000X,Physical Therapist,65,In_Network,J20.9,,43239,,0,Commercial,HDHP_HSA,56,F,2.5926,,,208.03,98.88,26.24,66.08,0.0,6.56,109.15,0.0,0.0,0,,0.0319,none,0,1,0,1,0,2e-06,0,0,SPC_Statin_Therapy,FFS
CLM0000001587,MBR00000251,Dental,Paid,Electronic_EDI,2023-08-31,2023-08-31,2023-08-31,2023-09-19,Clinical_Review,19,1462532026,1013600387,207RN0300X,Nephrology,31,Emergency,M54.5,I10,D2391,,0,Commercial,PPO,65,M,0.7737,,,443.87,245.81,34.0,190.3,13.0,8.5,198.06,0.0,0.0,0,,0.0543,none,0,1,0,0,0,3e-06,0,0,,Bundled_Payment
CLM0000001588,MBR00000151,Medical_Institutional,Paid,Electronic_EDI,2023-06-15,2023-06-15,2023-06-18,2023-06-25,Auto_Adjudicated,10,1804302686,1029818813,207RN0300X,Nephrology,22,In_Network,I10,Z00.01,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,77,M,0.8709,,,35977.58,22854.84,18243.79,13.11,37.0,4560.95,13122.74,0.0,0.0,0,,0.1308,phantom_billing_indicator,0,1,1,0,0,0.001689,0,0,,Bundled_Payment
CLM0000001589,MBR00000280,Medical_Professional,Denied,Electronic_EDI,2023-07-02,2023-07-02,2023-07-02,2023-07-14,Auto_Adjudicated,12,1388662212,1564691686,208600000X,Surgery General,11,In_Network,I10,Z00.00|R05.9,74177,,0,Commercial,PPO,79,F,0.6697,1,Duplicate,347.5,204.94,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0892,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001590,MBR00000273,Medical_Professional,Paid,Provider_Portal,2023-09-11,2023-09-11,2023-09-11,2023-09-26,Auto_Adjudicated,15,1518661623,1025886739,2084P0800X,Psychiatry,22,In_Network,F10.10,Z00.00,71046,,0,ACA_Marketplace,ACA_Bronze,4,M,1.3569,,,450.97,317.22,0.0,317.22,0.0,0.0,133.75,0.0,0.0,0,,0.0609,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001591,MBR00000058,Medical_Professional,Paid,Electronic_EDI,2023-09-16,2023-09-16,2023-09-16,2023-09-29,Auto_Adjudicated,13,1117755591,1396850418,207RC0000X,Cardiovascular Disease,31,In_Network,F32.9,F32.9,99204,,0,Commercial,PPO,56,F,1.1626,,,196.24,135.06,89.5,8.18,15.0,22.38,61.18,0.0,0.0,0,,0.0791,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000001592,MBR00000205,Dental,Paid,Electronic_EDI,2023-07-25,2023-07-25,2023-07-25,2023-08-01,Auto_Adjudicated,7,1886549972,1325999602,207RN0300X,Nephrology,11,Emergency,F32.9,G47.33,D7140,,0,Medicaid_MCO,MCO,1,F,0.9425,,,175.11,93.41,92.41,0.0,1.0,0.0,81.7,0.0,0.0,0,,0.1348,none,0,1,0,0,0,9e-06,0,0,,Capitation
CLM0000001593,MBR00000065,Medical_Professional,Paid,Electronic_EDI,2023-09-18,2023-09-18,2023-09-18,2023-09-30,Manual_Review,12,1078576574,1747935894,2084P0800X,Psychiatry,11,In_Network,OTHER,J06.9,99214,,0,Commercial,HDHP_HSA,63,M,0.7795,,,146.51,107.46,0.0,107.46,0.0,0.0,39.05,0.0,0.0,0,,0.0669,npi_mismatch,0,1,0,0,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,P4P
CLM0000001594,MBR00000246,Dental,Paid,Provider_Portal,2023-10-11,2023-10-11,2023-10-11,2023-10-20,Auto_Adjudicated,9,1263063839,1391074619,207RN0300X,Nephrology,65,In_Network,OTHER,I10|E11.9,D4341,,0,Commercial,PPO,80,F,0.7925,,,649.03,385.75,249.13,44.33,30.0,62.28,263.28,0.0,0.0,0,,0.1443,none,0,1,0,0,0,2.3e-05,0,0,,Bundled_Payment
CLM0000001595,MBR00000188,Medical_Professional,Paid,Electronic_EDI,2023-01-12,2023-01-12,2023-01-12,2023-01-26,Manual_Review,14,1207523397,1365397818,207Q00000X,Family Medicine,24,In_Network,Z00.00,,99392,,0,Commercial,HMO,8,F,1.5853,,,148.7,98.04,43.66,18.46,25.0,10.92,50.66,0.0,0.0,0,,0.0544,none,0,1,0,0,0,4e-06,0,0,,Capitation
CLM0000001596,MBR00000092,Behavioral_Health,Paid,Provider_Portal,2023-05-12,2023-05-12,2023-05-12,2023-05-24,Auto_Adjudicated,12,1617763056,1728466420,207RN0300X,Nephrology,22,In_Network,OTHER,,99396,,0,Medicaid_MCO,MLTSS,68,F,1.3217,,,90.18,63.37,60.37,0.0,3.0,0.0,26.81,0.0,0.0,0,,0.0445,none,0,1,0,1,0,6e-06,0,0,,Shared_Savings
CLM0000001597,MBR00000077,Pharmacy,Paid,Electronic_EDI,2023-11-20,2023-11-20,2023-11-20,2023-12-06,Clinical_Review,16,1478783612,1296566243,207RN0300X,Nephrology,65,In_Network,E78.5,,59148001506,,1,Medicare_Advantage,MA_HMO,27,F,0.9229,,,197.71,130.05,97.95,3.61,4.0,24.49,67.66,0.0,0.0,1,Kickback Arrangement,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|high_volume_same_code|benford_violation|billing_spike_recent|upcoding_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,9e-06,0,1,,Shared_Savings
CLM0000001598,MBR00000135,Medical_Professional,Denied,Electronic_EDI,2023-04-26,2023-04-26,2023-04-26,2023-05-21,Auto_Adjudicated,25,1706065807,1004714954,207R00000X,Internal Medicine,22,In_Network,F10.10,I10,70553,,0,Commercial,PPO,58,F,2.2702,97,Authorization,975.75,379.65,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.148,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001599,MBR00000236,Medical_Professional,Denied,Electronic_EDI,2023-10-23,2023-10-23,2023-10-23,2023-11-02,Auto_Adjudicated,10,1130461876,1447657873,101YP2500X,Psychologist Clinical,71,In_Network,I10,M54.5,82947,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,5,Timely_Filing,349.25,254.24,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1966,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001600,MBR00000236,Pharmacy,Partially_Paid,Electronic_EDI,2023-07-17,2023-07-17,2023-07-17,2023-07-19,Auto_Adjudicated,2,1893886964,1510751265,207RG0100X,Gastroenterology,11,In_Network,I10,J06.9|Z12.11,00006001954,,1,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,3,Medical_Necessity,112.43,66.07,46.59,0.0,3.0,0.0,62.84,0.0,0.0,0,,0.1237,none,0,1,0,0,0,4e-06,0,1,,Shared_Savings
CLM0000001601,MBR00000011,Medical_Professional,Paid,Electronic_EDI,2023-04-08,2023-04-08,2023-04-08,2023-05-03,Auto_Adjudicated,25,1110312325,1513198866,207RG0100X,Gastroenterology,21,In_Network,OTHER,E11.9|G47.33,99204,,0,Medicare_Advantage,SNP,35,F,1.0833,,,366.96,152.51,106.93,1.84,17.0,26.73,214.45,0.0,0.0,0,,0.1116,high_volume_same_code|npi_mismatch,0,1,0,0,0,1e-05,0,0,W30_Well_Child_Visit,Shared_Savings
CLM0000001602,MBR00000096,Medical_Professional,Paid,Electronic_EDI,2023-05-06,2023-05-06,2023-05-06,2023-05-12,Auto_Adjudicated,6,1346717076,1493836023,207RN0300X,Nephrology,23,In_Network,E11.65,Z00.00|K21.0|OTHER,81001,,0,Medicaid_MCO,MCO,62,M,0.7948,,,2246.96,1000.84,998.84,0.0,2.0,0.0,1246.12,0.0,0.0,1,Duplicate Billing,0.8899,outlier_billing_amount|temporal_clustering|high_volume_same_code|impossible_service_combo|billing_spike_recent|upcoding_pattern|unbundling_pattern|controlled_substance_high_volume,1,5,0,0,0,9.2e-05,0,0,PPC_Prenatal_Care,Shared_Savings
CLM0000001603,MBR00000134,Pharmacy,Paid,Electronic_EDI,2023-06-23,2023-06-23,2023-06-23,2023-07-21,Manual_Review,28,1556434733,1623053477,246ZN0300X,Neuropsychology,21,In_Network,J06.9,,00003014960,,1,Medicare_Advantage,MA_PPO,33,M,1.115,,,264.17,121.89,71.55,19.46,13.0,17.89,142.28,0.0,0.0,0,,0.067,none,0,1,0,0,0,7e-06,0,0,,Capitation
CLM0000001604,MBR00000176,Dental,Paid,Electronic_EDI,2023-02-14,2023-02-14,2023-02-14,2023-03-02,Auto_Adjudicated,16,1496340237,1027261156,208600000X,Surgery General,21,In_Network,OTHER,,D4341,,0,Commercial,POS,4,M,0.8792,,,129.45,102.72,0.0,102.72,0.0,0.0,26.73,0.0,0.0,0,,0.1276,benford_violation,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001605,MBR00000047,Pharmacy,Paid,Electronic_EDI,2023-04-21,2023-04-21,2023-04-21,2023-05-07,Manual_Review,16,1098094939,1662516615,2086S0122X,Orthopedic Surgery,23,Emergency,E78.5,,00006001954,,5,Commercial,PPO,37,M,0.565,,,89.37,58.23,0.0,58.23,0.0,0.0,31.14,0.0,0.0,0,,0.1331,none,0,1,0,0,0,0.0,0,0,BCS_Breast_Cancer_Screening,Shared_Savings
CLM0000001606,MBR00000106,Dental,Paid,Paper,2023-09-02,2023-09-02,2023-09-02,2023-09-15,Auto_Adjudicated,13,1111846258,1564691686,207RP1001X,Pulmonary Disease,22,In_Network,Z00.00,OTHER|M54.5,D2391,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,742.71,280.55,206.81,16.04,6.0,51.7,462.16,0.0,0.0,0,,0.1042,none,0,1,0,0,0,1.9e-05,0,0,,Bundled_Payment
CLM0000001607,MBR00000269,Medical_Institutional,Paid,Electronic_EDI,2023-11-22,2023-11-22,2023-11-25,2023-12-14,Auto_Adjudicated,22,1654042271,1354959095,207RC0000X,Cardiovascular Disease,11,In_Network,Z12.11,J20.9,revenue_code:0360,,0,Commercial,EPO,10,F,0.718,,,59063.6,44362.2,35411.96,27.25,70.0,8852.99,14701.4,23498.76,6215.44,0,,0.0842,outlier_billing_amount,0,1,1,0,0,0.003278,0,0,,FFS
CLM0000001608,MBR00000146,Pharmacy,Paid,Electronic_EDI,2023-12-08,2023-12-08,2023-12-08,2023-12-28,Auto_Adjudicated,20,1192302048,1985590322,207Q00000X,Family Medicine,22,In_Network,C50.911,OTHER,00169751112,,3,Medicaid_MCO,MCO,24,M,0.6484,,,167.81,117.24,113.24,0.0,4.0,0.0,50.57,0.0,0.0,0,,0.0266,none,0,1,0,0,0,1e-05,0,0,LCS_Lung_Cancer_Screening,Shared_Savings
CLM0000001609,MBR00000218,Medical_Professional,Denied,Electronic_EDI,2023-05-18,2023-05-18,2023-05-18,2023-06-15,Auto_Adjudicated,28,1897231867,1510751265,207RG0100X,Gastroenterology,23,In_Network,G47.33,N40.0,99213,,0,Commercial,HDHP_HSA,11,F,0.4964,22,Eligibility,256.45,155.75,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0362,none,0,1,0,1,0,0.0,0,0,,P4P
CLM0000001610,MBR00000150,Pharmacy,Paid,Electronic_EDI,2023-10-13,2023-10-13,2023-10-13,2023-10-14,Auto_Adjudicated,1,1677021292,1764064254,207RE0101X,Endocrinology,23,Out_of_Network,F32.9,J44.1|E11.65,50458085930,,2,Medicare_Advantage,MA_HMO,1,F,0.2444,,,80.82,61.66,40.16,2.46,9.0,10.04,19.16,0.0,0.0,0,,0.0346,none,0,1,0,0,0,4e-06,1,1,,FFS
CLM0000001611,MBR00000144,Pharmacy,Paid,Electronic_EDI,2023-05-23,2023-05-23,2023-05-23,2023-05-29,Auto_Adjudicated,6,1731980913,1187669363,207RN0300X,Nephrology,22,In_Network,M17.11,,00310075090,,1,Commercial,HDHP_HSA,56,F,2.5926,,,800.14,587.35,0.0,587.35,0.0,0.0,212.79,0.0,0.0,1,DME Fraud,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|benford_violation|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|unbundling_pattern|phantom_billing_indicator|npi_mismatch,1,5,0,0,0,0.0,0,1,LCS_Lung_Cancer_Screening,Capitation
CLM0000001612,MBR00000185,Medical_Institutional,Paid,Electronic_EDI,2023-10-17,2023-10-17,2023-10-21,2023-10-26,Auto_Adjudicated,9,1893327624,1616762819,207R00000X,Internal Medicine,11,In_Network,N39.0,OTHER,revenue_code:0360,,0,Medicaid_MCO,MCO,73,M,1.5417,,,70137.37,42192.34,42184.34,0.0,8.0,0.0,27945.03,0.0,0.0,0,,0.1161,outlier_billing_amount|impossible_service_combo,0,1,1,0,0,0.003905,0,0,,Shared_Savings
CLM0000001613,MBR00000081,Behavioral_Health,Denied,Paper,2023-11-24,2023-11-24,2023-11-24,2023-11-30,Auto_Adjudicated,6,1887322427,1330485436,208600000X,Surgery General,11,In_Network,Z12.11,E11.9,99385,,0,Medicare_Advantage,SNP,66,F,2.159,18,Medical_Necessity,211.2,151.75,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.09,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001614,MBR00000077,Medical_Institutional,Paid,Electronic_EDI,2023-06-09,2023-06-09,2023-06-13,2023-07-08,Auto_Adjudicated,29,1112402001,1330485436,207V00000X,Obstetrics & Gynecology,31,In_Network,Z00.01,I25.10,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,27,F,0.9229,,,5534.38,2000.94,1566.46,4.87,38.0,391.61,3533.44,0.0,0.0,0,,0.0614,none,0,1,0,0,0,0.000145,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000001615,MBR00000297,Medical_Institutional,Paid,Electronic_EDI,2023-08-04,2023-08-04,2023-08-08,2023-08-07,Auto_Adjudicated,3,1482771601,1912895973,225100000X,Physical Therapist,31,In_Network,I10,J06.9|F32.9,revenue_code:0300,,0,Commercial,HMO,88,M,1.5311,,,2411.16,1450.44,1120.04,11.39,39.0,280.01,960.72,0.0,0.0,0,,0.0031,none,0,1,0,0,0,0.000104,0,0,,Shared_Savings
CLM0000001616,MBR00000262,Medical_Institutional,Paid,Electronic_EDI,2023-11-08,2023-11-08,2023-11-09,2023-11-12,Auto_Adjudicated,4,1731980913,1847196500,2086S0122X,Orthopedic Surgery,22,In_Network,G43.909,Z00.00,revenue_code:0210,,0,Medicare_Advantage,PFFS,77,F,1.7452,,,12738.58,6813.72,5425.66,0.65,31.0,1356.41,5924.86,0.0,0.0,1,Duplicate Billing,0.9414,outlier_billing_amount|temporal_clustering|benford_violation|impossible_service_combo|duplicate_claim_indicator|upcoding_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,1,0,0,0.000502,0,0,,Capitation
CLM0000001617,MBR00000216,Medical_Professional,Denied,Electronic_EDI,2023-02-19,2023-02-19,2023-02-19,2023-03-05,Auto_Adjudicated,14,1976612978,1575884274,2084P0800X,Psychiatry,22,In_Network,OTHER,OTHER|I10,99383,,0,Medicare_Advantage,MA_HMO,71,F,0.7117,5,Coding_Error,238.74,111.14,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1262,none,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,Capitation
CLM0000001618,MBR00000042,Medical_Professional,Paid,Electronic_EDI,2023-03-30,2023-03-30,2023-03-30,2023-04-07,Auto_Adjudicated,8,1147937670,1034732777,207RN0300X,Nephrology,11,Emergency,Z12.11,E11.65|OTHER,99221,,0,Commercial,HMO,78,F,1.1448,,,280.71,162.91,98.05,20.34,20.0,24.51,117.8,0.0,0.0,0,,0.0472,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000001619,MBR00000010,Behavioral_Health,Paid,Electronic_EDI,2023-08-13,2023-08-13,2023-08-13,2023-08-23,Auto_Adjudicated,10,1898865801,1538261819,207RN0300X,Nephrology,22,In_Network,M54.5,E78.5,84443,,0,Medicare_Advantage,MA_HMO,44,F,1.4631,,,439.85,240.25,156.42,40.73,4.0,39.1,199.6,0.0,0.0,0,,0.1301,none,0,1,0,0,0,1.4e-05,0,0,,Capitation
CLM0000001620,MBR00000055,Medical_Professional,Paid,Electronic_EDI,2023-03-06,2023-03-06,2023-03-06,2023-03-25,Auto_Adjudicated,19,1756856314,1747596016,207Q00000X,Family Medicine,22,In_Network,N18.3,M54.5|Z23,17000,,0,Commercial,PPO,68,F,1.2896,,,1002.4,443.5,296.62,62.73,10.0,74.15,558.9,193.29,59.3,0,,0.1116,temporal_clustering,0,1,0,0,0,2.7e-05,0,0,,Bundled_Payment
CLM0000001621,MBR00000284,Pharmacy,Denied,Paper,2023-10-13,2023-10-13,2023-10-13,2023-10-30,Auto_Adjudicated,17,1154652946,1884259357,207Q00000X,Family Medicine,22,In_Network,Z00.00,J20.9,00169751112,,1,Medicaid_MCO,FFS_Medicaid,23,M,0.5234,1,Network,210.35,178.78,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0978,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000001622,MBR00000242,Medical_Institutional,Paid,Electronic_EDI,2023-04-06,2023-04-06,2023-04-09,2023-05-02,Manual_Review,26,1048378959,1450837722,246ZN0300X,Neuropsychology,11,In_Network,E11.65,E11.9|K29.70,revenue_code:0450,,0,Medicaid_MCO,MLTSS,75,F,0.7104,,,33529.4,12606.94,12604.94,0.0,2.0,0.0,20922.46,0.0,0.0,0,,0.0463,none,0,1,1,0,0,0.001167,0,0,,Capitation
CLM0000001623,MBR00000160,Dental,Paid,Electronic_EDI,2023-05-02,2023-05-02,2023-05-02,2023-05-16,Auto_Adjudicated,14,1853403237,1469642907,207RG0100X,Gastroenterology,11,In_Network,F32.9,Z79.4,D7140,,0,Commercial,HMO,73,M,1.9608,,,201.98,155.29,0.0,155.29,0.0,0.0,46.69,0.0,0.0,0,,0.0633,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001624,MBR00000293,Pharmacy,Paid,Electronic_EDI,2023-10-19,2023-10-19,2023-10-19,2023-11-17,Auto_Adjudicated,29,1688560518,1689327034,207RC0000X,Cardiovascular Disease,65,In_Network,K21.0,,16590051660,,1,Medicare_Advantage,MA_HMO,84,F,2.8513,,,318.51,231.57,138.72,47.18,11.0,34.68,86.94,0.0,0.0,0,,0.0359,none,0,1,0,1,0,1.3e-05,0,0,,Shared_Savings
CLM0000001625,MBR00000046,Medical_Professional,Paid,Electronic_EDI,2023-07-09,2023-07-09,2023-07-09,2023-07-15,Auto_Adjudicated,6,1091271799,1591405274,207RE0101X,Endocrinology,22,In_Network,Z00.00,Z00.01|M17.11,99284,,0,Commercial,HMO,76,F,0.9613,,,396.22,153.41,77.03,22.12,35.0,19.26,242.81,0.0,0.0,0,,0.0426,none,0,1,0,0,0,7e-06,0,0,,Shared_Savings
CLM0000001626,MBR00000168,Medical_Professional,Partially_Paid,Electronic_EDI,2023-10-11,2023-10-11,2023-10-11,2023-10-17,Auto_Adjudicated,6,1496489953,1330485436,246ZN0300X,Neuropsychology,31,In_Network,OTHER,J06.9|OTHER|E78.5,99385,,0,Commercial,HMO,76,M,1.2791,256,Medical_Necessity,592.67,308.52,0.0,155.13,0.0,0.0,437.54,0.0,0.0,0,,0.1093,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,MPT_Annual_Monitoring,FFS
CLM0000001627,MBR00000057,Pharmacy,Denied,Electronic_EDI,2023-08-14,2023-08-14,2023-08-14,2023-08-26,Auto_Adjudicated,12,1760186113,1055872102,207RP1001X,Pulmonary Disease,23,In_Network,I10,Z00.00|J06.9|J44.1,00071015523,,3,Medicare_Advantage,MA_PPO,45,M,0.6701,4,Authorization,60.13,39.52,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1097,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000001628,MBR00000097,Medical_Professional,Paid,Electronic_EDI,2023-07-04,2023-07-04,2023-07-04,2023-07-08,Auto_Adjudicated,4,1331264469,1319611206,2086S0122X,Orthopedic Surgery,31,In_Network,Z00.01,,99205,,0,Commercial,EPO,34,M,1.3765,,,181.58,77.63,0.0,77.63,0.0,0.0,103.95,0.0,0.0,0,,0.1878,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,CBP_Controlling_BP,Bundled_Payment
CLM0000001629,MBR00000285,Medical_Institutional,Paid,Electronic_EDI,2023-07-03,2023-07-03,2023-07-07,2023-07-04,Auto_Adjudicated,1,1603037534,1054984734,2084P0800X,Psychiatry,11,In_Network,Z12.11,N39.0,revenue_code:0300,,0,Commercial,HDHP_HSA,56,M,0.9226,,,15597.53,11253.88,8585.56,521.93,0.0,2146.39,4343.65,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|high_volume_same_code|benford_violation|impossible_service_combo|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,1,1,0,0.000795,0,0,,FFS
CLM0000001630,MBR00000262,Medical_Professional,Paid,Paper,2023-10-16,2023-10-16,2023-10-16,2023-10-28,Manual_Review,12,1428403730,1741177636,2084P0800X,Psychiatry,11,In_Network,OTHER,Z00.00|I10,99205,,0,Medicare_Advantage,PFFS,77,F,1.7452,,,313.18,164.62,127.54,1.2,4.0,31.88,148.56,0.0,0.0,0,,0.0093,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000001631,MBR00000030,Medical_Professional,Denied,Electronic_EDI,2023-12-25,2023-12-25,2023-12-25,2024-01-11,Manual_Review,17,1983779639,1564691686,207RN0300X,Nephrology,22,In_Network,OTHER,OTHER,99396,,0,Medicaid_MCO,MCO,67,M,0.4581,4,Authorization,371.92,156.51,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1365,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000001632,MBR00000077,Behavioral_Health,Paid,Electronic_EDI,2023-01-09,2023-01-09,2023-01-09,2023-01-18,Clinical_Review,9,1641779816,1297948643,207RC0000X,Cardiovascular Disease,22,Emergency,M17.11,Z00.00,43239,,0,Medicare_Advantage,MA_HMO,27,F,0.9229,,,76.72,53.36,33.35,7.67,4.0,8.34,23.36,0.0,0.0,0,,0.0957,none,0,1,0,0,0,3e-06,0,0,,FFS
CLM0000001633,MBR00000179,Vision,Paid,Electronic_EDI,2023-07-01,2023-07-01,2023-07-01,2023-07-10,Manual_Review,9,1419204214,1689327034,225100000X,Physical Therapist,11,In_Network,J20.9,E11.9|OTHER|R05.9,V2115,,0,Medicare_Advantage,SNP,82,F,0.5266,,,584.58,277.97,208.44,0.43,17.0,52.11,306.61,184.12,13.16,0,,0.0639,none,0,1,0,0,0,1.9e-05,0,0,SPC_Statin_Therapy,FFS
CLM0000001634,MBR00000018,Pharmacy,Paid,Paper,2023-10-09,2023-10-09,2023-10-09,2023-10-12,Auto_Adjudicated,3,1667149552,1148612764,207RE0101X,Endocrinology,22,In_Network,F32.9,E11.9,00003014960,,1,Commercial,EPO,5,F,0.5555,,,217.23,114.22,67.12,16.33,14.0,16.78,103.01,0.0,0.0,0,,0.0171,none,0,1,0,1,0,6e-06,0,1,,FFS
CLM0000001635,MBR00000166,Medical_Professional,Paid,Electronic_EDI,2023-08-19,2023-08-19,2023-08-19,2023-08-23,Auto_Adjudicated,4,1813729693,1619587398,207RE0101X,Endocrinology,11,In_Network,Z00.00,,99285,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,369.1,209.46,0.0,209.46,0.0,0.0,159.64,0.0,0.0,0,,0.1355,none,0,1,0,0,0,0.0,0,0,DDE_Diabetes_Short_Term_Complications,Shared_Savings
CLM0000001636,MBR00000176,Behavioral_Health,Paid,Electronic_EDI,2023-06-23,2023-06-23,2023-06-23,2023-07-20,Auto_Adjudicated,27,1269720844,1986847322,2084P0800X,Psychiatry,11,In_Network,E78.5,,97110,,0,Commercial,POS,4,M,0.8792,,,264.75,149.88,0.0,149.88,0.0,0.0,114.87,0.0,0.0,0,,0.0299,none,0,1,0,0,0,0.0,0,0,CCS_Cervical_Cancer_Screening,Bundled_Payment
CLM0000001637,MBR00000091,Medical_Institutional,Paid,Electronic_EDI,2023-10-12,2023-10-12,2023-10-14,2023-10-14,Manual_Review,2,1377412382,1509799493,207RN0300X,Nephrology,81,In_Network,Z12.11,E11.9,revenue_code:0370,,0,Commercial,PPO,13,F,1.2451,,,6820.06,5082.61,3910.67,160.28,34.0,977.67,1737.45,0.0,0.0,0,,0.1472,geographic_mismatch,0,1,0,0,0,0.000362,0,0,,FFS
CLM0000001638,MBR00000092,Vision,Denied,Electronic_EDI,2023-06-18,2023-06-18,2023-06-18,2023-07-10,Manual_Review,22,1064567615,1477113725,207Q00000X,Family Medicine,22,In_Network,J20.9,Z23,V2100,,0,Medicaid_MCO,MLTSS,68,F,1.3217,96,Duplicate,682.71,459.81,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Identity Theft,1.0,unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|benford_violation|impossible_service_combo|service_date_weekend|upcoding_pattern|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.0,0,0,IET_Initiation_Substance_Use,Bundled_Payment
CLM0000001639,MBR00000072,Medical_Professional,Denied,Electronic_EDI,2023-02-19,2023-02-19,2023-02-19,2023-03-13,Auto_Adjudicated,22,1443292773,1878017518,207RC0000X,Cardiovascular Disease,21,Out_of_Network,G47.33,M79.3|I10|I48.91,99394,,0,Medicare_Advantage,MA_PPO,39,M,0.4967,1,Timely_Filing,288.95,224.35,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1382,none,0,1,0,0,0,0.0,1,0,IET_Initiation_Substance_Use,FFS
CLM0000001640,MBR00000282,Medical_Professional,Paid,Electronic_EDI,2023-04-08,2023-04-08,2023-04-08,2023-04-15,Auto_Adjudicated,7,1666911728,1188760037,2084P0800X,Psychiatry,11,In_Network,OTHER,Z00.00|E11.9,73721,,0,Medicare_Advantage,MA_HMO,16,M,0.7304,,,918.01,675.3,512.47,16.71,18.0,128.12,242.71,0.0,0.0,0,,0.0532,none,0,1,0,0,0,4.7e-05,0,0,,FFS
CLM0000001641,MBR00000124,Pharmacy,Paid,Electronic_EDI,2023-01-16,2023-01-16,2023-01-16,2023-01-24,Auto_Adjudicated,8,1810800968,1391074619,207RC0000X,Cardiovascular Disease,65,In_Network,M17.11,,00003014960,,2,Commercial,EPO,40,F,0.4583,,,165.83,135.69,0.0,135.69,0.0,0.0,30.14,0.0,0.0,0,,0.1035,none,0,1,0,0,0,0.0,0,0,SPD_Spirometry_Testing,Shared_Savings
CLM0000001642,MBR00000176,Dental,Denied,Electronic_EDI,2023-09-10,2023-09-10,2023-09-10,2023-09-22,Auto_Adjudicated,12,1673449362,1509799493,2084P0800X,Psychiatry,71,In_Network,I50.9,J44.1|C50.911,D7140,,0,Commercial,POS,4,M,0.8792,3,Duplicate,154.71,81.15,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0668,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001643,MBR00000095,Medical_Professional,Paid,Electronic_EDI,2023-12-16,2023-12-16,2023-12-16,2024-01-05,Auto_Adjudicated,20,1211612843,1706603847,208600000X,Surgery General,11,Out_of_Network,OTHER,,90837,,0,Commercial,HMO,28,M,0.5827,,,572.45,366.08,228.95,57.89,22.0,57.24,206.37,0.0,0.0,0,,0.0646,controlled_substance_high_volume,0,1,0,1,0,2.1e-05,1,0,,Shared_Savings
CLM0000001644,MBR00000208,Medical_Professional,Paid,Electronic_EDI,2023-05-17,2023-05-17,2023-05-17,2023-05-19,Auto_Adjudicated,2,1878453830,1688513262,207RP1001X,Pulmonary Disease,21,In_Network,E78.5,,33510,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,2027.36,1563.02,1231.78,17.29,6.0,307.95,464.34,0.0,0.0,0,,0.0853,none,0,1,0,0,0,0.000114,0,0,ACR_Urine_Protein,FFS
CLM0000001645,MBR00000030,Medical_Institutional,Paid,Electronic_EDI,2023-09-20,2023-09-20,2023-09-20,2023-10-15,Auto_Adjudicated,25,1145498455,1577226132,207RN0300X,Nephrology,23,In_Network,F32.9,I50.9,revenue_code:0210,,0,Medicaid_MCO,MCO,67,M,0.4581,,,7292.36,5531.63,5527.63,0.0,4.0,0.0,1760.73,0.0,0.0,0,,0.1809,geographic_mismatch|phantom_billing_indicator,0,1,1,0,0,0.000512,0,0,CDC_BP_Control,Capitation
CLM0000001646,MBR00000022,Behavioral_Health,Denied,Electronic_EDI,2023-12-19,2023-12-19,2023-12-19,2023-12-30,Manual_Review,11,1451464799,1012893364,207V00000X,Obstetrics & Gynecology,11,In_Network,F10.10,E78.5,84443,,0,Medicare_Advantage,MA_HMO,34,M,0.9472,16,Network,230.6,174.07,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0447,none,0,1,0,0,0,0.0,0,0,PPC_Prenatal_Care,FFS
CLM0000001647,MBR00000218,Pharmacy,Paid,Provider_Portal,2023-05-22,2023-05-22,2023-05-22,2023-06-06,Auto_Adjudicated,15,1344162462,1144950506,101YP2500X,Psychologist Clinical,22,In_Network,E11.65,Z12.11,00071015523,,3,Commercial,HDHP_HSA,11,F,0.4964,,,350.88,198.33,0.21,198.07,0.0,0.05,152.55,0.0,0.0,0,,0.0853,none,0,1,0,0,0,0.0,0,0,MPT_Annual_Monitoring,FFS
CLM0000001648,MBR00000213,Vision,Paid,Electronic_EDI,2023-11-13,2023-11-13,2023-11-13,2023-12-11,Auto_Adjudicated,28,1055717021,1831337866,208600000X,Surgery General,11,In_Network,OTHER,Z00.00,92004,,0,Commercial,PPO,17,M,1.5857,,,807.91,479.13,322.75,47.69,28.0,80.69,328.78,0.0,0.0,0,,0.0891,none,0,1,0,0,0,3e-05,0,0,,FFS
CLM0000001649,MBR00000081,Pharmacy,Paid,Electronic_EDI,2023-01-07,2023-01-07,2023-01-07,2023-01-11,Auto_Adjudicated,4,1921056264,1330485436,246ZN0300X,Neuropsychology,11,Out_of_Network,E11.65,Z00.00|Z23|J20.9,00006001954,,1,Medicare_Advantage,SNP,66,F,2.159,,,400.9,156.24,120.6,0.49,5.0,30.15,244.66,0.0,0.0,1,Medically Unnecessary Services,1.0,unusual_service_frequency|provider_specialty_mismatch|high_volume_same_code|benford_violation|impossible_service_combo|service_date_weekend|duplicate_claim_indicator|unbundling_pattern|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,1.1e-05,1,0,,Shared_Savings
CLM0000001650,MBR00000112,Dental,Paid,Electronic_EDI,2023-09-01,2023-09-01,2023-09-01,2023-09-30,Auto_Adjudicated,29,1478458171,1577226132,207RN0300X,Nephrology,22,In_Network,OTHER,OTHER|F32.9,D7140,,0,Medicare_Advantage,MA_HMO,18,M,1.01,,,523.98,229.08,150.08,35.48,6.0,37.52,294.9,0.0,0.0,0,,0.0669,none,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000001651,MBR00000291,Medical_Institutional,Paid,Electronic_EDI,2023-03-01,2023-03-01,2023-03-03,2023-03-20,Auto_Adjudicated,19,1139362508,1874728994,225100000X,Physical Therapist,11,In_Network,I10,OTHER,revenue_code:0200,,0,Commercial,PPO,78,M,1.4773,,,5776.89,3296.24,2494.66,101.92,76.0,623.66,2480.65,0.0,0.0,0,,0.0151,none,0,1,0,0,0,0.000231,0,0,,FFS
CLM0000001652,MBR00000032,Medical_Professional,Paid,Electronic_EDI,2023-10-08,2023-10-08,2023-10-08,2023-10-21,Auto_Adjudicated,13,1209940651,1148659045,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,I10|OTHER|E78.5,99214,,0,Medicaid_MCO,FFS_Medicaid,87,M,0.4839,,,324.55,164.07,162.07,0.0,2.0,0.0,160.48,0.0,0.0,0,,0.071,none,0,1,0,1,0,1.5e-05,0,0,,FFS
CLM0000001653,MBR00000057,Pharmacy,Paid,Electronic_EDI,2023-01-04,2023-01-04,2023-01-04,2023-01-07,Manual_Review,3,1356562955,1473869105,207RC0000X,Cardiovascular Disease,11,In_Network,E11.9,,00078043215,,2,Medicare_Advantage,MA_PPO,45,M,0.6701,,,292.3,137.55,104.22,5.28,2.0,26.05,154.75,0.0,0.0,0,,0.0763,none,0,1,0,1,0,1e-05,0,0,MPT_Annual_Monitoring,FFS
CLM0000001654,MBR00000135,Medical_Institutional,Denied,Electronic_EDI,2023-10-26,2023-10-26,2023-10-27,2023-10-29,Auto_Adjudicated,3,1597649716,1144950506,225100000X,Physical Therapist,22,In_Network,Z00.00,,revenue_code:0120,,0,Commercial,PPO,58,F,2.2702,170,Duplicate,7794.93,3312.08,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0638,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001655,MBR00000088,Medical_Institutional,Paid,Electronic_EDI,2023-05-23,2023-05-23,2023-05-26,2023-06-17,Auto_Adjudicated,25,1083045036,1588993671,207RG0100X,Gastroenterology,65,In_Network,Z00.01,,revenue_code:0450,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,,,9393.78,6826.71,4430.57,407.32,90.0,1898.82,2567.07,0.0,0.0,0,,0.1395,none,0,1,0,0,0,0.00041,0,0,,Capitation
CLM0000001656,MBR00000193,Medical_Professional,Paid,Electronic_EDI,2023-03-27,2023-03-27,2023-03-27,2023-04-09,Auto_Adjudicated,13,1887322427,1887266184,2084P0800X,Psychiatry,22,In_Network,I25.10,,17000,,0,Commercial,PPO,11,M,0.5266,,,1153.35,871.23,663.75,11.54,30.0,165.94,282.12,0.0,0.0,0,,0.198,controlled_substance_high_volume,0,1,0,0,0,6.1e-05,0,0,,FFS
CLM0000001657,MBR00000206,Pharmacy,Partially_Paid,Electronic_EDI,2023-07-19,2023-07-19,2023-07-19,2023-08-11,Auto_Adjudicated,23,1092800235,1764064254,207RP1001X,Pulmonary Disease,22,Out_of_Network,E78.5,,00071015523,,1,Medicaid_MCO,MLTSS,21,M,1.4038,4,Medical_Necessity,431.41,256.91,202.97,0.0,1.0,0.0,227.44,0.0,0.0,0,,0.0971,none,0,1,0,0,0,1.9e-05,0,0,CDC_BP_Control,FFS
CLM0000001658,MBR00000160,Pharmacy,Paid,Electronic_EDI,2023-12-22,2023-12-22,2023-12-22,2024-01-16,Auto_Adjudicated,25,1878453830,1301869102,101YP2500X,Psychologist Clinical,22,In_Network,I10,Z23,00078043215,,2,Commercial,HMO,73,M,1.9608,,,186.48,142.2,35.21,75.19,23.0,8.8,44.28,0.0,0.0,0,,0.0856,benford_violation,0,1,0,0,0,3e-06,0,1,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000001659,MBR00000184,Medical_Professional,Denied,Electronic_EDI,2023-02-27,2023-02-27,2023-02-27,2023-03-12,Auto_Adjudicated,13,1631060535,1419347445,207R00000X,Internal Medicine,31,In_Network,Z79.4,Z00.00,90832,,0,Medicaid_MCO,MLTSS,30,M,2.8302,CO-45,COB,731.43,590.45,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1492,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000001660,MBR00000136,Vision,Paid,Electronic_EDI,2023-04-22,2023-04-22,2023-04-22,2023-05-02,Auto_Adjudicated,10,1393200616,1354265777,207Q00000X,Family Medicine,23,In_Network,F41.1,,V2100,,0,Commercial,POS,2,F,1.2611,,,159.62,68.03,0.0,68.03,0.0,0.0,91.59,0.0,0.0,0,,0.1277,none,0,1,0,1,0,0.0,0,0,MPT_Annual_Monitoring,FFS
CLM0000001661,MBR00000224,Medical_Professional,Paid,Provider_Portal,2023-08-18,2023-08-18,2023-08-18,2023-08-27,Manual_Review,9,1267286378,1433350836,207RN0300X,Nephrology,11,In_Network,Z12.11,,99281,,0,Medicaid_MCO,MCO,86,F,1.3289,,,297.03,227.34,224.34,0.0,3.0,0.0,69.69,0.0,0.0,0,,0.1212,none,0,1,0,0,0,2.1e-05,0,0,,FFS
CLM0000001662,MBR00000013,Medical_Professional,Paid,Electronic_EDI,2023-02-03,2023-02-03,2023-02-03,2023-02-23,Auto_Adjudicated,20,1220235547,1747596016,207RN0300X,Nephrology,11,Out_of_Network,N39.0,F32.9|R05.9,43239,,0,Commercial,PPO,64,F,1.428,,,494.14,179.81,0.0,179.81,0.0,0.0,314.33,0.0,0.0,0,,0.2531,unusual_service_frequency|billing_spike_recent,0,2,0,0,0,0.0,1,0,,Bundled_Payment
CLM0000001663,MBR00000099,Medical_Professional,Paid,Electronic_EDI,2023-12-09,2023-12-09,2023-12-09,2023-12-31,Auto_Adjudicated,22,1112402001,1415734567,246ZN0300X,Neuropsychology,22,In_Network,OTHER,E78.5,97110,,0,Commercial,HMO,10,F,0.7843,,,686.79,279.21,118.23,116.42,15.0,29.56,407.58,0.0,0.0,0,,0.0874,none,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000001664,MBR00000204,Medical_Institutional,Paid,Electronic_EDI,2023-07-07,2023-07-07,2023-07-11,2023-07-18,Manual_Review,11,1631060535,1625992541,207RN0300X,Nephrology,24,In_Network,G43.909,OTHER|K21.0,revenue_code:0100,,0,Commercial,HMO,12,M,0.8716,,,43004.29,23893.54,19018.66,50.21,70.0,4754.67,19110.75,13156.08,4701.56,0,,0.063,upcoding_pattern,0,1,1,0,0,0.00176,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000001665,MBR00000104,Medical_Professional,Paid,Electronic_EDI,2023-12-22,2023-12-22,2023-12-22,2024-01-09,Auto_Adjudicated,18,1019263018,1577226132,225100000X,Physical Therapist,11,In_Network,F41.1,,99396,,0,Medicaid_MCO,MCO,87,F,1.2297,,,400.23,274.35,274.35,0.0,0.0,0.0,125.88,0.0,0.0,1,Medically Unnecessary Services,1.0,unusual_service_frequency|provider_specialty_mismatch|high_volume_same_code|impossible_service_combo|service_date_weekend|duplicate_claim_indicator|upcoding_pattern|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,1,0,2.5e-05,0,0,PCR_Plan_All_Cause_Readmission,Capitation
CLM0000001666,MBR00000024,Pharmacy,Paid,Electronic_EDI,2023-05-30,2023-05-30,2023-05-30,2023-06-16,Auto_Adjudicated,17,1734752728,1321680994,207RN0300X,Nephrology,22,In_Network,OTHER,E11.9|Z87.891,00006001954,,3,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,210.35,125.08,122.08,0.0,3.0,0.0,85.27,0.0,0.0,0,,0.0481,none,0,1,0,1,0,1.1e-05,0,0,CBP_Controlling_BP,Capitation
CLM0000001667,MBR00000109,Pharmacy,Paid,Electronic_EDI,2023-10-27,2023-10-27,2023-10-27,2023-11-01,Auto_Adjudicated,5,1739169232,1274911960,101YP2500X,Psychologist Clinical,23,In_Network,OTHER,M54.5|I10|E78.5,00006001954,,1,Commercial,HMO,8,F,0.5723,,,176.16,80.08,0.0,62.2,17.88,0.0,96.08,0.0,0.0,0,,0.0222,none,0,1,0,0,0,0.0,0,0,CBP_Controlling_BP,Shared_Savings
CLM0000001668,MBR00000211,Medical_Institutional,Denied,Electronic_EDI,2023-04-29,2023-04-29,2023-05-02,2023-05-15,Manual_Review,16,1901547390,1951488764,207RP1001X,Pulmonary Disease,21,In_Network,Z12.11,,revenue_code:0300,291,0,Medicare_Advantage,MA_PPO,68,M,1.3146,1,Coding_Error,5490.65,3654.48,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1007,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001669,MBR00000037,Dental,Paid,Electronic_EDI,2023-06-09,2023-06-09,2023-06-09,2023-07-02,Auto_Adjudicated,23,1506426842,1607833568,207R00000X,Internal Medicine,23,In_Network,I10,K21.0,D0120,,0,Medicaid_MCO,MLTSS,11,M,1.043,,,413.91,324.66,323.66,0.0,1.0,0.0,89.25,0.0,0.0,0,,0.0657,none,0,1,0,0,0,3e-05,0,0,W30_Well_Child_Visit,Shared_Savings
CLM0000001670,MBR00000213,Vision,Paid,Electronic_EDI,2023-05-05,2023-05-05,2023-05-05,2023-06-03,Auto_Adjudicated,29,1145498455,1049766043,207RE0101X,Endocrinology,21,In_Network,Z00.01,E11.9|J06.9,V2115,,0,Commercial,PPO,17,M,1.5857,,,829.25,619.9,351.31,152.76,28.0,87.83,209.35,269.48,65.54,0,,0.1308,none,0,1,0,1,0,3.3e-05,0,0,,P4P
CLM0000001671,MBR00000229,Medical_Institutional,Paid,Paper,2023-07-16,2023-07-16,2023-07-18,2023-07-27,Manual_Review,11,1832660692,1105733833,225100000X,Physical Therapist,22,In_Network,M79.3,Z12.11,revenue_code:0200,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,1211.79,603.9,430.19,12.16,54.0,107.55,607.89,0.0,0.0,0,,0.0825,none,0,1,0,0,0,4e-05,0,0,,P4P
CLM0000001672,MBR00000188,Medical_Professional,Partially_Paid,Electronic_EDI,2023-03-22,2023-03-22,2023-03-22,2023-03-30,Manual_Review,8,1069440570,1321680994,207RN0300X,Nephrology,24,In_Network,OTHER,,83036,,0,Commercial,HMO,8,F,1.5853,CO-45,Medical_Necessity,165.36,132.46,2.05,61.76,25.0,0.51,76.04,0.0,0.0,0,,0.1139,high_volume_same_code,0,1,0,0,0,0.0,0,0,CCS_Cervical_Cancer_Screening,Capitation
CLM0000001673,MBR00000076,Medical_Professional,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-27,Auto_Adjudicated,27,1706046899,1061113875,101YP2500X,Psychologist Clinical,71,In_Network,Z00.00,,99394,,0,Commercial,HMO,26,M,2.1785,,,256.31,139.25,61.94,29.83,32.0,15.48,117.06,0.0,0.0,0,,0.1033,none,0,1,0,1,0,6e-06,0,0,,FFS
CLM0000001674,MBR00000239,Pharmacy,Paid,Electronic_EDI,2023-10-29,2023-10-29,2023-10-29,2023-11-26,Auto_Adjudicated,28,1424416273,1896197144,225100000X,Physical Therapist,23,In_Network,F41.1,Z00.121,59148001506,,4,Commercial,HMO,1,F,1.1193,,,233.82,186.91,42.82,114.39,19.0,10.7,46.91,0.0,0.0,0,,0.087,none,0,1,0,0,0,4e-06,0,1,MPT_Annual_Monitoring,FFS
CLM0000001675,MBR00000065,Medical_Institutional,Paid,Electronic_EDI,2023-02-25,2023-02-25,2023-02-27,2023-03-22,Auto_Adjudicated,25,1539066691,1196833348,207RG0100X,Gastroenterology,21,In_Network,E11.9,OTHER,revenue_code:0100,683,0,Commercial,HDHP_HSA,63,M,0.7795,,,27951.8,11228.94,8953.95,36.5,0.0,2238.49,16722.86,0.0,0.0,0,,0.1304,high_volume_same_code,0,1,1,0,0,0.000829,0,0,,FFS
CLM0000001676,MBR00000274,Pharmacy,Paid,Electronic_EDI,2023-10-12,2023-10-12,2023-10-12,2023-10-23,Auto_Adjudicated,11,1963647323,1706603847,207RC0000X,Cardiovascular Disease,23,In_Network,N39.0,OTHER|E11.9,00085163102,,1,Medicare_Advantage,MA_HMO,58,F,2.1025,,,258.44,211.33,167.08,2.48,0.0,41.77,47.11,0.0,0.0,0,,0.0777,service_date_weekend,0,1,0,0,0,1.5e-05,0,1,,Shared_Savings
CLM0000001677,MBR00000209,Pharmacy,Paid,Electronic_EDI,2023-11-03,2023-11-03,2023-11-03,2023-11-12,Auto_Adjudicated,9,1971354640,1447186817,207RC0000X,Cardiovascular Disease,24,In_Network,OTHER,,00069420020,,1,Medicare_Advantage,MA_HMO,10,F,0.5199,,,48.63,25.48,11.22,9.45,2.0,2.81,23.15,0.0,0.0,0,,0.0748,none,0,1,0,0,0,1e-06,0,0,,Capitation
CLM0000001678,MBR00000014,Medical_Institutional,Paid,Electronic_EDI,2023-01-13,2023-01-13,2023-01-15,2023-02-01,Auto_Adjudicated,19,1506426842,1020312030,207RN0300X,Nephrology,21,In_Network,OTHER,,revenue_code:0200,683,0,Commercial,HMO,77,M,2.8513,,,20892.85,11899.66,9158.92,416.01,35.0,2289.73,8993.19,0.0,0.0,0,,0.0638,none,0,1,1,1,0,0.000848,0,0,,FFS
CLM0000001679,MBR00000236,Medical_Professional,Paid,Electronic_EDI,2023-08-31,2023-08-31,2023-08-31,2023-09-08,Manual_Review,8,1958981650,1228356980,208600000X,Surgery General,21,In_Network,OTHER,OTHER,97010,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,576.05,442.97,439.97,0.0,3.0,0.0,133.08,0.0,0.0,0,,0.0934,none,0,1,0,1,0,4.1e-05,0,0,,Capitation
CLM0000001680,MBR00000156,Medical_Professional,Denied,Electronic_EDI,2023-06-24,2023-06-24,2023-06-24,2023-07-18,Auto_Adjudicated,24,1059948944,1587454801,208600000X,Surgery General,11,In_Network,F41.1,M79.3,10060,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,PR-1,Eligibility,1207.96,839.34,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1078,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001681,MBR00000140,Medical_Professional,Paid,Electronic_EDI,2023-08-18,2023-08-18,2023-08-18,2023-08-30,Auto_Adjudicated,12,1875632885,1415734567,207R00000X,Internal Medicine,23,In_Network,G47.33,E11.9,99382,,0,Medicare_Advantage,MA_HMO,7,M,1.3997,,,195.63,122.76,72.5,20.13,12.0,18.13,72.87,0.0,0.0,0,,0.0493,none,0,1,0,0,0,7e-06,0,0,CBP_Controlling_BP,FFS
CLM0000001682,MBR00000133,Pharmacy,Paid,Electronic_EDI,2023-04-16,2023-04-16,2023-04-16,2023-04-26,Auto_Adjudicated,10,1002224900,1498781755,208600000X,Surgery General,22,In_Network,OTHER,,00071015523,,3,Medicaid_MCO,MCO,57,M,0.9592,,,52.85,36.43,35.43,0.0,1.0,0.0,16.42,0.0,0.0,0,,0.0373,none,0,1,0,0,0,3e-06,0,0,,Capitation
CLM0000001683,MBR00000183,Pharmacy,Denied,Electronic_EDI,2023-03-21,2023-03-21,2023-03-21,2023-04-15,Manual_Review,25,1470105939,1977073565,207Q00000X,Family Medicine,11,Out_of_Network,M47.816,Z12.11,00071015523,,5,Commercial,PPO,51,M,0.8463,256,Duplicate,125.48,76.62,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0229,none,0,1,0,0,0,0.0,1,0,,FFS
CLM0000001684,MBR00000213,Medical_Institutional,Paid,Electronic_EDI,2023-04-14,2023-04-14,2023-04-16,2023-04-25,Auto_Adjudicated,11,1756856314,1513198866,207RC0000X,Cardiovascular Disease,22,In_Network,OTHER,J06.9|K21.0,revenue_code:0370,,0,Commercial,PPO,17,M,1.5857,,,18668.52,6779.08,5045.81,428.82,43.0,1261.45,11889.44,0.0,0.0,0,,0.0856,none,0,1,1,0,0,0.000467,0,0,BCS_Breast_Cancer_Screening,Bundled_Payment
CLM0000001685,MBR00000272,Pharmacy,Paid,Electronic_EDI,2023-02-24,2023-02-24,2023-02-24,2023-02-28,Auto_Adjudicated,4,1556434733,1542515060,225100000X,Physical Therapist,81,In_Network,E11.9,OTHER|Z23|Z00.00,59148001506,,2,Medicare_Advantage,MA_HMO,15,M,0.8525,,,244.53,143.09,62.14,50.42,15.0,15.53,101.44,0.0,0.0,0,,0.0216,none,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000001686,MBR00000085,Medical_Institutional,Paid,Electronic_EDI,2023-05-26,2023-05-26,2023-05-27,2023-06-19,Auto_Adjudicated,24,1901547390,1643323506,207RN0300X,Nephrology,11,Out_of_Network,I10,H52.4|OTHER,revenue_code:0450,,0,Medicare_Advantage,SNP,2,M,0.7823,,,12183.85,7947.38,6310.42,22.35,37.0,1577.61,4236.47,0.0,0.0,0,,0.0456,none,0,1,1,0,0,0.000584,1,0,PPC_Prenatal_Care,FFS
CLM0000001687,MBR00000187,Medical_Professional,Paid,Electronic_EDI,2023-11-10,2023-11-10,2023-11-10,2023-11-20,Auto_Adjudicated,10,1567711165,1706603847,101YP2500X,Psychologist Clinical,22,In_Network,I10,I25.10,99386,,0,Medicaid_MCO,MCO,36,F,1.191,,,206.23,85.73,82.73,0.0,3.0,0.0,120.5,0.0,0.0,0,,0.1591,unusual_service_frequency,0,1,0,0,0,8e-06,0,0,COA_Care_Transitions,FFS
CLM0000001688,MBR00000205,Medical_Professional,Paid,Electronic_EDI,2023-10-07,2023-10-07,2023-10-07,2023-10-27,Auto_Adjudicated,20,1193571728,1319611206,225100000X,Physical Therapist,65,Out_of_Network,OTHER,F32.9|OTHER,99396,,0,Medicaid_MCO,MCO,1,F,0.9425,,,262.12,121.34,120.34,0.0,1.0,0.0,140.78,0.0,0.0,0,,0.0839,none,0,1,0,0,0,1.1e-05,1,0,MPT_Annual_Monitoring,FFS
CLM0000001689,MBR00000200,Medical_Professional,Paid,Electronic_EDI,2023-03-06,2023-03-06,2023-03-06,2023-03-26,Auto_Adjudicated,20,1360102160,1291071007,225100000X,Physical Therapist,81,In_Network,Z00.00,Z00.00,27130,,0,Commercial,HDHP_HSA,29,M,0.8011,,,50785.03,23596.93,18339.81,672.17,0.0,4584.95,27188.1,0.0,0.0,0,,0.0931,outlier_billing_amount,0,1,1,1,0,0.001698,0,0,,Shared_Savings
CLM0000001690,MBR00000153,Medical_Professional,Paid,Electronic_EDI,2023-07-20,2023-07-20,2023-07-20,2023-07-23,Auto_Adjudicated,3,1915327071,1164525386,208600000X,Surgery General,21,In_Network,OTHER,,71046,,0,Commercial,POS,12,F,0.6525,,,3879.55,2407.25,1861.89,54.88,25.0,465.47,1472.3,0.0,0.0,0,,0.1349,diagnosis_procedure_mismatch,0,1,0,1,0,0.000172,0,0,,Bundled_Payment
CLM0000001691,MBR00000125,Medical_Professional,Paid,Electronic_EDI,2023-01-27,2023-01-27,2023-01-27,2023-01-29,Auto_Adjudicated,2,1929402739,1358873132,207RE0101X,Endocrinology,11,In_Network,F32.9,I25.10|OTHER|E11.9,99231,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,346.39,160.29,115.46,4.96,11.0,28.87,186.1,0.0,0.0,0,,0.142,none,0,1,0,0,0,1.1e-05,0,0,MMA_Medication_Management,Bundled_Payment
CLM0000001692,MBR00000224,Pharmacy,Paid,Provider_Portal,2023-01-22,2023-01-22,2023-01-22,2023-02-16,Auto_Adjudicated,25,1603037534,1132693989,207RG0100X,Gastroenterology,21,Emergency,E13.9,,00071015523,,4,Medicaid_MCO,MCO,86,F,1.3289,,,408.75,189.52,186.52,0.0,3.0,0.0,219.23,0.0,0.0,0,,0.0111,none,0,1,0,0,0,1.7e-05,0,1,CDC_HbA1c_Poor_Control,Shared_Savings
CLM0000001693,MBR00000095,Medical_Professional,Paid,Electronic_EDI,2023-08-13,2023-08-13,2023-08-13,2023-08-15,Auto_Adjudicated,2,1170257806,1105733833,207RP1001X,Pulmonary Disease,21,In_Network,I48.91,,74177,,0,Commercial,HMO,28,M,0.5827,,,390.65,219.83,137.56,25.88,22.0,34.39,170.82,0.0,0.0,0,,0.012,none,0,1,0,0,0,1.3e-05,0,0,,Shared_Savings
CLM0000001694,MBR00000063,Medical_Professional,Paid,Electronic_EDI,2023-04-19,2023-04-19,2023-04-19,2023-04-29,Auto_Adjudicated,10,1994365754,1179350099,208600000X,Surgery General,22,In_Network,Z23,,71046,,0,ACA_Marketplace,ACA_Silver,56,M,0.8198,,,1676.17,1247.35,726.72,187.18,22.0,311.45,428.82,0.0,0.0,0,,0.0472,none,0,1,0,1,0,6.7e-05,0,0,SPC_Statin_Therapy,Capitation
CLM0000001695,MBR00000166,Medical_Professional,Denied,Electronic_EDI,2023-09-10,2023-09-10,2023-09-10,2023-10-03,Auto_Adjudicated,23,1046058495,1170002937,2086S0122X,Orthopedic Surgery,22,In_Network,I10,OTHER,90853,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,4,Eligibility,509.04,249.29,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.019,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001696,MBR00000083,Medical_Professional,Paid,Paper,2023-02-25,2023-02-25,2023-02-25,2023-03-03,Auto_Adjudicated,6,1506426842,1574982369,207RE0101X,Endocrinology,24,In_Network,F33.0,E11.9,97140,,0,Commercial,PPO,76,M,0.6621,,,267.8,127.41,0.0,127.41,0.0,0.0,140.39,0.0,0.0,0,,0.0658,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,ACR_Urine_Protein,Bundled_Payment
CLM0000001697,MBR00000011,Medical_Professional,Paid,Electronic_EDI,2023-02-12,2023-02-12,2023-02-12,2023-02-28,Auto_Adjudicated,16,1866366547,1368666316,2086S0122X,Orthopedic Surgery,23,In_Network,OTHER,J20.9,99395,,0,Medicare_Advantage,SNP,35,F,1.0833,,,498.16,299.55,223.88,2.7,17.0,55.97,198.61,0.0,0.0,0,,0.1093,provider_specialty_mismatch,0,1,0,0,0,2.1e-05,0,0,,Capitation
CLM0000001698,MBR00000014,Medical_Professional,Paid,Provider_Portal,2023-09-14,2023-09-14,2023-09-14,2023-09-18,Auto_Adjudicated,4,1688560518,1662516615,101YP2500X,Psychologist Clinical,32,In_Network,Z00.00,,99214,,0,Commercial,HMO,77,M,2.8513,,,292.84,154.12,0.0,154.12,0.0,0.0,138.72,0.0,0.0,0,,0.1437,none,0,1,0,0,0,0.0,0,0,IET_Initiation_Substance_Use,FFS
CLM0000001699,MBR00000207,Medical_Professional,Paid,Paper,2023-03-16,2023-03-16,2023-03-16,2023-04-02,Auto_Adjudicated,17,1181941909,1930040953,208600000X,Surgery General,24,In_Network,E11.9,,74177,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,1724.37,1449.22,1449.22,0.0,0.0,0.0,275.15,0.0,0.0,0,,0.1441,unbundling_pattern|phantom_billing_indicator,0,1,0,0,0,0.000134,0,0,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000001700,MBR00000293,Behavioral_Health,Paid,Electronic_EDI,2023-01-21,2023-01-21,2023-01-21,2023-02-12,Auto_Adjudicated,22,1593056613,1304018750,2086S0122X,Orthopedic Surgery,22,In_Network,OTHER,,97110,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,332.56,250.5,157.23,42.97,11.0,39.31,82.06,0.0,0.0,0,,0.0852,none,0,1,0,1,0,1.5e-05,0,0,DDE_Diabetes_Short_Term_Complications,P4P
CLM0000001701,MBR00000141,Medical_Professional,Paid,Electronic_EDI,2023-10-11,2023-10-11,2023-10-11,2023-10-19,Auto_Adjudicated,8,1388566092,1765164601,101YP2500X,Psychologist Clinical,11,In_Network,Z00.00,,97010,,0,Commercial,HMO,47,F,0.6724,,,262.81,143.46,57.46,45.63,26.0,14.37,119.35,0.0,0.0,0,,0.0981,none,0,1,0,1,0,5e-06,0,0,,P4P
CLM0000001702,MBR00000046,Medical_Professional,Paid,Electronic_EDI,2023-09-11,2023-09-11,2023-09-11,2023-09-20,Manual_Review,9,1319616460,1297948643,246ZN0300X,Neuropsychology,24,In_Network,Z00.00,,99203,,0,Commercial,HMO,76,F,0.9613,,,307.08,125.86,0.0,122.42,3.44,0.0,181.22,0.0,0.0,0,,0.1206,high_volume_same_code,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001703,MBR00000244,Medical_Institutional,Paid,Electronic_EDI,2023-11-30,2023-11-30,2023-12-03,2023-12-16,Auto_Adjudicated,16,1461820376,1365397818,207RN0300X,Nephrology,23,In_Network,OTHER,,revenue_code:0360,,0,Commercial,PPO,52,M,0.6677,,,5353.7,2457.04,1875.24,54.99,58.0,468.81,2896.66,0.0,0.0,0,,0.1136,none,0,1,0,0,0,0.000174,0,0,,FFS
CLM0000001704,MBR00000081,Medical_Professional,Paid,Electronic_EDI,2023-08-04,2023-08-04,2023-08-04,2023-08-28,Auto_Adjudicated,24,1324084461,1747935894,207Q00000X,Family Medicine,21,In_Network,OTHER,F33.0|Z00.00|I10,90837,,0,Medicare_Advantage,SNP,66,F,2.159,,,1574.39,1167.69,928.88,1.59,5.0,232.22,406.7,0.0,0.0,0,,0.1832,provider_specialty_mismatch,0,1,0,0,0,8.6e-05,0,0,,Bundled_Payment
CLM0000001705,MBR00000299,Medical_Institutional,Paid,Paper,2023-06-21,2023-06-21,2023-06-22,2023-07-08,Auto_Adjudicated,17,1048378959,1447186817,246ZN0300X,Neuropsychology,11,In_Network,E78.5,J20.9|I10,revenue_code:0300,,0,Medicaid_MCO,MCO,74,F,0.8833,,,12968.07,7501.75,7499.75,0.0,2.0,0.0,5466.32,0.0,0.0,0,,0.076,none,0,1,1,0,0,0.000694,0,0,,FFS
CLM0000001706,MBR00000169,Medical_Institutional,Denied,Paper,2023-08-29,2023-08-29,2023-08-29,2023-09-20,Auto_Adjudicated,22,1564110057,1105871325,207R00000X,Internal Medicine,23,In_Network,OTHER,Z23,revenue_code:0300,,0,Commercial,EPO,30,M,1.4348,3,Coding_Error,6635.74,2970.67,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2589,temporal_clustering|diagnosis_procedure_mismatch,0,2,0,0,0,0.0,0,0,,Capitation
CLM0000001707,MBR00000073,Dental,Paid,Electronic_EDI,2023-10-12,2023-10-12,2023-10-12,2023-10-25,Clinical_Review,13,1994365754,1005335812,207Q00000X,Family Medicine,11,In_Network,N40.0,Z87.891,D3310,,0,Commercial,POS,79,M,1.1768,,,103.53,68.58,0.0,68.58,0.0,0.0,34.95,0.0,0.0,0,,0.1512,geographic_mismatch,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001708,MBR00000154,Vision,Paid,Electronic_EDI,2023-08-14,2023-08-14,2023-08-14,2023-08-18,Manual_Review,4,1014482814,1450837722,2084P0800X,Psychiatry,24,Out_of_Network,Z00.01,F33.0|OTHER|Z87.891,V2103,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,501.64,335.96,261.87,8.63,0.0,65.47,165.68,0.0,0.0,0,,0.0157,none,0,1,0,0,0,2.4e-05,1,0,,FFS
CLM0000001709,MBR00000106,Pharmacy,Paid,Electronic_EDI,2023-04-25,2023-04-25,2023-04-25,2023-05-24,Auto_Adjudicated,29,1594587354,1662516615,208600000X,Surgery General,11,In_Network,F32.9,Z12.11|I10,00169751112,,2,Medicare_Advantage,MA_PPO,69,M,1.7254,,,136.84,70.42,47.12,5.52,6.0,11.78,66.42,0.0,0.0,0,,0.0488,none,0,1,0,0,0,4e-06,0,1,,FFS
CLM0000001710,MBR00000230,Medical_Professional,Partially_Paid,Electronic_EDI,2023-11-16,2023-11-16,2023-11-16,2023-12-10,Auto_Adjudicated,24,1175252466,1320546364,207R00000X,Internal Medicine,22,In_Network,OTHER,I50.9|OTHER,85025,,0,Commercial,HMO,9,M,0.4087,16,Medical_Necessity,541.16,228.4,76.72,54.21,13.0,19.18,378.06,0.0,0.0,0,,0.0884,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000001711,MBR00000033,Medical_Institutional,Paid,Electronic_EDI,2023-09-10,2023-09-10,2023-09-14,2023-09-12,Auto_Adjudicated,2,1639236553,1513198866,207V00000X,Obstetrics & Gynecology,11,In_Network,I50.9,OTHER|M47.816,revenue_code:0450,,0,Medicare_Advantage,PFFS,31,F,0.821,,,18547.54,11720.3,9337.83,8.02,40.0,2334.46,6827.24,0.0,0.0,0,,0.0115,none,0,1,1,0,0,0.000864,0,0,,Bundled_Payment
CLM0000001712,MBR00000259,Medical_Professional,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-11-20,Clinical_Review,9,1156265220,1447657873,225100000X,Physical Therapist,22,In_Network,I25.10,,99231,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,179.93,113.7,82.64,3.4,7.0,20.66,66.23,0.0,0.0,0,,0.1193,none,0,1,0,0,0,8e-06,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000001713,MBR00000226,Pharmacy,Paid,Electronic_EDI,2023-07-20,2023-07-20,2023-07-20,2023-08-02,Manual_Review,13,1033622184,1287472731,207RP1001X,Pulmonary Disease,24,In_Network,Z23,,00003014960,,2,Medicare_Advantage,MA_PPO,84,M,1.0796,,,53.43,30.91,16.28,0.56,10.0,4.07,22.52,0.0,0.0,0,,0.1482,none,0,1,0,0,0,2e-06,0,0,TRC_Transition_of_Care,Shared_Savings
CLM0000001714,MBR00000259,Medical_Professional,Paid,Provider_Portal,2023-06-11,2023-06-11,2023-06-11,2023-06-14,Auto_Adjudicated,3,1958171947,1461075342,101YP2500X,Psychologist Clinical,11,In_Network,E78.5,,99213,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,308.37,257.47,199.77,0.75,7.0,49.94,50.9,0.0,0.0,0,,0.0181,none,0,1,0,0,0,1.8e-05,0,0,,Shared_Savings
CLM0000001715,MBR00000271,Pharmacy,Paid,Electronic_EDI,2023-10-30,2023-10-30,2023-10-30,2023-11-25,Auto_Adjudicated,26,1733777382,1689327034,225100000X,Physical Therapist,11,In_Network,N18.3,OTHER,00169751112,,5,Medicaid_MCO,MCO,4,F,0.6696,,,85.47,43.61,43.61,0.0,0.0,0.0,41.86,0.0,0.0,0,,0.0443,none,0,1,0,0,0,4e-06,0,1,,FFS
CLM0000001716,MBR00000072,Medical_Professional,Paid,Electronic_EDI,2023-08-08,2023-08-08,2023-08-08,2023-08-14,Auto_Adjudicated,6,1360102160,1804282800,246ZN0300X,Neuropsychology,11,In_Network,I10,Z23|M17.11|E11.9,20610,,0,Medicare_Advantage,MA_PPO,39,M,0.4967,,,615.97,370.45,265.03,31.16,8.0,66.26,245.52,0.0,0.0,0,,0.0956,none,0,1,0,0,0,2.5e-05,0,0,DAE_Drug_Alcohol_Dependence,FFS
CLM0000001717,MBR00000159,Medical_Institutional,Paid,Electronic_EDI,2023-10-06,2023-10-06,2023-10-08,2023-10-13,Auto_Adjudicated,7,1568777164,1789540567,207RC0000X,Cardiovascular Disease,11,Out_of_Network,OTHER,I50.9,revenue_code:0370,,0,Commercial,PPO,70,F,1.2009,,,5507.23,3677.12,2883.49,1.76,71.0,720.87,1830.11,0.0,0.0,0,,0.0609,none,0,1,0,0,0,0.000267,1,0,,Capitation
CLM0000001718,MBR00000255,Medical_Professional,Denied,Electronic_EDI,2023-11-16,2023-11-16,2023-11-16,2023-11-26,Auto_Adjudicated,10,1981623199,1489434038,207RP1001X,Pulmonary Disease,22,In_Network,E11.9,J06.9|E78.5,10060,,0,Medicare_Advantage,MA_HMO,21,M,0.6945,1,Timely_Filing,251.01,174.52,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0042,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001719,MBR00000120,Medical_Professional,Paid,Electronic_EDI,2023-04-13,2023-04-13,2023-04-13,2023-05-12,Auto_Adjudicated,29,1171387771,1788579687,207R00000X,Internal Medicine,11,In_Network,Z00.01,E78.5|M17.11,90834,,0,Commercial,PPO,62,F,1.0823,,,206.03,159.19,0.0,159.19,0.0,0.0,46.84,0.0,0.0,0,,0.1095,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001720,MBR00000018,Pharmacy,Paid,Electronic_EDI,2023-03-11,2023-03-11,2023-03-11,2023-03-18,Auto_Adjudicated,7,1746688640,1764064254,207RN0300X,Nephrology,21,In_Network,Z00.00,J20.9|OTHER,00006001954,,3,Commercial,EPO,5,F,0.5555,,,195.15,89.85,41.7,23.72,14.0,10.43,105.3,0.0,0.0,0,,0.1398,billing_spike_recent,0,1,0,0,0,4e-06,0,1,,FFS
CLM0000001721,MBR00000091,Medical_Institutional,Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-25,2023-03-08,Auto_Adjudicated,13,1269720844,1831337866,225100000X,Physical Therapist,23,In_Network,OTHER,OTHER|M54.5,revenue_code:0120,,0,Commercial,PPO,13,F,1.2451,,,32193.35,25148.6,19941.19,188.12,34.0,4985.3,7044.75,0.0,0.0,0,,0.0787,service_date_weekend,0,1,1,0,0,0.001846,0,0,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000001722,MBR00000076,Medical_Professional,Paid,Electronic_EDI,2023-08-04,2023-08-04,2023-08-04,2023-08-25,Manual_Review,21,1377412382,1774401124,207R00000X,Internal Medicine,32,In_Network,F32.9,M54.5,70553,,0,Commercial,HMO,26,M,2.1785,,,1288.91,516.38,350.88,45.78,32.0,87.72,772.53,0.0,0.0,0,,0.1526,temporal_clustering,0,1,0,1,0,3.2e-05,0,0,,Shared_Savings
CLM0000001723,MBR00000263,Medical_Professional,Partially_Paid,Electronic_EDI,2023-10-17,2023-10-17,2023-10-17,2023-10-22,Auto_Adjudicated,5,1075661656,1694343357,2086S0122X,Orthopedic Surgery,11,In_Network,Z12.11,E78.5|M54.5,90834,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,PR-1,Medical_Necessity,661.41,252.95,124.72,9.86,19.0,31.18,476.66,0.0,0.0,0,,0.0981,none,0,1,0,1,0,1.2e-05,0,0,,FFS
CLM0000001724,MBR00000143,Dental,Denied,Electronic_EDI,2023-12-17,2023-12-17,2023-12-17,2023-12-20,Manual_Review,3,1972755666,1034732777,207R00000X,Internal Medicine,32,Out_of_Network,N39.0,L70.0|Z79.4,D4341,,0,Commercial,POS,85,M,1.6078,50,Timely_Filing,822.86,646.39,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1434,none,0,1,0,0,0,0.0,1,0,,P4P
CLM0000001725,MBR00000204,Medical_Institutional,Paid,Electronic_EDI,2023-01-12,2023-01-12,2023-01-14,2023-01-15,Auto_Adjudicated,3,1007414142,1763260577,207V00000X,Obstetrics & Gynecology,81,In_Network,J44.1,Z00.00,revenue_code:0210,,0,Commercial,HMO,12,M,0.8716,,,7409.95,3797.95,2944.27,47.61,70.0,736.07,3612.0,0.0,0.0,0,,0.0179,none,0,1,0,0,0,0.000273,0,0,,P4P
CLM0000001726,MBR00000291,Medical_Institutional,Paid,Electronic_EDI,2023-01-01,2023-01-01,2023-01-01,2023-01-07,Auto_Adjudicated,6,1064567615,1746676564,208600000X,Surgery General,23,In_Network,OTHER,,revenue_code:0300,,0,Commercial,PPO,78,M,1.4773,,,25074.43,18760.54,14670.88,345.93,76.0,3667.72,6313.89,0.0,0.0,0,,0.0658,none,0,1,1,0,0,0.001358,0,0,,Bundled_Payment
CLM0000001727,MBR00000094,Medical_Institutional,Denied,Electronic_EDI,2023-09-01,2023-09-01,2023-09-03,2023-09-11,Manual_Review,10,1505049857,1938465393,225100000X,Physical Therapist,24,In_Network,J06.9,I25.10,revenue_code:0450,,0,Commercial,POS,36,F,0.3997,170,COB,7706.1,5679.57,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.056,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001728,MBR00000224,Medical_Institutional,Paid,Electronic_EDI,2023-04-07,2023-04-07,2023-04-09,2023-05-06,Auto_Adjudicated,29,1719850506,1978943761,207RN0300X,Nephrology,22,In_Network,I10,OTHER,revenue_code:0110,,0,Medicaid_MCO,MCO,86,F,1.3289,,,6243.83,4294.1,4285.1,0.0,9.0,0.0,1949.73,0.0,0.0,0,,0.018,none,0,1,0,0,0,0.000397,0,0,,Shared_Savings
CLM0000001729,MBR00000007,Medical_Institutional,Paid,Electronic_EDI,2023-06-20,2023-06-20,2023-06-22,2023-07-18,Auto_Adjudicated,28,1015411732,1368666316,207RN0300X,Nephrology,11,In_Network,OTHER,Z00.00|OTHER,revenue_code:0120,,0,Commercial,HDHP_HSA,72,F,0.7578,,,24867.64,11247.07,8697.7,374.95,0.0,2174.42,13620.57,0.0,0.0,0,,0.0169,none,0,1,1,0,0,0.000805,0,0,POD_Persistence_of_Beta_Blocker,Capitation
CLM0000001730,MBR00000032,Medical_Professional,Paid,Paper,2023-01-29,2023-01-29,2023-01-29,2023-02-16,Auto_Adjudicated,18,1133514780,1623053477,207RP1001X,Pulmonary Disease,81,In_Network,F41.1,,99231,,0,Medicaid_MCO,FFS_Medicaid,87,M,0.4839,,,347.62,195.48,193.48,0.0,2.0,0.0,152.14,0.0,0.0,0,,0.0096,none,0,1,0,0,0,1.8e-05,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000001731,MBR00000051,Medical_Institutional,Denied,Electronic_EDI,2023-01-28,2023-01-28,2023-01-28,2023-02-26,Auto_Adjudicated,29,1658382624,1339359594,207RG0100X,Gastroenterology,71,In_Network,I25.10,,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,17,F,1.0695,22,Duplicate,21147.25,15959.41,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0173,none,0,1,0,0,0,0.0,0,0,BPD_BP_Declined,FFS
CLM0000001732,MBR00000099,Medical_Institutional,Denied,Electronic_EDI,2023-07-09,2023-07-09,2023-07-12,2023-07-10,Manual_Review,1,1624242487,1312595355,101YP2500X,Psychologist Clinical,21,In_Network,I10,E78.5,revenue_code:0250,292,0,Commercial,HMO,10,F,0.7843,256,Timely_Filing,3143.22,1254.37,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0551,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001733,MBR00000128,Medical_Professional,Paid,Electronic_EDI,2023-09-05,2023-09-05,2023-09-05,2023-09-22,Auto_Adjudicated,17,1932483309,1741177636,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,M54.5|Z23,99203,,0,Commercial,PPO,13,F,1.4203,,,468.39,282.43,174.53,51.26,13.0,43.63,185.96,0.0,0.0,0,,0.0241,none,0,1,0,0,0,1.6e-05,0,0,,FFS
CLM0000001734,MBR00000146,Pharmacy,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-11-29,Auto_Adjudicated,14,1918160357,1228356980,207Q00000X,Family Medicine,11,In_Network,OTHER,I10,00085163102,,1,Medicaid_MCO,MCO,24,M,0.6484,,,309.42,132.07,128.07,0.0,4.0,0.0,177.35,0.0,0.0,0,,0.1153,none,0,1,0,0,0,1.2e-05,0,1,PCR_Plan_All_Cause_Readmission,FFS
CLM0000001735,MBR00000076,Medical_Professional,Paid,Electronic_EDI,2023-06-23,2023-06-23,2023-06-23,2023-06-27,Auto_Adjudicated,4,1994365754,1831337866,207RP1001X,Pulmonary Disease,22,In_Network,K21.0,Z00.01,90832,,0,Commercial,HMO,26,M,2.1785,,,490.29,196.66,98.73,41.25,32.0,24.68,293.63,0.0,0.0,0,,0.016,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000001736,MBR00000020,Medical_Professional,Paid,Electronic_EDI,2023-08-20,2023-08-20,2023-08-20,2023-09-06,Auto_Adjudicated,17,1813729693,1575884274,207R00000X,Internal Medicine,65,In_Network,Z00.00,E11.9|Z00.00,99397,,0,Medicare_Advantage,MA_PPO,63,F,0.7119,,,816.9,466.23,323.73,55.57,6.0,80.93,350.67,0.0,0.0,1,Upcoding,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|high_volume_same_code|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,3e-05,0,0,SPC_Statin_Therapy,P4P
CLM0000001737,MBR00000201,Pharmacy,Paid,Electronic_EDI,2023-11-05,2023-11-05,2023-11-05,2023-11-19,Manual_Review,14,1102040918,1301869102,208600000X,Surgery General,11,In_Network,Z00.00,I25.10,00071015523,,1,Medicare_Advantage,MA_PPO,74,M,1.1575,,,99.9,50.43,31.83,4.65,6.0,7.96,49.47,0.0,0.0,0,,0.0936,none,0,1,0,0,0,3e-06,0,0,,Shared_Savings
CLM0000001738,MBR00000008,Dental,Paid,Electronic_EDI,2023-06-05,2023-06-05,2023-06-05,2023-06-28,Manual_Review,23,1097563011,1055872102,2086S0122X,Orthopedic Surgery,22,In_Network,M54.5,I10,D4341,,0,Medicaid_MCO,MCO,74,M,0.8375,,,225.95,171.81,170.81,0.0,1.0,0.0,54.14,0.0,0.0,0,,0.0185,none,0,1,0,0,0,1.6e-05,0,0,,FFS
CLM0000001739,MBR00000240,Medical_Professional,Paid,Provider_Portal,2023-03-16,2023-03-16,2023-03-16,2023-03-29,Auto_Adjudicated,13,1117755591,1643673796,207RP1001X,Pulmonary Disease,31,In_Network,F41.1,Z00.01,99394,,0,Medicaid_MCO,MCO,9,F,0.386,,,242.39,143.98,141.98,0.0,2.0,0.0,98.41,116.98,21.23,0,,0.0046,none,0,1,0,0,0,1.3e-05,0,0,,Capitation
CLM0000001740,MBR00000280,Pharmacy,Partially_Paid,Electronic_EDI,2023-10-24,2023-10-24,2023-10-24,2023-11-06,Manual_Review,13,1543927384,1287935251,207Q00000X,Family Medicine,21,In_Network,K21.0,E11.65|J44.1,59148001506,,1,Commercial,PPO,79,F,0.6697,2,Medical_Necessity,30.44,21.93,0.0,15.42,0.0,0.0,15.02,0.0,0.0,0,,0.0531,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001741,MBR00000210,Medical_Professional,Paid,Electronic_EDI,2023-01-01,2023-01-01,2023-01-01,2023-01-08,Auto_Adjudicated,7,1893886964,1415734567,207V00000X,Obstetrics & Gynecology,22,In_Network,E11.65,,12001,,0,Medicare_Advantage,SNP,49,M,0.6952,,,818.97,557.44,410.2,26.7,18.0,102.55,261.53,0.0,0.0,0,,0.0215,none,0,1,0,0,0,3.8e-05,0,0,,FFS
CLM0000001742,MBR00000180,Pharmacy,Paid,Electronic_EDI,2023-04-10,2023-04-10,2023-04-10,2023-04-25,Auto_Adjudicated,15,1549436467,1267212691,207RN0300X,Nephrology,22,In_Network,E78.5,,00071015523,,1,Medicare_Advantage,MA_PPO,72,F,1.1909,,,373.02,307.98,216.03,20.94,17.0,54.01,65.04,0.0,0.0,0,,0.2063,unusual_service_frequency|diagnosis_procedure_mismatch,0,2,0,0,0,2e-05,0,0,,FFS
CLM0000001743,MBR00000196,Medical_Institutional,Paid,Electronic_EDI,2023-02-16,2023-02-16,2023-02-19,2023-02-19,Auto_Adjudicated,3,1728728765,1878874025,207Q00000X,Family Medicine,11,In_Network,E11.9,G47.33|M17.11,revenue_code:0200,,0,Commercial,PPO,16,F,1.6015,,,20044.72,9621.68,7535.45,166.37,36.0,1883.86,10423.04,0.0,0.0,0,,0.1031,none,0,1,1,0,0,0.000697,0,0,,FFS
CLM0000001744,MBR00000194,Pharmacy,Paid,Electronic_EDI,2023-08-20,2023-08-20,2023-08-20,2023-09-06,Auto_Adjudicated,17,1323379997,1355732274,2084P0800X,Psychiatry,22,In_Network,OTHER,,00071012831,,3,Commercial,PPO,77,M,0.9783,,,264.11,195.55,19.14,153.62,18.0,4.79,68.56,0.0,0.0,0,,0.0726,none,0,1,0,0,0,2e-06,0,1,MMA_Medication_Management,FFS
CLM0000001745,MBR00000281,Medical_Professional,Paid,Electronic_EDI,2023-04-07,2023-04-07,2023-04-07,2023-04-19,Auto_Adjudicated,12,1170319307,1128148362,2084P0800X,Psychiatry,11,Out_of_Network,E78.5,OTHER,99285,,0,Medicare_Advantage,MA_HMO,3,M,0.8531,,,467.1,207.3,161.54,2.37,3.0,40.39,259.8,0.0,0.0,0,,0.0466,none,0,1,0,0,0,1.5e-05,1,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000001746,MBR00000292,Medical_Professional,Paid,Electronic_EDI,2023-05-04,2023-05-04,2023-05-04,2023-05-13,Manual_Review,9,1700802848,1560230600,2084P0800X,Psychiatry,23,In_Network,OTHER,I10,99212,,0,Medicare_Advantage,MA_HMO,4,M,1.1779,,,266.31,208.03,151.21,16.02,3.0,37.8,58.28,0.0,0.0,0,,0.0441,none,0,1,0,0,0,1.4e-05,0,0,,P4P
CLM0000001747,MBR00000135,Pharmacy,Paid,Electronic_EDI,2023-08-23,2023-08-23,2023-08-23,2023-09-04,Auto_Adjudicated,12,1756856314,1469642907,208600000X,Surgery General,11,In_Network,E11.65,OTHER,00169751112,,2,Commercial,PPO,58,F,2.2702,,,51.19,40.27,0.78,2.3,37.0,0.19,10.92,0.0,0.0,0,,0.1152,none,0,1,0,1,0,0.0,0,0,W30_Well_Child_Visit,Capitation
CLM0000001748,MBR00000184,Medical_Professional,Paid,Electronic_EDI,2023-04-17,2023-04-17,2023-04-17,2023-05-14,Auto_Adjudicated,27,1086690796,1527857018,207RC0000X,Cardiovascular Disease,24,Out_of_Network,Z00.00,Z23|OTHER,81001,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,711.64,539.93,537.93,0.0,2.0,0.0,171.71,0.0,0.0,0,,0.0109,none,0,1,0,1,0,5e-05,1,0,,Bundled_Payment
CLM0000001749,MBR00000237,Medical_Professional,Paid,Electronic_EDI,2023-05-11,2023-05-11,2023-05-11,2023-06-02,Auto_Adjudicated,22,1896279539,1402472115,2086S0122X,Orthopedic Surgery,22,In_Network,J44.1,E11.9|OTHER,99285,,0,Commercial,PPO,45,M,0.7983,,,536.73,274.01,61.19,172.52,25.0,15.3,262.72,0.0,0.0,0,,0.0307,none,0,1,0,0,0,6e-06,0,0,,Shared_Savings
CLM0000001750,MBR00000001,Medical_Institutional,Paid,Electronic_EDI,2023-06-29,2023-06-29,2023-07-02,2023-07-25,Auto_Adjudicated,26,1379875145,1450837722,207R00000X,Internal Medicine,65,In_Network,OTHER,,revenue_code:0450,,0,Commercial,EPO,73,M,0.6527,,,16610.2,7032.08,5569.45,27.27,43.0,1392.36,9578.12,3397.31,1445.16,0,,0.1,none,0,1,1,0,0,0.000516,0,0,,FFS
CLM0000001751,MBR00000160,Medical_Institutional,Paid,Electronic_EDI,2023-02-12,2023-02-12,2023-02-14,2023-02-24,Auto_Adjudicated,12,1205349488,1123879500,207R00000X,Internal Medicine,24,In_Network,OTHER,,revenue_code:0200,,0,Commercial,HMO,73,M,1.9608,,,21479.67,16574.23,12966.7,325.86,40.0,3241.67,4905.44,0.0,0.0,1,Unbundling,0.8963,outlier_billing_amount|unusual_service_frequency|temporal_clustering|high_volume_same_code|billing_spike_recent|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch,1,5,1,0,0,0.0012,0,0,,FFS
CLM0000001752,MBR00000194,Medical_Professional,Paid,Paper,2023-12-02,2023-12-02,2023-12-02,2023-12-14,Clinical_Review,12,1263063839,1995553359,207V00000X,Obstetrics & Gynecology,23,In_Network,M54.5,OTHER|I10|K21.0,90834,,0,Commercial,PPO,77,M,0.9783,,,851.72,549.18,359.42,81.9,18.0,89.86,302.54,0.0,0.0,0,,0.0169,none,0,1,0,0,0,3.3e-05,0,0,,FFS
CLM0000001753,MBR00000212,Medical_Institutional,Paid,Electronic_EDI,2023-12-19,2023-12-19,2023-12-20,2023-12-20,Manual_Review,1,1918578486,1880530717,225100000X,Physical Therapist,11,In_Network,Z00.01,,revenue_code:0360,,0,Commercial,HMO,57,F,2.5456,,,9881.82,5672.21,4338.08,181.61,68.0,1084.52,4209.61,0.0,0.0,0,,0.1562,phantom_billing_indicator,0,1,0,0,0,0.000402,0,0,,FFS
CLM0000001754,MBR00000117,Medical_Professional,Paid,Electronic_EDI,2023-09-13,2023-09-13,2023-09-13,2023-10-04,Auto_Adjudicated,21,1375680589,1105733833,207RG0100X,Gastroenterology,22,In_Network,F32.9,E11.9|I10,99397,,0,Medicaid_MCO,MLTSS,72,F,0.8628,,,297.18,165.32,161.32,0.0,4.0,0.0,131.86,0.0,0.0,0,,0.1362,none,0,1,0,0,0,1.5e-05,0,0,,Capitation
CLM0000001755,MBR00000092,Medical_Institutional,Paid,Electronic_EDI,2023-02-08,2023-02-08,2023-02-12,2023-02-09,Auto_Adjudicated,1,1943769986,1408846353,2084P0800X,Psychiatry,24,In_Network,Z00.01,,revenue_code:0110,,0,Medicaid_MCO,MLTSS,68,F,1.3217,,,9018.38,3613.36,3604.36,0.0,9.0,0.0,5405.02,0.0,0.0,0,,0.0565,none,0,1,0,0,0,0.000334,0,0,DDE_Diabetes_Short_Term_Complications,Bundled_Payment
CLM0000001756,MBR00000057,Dental,Denied,Provider_Portal,2023-06-19,2023-06-19,2023-06-19,2023-07-19,Manual_Review,30,1506426842,1450837722,2084P0800X,Psychiatry,23,In_Network,M54.5,Z12.11,D0120,,0,Medicare_Advantage,MA_PPO,45,M,0.6701,170,Network,506.15,340.88,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1364,billing_spike_recent|npi_mismatch,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001757,MBR00000168,Medical_Institutional,Denied,Electronic_EDI,2023-05-08,2023-05-08,2023-05-09,2023-05-29,Manual_Review,21,1580443769,1691162131,2086S0122X,Orthopedic Surgery,23,In_Network,OTHER,N39.0,revenue_code:0250,,0,Commercial,HMO,76,M,1.2791,16,Eligibility,5338.79,3258.81,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0676,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001758,MBR00000277,Medical_Institutional,Paid,Electronic_EDI,2023-03-01,2023-03-01,2023-03-03,2023-03-15,Auto_Adjudicated,14,1788188920,1577226132,207Q00000X,Family Medicine,11,In_Network,R05.9,Z23,revenue_code:0450,,0,Medicaid_MCO,MCO,30,M,1.8495,,,16149.09,13414.07,13412.07,0.0,2.0,0.0,2735.02,0.0,0.0,0,,0.1053,none,0,1,1,0,0,0.001241,0,0,,FFS
CLM0000001759,MBR00000272,Medical_Institutional,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-12-01,Manual_Review,20,1769163673,1643673796,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,M54.5,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,15,M,0.8525,,,26238.98,18040.14,14379.07,45.3,21.0,3594.77,8198.84,0.0,0.0,0,,0.0728,none,0,1,1,1,0,0.001331,0,0,,Capitation
CLM0000001760,MBR00000113,Medical_Professional,Paid,Electronic_EDI,2023-05-29,2023-05-29,2023-05-29,2023-06-28,Auto_Adjudicated,30,1603037534,1690197969,207RC0000X,Cardiovascular Disease,11,In_Network,J20.9,,99231,,0,Medicaid_MCO,MLTSS,29,F,1.1621,,,315.37,262.65,261.65,0.0,1.0,0.0,52.72,0.0,0.0,0,,0.0962,unbundling_pattern,0,1,0,0,0,2.4e-05,0,0,,FFS
CLM0000001761,MBR00000080,Pharmacy,Paid,Provider_Portal,2023-08-23,2023-08-23,2023-08-23,2023-08-28,Auto_Adjudicated,5,1007414142,1827839595,207RG0100X,Gastroenterology,11,Emergency,I10,,00085163102,,1,Commercial,HDHP_HSA,74,M,0.5935,,,219.72,92.26,71.44,2.96,0.0,17.86,127.46,0.0,0.0,0,,0.0949,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000001762,MBR00000233,Dental,Paid,Electronic_EDI,2023-09-06,2023-09-06,2023-09-06,2023-09-29,Auto_Adjudicated,23,1542851144,1983760474,2084P0800X,Psychiatry,24,In_Network,I10,M54.5,D0150,,0,Medicare_Advantage,MA_PPO,87,M,0.8034,,,365.02,252.32,185.13,17.91,3.0,46.28,112.7,0.0,0.0,0,,0.1409,high_volume_same_code,0,1,0,0,0,1.7e-05,0,0,,FFS
CLM0000001763,MBR00000213,Pharmacy,Paid,Electronic_EDI,2023-04-25,2023-04-25,2023-04-25,2023-05-21,Manual_Review,26,1207676414,1469881892,2084P0800X,Psychiatry,22,Out_of_Network,OTHER,I10|E11.9,59148001506,,2,Commercial,PPO,17,M,1.5857,,,276.06,209.02,0.0,209.02,0.0,0.0,67.04,0.0,0.0,0,,0.072,none,0,1,0,0,0,0.0,1,1,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000001764,MBR00000156,Vision,Paid,Electronic_EDI,2023-05-06,2023-05-06,2023-05-06,2023-05-24,Auto_Adjudicated,18,1124477249,1945682535,208600000X,Surgery General,22,In_Network,K21.0,N39.0,92002,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,233.96,153.38,104.22,10.1,13.0,26.06,80.58,0.0,0.0,0,,0.1345,geographic_mismatch|provider_specialty_mismatch,0,1,0,0,0,1e-05,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000001765,MBR00000124,Medical_Institutional,Paid,Electronic_EDI,2023-12-15,2023-12-15,2023-12-15,2024-01-04,Auto_Adjudicated,20,1331903993,1622950074,207R00000X,Internal Medicine,11,In_Network,M17.11,I10,revenue_code:0100,,0,Commercial,EPO,40,F,0.4583,,,10669.88,7014.66,5291.54,342.23,58.0,1322.89,3655.22,0.0,0.0,0,,0.1382,none,0,1,1,0,0,0.00049,0,0,,Shared_Savings
CLM0000001766,MBR00000038,Pharmacy,Denied,Paper,2023-10-24,2023-10-24,2023-10-24,2023-11-09,Auto_Adjudicated,16,1539066691,1581533104,207RE0101X,Endocrinology,24,In_Network,I10,OTHER|H52.4|E11.9,00003014960,,1,Commercial,EPO,46,M,1.1295,4,Authorization,169.76,72.64,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Phantom Billing,0.9493,outlier_billing_amount|provider_specialty_mismatch|temporal_clustering|impossible_service_combo|service_date_weekend|billing_spike_recent|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,0.0,0,0,,FFS
CLM0000001767,MBR00000232,Medical_Professional,Paid,Electronic_EDI,2023-06-29,2023-06-29,2023-06-29,2023-07-04,Auto_Adjudicated,5,1257723293,1352413270,207RE0101X,Endocrinology,11,In_Network,J06.9,I10,17000,,0,Medicaid_MCO,MCO,40,M,1.1083,,,159.78,81.58,79.58,0.0,2.0,0.0,78.2,57.54,15.52,0,,0.125,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000001768,MBR00000185,Behavioral_Health,Partially_Paid,Electronic_EDI,2023-07-11,2023-07-11,2023-07-11,2023-08-10,Auto_Adjudicated,30,1542851144,1930040953,246ZN0300X,Neuropsychology,11,In_Network,I10,Z00.00,99386,,0,Medicaid_MCO,MCO,73,M,1.5417,18,Medical_Necessity,223.16,148.69,72.14,0.0,3.0,0.0,148.02,0.0,0.0,0,,0.1909,geographic_mismatch,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000001769,MBR00000120,Medical_Institutional,Paid,Electronic_EDI,2023-01-03,2023-01-03,2023-01-03,2023-01-12,Auto_Adjudicated,9,1887322427,1391074619,207RC0000X,Cardiovascular Disease,31,In_Network,E11.9,,revenue_code:0360,,0,Commercial,PPO,62,F,1.0823,,,20890.9,12252.6,9693.42,56.83,79.0,2423.35,8638.3,0.0,0.0,0,,0.1108,none,0,1,1,0,0,0.000897,0,0,,FFS
CLM0000001770,MBR00000277,Medical_Professional,Paid,Electronic_EDI,2023-03-15,2023-03-15,2023-03-15,2023-03-27,Auto_Adjudicated,12,1325430913,1312595355,207R00000X,Internal Medicine,23,In_Network,OTHER,J06.9|OTHER,99203,,0,Medicaid_MCO,MCO,30,M,1.8495,,,270.78,211.62,208.62,0.0,3.0,0.0,59.16,0.0,0.0,0,,0.1059,none,0,1,0,0,0,1.9e-05,0,0,,Shared_Savings
CLM0000001771,MBR00000196,Pharmacy,Paid,Electronic_EDI,2023-01-03,2023-01-03,2023-01-03,2023-02-02,Manual_Review,30,1728728765,1579331190,207RE0101X,Endocrinology,11,In_Network,N40.0,,00169751112,,1,Commercial,PPO,16,F,1.6015,,,376.13,277.83,0.0,277.83,0.0,0.0,98.3,0.0,0.0,0,,0.0968,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000001772,MBR00000280,Medical_Institutional,Paid,Paper,2023-10-17,2023-10-17,2023-10-19,2023-10-19,Auto_Adjudicated,2,1539066691,1574982369,208600000X,Surgery General,11,In_Network,OTHER,,revenue_code:0360,,0,Commercial,PPO,79,F,0.6697,,,39914.65,24646.06,19532.98,178.83,51.0,4883.25,15268.59,0.0,0.0,0,,0.0825,none,0,1,1,0,0,0.001808,0,0,,Capitation
CLM0000001773,MBR00000145,Vision,Paid,Electronic_EDI,2023-12-04,2023-12-04,2023-12-04,2023-12-17,Manual_Review,13,1555292468,1447186817,207RP1001X,Pulmonary Disease,21,In_Network,OTHER,,92002,,0,Medicaid_MCO,MLTSS,46,M,0.5813,,,277.76,182.19,179.19,0.0,3.0,0.0,95.57,0.0,0.0,0,,0.0202,none,0,1,0,1,0,1.7e-05,0,0,SPC_Statin_Therapy,FFS
CLM0000001774,MBR00000141,Pharmacy,Paid,Paper,2023-02-28,2023-02-28,2023-02-28,2023-03-17,Manual_Review,17,1856989511,1105733833,208600000X,Surgery General,22,In_Network,J44.1,,59148001506,,1,Commercial,HMO,47,F,0.6724,,,81.11,55.01,0.0,55.01,0.0,0.0,26.1,0.0,0.0,0,,0.13,none,0,1,0,1,0,0.0,0,1,,Capitation
CLM0000001775,MBR00000283,Dental,Paid,Electronic_EDI,2023-04-11,2023-04-11,2023-04-11,2023-04-19,Auto_Adjudicated,8,1067329999,1623053477,207V00000X,Obstetrics & Gynecology,11,In_Network,M54.5,J44.1,D7140,,0,Medicare_Advantage,MA_HMO,21,M,0.5294,,,673.72,456.52,352.42,2.0,14.0,88.1,217.2,0.0,0.0,0,,0.1656,high_volume_same_code,0,1,0,0,0,3.3e-05,0,0,,Capitation
CLM0000001776,MBR00000291,Medical_Institutional,Paid,Electronic_EDI,2023-05-07,2023-05-07,2023-05-08,2023-05-28,Auto_Adjudicated,21,1804302686,1938465393,2086S0122X,Orthopedic Surgery,22,In_Network,F41.1,,revenue_code:0300,,0,Commercial,PPO,78,M,1.4773,,,26714.4,18647.7,14656.72,250.8,76.0,3664.18,8066.7,0.0,0.0,0,,0.0785,none,0,1,1,0,0,0.001357,0,0,,Bundled_Payment
CLM0000001777,MBR00000291,Medical_Institutional,Paid,Provider_Portal,2023-10-19,2023-10-19,2023-10-20,2023-11-04,Auto_Adjudicated,16,1323379997,1433350836,207RC0000X,Cardiovascular Disease,21,In_Network,Z00.00,OTHER,revenue_code:0120,194,0,Commercial,PPO,78,M,1.4773,,,28213.7,16888.41,13071.71,472.77,76.0,3267.93,11325.29,0.0,0.0,1,Identity Theft,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|benford_violation|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,1,0,0,0.00121,0,0,FUM_Follow_Up_ED_Mental_Health,Capitation
CLM0000001778,MBR00000244,Pharmacy,Denied,Electronic_EDI,2023-05-27,2023-05-27,2023-05-27,2023-06-04,Manual_Review,8,1756856314,1625992541,207Q00000X,Family Medicine,22,In_Network,OTHER,OTHER,00169751112,,2,Commercial,PPO,52,M,0.6677,50,Network,243.55,100.32,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0666,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001779,MBR00000143,Medical_Professional,Paid,Electronic_EDI,2023-01-16,2023-01-16,2023-01-16,2023-01-23,Manual_Review,7,1263063839,1591405274,207RG0100X,Gastroenterology,23,In_Network,OTHER,,99283,,0,Commercial,POS,85,M,1.6078,,,239.62,198.3,0.0,198.3,0.0,0.0,41.32,0.0,0.0,0,,0.0344,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001780,MBR00000064,Medical_Professional,Paid,Electronic_EDI,2023-07-30,2023-07-30,2023-07-30,2023-08-08,Auto_Adjudicated,9,1097702209,1450837722,101YP2500X,Psychologist Clinical,31,In_Network,M17.11,,85025,,0,Medicare_Advantage,SNP,73,M,1.0644,,,388.92,139.32,103.15,0.39,10.0,25.79,249.6,0.0,0.0,0,,0.0857,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000001781,MBR00000121,Behavioral_Health,Paid,Electronic_EDI,2023-02-22,2023-02-22,2023-02-22,2023-03-18,Auto_Adjudicated,24,1878057972,1704466150,207Q00000X,Family Medicine,11,In_Network,Z12.11,Z12.11,99283,,0,Medicare_Advantage,MA_PPO,58,M,1.226,,,263.28,94.33,58.49,3.22,18.0,14.62,168.95,0.0,0.0,0,,0.0828,none,0,1,0,0,0,5e-06,0,0,,Bundled_Payment
CLM0000001782,MBR00000284,Dental,Paid,Electronic_EDI,2023-08-20,2023-08-20,2023-08-20,2023-09-05,Auto_Adjudicated,16,1501282310,1039962073,225100000X,Physical Therapist,11,In_Network,I10,K21.0|M54.5,D7140,,0,Medicaid_MCO,FFS_Medicaid,23,M,0.5234,,,195.2,159.91,157.91,0.0,2.0,0.0,35.29,0.0,0.0,0,,0.0421,none,0,1,0,1,0,1.5e-05,0,0,ACR_Urine_Protein,FFS
CLM0000001783,MBR00000114,Vision,Denied,Electronic_EDI,2023-11-04,2023-11-04,2023-11-04,2023-11-28,Manual_Review,24,1886537420,1301833092,225100000X,Physical Therapist,11,In_Network,Z00.00,J45.20,92014,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,4,Duplicate,408.6,244.01,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.112,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001784,MBR00000222,Medical_Professional,Paid,Provider_Portal,2023-01-25,2023-01-25,2023-01-25,2023-02-16,Manual_Review,22,1324084461,1898471307,207RN0300X,Nephrology,11,In_Network,M54.5,,20610,,0,Commercial,PPO,48,F,0.6945,,,791.61,600.66,287.94,201.74,39.0,71.98,190.95,0.0,0.0,0,,0.1489,none,0,1,0,0,0,2.7e-05,0,0,,FFS
CLM0000001785,MBR00000279,Medical_Professional,Paid,Electronic_EDI,2023-12-23,2023-12-23,2023-12-23,2024-01-17,Auto_Adjudicated,25,1915327071,1995553359,207V00000X,Obstetrics & Gynecology,21,In_Network,OTHER,,12001,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,,,601.21,326.37,250.53,4.21,9.0,62.63,274.84,0.0,0.0,0,,0.0366,none,0,1,0,0,0,2.3e-05,0,0,,FFS
CLM0000001786,MBR00000293,Dental,Denied,Electronic_EDI,2023-08-27,2023-08-27,2023-08-27,2023-09-22,Clinical_Review,26,1853233709,1473869105,2084P0800X,Psychiatry,11,In_Network,Z00.00,,D7140,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,5,Timely_Filing,341.37,193.04,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1364,unusual_service_frequency,0,1,0,0,0,0.0,0,0,MMA_Medication_Management,Shared_Savings
CLM0000001787,MBR00000287,Medical_Professional,Paid,Electronic_EDI,2023-01-19,2023-01-19,2023-01-19,2023-02-07,Manual_Review,19,1012271279,1196833348,207V00000X,Obstetrics & Gynecology,31,In_Network,OTHER,E11.65|Z00.00,90832,,0,Commercial,PPO,4,M,0.7685,,,306.66,215.49,0.0,197.52,17.97,0.0,91.17,0.0,0.0,0,,0.1497,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000001788,MBR00000168,Medical_Institutional,Denied,Electronic_EDI,2023-03-20,2023-03-20,2023-03-23,2023-03-31,Manual_Review,11,1850379080,1489434038,207Q00000X,Family Medicine,31,In_Network,N39.0,OTHER|I10|E11.65,revenue_code:0200,,0,Commercial,HMO,76,M,1.2791,16,COB,4821.38,2914.17,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0635,benford_violation,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001789,MBR00000152,Medical_Professional,Paid,Electronic_EDI,2023-03-02,2023-03-02,2023-03-02,2023-03-23,Auto_Adjudicated,21,1813729693,1112696614,207RN0300X,Nephrology,23,In_Network,K21.0,Z79.4,99381,,0,Commercial,HMO,82,F,1.2506,,,665.95,532.97,305.13,134.55,17.0,76.28,132.98,0.0,0.0,0,,0.1359,none,0,1,0,0,0,2.8e-05,0,0,,P4P
CLM0000001790,MBR00000297,Dental,Paid,Provider_Portal,2023-11-14,2023-11-14,2023-11-14,2023-12-13,Auto_Adjudicated,29,1006539337,1706603847,2084P0800X,Psychiatry,21,In_Network,I10,I10|E78.5|E11.9,D7140,,0,Commercial,HMO,88,M,1.5311,,,319.7,222.43,136.42,24.91,27.0,34.1,97.27,0.0,0.0,0,,0.016,none,0,1,0,0,0,1.3e-05,0,0,,Shared_Savings
CLM0000001791,MBR00000067,Medical_Institutional,Paid,Electronic_EDI,2023-09-17,2023-09-17,2023-09-20,2023-09-27,Auto_Adjudicated,10,1299958874,1012893364,2086S0122X,Orthopedic Surgery,23,In_Network,Z00.00,,revenue_code:0250,,0,Medicaid_MCO,MCO,55,M,0.4175,,,3331.19,2044.13,2036.13,0.0,8.0,0.0,1287.06,0.0,0.0,0,,0.1225,unusual_service_frequency,0,1,0,0,0,0.000188,0,0,,FFS
CLM0000001792,MBR00000058,Medical_Professional,Paid,Provider_Portal,2023-05-14,2023-05-14,2023-05-14,2023-05-29,Auto_Adjudicated,15,1630305772,1267212691,207RN0300X,Nephrology,22,In_Network,J20.9,R05.9|OTHER,99383,,0,Commercial,PPO,56,F,1.1626,,,443.21,339.0,239.59,24.51,15.0,59.9,104.21,210.29,16.2,0,,0.1408,none,0,1,0,1,0,2.2e-05,0,0,,Shared_Savings
CLM0000001793,MBR00000292,Medical_Institutional,Paid,Electronic_EDI,2023-07-10,2023-07-10,2023-07-13,2023-08-06,Auto_Adjudicated,27,1513278494,1289435414,208600000X,Surgery General,23,In_Network,J44.1,OTHER,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,4,M,1.1779,,,4773.14,2971.04,2348.78,6.06,29.0,587.2,1802.1,0.0,0.0,0,,0.1084,none,0,1,0,0,0,0.000217,0,0,PCR_Plan_All_Cause_Readmission,P4P
CLM0000001794,MBR00000206,Medical_Professional,Denied,Electronic_EDI,2023-05-06,2023-05-06,2023-05-06,2023-05-24,Auto_Adjudicated,18,1532359759,1220755708,207RG0100X,Gastroenterology,11,In_Network,K21.0,E11.9,99232,,0,Medicaid_MCO,MLTSS,21,M,1.4038,5,Duplicate,373.57,186.71,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0484,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001795,MBR00000163,Pharmacy,Paid,Electronic_EDI,2023-05-26,2023-05-26,2023-05-26,2023-05-31,Auto_Adjudicated,5,1175448241,1522426351,101YP2500X,Psychologist Clinical,32,Out_of_Network,E78.5,I50.9|Z00.00,00169751112,,1,Medicaid_MCO,MCO,21,F,0.9607,,,585.41,240.13,236.13,0.0,4.0,0.0,345.28,0.0,0.0,0,,0.1698,provider_specialty_mismatch|controlled_substance_high_volume,0,1,0,0,0,2.2e-05,0,0,DAE_Drug_Alcohol_Dependence,Capitation
CLM0000001796,MBR00000041,Medical_Institutional,Paid,Electronic_EDI,2023-08-18,2023-08-18,2023-08-22,2023-08-29,Auto_Adjudicated,11,1232573801,1887266184,246ZN0300X,Neuropsychology,21,In_Network,Z00.00,E11.9,revenue_code:0370,439,0,Commercial,PPO,42,F,0.8283,,,9870.16,5184.55,3966.61,173.29,53.0,991.65,4685.61,0.0,0.0,0,,0.1115,none,0,1,0,0,0,0.000367,0,0,,FFS
CLM0000001797,MBR00000158,Medical_Institutional,Paid,Electronic_EDI,2023-03-11,2023-03-11,2023-03-12,2023-03-19,Auto_Adjudicated,8,1097563011,1489434038,207R00000X,Internal Medicine,11,In_Network,E78.5,OTHER|H52.4,revenue_code:0110,,0,Commercial,HMO,65,M,1.5361,,,34017.71,22699.37,17981.82,172.1,50.0,4495.45,11318.34,0.0,0.0,0,,0.0718,none,0,1,1,0,0,0.001664,0,0,,Capitation
CLM0000001798,MBR00000286,Medical_Institutional,Paid,Electronic_EDI,2023-09-30,2023-09-30,2023-10-03,2023-10-15,Auto_Adjudicated,15,1618564043,1354265777,207V00000X,Obstetrics & Gynecology,21,In_Network,N40.0,,revenue_code:0110,871,0,Medicare_Advantage,PFFS,40,F,1.2751,,,23228.05,19531.16,15576.37,10.7,50.0,3894.09,3696.89,0.0,0.0,0,,0.1607,geographic_mismatch,0,1,1,0,0,0.001442,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000001799,MBR00000182,Medical_Professional,Paid,Electronic_EDI,2023-12-06,2023-12-06,2023-12-06,2024-01-05,Auto_Adjudicated,30,1243349799,1123879500,208600000X,Surgery General,11,In_Network,N18.3,,99393,,0,Commercial,HMO,82,F,0.8489,,,614.88,444.42,226.99,143.68,17.0,56.75,170.46,0.0,0.0,0,,0.0314,none,0,1,0,0,0,2.1e-05,0,0,,FFS
CLM0000001800,MBR00000129,Medical_Professional,Paid,Electronic_EDI,2023-12-16,2023-12-16,2023-12-16,2024-01-11,Auto_Adjudicated,26,1710617771,1461075342,2086S0122X,Orthopedic Surgery,81,In_Network,I10,F32.9,99204,,0,Medicare_Advantage,MA_PPO,9,F,0.8196,,,374.55,247.01,178.26,7.18,17.0,44.57,127.54,0.0,0.0,0,,0.0882,impossible_service_combo,0,1,0,0,0,1.6e-05,0,0,,Capitation
CLM0000001801,MBR00000166,Vision,Paid,Electronic_EDI,2023-03-03,2023-03-03,2023-03-03,2023-04-01,Clinical_Review,29,1139362508,1903401648,207RN0300X,Nephrology,23,In_Network,OTHER,,92012,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,214.96,96.99,0.0,96.99,0.0,0.0,117.97,0.0,0.0,0,,0.0021,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001802,MBR00000269,Medical_Institutional,Denied,Electronic_EDI,2023-05-28,2023-05-28,2023-06-01,2023-06-20,Auto_Adjudicated,23,1015096289,1498781755,207RN0300X,Nephrology,65,Out_of_Network,I10,,revenue_code:0370,,0,Commercial,EPO,10,F,0.718,4,Medical_Necessity,1840.84,1295.03,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1236,service_date_weekend,0,1,0,0,0,0.0,1,0,,Capitation
CLM0000001803,MBR00000276,Medical_Institutional,Paid,Electronic_EDI,2023-04-06,2023-04-06,2023-04-07,2023-04-22,Manual_Review,16,1192302048,1746676564,207V00000X,Obstetrics & Gynecology,71,In_Network,OTHER,,revenue_code:0120,,0,Commercial,POS,38,M,0.8085,,,5882.93,3597.28,2776.43,79.75,47.0,694.11,2285.65,2247.77,275.06,0,,0.1246,none,0,1,0,0,0,0.000257,0,0,MPT_Annual_Monitoring,FFS
CLM0000001804,MBR00000128,Medical_Professional,Paid,Electronic_EDI,2023-08-16,2023-08-16,2023-08-16,2023-09-05,Auto_Adjudicated,20,1264953395,1938465393,225100000X,Physical Therapist,22,In_Network,M17.11,H52.4,99285,,0,Commercial,PPO,13,F,1.4203,,,217.82,156.72,79.56,44.28,13.0,19.89,61.1,0.0,0.0,0,,0.0897,none,0,1,0,0,0,7e-06,0,0,PPC_Prenatal_Care,P4P
CLM0000001805,MBR00000184,Behavioral_Health,Paid,Electronic_EDI,2023-04-27,2023-04-27,2023-04-27,2023-05-12,Auto_Adjudicated,15,1838794554,1894215172,207V00000X,Obstetrics & Gynecology,24,In_Network,N40.0,Z12.11|Z87.891,90837,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,361.39,192.53,190.53,0.0,2.0,0.0,168.86,0.0,0.0,0,,0.0046,none,0,1,0,0,0,1.8e-05,0,0,,Shared_Savings
CLM0000001806,MBR00000087,Pharmacy,Paid,Electronic_EDI,2023-05-22,2023-05-22,2023-05-22,2023-05-24,Auto_Adjudicated,2,1647029816,1179350099,207V00000X,Obstetrics & Gynecology,65,In_Network,Z00.01,I10,00003014960,,1,Medicaid_MCO,MCO,70,F,0.9232,,,475.46,280.08,279.08,0.0,1.0,0.0,195.38,199.82,59.25,0,,0.0333,none,0,1,0,1,0,2.6e-05,0,1,SPC_Statin_Therapy,FFS
CLM0000001807,MBR00000140,Medical_Professional,Paid,Electronic_EDI,2023-02-19,2023-02-19,2023-02-19,2023-02-23,Manual_Review,4,1091395764,1408846353,225100000X,Physical Therapist,11,Out_of_Network,K29.70,I10,99396,,0,Medicare_Advantage,MA_HMO,7,M,1.3997,,,161.87,99.23,62.54,9.05,12.0,15.64,62.64,0.0,0.0,0,,0.1089,none,0,1,0,0,0,6e-06,0,0,DAE_Drug_Alcohol_Dependence,FFS
CLM0000001808,MBR00000068,Medical_Institutional,Paid,Electronic_EDI,2023-07-21,2023-07-21,2023-07-22,2023-08-07,Manual_Review,17,1950560596,1098360555,207Q00000X,Family Medicine,11,In_Network,F10.10,,revenue_code:0210,,0,Medicare_Advantage,MA_HMO,28,F,0.8494,,,36072.65,19156.33,15290.03,3.8,40.0,3822.51,16916.32,0.0,0.0,0,,0.0133,none,0,1,1,0,0,0.001415,0,0,,Capitation
CLM0000001809,MBR00000162,Medical_Institutional,Paid,Electronic_EDI,2023-07-12,2023-07-12,2023-07-14,2023-08-01,Auto_Adjudicated,20,1102590784,1977073565,2084P0800X,Psychiatry,21,In_Network,I10,OTHER,revenue_code:0300,872,0,Medicaid_MCO,MLTSS,84,F,1.324,,,5982.54,3824.99,3815.99,0.0,9.0,0.0,2157.55,0.0,0.0,0,,0.0141,none,0,1,0,1,0,0.000353,0,0,MPT_Annual_Monitoring,Capitation
CLM0000001810,MBR00000174,Pharmacy,Denied,Electronic_EDI,2023-07-18,2023-07-18,2023-07-18,2023-07-26,Auto_Adjudicated,8,1650193199,1388050552,2086S0122X,Orthopedic Surgery,22,Out_of_Network,I10,M54.5,00169751112,,1,Medicare_Advantage,MA_HMO,85,M,0.3901,PR-1,Duplicate,92.41,45.11,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1489,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,1,0,,P4P
CLM0000001811,MBR00000106,Behavioral_Health,Paid,Electronic_EDI,2023-05-03,2023-05-03,2023-05-03,2023-05-04,Manual_Review,1,1139362508,1912895973,207Q00000X,Family Medicine,24,In_Network,I48.91,,74177,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,110.15,42.76,21.89,9.4,6.0,5.47,67.39,0.0,0.0,0,,0.012,none,0,1,0,0,0,2e-06,0,0,POD_Persistence_of_Beta_Blocker,P4P
CLM0000001812,MBR00000084,Pharmacy,Paid,Electronic_EDI,2023-09-29,2023-09-29,2023-09-29,2023-10-02,Auto_Adjudicated,3,1981623199,1040061910,2086S0122X,Orthopedic Surgery,21,In_Network,Z23,OTHER,00071015523,,4,Medicare_Advantage,MA_HMO,15,F,0.8004,,,235.84,103.58,71.02,3.8,11.0,17.76,132.26,0.0,0.0,0,,0.0056,none,0,1,0,0,0,7e-06,0,1,MPT_Annual_Monitoring,FFS
CLM0000001813,MBR00000048,Dental,Paid,Provider_Portal,2023-08-07,2023-08-07,2023-08-07,2023-08-17,Auto_Adjudicated,10,1550698436,1489993356,225100000X,Physical Therapist,31,In_Network,R05.9,,D7140,,0,Commercial,POS,27,F,0.639,,,246.29,147.06,0.0,126.59,20.47,0.0,99.23,0.0,0.0,0,,0.0435,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001814,MBR00000044,Medical_Institutional,Paid,Paper,2023-03-05,2023-03-05,2023-03-08,2023-03-31,Manual_Review,26,1770431137,1874728994,207RN0300X,Nephrology,23,In_Network,Z00.00,Z00.00,revenue_code:0110,,0,Commercial,PPO,29,M,0.7512,,,39119.59,15004.61,11818.59,158.37,73.0,2954.65,24114.98,0.0,0.0,0,,0.1309,none,0,1,1,0,0,0.001094,0,0,,FFS
CLM0000001815,MBR00000211,Medical_Professional,Paid,Provider_Portal,2023-05-13,2023-05-13,2023-05-13,2023-05-26,Auto_Adjudicated,13,1603037534,1689327034,207Q00000X,Family Medicine,21,Out_of_Network,I10,OTHER|Z00.00|J06.9,99214,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,,,177.81,96.61,67.61,0.1,12.0,16.9,81.2,56.01,6.89,0,,0.0322,none,0,1,0,0,0,6e-06,0,0,,Shared_Savings
CLM0000001816,MBR00000069,Medical_Institutional,Denied,Electronic_EDI,2023-08-26,2023-08-26,2023-08-26,2023-09-25,Auto_Adjudicated,30,1340676357,1540743888,225100000X,Physical Therapist,23,In_Network,I48.91,OTHER,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,2,M,0.5765,97,Medical_Necessity,23193.97,15953.85,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0982,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000001817,MBR00000036,Pharmacy,Paid,Electronic_EDI,2023-02-11,2023-02-11,2023-02-11,2023-03-10,Manual_Review,27,1539066691,1741177636,207RN0300X,Nephrology,31,In_Network,E11.9,Z00.00|M54.5|E78.5,00069420020,,1,Commercial,EPO,17,M,2.0136,,,68.24,41.36,0.0,41.36,0.0,0.0,26.88,0.0,0.0,0,,0.1306,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001818,MBR00000300,Medical_Professional,Paid,Paper,2023-05-07,2023-05-07,2023-05-07,2023-06-02,Auto_Adjudicated,26,1124477249,1588993671,225100000X,Physical Therapist,21,In_Network,Z00.00,I10,99393,,0,Commercial,PPO,64,F,1.0393,,,469.06,294.0,147.64,80.45,29.0,36.91,175.06,0.0,0.0,0,,0.0418,none,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000001819,MBR00000081,Medical_Institutional,Denied,Provider_Portal,2023-11-10,2023-11-10,2023-11-12,2023-12-10,Auto_Adjudicated,30,1826043246,1012893364,207RC0000X,Cardiovascular Disease,21,Out_of_Network,I10,,revenue_code:0250,291,0,Medicare_Advantage,SNP,66,F,2.159,96,Coding_Error,13333.97,9496.73,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0645,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001820,MBR00000272,Medical_Professional,Denied,Paper,2023-06-08,2023-06-08,2023-06-08,2023-06-16,Auto_Adjudicated,8,1323379997,1650774392,225100000X,Physical Therapist,23,In_Network,OTHER,Z00.01|E78.5,80053,,0,Medicare_Advantage,MA_HMO,15,M,0.8525,2,Authorization,797.95,327.52,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0581,high_oop_waiver,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001821,MBR00000184,Medical_Professional,Paid,Electronic_EDI,2023-07-02,2023-07-02,2023-07-02,2023-08-01,Auto_Adjudicated,30,1648123576,1747596016,207Q00000X,Family Medicine,21,In_Network,J06.9,E11.9|OTHER,99215,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,234.06,112.79,110.79,0.0,2.0,0.0,121.27,0.0,0.0,0,,0.211,geographic_mismatch|high_volume_same_code|benford_violation,0,2,0,0,0,1e-05,0,0,,FFS
CLM0000001822,MBR00000212,Dental,Paid,Electronic_EDI,2023-09-02,2023-09-02,2023-09-02,2023-09-30,Manual_Review,28,1793406356,1972530373,207Q00000X,Family Medicine,11,In_Network,N39.0,Z00.00|I10|OTHER,D1110,,0,Commercial,HMO,57,F,2.5456,,,272.84,153.13,11.84,120.33,18.0,2.96,119.71,0.0,0.0,0,,0.1633,duplicate_claim_indicator|controlled_substance_high_volume,0,1,0,0,0,1e-06,0,0,BCS_Breast_Cancer_Screening,Bundled_Payment
CLM0000001823,MBR00000169,Medical_Professional,Paid,Electronic_EDI,2023-04-26,2023-04-26,2023-04-26,2023-05-20,Auto_Adjudicated,24,1590338573,1170002937,2084P0800X,Psychiatry,31,Out_of_Network,I25.10,OTHER,99213,,0,Commercial,EPO,30,M,1.4348,,,358.95,173.76,88.68,40.91,22.0,22.17,185.19,0.0,0.0,0,,0.0459,none,0,1,0,0,0,8e-06,1,0,,FFS
CLM0000001824,MBR00000056,Pharmacy,Paid,Electronic_EDI,2023-10-24,2023-10-24,2023-10-24,2023-10-30,Manual_Review,6,1965682436,1574982369,246ZN0300X,Neuropsychology,11,In_Network,Z12.11,,00071015523,,3,Commercial,EPO,74,F,1.3941,,,764.91,435.54,119.72,274.89,11.0,29.93,329.37,0.0,0.0,0,,0.1007,none,0,1,0,0,0,1.1e-05,0,0,,Shared_Savings
CLM0000001825,MBR00000254,Medical_Professional,Denied,Electronic_EDI,2023-01-06,2023-01-06,2023-01-06,2023-01-15,Clinical_Review,9,1893886964,1432077493,246ZN0300X,Neuropsychology,11,In_Network,Z00.01,F32.9,99391,,0,Commercial,PPO,22,F,0.9285,PR-1,Coding_Error,165.66,132.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0376,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001826,MBR00000247,Pharmacy,Paid,Electronic_EDI,2023-06-19,2023-06-19,2023-06-19,2023-07-09,Auto_Adjudicated,20,1393200616,1068662623,207RP1001X,Pulmonary Disease,32,In_Network,E78.5,,00006001954,,4,Medicare_Advantage,MA_PPO,60,F,1.0618,,,137.06,55.81,37.5,3.93,5.0,9.38,81.25,0.0,0.0,0,,0.1325,phantom_billing_indicator,0,1,0,1,0,3e-06,0,0,KED_ESRD_Patients,Capitation
CLM0000001827,MBR00000110,Dental,Paid,Provider_Portal,2023-08-03,2023-08-03,2023-08-03,2023-08-05,Auto_Adjudicated,2,1055095309,1522426351,207Q00000X,Family Medicine,23,In_Network,I10,,D7140,,0,Medicare_Advantage,MA_HMO,83,F,1.127,,,242.35,120.52,86.85,2.95,9.0,21.71,121.83,0.0,0.0,0,,0.0627,none,0,1,0,0,0,8e-06,0,0,ACR_Urine_Protein,FFS
CLM0000001828,MBR00000224,Pharmacy,Paid,Electronic_EDI,2023-03-27,2023-03-27,2023-03-27,2023-04-21,Manual_Review,25,1346717076,1209882852,225100000X,Physical Therapist,21,In_Network,OTHER,,59148001506,,1,Medicaid_MCO,MCO,86,F,1.3289,,,53.71,42.09,39.09,0.0,3.0,0.0,11.62,0.0,0.0,0,,0.0461,none,0,1,0,1,0,4e-06,0,0,,Bundled_Payment
CLM0000001829,MBR00000165,Pharmacy,Paid,Electronic_EDI,2023-10-08,2023-10-08,2023-10-08,2023-10-21,Auto_Adjudicated,13,1898865801,1452088018,207RE0101X,Endocrinology,21,In_Network,K29.70,,00069420020,,1,ACA_Marketplace,ACA_Bronze,55,M,0.9775,,,53.17,33.63,0.0,33.63,0.0,0.0,19.54,0.0,0.0,0,,0.0016,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001830,MBR00000274,Medical_Professional,Paid,Provider_Portal,2023-01-29,2023-01-29,2023-01-29,2023-01-30,Auto_Adjudicated,1,1924450526,1827839595,207RN0300X,Nephrology,11,Out_of_Network,OTHER,Z12.11,99221,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,194.13,162.1,108.48,26.49,0.0,27.12,32.03,0.0,0.0,0,,0.0869,provider_specialty_mismatch,0,1,0,0,0,1e-05,1,0,,Shared_Savings
CLM0000001831,MBR00000237,Medical_Professional,Paid,Electronic_EDI,2023-08-22,2023-08-22,2023-08-22,2023-08-31,Auto_Adjudicated,9,1288855406,1447186817,207RN0300X,Nephrology,11,In_Network,OTHER,J06.9|OTHER|I10,97110,,0,Commercial,PPO,45,M,0.7983,,,492.66,214.91,37.85,142.6,25.0,9.46,277.75,0.0,0.0,0,,0.0776,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000001832,MBR00000013,Pharmacy,Partially_Paid,Provider_Portal,2023-08-16,2023-08-16,2023-08-16,2023-08-28,Clinical_Review,12,1746688640,1175334579,207V00000X,Obstetrics & Gynecology,65,Out_of_Network,Z00.00,F32.9|I48.91,59148001506,,4,Commercial,PPO,64,F,1.428,256,Medical_Necessity,558.82,406.74,0.0,264.39,0.0,0.0,294.43,0.0,0.0,0,,0.0684,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001833,MBR00000265,Pharmacy,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-10,2023-10-30,Auto_Adjudicated,20,1629674542,1540743888,207R00000X,Internal Medicine,11,In_Network,I48.91,OTHER|I10,00071012831,,3,Commercial,PPO,84,F,0.7969,,,397.19,305.66,157.82,83.39,25.0,39.45,91.53,0.0,0.0,0,,0.0101,none,0,1,0,0,0,1.5e-05,0,1,,FFS
CLM0000001834,MBR00000293,Pharmacy,Paid,Electronic_EDI,2023-03-16,2023-03-16,2023-03-16,2023-04-04,Auto_Adjudicated,19,1272115456,1498781755,101YP2500X,Psychologist Clinical,11,In_Network,F41.1,OTHER|Z12.11,00071012831,,1,Medicare_Advantage,MA_HMO,84,F,2.8513,,,93.38,77.44,50.14,3.77,11.0,12.53,15.94,0.0,0.0,0,,0.1717,high_volume_same_code,0,1,0,0,0,5e-06,0,0,,Bundled_Payment
CLM0000001835,MBR00000217,Pharmacy,Paid,Electronic_EDI,2023-02-25,2023-02-25,2023-02-25,2023-03-09,Auto_Adjudicated,12,1064567615,1513198866,207R00000X,Internal Medicine,24,In_Network,OTHER,,00069420020,,2,ACA_Marketplace,ACA_Bronze,11,F,1.1619,,,334.03,143.26,0.0,143.26,0.0,0.0,190.77,0.0,0.0,0,,0.0993,none,0,1,0,0,0,0.0,0,0,COA_Care_Transitions,P4P
CLM0000001836,MBR00000037,Medical_Professional,Paid,Paper,2023-07-28,2023-07-28,2023-07-28,2023-08-16,Auto_Adjudicated,19,1699014308,1157814306,101YP2500X,Psychologist Clinical,32,In_Network,OTHER,M17.11,12001,,0,Medicaid_MCO,MLTSS,11,M,1.043,,,371.46,229.52,228.52,0.0,1.0,0.0,141.94,0.0,0.0,0,,0.1429,none,0,1,0,0,0,2.1e-05,0,0,,Bundled_Payment
CLM0000001837,MBR00000239,Medical_Professional,Paid,Electronic_EDI,2023-12-15,2023-12-15,2023-12-15,2024-01-11,Auto_Adjudicated,27,1688560518,1020312030,225100000X,Physical Therapist,23,Out_of_Network,J06.9,M17.11|OTHER,47562,,0,Commercial,HMO,1,F,1.1193,,,611.24,337.11,243.92,13.2,19.0,60.98,274.13,0.0,0.0,0,,0.0206,none,0,1,0,0,0,2.3e-05,0,0,,Capitation
CLM0000001838,MBR00000192,Vision,Paid,Electronic_EDI,2023-10-09,2023-10-09,2023-10-09,2023-10-20,Auto_Adjudicated,11,1256824549,1061113875,207RC0000X,Cardiovascular Disease,11,In_Network,N18.3,J20.9,92012,,0,Medicaid_MCO,MCO,22,F,1.1739,,,329.21,214.97,214.97,0.0,0.0,0.0,114.24,0.0,0.0,0,,0.1176,high_volume_same_code,0,1,0,0,0,2e-05,0,0,,FFS
CLM0000001839,MBR00000106,Medical_Institutional,Paid,Electronic_EDI,2023-03-17,2023-03-17,2023-03-18,2023-03-29,Auto_Adjudicated,12,1588313061,1666461892,207RG0100X,Gastroenterology,11,In_Network,M54.5,OTHER,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,80150.79,31238.4,24959.65,3.84,35.0,6239.91,48912.39,0.0,0.0,0,,0.0666,outlier_billing_amount,0,1,1,0,0,0.00231,0,0,FLU_Flu_Vaccination,FFS
CLM0000001840,MBR00000267,Pharmacy,Denied,Provider_Portal,2023-05-27,2023-05-27,2023-05-27,2023-05-31,Auto_Adjudicated,4,1014482814,1112696614,2084P0800X,Psychiatry,81,In_Network,OTHER,OTHER|Z87.891,59148001506,,1,Medicare_Advantage,MA_HMO,26,F,0.2859,22,Medical_Necessity,223.19,130.99,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.049,none,0,1,0,0,0,0.0,0,0,FLU_Flu_Vaccination,FFS
CLM0000001841,MBR00000170,Medical_Institutional,Paid,Provider_Portal,2023-04-06,2023-04-06,2023-04-09,2023-04-18,Manual_Review,12,1273835569,1860951128,207RN0300X,Nephrology,23,In_Network,E78.5,Z00.00|K21.0,revenue_code:0120,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,3173.08,1156.55,872.06,20.47,46.0,218.02,2016.53,757.16,84.81,0,,0.1094,npi_mismatch,0,1,0,0,0,8.1e-05,0,0,,Shared_Savings
CLM0000001842,MBR00000257,Vision,Paid,Electronic_EDI,2023-10-07,2023-10-07,2023-10-07,2023-10-16,Auto_Adjudicated,9,1092800235,1415734567,207RN0300X,Nephrology,31,In_Network,J06.9,E78.5,92004,,0,Medicaid_MCO,MCO,76,F,0.8322,,,406.22,205.03,204.03,0.0,1.0,0.0,201.19,0.0,0.0,0,,0.0219,none,0,1,0,1,0,1.9e-05,0,0,,Bundled_Payment
CLM0000001843,MBR00000199,Dental,Paid,Electronic_EDI,2023-07-03,2023-07-03,2023-07-03,2023-07-26,Auto_Adjudicated,23,1641660170,1560230600,207RE0101X,Endocrinology,22,In_Network,OTHER,Z00.00,D4341,,0,Medicaid_MCO,MLTSS,17,F,1.0776,,,692.46,526.79,524.79,0.0,2.0,0.0,165.67,0.0,0.0,0,,0.0277,none,0,1,0,0,0,4.9e-05,0,0,,Bundled_Payment
CLM0000001844,MBR00000091,Medical_Professional,Paid,Provider_Portal,2023-06-07,2023-06-07,2023-06-07,2023-06-11,Auto_Adjudicated,4,1590338573,1809122260,101YP2500X,Psychologist Clinical,24,Out_of_Network,Z00.01,R05.9|M17.11,99213,,0,Commercial,PPO,13,F,1.2451,,,436.63,254.8,125.57,73.84,24.0,31.39,181.83,0.0,0.0,0,,0.1105,duplicate_claim_indicator,0,1,0,0,0,1.2e-05,1,0,,Capitation
CLM0000001845,MBR00000293,Dental,Paid,Provider_Portal,2023-01-02,2023-01-02,2023-01-02,2023-01-20,Auto_Adjudicated,18,1260336577,1527857018,207Q00000X,Family Medicine,81,In_Network,F41.1,Z00.00|F33.0|I10,D0120,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,192.75,149.51,96.13,18.35,11.0,24.03,43.24,0.0,0.0,0,,0.1978,service_date_weekend,0,1,0,0,0,9e-06,0,0,DDE_Diabetes_Short_Term_Complications,P4P
CLM0000001846,MBR00000171,Medical_Professional,Paid,Provider_Portal,2023-08-16,2023-08-16,2023-08-16,2023-09-09,Auto_Adjudicated,24,1190787795,1061149198,2084P0800X,Psychiatry,21,In_Network,I25.10,OTHER|M47.816,11200,,0,Commercial,PPO,27,F,0.819,,,709.1,268.8,175.01,38.04,12.0,43.75,440.3,0.0,0.0,0,,0.017,none,0,1,0,0,0,1.6e-05,0,0,FLU_Flu_Vaccination,FFS
CLM0000001847,MBR00000158,Medical_Institutional,Denied,Paper,2023-06-08,2023-06-08,2023-06-09,2023-06-16,Auto_Adjudicated,8,1986485249,1865266296,2084P0800X,Psychiatry,21,In_Network,I25.10,,revenue_code:0200,247,0,Commercial,HMO,65,M,1.5361,CO-45,Coding_Error,32373.4,22661.94,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Upcoding,1.0,unusual_service_frequency|high_volume_same_code|benford_violation|impossible_service_combo|billing_spike_recent|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,0.0,0,0,,FFS
CLM0000001848,MBR00000128,Dental,Paid,Paper,2023-01-15,2023-01-15,2023-01-15,2023-01-18,Auto_Adjudicated,3,1424643153,1622950074,208600000X,Surgery General,11,In_Network,Z00.01,Z00.00,D2140,,0,Commercial,PPO,13,F,1.4203,,,506.73,192.55,55.16,110.6,13.0,13.79,314.18,0.0,0.0,0,,0.0002,none,0,1,0,0,0,5e-06,0,0,,Bundled_Payment
CLM0000001849,MBR00000042,Medical_Professional,Partially_Paid,Electronic_EDI,2023-03-12,2023-03-12,2023-03-12,2023-04-02,Auto_Adjudicated,21,1461820376,1461075342,207RN0300X,Nephrology,24,In_Network,Z00.00,OTHER|Z00.00|J06.9,99282,,0,Commercial,HMO,78,F,1.1448,256,Medical_Necessity,660.6,282.53,102.82,30.16,20.0,25.71,481.91,0.0,0.0,0,,0.133,impossible_service_combo,0,1,0,1,0,1e-05,0,0,,FFS
CLM0000001850,MBR00000205,Medical_Professional,Paid,Provider_Portal,2023-09-18,2023-09-18,2023-09-18,2023-10-06,Clinical_Review,18,1913217838,1662516615,207RP1001X,Pulmonary Disease,11,In_Network,Z23,I10,82947,,0,Medicaid_MCO,MCO,1,F,0.9425,,,395.61,297.42,296.42,0.0,1.0,0.0,98.19,0.0,0.0,0,,0.1233,provider_specialty_mismatch|controlled_substance_high_volume,0,1,0,1,0,2.7e-05,0,0,,FFS
CLM0000001851,MBR00000135,Pharmacy,Denied,Electronic_EDI,2023-09-26,2023-09-26,2023-09-26,2023-10-13,Auto_Adjudicated,17,1994365754,1804282800,225100000X,Physical Therapist,11,In_Network,F32.9,OTHER|J44.1,00003014960,,4,Commercial,PPO,58,F,2.2702,3,COB,151.35,54.46,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1908,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001852,MBR00000282,Behavioral_Health,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-27,2023-07-24,Auto_Adjudicated,27,1864546991,1291071007,207RG0100X,Gastroenterology,23,In_Network,OTHER,J06.9,99215,,0,Medicare_Advantage,MA_HMO,16,M,0.7304,,,168.15,90.85,22.84,44.29,18.0,5.71,77.3,0.0,0.0,0,,0.0158,none,0,1,0,0,0,2e-06,0,0,SPC_Statin_Therapy,Capitation
CLM0000001853,MBR00000292,Medical_Professional,Paid,Electronic_EDI,2023-09-30,2023-09-30,2023-09-30,2023-10-04,Auto_Adjudicated,4,1793406356,1447657873,207RE0101X,Endocrinology,24,In_Network,Z00.121,E78.5,74177,,0,Medicare_Advantage,MA_HMO,4,M,1.1779,,,1289.57,1055.06,840.04,2.01,3.0,210.01,234.51,0.0,0.0,0,,0.0744,none,0,1,0,0,0,7.8e-05,0,0,,P4P
CLM0000001854,MBR00000226,Pharmacy,Paid,Electronic_EDI,2023-09-23,2023-09-23,2023-09-23,2023-09-29,Auto_Adjudicated,6,1539066691,1132693989,101YP2500X,Psychologist Clinical,21,In_Network,J44.1,J06.9,00071012831,,5,Medicare_Advantage,MA_PPO,84,M,1.0796,,,447.92,191.53,143.19,2.54,10.0,35.8,256.39,0.0,0.0,0,,0.0086,none,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000001855,MBR00000076,Medical_Institutional,Paid,Electronic_EDI,2023-08-10,2023-08-10,2023-08-11,2023-08-25,Manual_Review,15,1325430913,1741177636,208600000X,Surgery General,71,In_Network,E11.9,Z00.01,revenue_code:0210,,0,Commercial,HMO,26,M,2.1785,,,17058.14,14054.68,11211.62,0.15,40.0,2802.91,3003.46,0.0,0.0,0,,0.1402,none,0,1,1,0,0,0.001038,0,0,,FFS
CLM0000001856,MBR00000212,Medical_Institutional,Paid,Electronic_EDI,2023-03-16,2023-03-16,2023-03-17,2023-04-02,Manual_Review,17,1673449362,1296566243,207RN0300X,Nephrology,11,In_Network,OTHER,OTHER,revenue_code:0200,,0,Commercial,HMO,57,F,2.5456,,,13068.46,5852.77,4524.05,129.7,68.0,1131.01,7215.69,0.0,0.0,0,,0.0183,none,0,1,0,0,0,0.000419,0,0,CBP_Controlling_BP,Shared_Savings
CLM0000001857,MBR00000006,Pharmacy,Paid,Electronic_EDI,2023-06-01,2023-06-01,2023-06-01,2023-06-29,Auto_Adjudicated,28,1534538584,1867626800,207RG0100X,Gastroenterology,22,In_Network,E11.9,E11.9|E78.5,00310075090,,2,Commercial,EPO,88,M,1.4365,,,251.44,121.94,55.51,19.56,33.0,13.88,129.5,0.0,0.0,0,,0.1159,benford_violation,0,1,0,0,0,5e-06,0,0,SPD_Spirometry_Testing,P4P
CLM0000001858,MBR00000247,Medical_Institutional,Paid,Electronic_EDI,2023-10-21,2023-10-21,2023-10-21,2023-11-09,Auto_Adjudicated,19,1843445592,1622950074,101YP2500X,Psychologist Clinical,22,In_Network,OTHER,N40.0,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,3457.74,2313.4,1795.31,17.26,52.0,448.83,1144.34,0.0,0.0,0,,0.1369,none,0,1,0,0,0,0.000166,0,0,,Capitation
CLM0000001859,MBR00000153,Pharmacy,Paid,Electronic_EDI,2023-04-22,2023-04-22,2023-04-22,2023-04-29,Manual_Review,7,1175252466,1140170394,207RN0300X,Nephrology,22,In_Network,OTHER,F33.0|OTHER|M54.5,00169751112,,1,Commercial,POS,12,F,0.6525,,,129.54,45.76,0.0,45.76,0.0,0.0,83.78,0.0,0.0,0,,0.0989,none,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,Capitation
CLM0000001860,MBR00000283,Pharmacy,Paid,Electronic_EDI,2023-08-25,2023-08-25,2023-08-25,2023-09-20,Auto_Adjudicated,26,1222934819,1643323506,207RE0101X,Endocrinology,23,In_Network,OTHER,,50458085930,,5,Medicare_Advantage,MA_HMO,21,M,0.5294,,,138.14,97.32,59.99,8.33,14.0,15.0,40.82,0.0,0.0,0,,0.2041,unusual_service_frequency,0,2,0,0,0,6e-06,0,0,,Bundled_Payment
CLM0000001861,MBR00000120,Behavioral_Health,Paid,Electronic_EDI,2023-10-25,2023-10-25,2023-10-25,2023-11-07,Auto_Adjudicated,13,1780111559,1320546364,207RN0300X,Nephrology,23,Emergency,E78.5,OTHER|R05.9,99396,,0,Commercial,PPO,62,F,1.0823,,,218.51,175.19,43.5,103.82,17.0,10.87,43.32,0.0,0.0,0,,0.0539,none,0,1,0,1,0,4e-06,0,0,COL_Colorectal_Cancer_Screening,Shared_Savings
CLM0000001862,MBR00000081,Pharmacy,Denied,Electronic_EDI,2023-07-11,2023-07-11,2023-07-11,2023-08-07,Manual_Review,27,1377412382,1365397818,2086S0122X,Orthopedic Surgery,24,In_Network,I10,,00003014960,,1,Medicare_Advantage,SNP,66,F,2.159,50,Medical_Necessity,106.84,56.4,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0577,none,0,1,0,0,0,0.0,0,0,CBP_Controlling_BP,FFS
CLM0000001863,MBR00000299,Medical_Professional,Paid,Electronic_EDI,2023-07-02,2023-07-02,2023-07-02,2023-07-11,Auto_Adjudicated,9,1183801932,1493836023,207RG0100X,Gastroenterology,31,In_Network,Z79.4,OTHER|J44.1,99231,,0,Medicaid_MCO,MCO,74,F,0.8833,,,183.12,119.52,117.52,0.0,2.0,0.0,63.6,0.0,0.0,0,,0.0281,none,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000001864,MBR00000161,Pharmacy,Paid,Electronic_EDI,2023-03-09,2023-03-09,2023-03-09,2023-04-02,Manual_Review,24,1273835569,1447657873,208600000X,Surgery General,81,In_Network,Z23,Z00.01|OTHER,00069420020,,2,Medicaid_MCO,MLTSS,9,F,0.8354,,,50.13,26.5,22.5,0.0,4.0,0.0,23.63,0.0,0.0,0,,0.0766,benford_violation,0,1,0,0,0,2e-06,0,1,FUH_Follow_Up_Hospitalization,Bundled_Payment
CLM0000001865,MBR00000261,Medical_Institutional,Paid,Electronic_EDI,2023-06-28,2023-06-28,2023-07-01,2023-07-15,Manual_Review,17,1869706360,1406199453,207Q00000X,Family Medicine,71,In_Network,Z12.11,M54.5|OTHER,revenue_code:0360,,0,Medicare_Advantage,MA_PPO,13,F,0.4259,,,17703.79,12321.06,9813.81,9.79,44.0,2453.45,5382.73,0.0,0.0,0,,0.0255,none,0,1,1,0,0,0.000908,0,0,,FFS
CLM0000001866,MBR00000275,Medical_Professional,Paid,Provider_Portal,2023-01-16,2023-01-16,2023-01-16,2023-02-02,Auto_Adjudicated,17,1526973051,1391074619,2084P0800X,Psychiatry,22,In_Network,E11.65,N39.0,99395,,0,Medicare_Advantage,MA_PPO,67,M,0.8169,,,141.02,86.51,39.43,22.22,15.0,9.86,54.51,0.0,0.0,0,,0.1126,none,0,1,0,1,0,4e-06,0,0,,P4P
CLM0000001867,MBR00000159,Medical_Institutional,Denied,Electronic_EDI,2023-02-10,2023-02-10,2023-02-11,2023-03-12,Manual_Review,30,1915327071,1312595355,246ZN0300X,Neuropsychology,23,In_Network,E13.9,,revenue_code:0200,,0,Commercial,PPO,70,F,1.2009,1,Duplicate,29500.97,17739.79,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0743,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000001868,MBR00000142,Pharmacy,Paid,Electronic_EDI,2023-07-14,2023-07-14,2023-07-14,2023-07-19,Clinical_Review,5,1648123576,1402472115,101YP2500X,Psychologist Clinical,21,Out_of_Network,M54.5,F41.1|OTHER|Z12.11,00169751112,,3,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,233.25,87.74,0.0,87.74,0.0,0.0,145.51,0.0,0.0,0,,0.0297,none,0,1,0,0,0,0.0,1,0,,Shared_Savings
CLM0000001869,MBR00000167,Medical_Professional,Denied,Paper,2023-03-20,2023-03-20,2023-03-20,2023-03-30,Auto_Adjudicated,10,1102590784,1289435414,2084P0800X,Psychiatry,23,In_Network,J06.9,Z00.01,99203,,0,Commercial,PPO,77,F,0.9377,PR-1,Authorization,436.16,296.95,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1239,none,0,1,0,0,0,0.0,0,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000001870,MBR00000254,Medical_Institutional,Paid,Electronic_EDI,2023-05-05,2023-05-05,2023-05-07,2023-05-11,Manual_Review,6,1702283246,1898471307,207RG0100X,Gastroenterology,11,In_Network,N18.3,,revenue_code:0370,,0,Commercial,PPO,22,F,0.9285,,,5378.01,3242.94,2555.59,5.45,43.0,638.9,2135.07,0.0,0.0,0,,0.0665,none,0,1,0,0,0,0.000237,0,0,,FFS
CLM0000001871,MBR00000292,Medical_Institutional,Paid,Electronic_EDI,2023-05-10,2023-05-10,2023-05-13,2023-06-04,Auto_Adjudicated,25,1923332120,1388050552,207R00000X,Internal Medicine,21,In_Network,Z00.00,,revenue_code:0110,470,0,Medicare_Advantage,MA_HMO,4,M,1.1779,,,64220.05,32780.66,26190.59,13.42,29.0,6547.65,31439.39,0.0,0.0,0,,0.2429,outlier_billing_amount|service_date_weekend,0,2,1,0,0,0.002424,0,0,,P4P
CLM0000001872,MBR00000104,Medical_Institutional,Paid,Electronic_EDI,2023-06-19,2023-06-19,2023-06-22,2023-07-15,Auto_Adjudicated,26,1721465780,1473869105,207RE0101X,Endocrinology,65,In_Network,Z87.891,OTHER|E78.5,revenue_code:0200,,0,Medicaid_MCO,MCO,87,F,1.2297,,,88467.77,52183.61,52182.61,0.0,1.0,0.0,36284.16,0.0,0.0,0,,0.1669,outlier_billing_amount|impossible_service_combo,0,1,1,0,0,0.00483,0,0,W30_Well_Child_Visit,FFS
CLM0000001873,MBR00000216,Dental,Paid,Electronic_EDI,2023-09-08,2023-09-08,2023-09-08,2023-10-04,Auto_Adjudicated,26,1256824549,1388050552,207RG0100X,Gastroenterology,23,In_Network,OTHER,OTHER|M54.5,D1110,,0,Medicare_Advantage,MA_HMO,71,F,0.7117,,,356.37,183.62,126.69,15.26,10.0,31.67,172.75,0.0,0.0,0,,0.1646,service_date_weekend,0,1,0,0,0,1.2e-05,0,0,,P4P
CLM0000001874,MBR00000089,Medical_Professional,Paid,Electronic_EDI,2023-06-10,2023-06-10,2023-06-10,2023-06-18,Auto_Adjudicated,8,1630305772,1114756459,207Q00000X,Family Medicine,11,In_Network,OTHER,I50.9|Z00.00,99232,,0,Commercial,PPO,14,M,0.5668,,,340.87,165.51,57.79,59.28,34.0,14.45,175.36,0.0,0.0,0,,0.1355,none,0,1,0,0,0,5e-06,0,0,,Shared_Savings
CLM0000001875,MBR00000184,Pharmacy,Paid,Electronic_EDI,2023-10-31,2023-10-31,2023-10-31,2023-11-08,Manual_Review,8,1429653002,1068662623,207RN0300X,Nephrology,22,In_Network,Z00.121,OTHER,00310075090,,2,Medicaid_MCO,MLTSS,30,M,2.8302,,,178.17,73.16,71.16,0.0,2.0,0.0,105.01,0.0,0.0,0,,0.1021,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000001876,MBR00000238,Pharmacy,Paid,Electronic_EDI,2023-06-23,2023-06-23,2023-06-23,2023-07-06,Auto_Adjudicated,13,1878453830,1829216053,101YP2500X,Psychologist Clinical,21,In_Network,M17.11,F32.9,00310075090,,1,Commercial,PPO,74,F,0.4382,,,402.95,185.33,116.16,15.13,25.0,29.04,217.62,0.0,0.0,0,,0.1361,provider_specialty_mismatch,0,1,0,0,0,1.1e-05,0,1,,FFS
CLM0000001877,MBR00000269,Medical_Institutional,Paid,Electronic_EDI,2023-12-23,2023-12-23,2023-12-27,2024-01-16,Manual_Review,24,1330688043,1287472731,207R00000X,Internal Medicine,24,Out_of_Network,OTHER,E78.5|OTHER|Z23,revenue_code:0360,,0,Commercial,EPO,10,F,0.718,,,24490.98,10159.91,8065.65,7.84,70.0,2016.41,14331.07,0.0,0.0,0,,0.0853,none,0,1,1,1,0,0.000747,1,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000001878,MBR00000140,Medical_Institutional,Paid,Electronic_EDI,2023-12-25,2023-12-25,2023-12-25,2024-01-17,Auto_Adjudicated,23,1015411732,1509799493,207V00000X,Obstetrics & Gynecology,11,In_Network,F41.1,OTHER|Z23,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,7,M,1.3997,,,2428.01,862.08,645.08,0.73,55.0,161.27,1565.93,0.0,0.0,0,,0.0893,none,0,1,0,1,0,6e-05,0,0,CDC_HbA1c_Poor_Control,Bundled_Payment
CLM0000001879,MBR00000117,Medical_Professional,Paid,Electronic_EDI,2023-06-03,2023-06-03,2023-06-03,2023-07-03,Auto_Adjudicated,30,1898865801,1666461892,2084P0800X,Psychiatry,22,In_Network,OTHER,OTHER,97140,,0,Medicaid_MCO,MLTSS,72,F,0.8628,,,364.43,261.98,257.98,0.0,4.0,0.0,102.45,0.0,0.0,0,,0.1788,controlled_substance_high_volume,0,1,0,0,0,2.4e-05,0,0,,FFS
CLM0000001880,MBR00000078,Medical_Professional,Paid,Electronic_EDI,2023-10-02,2023-10-02,2023-10-02,2023-10-26,Auto_Adjudicated,24,1648123576,1175334579,207RP1001X,Pulmonary Disease,23,In_Network,Z00.00,I50.9|I10|OTHER,99396,,0,Commercial,EPO,65,F,1.3174,,,340.76,135.36,0.0,135.36,0.0,0.0,205.4,0.0,0.0,0,,0.0065,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001881,MBR00000041,Medical_Institutional,Partially_Paid,Paper,2023-06-12,2023-06-12,2023-06-15,2023-07-11,Auto_Adjudicated,29,1893886964,1589482133,225100000X,Physical Therapist,22,In_Network,C50.911,N39.0|F10.10|OTHER,revenue_code:0250,,0,Commercial,PPO,42,F,0.8283,22,Medical_Necessity,24076.92,13180.44,7124.35,73.41,53.0,1781.09,15045.07,6292.37,564.93,0,,0.0477,none,0,1,1,0,0,0.000659,0,0,,Bundled_Payment
CLM0000001882,MBR00000115,Medical_Professional,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-11-19,Manual_Review,8,1008470017,1151295616,207R00000X,Internal Medicine,11,In_Network,Z00.01,Z87.891,99232,,0,Commercial,PPO,15,F,0.7398,,,301.71,203.28,0.0,203.28,0.0,0.0,98.43,0.0,0.0,0,,0.2019,service_date_weekend,0,2,0,0,0,0.0,0,0,,Capitation
CLM0000001883,MBR00000263,Pharmacy,Paid,Electronic_EDI,2023-10-03,2023-10-03,2023-10-03,2023-10-22,Auto_Adjudicated,19,1260336577,1728466420,207RG0100X,Gastroenterology,24,In_Network,Z00.00,M17.11,00085163102,,4,Medicare_Advantage,MA_HMO,29,F,1.5001,,,46.32,32.6,8.22,3.33,19.0,2.05,13.72,0.0,0.0,0,,0.0451,none,0,1,0,0,0,1e-06,0,1,MMA_Medication_Management,FFS
CLM0000001884,MBR00000133,Medical_Institutional,Paid,Electronic_EDI,2023-05-02,2023-05-02,2023-05-03,2023-05-18,Auto_Adjudicated,16,1380824221,1473869105,207RC0000X,Cardiovascular Disease,24,In_Network,M17.11,OTHER|K29.70|E13.9,revenue_code:0370,,0,Medicaid_MCO,MCO,57,M,0.9592,,,19802.9,7689.86,7683.86,0.0,6.0,0.0,12113.04,0.0,0.0,0,,0.0849,high_volume_same_code,0,1,1,0,0,0.000711,0,0,,FFS
CLM0000001885,MBR00000100,Medical_Professional,Paid,Electronic_EDI,2023-04-26,2023-04-26,2023-04-26,2023-05-01,Auto_Adjudicated,5,1658094898,1829216053,207V00000X,Obstetrics & Gynecology,21,In_Network,Z00.01,I10|M17.11,70553,,0,ACA_Marketplace,ACA_Gold,87,M,1.435,,,2331.73,1843.8,1406.43,73.77,12.0,351.61,487.93,0.0,0.0,0,,0.0979,geographic_mismatch,0,1,0,0,0,0.00013,0,0,,Bundled_Payment
CLM0000001886,MBR00000216,Medical_Professional,Partially_Paid,Provider_Portal,2023-11-13,2023-11-13,2023-11-13,2023-12-12,Auto_Adjudicated,29,1042080259,1447186817,208600000X,Surgery General,11,Out_of_Network,M54.5,,99386,,0,Medicare_Advantage,MA_HMO,71,F,0.7117,256,Medical_Necessity,88.83,35.07,6.07,5.0,10.0,1.52,66.24,0.0,0.0,0,,0.0987,duplicate_claim_indicator,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000001887,MBR00000066,Dental,Paid,Electronic_EDI,2023-07-14,2023-07-14,2023-07-14,2023-07-18,Manual_Review,4,1945264928,1415734567,2086S0122X,Orthopedic Surgery,23,In_Network,OTHER,I10|M25.511|K21.0,D1110,,0,Medicaid_MCO,MCO,54,M,0.6083,,,614.93,373.03,370.03,0.0,3.0,0.0,241.9,0.0,0.0,0,,0.0856,phantom_billing_indicator,0,1,0,0,0,3.4e-05,0,0,,FFS
CLM0000001888,MBR00000079,Medical_Professional,Paid,Electronic_EDI,2023-09-07,2023-09-07,2023-09-07,2023-10-03,Auto_Adjudicated,26,1915327071,1356856197,207RN0300X,Nephrology,21,In_Network,J20.9,F10.10|I10,99203,,0,Medicaid_MCO,MLTSS,55,F,0.5016,,,699.83,532.66,528.66,0.0,4.0,0.0,167.17,0.0,0.0,0,,0.058,none,0,1,0,0,0,4.9e-05,0,0,,FFS
CLM0000001889,MBR00000283,Pharmacy,Paid,Paper,2023-09-01,2023-09-01,2023-09-01,2023-09-10,Auto_Adjudicated,9,1930591083,1187669363,207RP1001X,Pulmonary Disease,21,In_Network,H52.4,F33.0|Z00.01,00078043215,,1,Medicare_Advantage,MA_HMO,21,M,0.5294,,,382.91,221.67,146.61,24.4,14.0,36.65,161.24,0.0,0.0,0,,0.0834,none,0,1,0,0,0,1.4e-05,0,0,,Shared_Savings
CLM0000001890,MBR00000025,Medical_Professional,Paid,Electronic_EDI,2023-03-01,2023-03-01,2023-03-01,2023-03-08,Auto_Adjudicated,7,1207676414,1469697158,2084P0800X,Psychiatry,22,In_Network,OTHER,J06.9,43239,,0,Commercial,POS,74,M,1.3309,,,614.29,522.04,337.8,74.79,25.0,84.45,92.25,0.0,0.0,0,,0.0954,unusual_service_frequency,0,1,0,1,0,3.1e-05,0,0,,FFS
CLM0000001891,MBR00000132,Vision,Paid,Electronic_EDI,2023-03-26,2023-03-26,2023-03-26,2023-04-14,Auto_Adjudicated,19,1813729693,1938465393,207RP1001X,Pulmonary Disease,22,In_Network,F41.1,,V2103,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,,,438.44,308.18,241.38,0.46,6.0,60.34,130.26,0.0,0.0,0,,0.1174,none,0,1,0,0,0,2.2e-05,0,0,MPT_Annual_Monitoring,Capitation
CLM0000001892,MBR00000173,Medical_Institutional,Paid,Electronic_EDI,2023-11-20,2023-11-20,2023-11-23,2023-12-05,Auto_Adjudicated,15,1113370285,1662516615,207V00000X,Obstetrics & Gynecology,31,In_Network,OTHER,,revenue_code:0120,,0,Medicare_Advantage,PFFS,23,F,1.0279,,,11100.09,5765.49,4557.62,28.47,40.0,1139.4,5334.6,0.0,0.0,0,,0.0636,none,0,1,0,0,0,0.000422,0,0,,Shared_Savings
CLM0000001893,MBR00000073,Medical_Institutional,Paid,Electronic_EDI,2023-04-11,2023-04-11,2023-04-12,2023-04-23,Auto_Adjudicated,12,1618546650,1619587398,207R00000X,Internal Medicine,71,In_Network,E11.9,N39.0,revenue_code:0300,,0,Commercial,POS,79,M,1.1768,,,19545.28,7585.61,5838.7,215.23,72.0,1459.68,11959.67,0.0,0.0,0,,0.1078,none,0,1,1,0,0,0.00054,0,0,,P4P
CLM0000001894,MBR00000088,Medical_Institutional,Paid,Electronic_EDI,2023-11-08,2023-11-08,2023-11-08,2023-12-06,Auto_Adjudicated,28,1679629515,1288028182,207RP1001X,Pulmonary Disease,23,In_Network,Z00.01,E13.9,revenue_code:0370,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,,,12934.51,9863.31,6477.99,519.04,90.0,2776.28,3071.2,0.0,0.0,0,,0.0946,none,0,1,1,0,0,0.0006,0,0,,Shared_Savings
CLM0000001895,MBR00000069,Medical_Professional,Paid,Electronic_EDI,2023-05-08,2023-05-08,2023-05-08,2023-05-29,Auto_Adjudicated,21,1832660692,1005335812,2084P0800X,Psychiatry,11,In_Network,M54.5,M17.11|L70.0,82947,,0,Medicare_Advantage,MA_PPO,2,M,0.5765,,,702.67,551.77,434.36,0.82,8.0,108.59,150.9,352.18,60.35,0,,0.0442,none,0,1,0,1,0,4e-05,0,0,,FFS
CLM0000001896,MBR00000109,Pharmacy,Paid,Electronic_EDI,2023-10-31,2023-10-31,2023-10-31,2023-11-19,Auto_Adjudicated,19,1990244466,1978943761,207RC0000X,Cardiovascular Disease,21,In_Network,OTHER,I10,00085163102,,1,Commercial,HMO,8,F,0.5723,,,97.85,65.1,0.0,65.1,0.0,0.0,32.75,0.0,0.0,0,,0.0321,none,0,1,0,1,0,0.0,0,1,,FFS
CLM0000001897,MBR00000273,Medical_Professional,Paid,Electronic_EDI,2023-07-27,2023-07-27,2023-07-27,2023-08-20,Manual_Review,24,1514646292,1643673796,2086S0122X,Orthopedic Surgery,11,In_Network,Z00.01,M79.3,12001,,0,ACA_Marketplace,ACA_Bronze,4,M,1.3569,,,469.96,242.19,0.0,242.19,0.0,0.0,227.77,0.0,0.0,0,,0.074,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001898,MBR00000135,Medical_Professional,Paid,Provider_Portal,2023-02-05,2023-02-05,2023-02-05,2023-03-02,Auto_Adjudicated,25,1292920374,1123879500,2086S0122X,Orthopedic Surgery,23,In_Network,F32.9,,99397,,0,Commercial,PPO,58,F,2.2702,,,630.9,399.31,289.64,0.26,37.0,72.41,231.59,0.0,0.0,0,,0.1156,none,0,1,0,1,0,2.7e-05,0,0,KED_ESRD_Patients,Capitation
CLM0000001899,MBR00000132,Medical_Professional,Paid,Provider_Portal,2023-04-08,2023-04-08,2023-04-08,2023-04-14,Auto_Adjudicated,6,1603037534,1114756459,207RG0100X,Gastroenterology,22,Out_of_Network,E11.65,Z12.11|I10,80053,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,,,421.2,148.0,113.05,0.69,6.0,28.26,273.2,0.0,0.0,0,,0.1253,none,0,1,0,0,0,1e-05,0,0,DDE_Diabetes_Short_Term_Complications,Bundled_Payment
CLM0000001900,MBR00000122,Medical_Institutional,Paid,Electronic_EDI,2023-12-09,2023-12-09,2023-12-13,2023-12-23,Auto_Adjudicated,14,1928139578,1300957944,208600000X,Surgery General,81,Out_of_Network,OTHER,OTHER|I10,revenue_code:0370,,0,Commercial,EPO,64,F,0.8625,,,3805.31,2125.98,1617.89,60.62,43.0,404.47,1679.33,0.0,0.0,1,Unbundling,0.9971,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|benford_violation|service_date_weekend|npi_mismatch|high_oop_waiver,1,5,0,0,0,0.00015,0,0,,Shared_Savings
CLM0000001901,MBR00000292,Dental,Paid,Electronic_EDI,2023-03-16,2023-03-16,2023-03-16,2023-04-13,Auto_Adjudicated,28,1243052462,1319611206,207RN0300X,Nephrology,22,In_Network,OTHER,I10,D4341,,0,Medicare_Advantage,MA_HMO,4,M,1.1779,,,269.35,227.11,159.55,24.67,3.0,39.89,42.24,0.0,0.0,0,,0.0451,none,0,1,0,1,0,1.5e-05,0,0,TRC_Transition_of_Care,FFS
CLM0000001902,MBR00000036,Medical_Professional,Denied,Electronic_EDI,2023-03-23,2023-03-23,2023-03-23,2023-04-17,Auto_Adjudicated,25,1443292773,1728466420,207RN0300X,Nephrology,11,In_Network,E11.9,,99284,,0,Commercial,EPO,17,M,2.0136,CO-45,Timely_Filing,244.82,111.78,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0368,none,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,P4P
CLM0000001903,MBR00000263,Dental,Denied,Electronic_EDI,2023-02-23,2023-02-23,2023-02-23,2023-02-25,Auto_Adjudicated,2,1330688043,1004714954,207RP1001X,Pulmonary Disease,22,In_Network,E78.5,,D0150,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,170,Coding_Error,274.98,190.14,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0134,none,0,1,0,0,0,0.0,0,0,AWV_Annual_Wellness_Visit,FFS
CLM0000001904,MBR00000104,Pharmacy,Denied,Electronic_EDI,2023-08-07,2023-08-07,2023-08-07,2023-08-15,Manual_Review,8,1853233709,1012893364,101YP2500X,Psychologist Clinical,21,In_Network,E13.9,OTHER|M54.5,16590051660,,1,Medicaid_MCO,MCO,87,F,1.2297,18,Medical_Necessity,182.31,73.38,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0416,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000001905,MBR00000290,Medical_Professional,Paid,Electronic_EDI,2023-10-18,2023-10-18,2023-10-18,2023-10-26,Auto_Adjudicated,8,1231231881,1619587398,207V00000X,Obstetrics & Gynecology,11,In_Network,OTHER,OTHER|I10,99214,,0,Commercial,PPO,9,M,0.5261,,,191.56,136.96,64.3,17.59,39.0,16.07,54.6,0.0,0.0,0,,0.0174,none,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000001906,MBR00000100,Medical_Professional,Paid,Electronic_EDI,2023-12-03,2023-12-03,2023-12-03,2023-12-19,Manual_Review,16,1976304517,1878017518,207RG0100X,Gastroenterology,21,In_Network,I10,E11.9|I10,70553,,0,ACA_Marketplace,ACA_Gold,87,M,1.435,,,1843.79,1050.96,800.91,37.82,12.0,200.23,792.83,0.0,0.0,0,,0.0392,none,0,1,0,0,0,7.4e-05,0,0,,FFS
CLM0000001907,MBR00000025,Medical_Professional,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-12-10,Auto_Adjudicated,25,1288855406,1809122260,2084P0800X,Psychiatry,11,Out_of_Network,F10.10,G47.33|J44.1,99203,,0,Commercial,POS,74,M,1.3309,,,253.41,131.87,1.37,105.15,25.0,0.34,121.54,1.22,0.1,0,,0.0969,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001908,MBR00000159,Medical_Professional,Paid,Electronic_EDI,2023-11-14,2023-11-14,2023-11-14,2023-11-29,Manual_Review,15,1688560518,1513198866,207RG0100X,Gastroenterology,11,In_Network,E11.9,G47.33|I10,27130,,0,Commercial,PPO,70,F,1.2009,,,8658.05,5219.02,4127.66,45.45,14.0,1031.91,3439.03,0.0,0.0,0,,0.0372,none,0,1,0,0,0,0.000382,0,0,,Capitation
CLM0000001909,MBR00000071,Pharmacy,Denied,Paper,2023-11-21,2023-11-21,2023-11-21,2023-11-27,Auto_Adjudicated,6,1966338974,1287472731,246ZN0300X,Neuropsychology,22,In_Network,I10,Z00.01,16590051660,,2,Commercial,EPO,19,F,0.5699,97,Eligibility,18.14,13.77,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0297,none,0,1,0,0,0,0.0,0,1,,P4P
CLM0000001910,MBR00000221,Medical_Institutional,Paid,Electronic_EDI,2023-07-23,2023-07-23,2023-07-26,2023-08-09,Auto_Adjudicated,17,1102590784,1662516615,225100000X,Physical Therapist,24,In_Network,J06.9,,revenue_code:0250,,0,Commercial,HDHP_HSA,28,M,1.6683,,,32146.19,24726.29,19450.41,413.27,0.0,4862.6,7419.9,0.0,0.0,0,,0.0795,none,0,1,1,0,0,0.0018,0,0,MPT_Annual_Monitoring,Shared_Savings
CLM0000001911,MBR00000196,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-10-22,2023-10-22,2023-10-23,2023-10-29,Manual_Review,7,1177281088,1728466420,225100000X,Physical Therapist,32,In_Network,OTHER,N39.0,revenue_code:0120,,0,Commercial,PPO,16,F,1.6015,CO-45,Medical_Necessity,8071.04,4248.96,2334.0,228.2,36.0,583.5,4889.33,0.0,0.0,0,,0.0721,none,0,1,0,0,0,0.000216,0,0,SPC_Statin_Therapy,P4P
CLM0000001912,MBR00000205,Pharmacy,Paid,Electronic_EDI,2023-08-16,2023-08-16,2023-08-16,2023-09-06,Auto_Adjudicated,21,1969707582,1098360555,207RN0300X,Nephrology,11,In_Network,J45.20,,59148001506,,1,Medicaid_MCO,MCO,1,F,0.9425,,,243.11,162.02,161.02,0.0,1.0,0.0,81.09,0.0,0.0,0,,0.0707,diagnosis_procedure_mismatch,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000001913,MBR00000060,Medical_Professional,Paid,Electronic_EDI,2023-02-19,2023-02-19,2023-02-19,2023-03-21,Auto_Adjudicated,30,1014995735,1564691686,246ZN0300X,Neuropsychology,22,In_Network,F41.1,,99223,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,175.97,90.01,0.0,90.01,0.0,0.0,85.96,0.0,0.0,0,,0.1079,none,0,1,0,0,0,0.0,0,0,KED_ESRD_Patients,FFS
CLM0000001914,MBR00000210,Dental,Denied,Electronic_EDI,2023-01-09,2023-01-09,2023-01-09,2023-01-28,Auto_Adjudicated,19,1670125610,1788579687,2084P0800X,Psychiatry,31,In_Network,N40.0,,D4341,,0,Medicare_Advantage,SNP,49,M,0.6952,97,Timely_Filing,370.26,213.23,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2047,duplicate_claim_indicator,0,2,0,0,0,0.0,0,0,,FFS
CLM0000001915,MBR00000099,Pharmacy,Paid,Electronic_EDI,2023-02-05,2023-02-05,2023-02-05,2023-03-05,Auto_Adjudicated,28,1256824549,1994275960,225100000X,Physical Therapist,81,In_Network,Z23,,16590051660,,2,Commercial,HMO,10,F,0.7843,,,176.11,119.43,0.0,119.43,0.0,0.0,56.68,0.0,0.0,0,,0.1231,temporal_clustering,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001916,MBR00000300,Medical_Professional,Paid,Electronic_EDI,2023-05-05,2023-05-05,2023-05-05,2023-05-22,Auto_Adjudicated,17,1356408757,1175334579,207Q00000X,Family Medicine,31,Out_of_Network,E11.9,,10060,,0,Commercial,PPO,64,F,1.0393,,,1238.41,591.77,408.56,52.07,29.0,102.14,646.64,0.0,0.0,0,,0.0294,none,0,1,0,0,0,3.8e-05,1,0,,Shared_Savings
CLM0000001917,MBR00000214,Medical_Institutional,Paid,Electronic_EDI,2023-06-29,2023-06-29,2023-07-03,2023-07-24,Clinical_Review,25,1215358845,1300957944,225100000X,Physical Therapist,22,In_Network,OTHER,N39.0|Z23,revenue_code:0360,,0,Commercial,HDHP_HSA,76,M,1.7526,,,13927.96,7137.11,5400.25,386.79,0.0,1350.06,6790.85,0.0,0.0,0,,0.1128,none,0,1,1,0,0,0.0005,0,0,,FFS
CLM0000001918,MBR00000177,Medical_Professional,Paid,Electronic_EDI,2023-08-18,2023-08-18,2023-08-18,2023-09-16,Auto_Adjudicated,29,1035707913,1252125670,207RE0101X,Endocrinology,32,In_Network,Z00.00,K57.30,99284,,0,Commercial,HMO,42,F,1.2774,,,234.7,101.62,0.0,101.62,0.0,0.0,133.08,0.0,0.0,1,Kickback Arrangement,1.0,outlier_billing_amount|geographic_mismatch|provider_specialty_mismatch|high_volume_same_code|impossible_service_combo|service_date_weekend|duplicate_claim_indicator|npi_mismatch|diagnosis_procedure_mismatch,1,5,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001919,MBR00000262,Behavioral_Health,Paid,Electronic_EDI,2023-07-07,2023-07-07,2023-07-07,2023-07-13,Auto_Adjudicated,6,1462532026,1493836023,207RE0101X,Endocrinology,23,In_Network,OTHER,Z23,17000,,0,Medicare_Advantage,PFFS,77,F,1.7452,,,273.39,177.91,138.3,1.04,4.0,34.57,95.48,0.0,0.0,0,,0.0218,none,0,1,0,0,0,1.3e-05,0,0,,Shared_Savings
CLM0000001920,MBR00000177,Medical_Institutional,Paid,Electronic_EDI,2023-05-12,2023-05-12,2023-05-14,2023-06-01,Auto_Adjudicated,20,1901547390,1809122260,207V00000X,Obstetrics & Gynecology,11,In_Network,OTHER,,revenue_code:0110,,0,Commercial,HMO,42,F,1.2774,,,5126.96,3962.05,2937.57,213.08,77.0,734.39,1164.91,0.0,0.0,0,,0.1335,high_volume_same_code,0,1,0,0,0,0.000272,0,0,,Capitation
CLM0000001921,MBR00000167,Dental,Paid,Electronic_EDI,2023-09-21,2023-09-21,2023-09-21,2023-09-29,Manual_Review,8,1909649019,1789540567,2086S0122X,Orthopedic Surgery,11,In_Network,G43.909,OTHER,D1110,,0,Commercial,PPO,77,F,0.9377,,,392.05,317.19,152.7,114.31,12.0,38.18,74.86,0.0,0.0,0,,0.1945,temporal_clustering,0,1,0,0,0,1.4e-05,0,0,,Shared_Savings
CLM0000001922,MBR00000075,Behavioral_Health,Paid,Electronic_EDI,2023-11-06,2023-11-06,2023-11-06,2023-11-09,Clinical_Review,3,1513407277,1867626800,207RC0000X,Cardiovascular Disease,65,In_Network,E11.65,OTHER|J06.9|Z12.11,70553,,0,Medicaid_MCO,MCO,5,M,1.0573,,,267.51,219.71,215.71,0.0,4.0,0.0,47.8,130.95,67.34,0,,0.0702,none,0,1,0,0,0,2e-05,0,0,AMR_Asthma_Medication_Ratio,P4P
CLM0000001923,MBR00000201,Medical_Institutional,Paid,Electronic_EDI,2023-03-22,2023-03-22,2023-03-24,2023-03-30,Auto_Adjudicated,8,1770738194,1228356980,207V00000X,Obstetrics & Gynecology,65,In_Network,OTHER,F32.9,revenue_code:0100,,0,Medicare_Advantage,MA_PPO,74,M,1.1575,,,18552.31,13724.39,10931.09,14.53,46.0,2732.77,4827.92,0.0,0.0,0,,0.1603,unbundling_pattern,0,1,1,1,0,0.001012,0,0,CCS_Cervical_Cancer_Screening,Capitation
CLM0000001924,MBR00000118,Pharmacy,Paid,Provider_Portal,2023-04-04,2023-04-04,2023-04-04,2023-04-09,Auto_Adjudicated,5,1813729693,1175334579,246ZN0300X,Neuropsychology,22,In_Network,Z00.00,F10.10|OTHER,50458085930,,3,Medicaid_MCO,MCO,69,M,1.2773,,,240.71,141.18,140.18,0.0,1.0,0.0,99.53,0.0,0.0,0,,0.0252,none,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000001925,MBR00000013,Medical_Institutional,Paid,Electronic_EDI,2023-12-01,2023-12-01,2023-12-02,2023-12-07,Clinical_Review,6,1756856314,1288028182,2086S0122X,Orthopedic Surgery,23,In_Network,J44.1,Z00.00|I10|OTHER,revenue_code:0110,,0,Commercial,PPO,64,F,1.428,,,14965.09,11317.31,8976.82,60.29,36.0,2244.2,3647.78,0.0,0.0,0,,0.1534,provider_specialty_mismatch,0,1,1,1,0,0.000831,0,0,MPT_Annual_Monitoring,FFS
CLM0000001926,MBR00000242,Medical_Professional,Denied,Electronic_EDI,2023-12-15,2023-12-15,2023-12-15,2023-12-16,Manual_Review,1,1597245892,1055872102,207V00000X,Obstetrics & Gynecology,11,Emergency,E78.5,K21.0|OTHER,84443,,0,Medicaid_MCO,MLTSS,75,F,0.7104,3,Eligibility,1235.66,590.47,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.091,none,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000001927,MBR00000014,Vision,Paid,Paper,2023-04-22,2023-04-22,2023-04-22,2023-05-22,Auto_Adjudicated,30,1331264469,1774401124,246ZN0300X,Neuropsychology,23,In_Network,M79.3,J06.9,92014,,0,Commercial,HMO,77,M,2.8513,,,402.91,243.95,0.0,243.95,0.0,0.0,158.96,0.0,0.0,0,,0.0313,none,0,1,0,0,0,0.0,0,0,CDC_BP_Control,FFS
CLM0000001928,MBR00000199,Medical_Institutional,Paid,Electronic_EDI,2023-07-02,2023-07-02,2023-07-04,2023-07-16,Auto_Adjudicated,14,1637260822,1564691686,207RC0000X,Cardiovascular Disease,22,In_Network,I50.9,OTHER,revenue_code:0450,,0,Medicaid_MCO,MLTSS,17,F,1.0776,,,23493.43,19012.03,19012.03,0.0,0.0,0.0,4481.4,0.0,0.0,0,,0.0176,none,0,1,1,0,0,0.00176,0,0,,FFS
CLM0000001929,MBR00000050,Dental,Paid,Provider_Portal,2023-07-27,2023-07-27,2023-07-27,2023-08-01,Auto_Adjudicated,5,1496340237,1662516615,207RN0300X,Nephrology,21,In_Network,E11.9,,D7140,,0,Medicare_Advantage,MA_PPO,12,F,0.8486,,,120.54,77.03,59.53,2.62,0.0,14.88,43.51,0.0,0.0,0,,0.0946,none,0,1,0,0,0,6e-06,0,0,,Bundled_Payment
CLM0000001930,MBR00000135,Pharmacy,Paid,Electronic_EDI,2023-08-16,2023-08-16,2023-08-16,2023-08-27,Auto_Adjudicated,11,1210349885,1013600387,225100000X,Physical Therapist,22,In_Network,I10,E11.9|OTHER,00169751112,,5,Commercial,PPO,58,F,2.2702,,,44.95,29.47,0.0,3.33,26.14,0.0,15.48,0.0,0.0,0,,0.0261,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000001931,MBR00000259,Medical_Professional,Paid,Electronic_EDI,2023-11-07,2023-11-07,2023-11-07,2023-11-30,Manual_Review,23,1871348663,1432077493,207RC0000X,Cardiovascular Disease,22,In_Network,J44.1,OTHER|I10|M54.5,99232,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,188.33,124.42,90.23,4.64,7.0,22.56,63.91,0.0,0.0,0,,0.1692,duplicate_claim_indicator,0,1,0,0,0,8e-06,0,0,,Capitation
CLM0000001932,MBR00000028,Medical_Institutional,Paid,Electronic_EDI,2023-02-07,2023-02-07,2023-02-11,2023-02-26,Auto_Adjudicated,19,1728728765,1804282800,207RE0101X,Endocrinology,71,In_Network,OTHER,E11.9|OTHER,revenue_code:0300,,0,Commercial,HMO,3,F,2.116,,,9595.67,7214.83,5570.32,172.94,79.0,1392.58,2380.84,0.0,0.0,0,,0.0564,none,0,1,1,0,0,0.000516,0,0,,FFS
CLM0000001933,MBR00000198,Medical_Professional,Denied,Electronic_EDI,2023-07-07,2023-07-07,2023-07-07,2023-07-09,Auto_Adjudicated,2,1033622184,1765164601,207RN0300X,Nephrology,32,In_Network,G47.33,,27130,,0,Medicaid_MCO,MCO,81,F,1.4199,5,Authorization,10574.13,4145.71,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0721,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001934,MBR00000184,Medical_Professional,Denied,Electronic_EDI,2023-03-19,2023-03-19,2023-03-19,2023-03-24,Manual_Review,5,1364746046,1938465393,246ZN0300X,Neuropsychology,11,In_Network,F41.1,,99221,,0,Medicaid_MCO,MLTSS,30,M,2.8302,5,Duplicate,168.49,90.46,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0804,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001935,MBR00000262,Pharmacy,Paid,Electronic_EDI,2023-09-28,2023-09-28,2023-09-28,2023-10-15,Clinical_Review,17,1375098560,1144950506,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,E78.5,00071012831,,3,Medicare_Advantage,PFFS,77,F,1.7452,,,217.9,178.3,139.14,0.38,4.0,34.78,39.6,0.0,0.0,0,,0.1713,unbundling_pattern|controlled_substance_high_volume,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000001936,MBR00000055,Medical_Professional,Denied,Electronic_EDI,2023-08-03,2023-08-03,2023-08-03,2023-09-02,Auto_Adjudicated,30,1101385540,1007652766,2084P0800X,Psychiatry,11,In_Network,OTHER,N39.0|E11.9|C50.911,27447,,0,Commercial,PPO,68,F,1.2896,50,Timely_Filing,9770.93,8134.8,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0372,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001937,MBR00000236,Vision,Paid,Electronic_EDI,2023-09-26,2023-09-26,2023-09-26,2023-09-29,Auto_Adjudicated,3,1603037534,1252125670,208600000X,Surgery General,11,In_Network,L70.0,,V2320,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,84.18,52.99,49.99,0.0,3.0,0.0,31.19,0.0,0.0,0,,0.0106,none,0,1,0,1,0,5e-06,0,0,,P4P
CLM0000001938,MBR00000140,Medical_Institutional,Denied,Provider_Portal,2023-11-22,2023-11-22,2023-11-22,2023-12-18,Auto_Adjudicated,26,1520692162,1415734567,207R00000X,Internal Medicine,22,In_Network,K21.0,J45.20,revenue_code:0210,,0,Medicare_Advantage,MA_HMO,7,M,1.3997,2,COB,3534.25,1767.17,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0374,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001939,MBR00000135,Medical_Institutional,Paid,Electronic_EDI,2023-10-11,2023-10-11,2023-10-13,2023-10-13,Manual_Review,2,1039678579,1930040953,207R00000X,Internal Medicine,22,In_Network,F41.1,Z00.01,revenue_code:0200,,0,Commercial,PPO,58,F,2.2702,,,6931.89,5377.56,4252.72,2.66,59.0,1063.18,1554.33,0.0,0.0,0,,0.0922,high_oop_waiver,0,1,0,0,0,0.000394,0,0,SPD_Spirometry_Testing,FFS
CLM0000001940,MBR00000114,Medical_Professional,Paid,Electronic_EDI,2023-11-03,2023-11-03,2023-11-03,2023-11-18,Auto_Adjudicated,15,1718336220,1148612764,2084P0800X,Psychiatry,11,In_Network,E78.5,,99385,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,246.08,195.74,132.95,10.56,19.0,33.24,50.34,0.0,0.0,0,,0.2419,geographic_mismatch|high_oop_waiver,0,2,0,0,0,1.2e-05,0,0,,P4P
CLM0000001941,MBR00000122,Medical_Professional,Paid,Electronic_EDI,2023-10-19,2023-10-19,2023-10-19,2023-10-26,Auto_Adjudicated,7,1421421733,1163639177,207R00000X,Internal Medicine,81,In_Network,OTHER,,99384,,0,Commercial,EPO,64,F,0.8625,,,438.84,218.82,0.0,218.82,0.0,0.0,220.02,0.0,0.0,0,,0.1983,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001942,MBR00000159,Medical_Institutional,Paid,Electronic_EDI,2023-08-13,2023-08-13,2023-08-13,2023-08-26,Manual_Review,13,1637260822,1896197144,101YP2500X,Psychologist Clinical,24,In_Network,E78.5,,revenue_code:0360,,0,Commercial,PPO,70,F,1.2009,,,17743.06,12723.02,10089.68,39.92,71.0,2522.42,5020.04,0.0,0.0,0,,0.0312,none,0,1,1,0,0,0.000934,0,0,,FFS
CLM0000001943,MBR00000033,Medical_Professional,Paid,Electronic_EDI,2023-05-21,2023-05-21,2023-05-21,2023-06-18,Auto_Adjudicated,28,1591624417,1564636990,208600000X,Surgery General,11,In_Network,Z87.891,E13.9,99214,,0,Medicare_Advantage,PFFS,31,F,0.821,,,102.74,84.82,39.36,30.62,5.0,9.84,17.92,0.0,0.0,0,,0.0478,none,0,1,0,1,0,4e-06,0,0,,FFS
CLM0000001944,MBR00000134,Medical_Institutional,Paid,Electronic_EDI,2023-05-01,2023-05-01,2023-05-01,2023-05-08,Auto_Adjudicated,7,1624242487,1132693989,207Q00000X,Family Medicine,23,Emergency,OTHER,,revenue_code:0450,,0,Medicare_Advantage,MA_PPO,33,M,1.115,,,44355.03,25108.98,20060.72,11.08,22.0,5015.18,19246.05,0.0,0.0,0,,0.1377,temporal_clustering,0,1,1,0,0,0.001857,0,0,,Capitation
CLM0000001945,MBR00000194,Medical_Institutional,Paid,Electronic_EDI,2023-05-11,2023-05-11,2023-05-11,2023-05-31,Auto_Adjudicated,20,1706065807,1764064254,207RP1001X,Pulmonary Disease,21,In_Network,J20.9,,revenue_code:0300,872,0,Commercial,PPO,77,M,0.9783,,,22523.24,8801.13,6920.18,113.9,37.0,1730.05,13722.11,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|provider_specialty_mismatch|high_volume_same_code|impossible_service_combo|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|unbundling_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch,1,5,1,0,0,0.000641,0,0,,Capitation
CLM0000001946,MBR00000154,Medical_Professional,Denied,Electronic_EDI,2023-08-07,2023-08-07,2023-08-07,2023-08-17,Auto_Adjudicated,10,1906448800,1903401648,207RN0300X,Nephrology,23,In_Network,I10,I10,97140,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,2,Medical_Necessity,707.57,542.54,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0128,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001947,MBR00000052,Medical_Institutional,Paid,Electronic_EDI,2023-10-16,2023-10-16,2023-10-17,2023-11-05,Auto_Adjudicated,20,1810800968,1300957944,207RP1001X,Pulmonary Disease,22,Out_of_Network,Z00.00,OTHER|I10,revenue_code:0210,,0,Commercial,PPO,0,F,1.325,,,5570.55,3825.92,2748.62,314.15,76.0,687.15,1744.63,0.0,0.0,0,,0.1412,none,0,1,0,0,0,0.000254,1,0,,FFS
CLM0000001948,MBR00000114,Medical_Professional,Paid,Electronic_EDI,2023-05-12,2023-05-12,2023-05-12,2023-05-14,Auto_Adjudicated,2,1702283246,1825450791,207V00000X,Obstetrics & Gynecology,11,In_Network,I50.9,J06.9|J44.1,90834,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,964.27,703.06,533.25,17.49,19.0,133.31,261.21,0.0,0.0,0,,0.0952,high_volume_same_code,0,1,0,0,0,4.9e-05,0,0,,FFS
CLM0000001949,MBR00000139,Medical_Professional,Paid,Electronic_EDI,2023-07-28,2023-07-28,2023-07-28,2023-08-06,Auto_Adjudicated,9,1770431137,1746676564,207R00000X,Internal Medicine,22,In_Network,E11.9,OTHER|M54.5,97035,,0,Commercial,PPO,74,M,1.7701,,,166.2,113.02,54.31,24.13,21.0,13.58,53.18,0.0,0.0,0,,0.1128,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000001950,MBR00000198,Pharmacy,Partially_Paid,Electronic_EDI,2023-05-29,2023-05-29,2023-05-29,2023-06-27,Auto_Adjudicated,29,1267286378,1301869102,207RG0100X,Gastroenterology,81,In_Network,Z00.00,F41.1,16590051660,,1,Medicaid_MCO,MCO,81,F,1.4199,97,Medical_Necessity,525.86,294.41,183.75,0.0,2.0,0.0,340.11,0.0,0.0,0,,0.1205,none,0,1,0,0,0,1.7e-05,0,0,,FFS
CLM0000001951,MBR00000273,Medical_Professional,Paid,Electronic_EDI,2023-08-07,2023-08-07,2023-08-07,2023-08-29,Auto_Adjudicated,22,1263063839,1469642907,101YP2500X,Psychologist Clinical,24,In_Network,J06.9,I10|J06.9,90837,,0,ACA_Marketplace,ACA_Bronze,4,M,1.3569,,,741.18,616.86,0.0,616.86,0.0,0.0,124.32,0.0,0.0,0,,0.1389,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000001952,MBR00000166,Medical_Professional,Paid,Electronic_EDI,2023-10-21,2023-10-21,2023-10-21,2023-11-19,Auto_Adjudicated,29,1913217838,1123879500,2084P0800X,Psychiatry,23,In_Network,I25.10,,90834,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,838.18,554.21,0.0,554.21,0.0,0.0,283.97,0.0,0.0,0,,0.0139,none,0,1,0,0,0,0.0,0,0,IET_Initiation_Substance_Use,Shared_Savings
CLM0000001953,MBR00000201,Medical_Institutional,Denied,Electronic_EDI,2023-05-28,2023-05-28,2023-05-31,2023-06-18,Manual_Review,21,1864546991,1489434038,207R00000X,Internal Medicine,31,In_Network,J20.9,,revenue_code:0120,,0,Medicare_Advantage,MA_PPO,74,M,1.1575,1,Network,40825.71,25011.61,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Provider Impersonation,1.0,unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|benford_violation|impossible_service_combo|service_date_weekend|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|controlled_substance_high_volume,1,5,0,0,0,0.0,0,0,,Capitation
CLM0000001954,MBR00000024,Medical_Institutional,Paid,Electronic_EDI,2023-05-23,2023-05-23,2023-05-26,2023-05-29,Auto_Adjudicated,6,1923332120,1296566243,207RE0101X,Endocrinology,31,In_Network,I10,OTHER|M54.5,revenue_code:0210,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,37673.1,23668.13,23666.13,0.0,2.0,0.0,14004.97,19971.83,2205.14,0,,0.0964,npi_mismatch,0,1,1,0,0,0.002191,0,0,CBP_Controlling_BP,FFS
CLM0000001955,MBR00000289,Vision,Paid,Electronic_EDI,2023-03-14,2023-03-14,2023-03-14,2023-03-28,Clinical_Review,14,1728728765,1282319940,207RP1001X,Pulmonary Disease,32,In_Network,N18.3,E11.9,V2320,,0,Commercial,POS,51,M,1.0534,,,194.84,142.59,6.08,95.99,39.0,1.52,52.25,0.0,0.0,0,,0.0233,none,0,1,0,0,0,1e-06,0,0,POD_Persistence_of_Beta_Blocker,Shared_Savings
CLM0000001956,MBR00000100,Pharmacy,Paid,Electronic_EDI,2023-06-29,2023-06-29,2023-06-29,2023-07-26,Manual_Review,27,1145887050,1461075342,207RP1001X,Pulmonary Disease,11,In_Network,Z23,,00169751112,,4,ACA_Marketplace,ACA_Gold,87,M,1.435,,,80.84,52.91,3.89,36.05,12.0,0.97,27.93,0.0,0.0,0,,0.0257,none,0,1,0,0,0,0.0,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000001957,MBR00000112,Pharmacy,Paid,Electronic_EDI,2023-06-14,2023-06-14,2023-06-14,2023-07-05,Auto_Adjudicated,21,1731980913,1788579687,225100000X,Physical Therapist,11,In_Network,F41.1,,00078043215,,5,Medicare_Advantage,MA_HMO,18,M,1.01,,,202.79,78.43,36.02,27.4,6.0,9.01,124.36,0.0,0.0,0,,0.0567,none,0,1,0,0,0,3e-06,0,1,,FFS
CLM0000001958,MBR00000069,Medical_Institutional,Paid,Electronic_EDI,2023-02-27,2023-02-27,2023-03-02,2023-03-15,Auto_Adjudicated,16,1901508637,1564691686,208600000X,Surgery General,24,In_Network,OTHER,I25.10|Z23,revenue_code:0450,,0,Medicare_Advantage,MA_PPO,2,M,0.5765,,,3472.6,1697.25,1326.12,2.6,37.0,331.53,1775.35,0.0,0.0,0,,0.0606,none,0,1,0,0,0,0.000123,0,0,,FFS
CLM0000001959,MBR00000026,Medical_Institutional,Paid,Electronic_EDI,2023-12-15,2023-12-15,2023-12-15,2024-01-11,Clinical_Review,27,1156265220,1878874025,225100000X,Physical Therapist,81,In_Network,Z00.00,M25.511|Z79.4,revenue_code:0370,,0,Medicaid_MCO,MCO,17,M,1.0686,,,7208.35,4372.68,4365.68,0.0,7.0,0.0,2835.67,0.0,0.0,0,,0.0945,none,0,1,0,1,0,0.000404,0,0,MPT_Annual_Monitoring,Capitation
CLM0000001960,MBR00000234,Medical_Professional,Denied,Electronic_EDI,2023-11-05,2023-11-05,2023-11-05,2023-11-09,Auto_Adjudicated,4,1592228076,1356856197,207RN0300X,Nephrology,22,In_Network,N39.0,,99284,,0,Medicare_Advantage,MA_HMO,59,M,0.395,18,Medical_Necessity,319.0,137.99,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1422,temporal_clustering,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001961,MBR00000076,Pharmacy,Paid,Electronic_EDI,2023-04-15,2023-04-15,2023-04-15,2023-05-14,Auto_Adjudicated,29,1898865801,1450837722,2086S0122X,Orthopedic Surgery,81,In_Network,I10,G47.33,00071015523,,4,Commercial,HMO,26,M,2.1785,,,668.51,520.03,382.47,9.95,32.0,95.62,148.48,0.0,0.0,1,Provider Impersonation,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|benford_violation|impossible_service_combo|billing_spike_recent|phantom_billing_indicator|npi_mismatch|controlled_substance_high_volume,1,5,0,0,0,3.5e-05,0,1,,FFS
CLM0000001962,MBR00000088,Medical_Institutional,Denied,Paper,2023-12-06,2023-12-06,2023-12-06,2023-12-10,Auto_Adjudicated,4,1181941909,1874728994,207RP1001X,Pulmonary Disease,23,In_Network,I10,,revenue_code:0110,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,CO-45,Duplicate,5317.83,3926.17,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0959,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,,P4P
CLM0000001963,MBR00000057,Medical_Professional,Paid,Electronic_EDI,2023-04-08,2023-04-08,2023-04-08,2023-05-08,Manual_Review,30,1014995735,1415734567,207RN0300X,Nephrology,11,In_Network,N18.3,,97110,,0,Medicare_Advantage,MA_PPO,45,M,0.6701,,,513.34,373.85,260.57,46.14,2.0,65.14,139.49,0.0,0.0,0,,0.2566,geographic_mismatch|benford_violation,0,2,0,0,0,2.4e-05,0,0,,FFS
CLM0000001964,MBR00000293,Medical_Institutional,Denied,Electronic_EDI,2023-05-31,2023-05-31,2023-06-04,2023-06-25,Manual_Review,25,1932483309,1289435414,2084P0800X,Psychiatry,65,In_Network,I50.9,,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,2,Medical_Necessity,6577.48,3840.11,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1312,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001965,MBR00000231,Pharmacy,Paid,Electronic_EDI,2023-02-16,2023-02-16,2023-02-16,2023-03-03,Auto_Adjudicated,15,1082088479,1132693989,246ZN0300X,Neuropsychology,31,In_Network,N18.3,,00071012831,,1,ACA_Marketplace,ACA_Silver,12,M,0.6456,,,166.47,82.4,0.0,82.4,0.0,0.0,84.07,0.0,0.0,0,,0.1115,none,0,1,0,0,0,0.0,0,1,COL_Colorectal_Cancer_Screening,FFS
CLM0000001966,MBR00000280,Medical_Institutional,Paid,Electronic_EDI,2023-08-08,2023-08-08,2023-08-12,2023-08-23,Auto_Adjudicated,15,1986485249,1581533104,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,Z12.11|F33.0,revenue_code:0100,,0,Commercial,PPO,79,F,0.6697,,,6866.66,5280.19,4138.01,56.67,51.0,1034.5,1586.47,0.0,0.0,0,,0.0154,none,0,1,0,0,0,0.000383,0,0,,Bundled_Payment
CLM0000001967,MBR00000260,Medical_Professional,Paid,Electronic_EDI,2023-06-22,2023-06-22,2023-06-22,2023-06-23,Manual_Review,1,1177281088,1419347445,207RP1001X,Pulmonary Disease,24,In_Network,OTHER,E13.9|R05.9|M47.816,99397,,0,Medicare_Advantage,SNP,59,M,0.3786,,,171.77,90.42,58.98,10.69,6.0,14.75,81.35,0.0,0.0,0,,0.0613,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000001968,MBR00000274,Vision,Paid,Electronic_EDI,2023-04-06,2023-04-06,2023-04-06,2023-04-16,Manual_Review,10,1411619682,1829216053,207RP1001X,Pulmonary Disease,21,Out_of_Network,E11.9,,92004,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,161.4,101.56,67.97,16.6,0.0,16.99,59.84,0.0,0.0,0,,0.0132,none,0,1,0,0,0,6e-06,0,0,IET_Initiation_Substance_Use,P4P
CLM0000001969,MBR00000147,Medical_Professional,Paid,Electronic_EDI,2023-04-14,2023-04-14,2023-04-14,2023-04-21,Auto_Adjudicated,7,1209940651,1228356980,207RN0300X,Nephrology,22,In_Network,Z79.4,OTHER,73721,,0,Commercial,PPO,31,F,0.7098,,,179.49,89.11,0.0,89.11,0.0,0.0,90.38,0.0,0.0,0,,0.1518,impossible_service_combo,0,1,0,1,0,0.0,0,0,BPD_BP_Declined,FFS
CLM0000001970,MBR00000054,Vision,Paid,Electronic_EDI,2023-12-02,2023-12-02,2023-12-02,2023-12-24,Auto_Adjudicated,22,1098094939,1513198866,101YP2500X,Psychologist Clinical,21,In_Network,F33.0,E78.5|I10,V2115,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,,,480.79,404.49,321.82,1.22,1.0,80.45,76.3,0.0,0.0,0,,0.1672,impossible_service_combo,0,1,0,1,0,3e-05,0,0,KED_ESRD_Patients,FFS
CLM0000001971,MBR00000104,Medical_Institutional,Paid,Electronic_EDI,2023-09-04,2023-09-04,2023-09-07,2023-09-10,Auto_Adjudicated,6,1580443769,1301833092,2084P0800X,Psychiatry,22,Out_of_Network,M79.3,Z00.00,revenue_code:0360,,0,Medicaid_MCO,MCO,87,F,1.2297,,,22853.82,16083.92,16082.92,0.0,1.0,0.0,6769.9,0.0,0.0,0,,0.0574,none,0,1,1,0,0,0.001489,0,0,,FFS
CLM0000001972,MBR00000092,Vision,Paid,Electronic_EDI,2023-02-24,2023-02-24,2023-02-24,2023-03-21,Auto_Adjudicated,25,1064567615,1396850418,2084P0800X,Psychiatry,23,In_Network,K21.0,,92002,,0,Medicaid_MCO,MLTSS,68,F,1.3217,,,151.49,126.1,123.1,0.0,3.0,0.0,25.39,0.0,0.0,0,,0.0453,none,0,1,0,0,0,1.1e-05,0,0,,Shared_Savings
CLM0000001973,MBR00000212,Dental,Denied,Electronic_EDI,2023-02-18,2023-02-18,2023-02-18,2023-02-28,Auto_Adjudicated,10,1900799244,1649705287,225100000X,Physical Therapist,11,In_Network,OTHER,,D4341,,0,Commercial,HMO,57,F,2.5456,1,Authorization,517.18,429.43,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1712,geographic_mismatch,0,1,0,1,0,0.0,0,0,,P4P
CLM0000001974,MBR00000008,Medical_Institutional,Paid,Electronic_EDI,2023-01-26,2023-01-26,2023-01-30,2023-02-21,Auto_Adjudicated,26,1903785749,1878017518,2086S0122X,Orthopedic Surgery,11,In_Network,F32.9,Z87.891,revenue_code:0200,,0,Medicaid_MCO,MCO,74,M,0.8375,,,12466.55,5667.61,5664.61,0.0,3.0,0.0,6798.94,0.0,0.0,0,,0.0335,none,0,1,1,0,0,0.000524,0,0,,FFS
CLM0000001975,MBR00000045,Pharmacy,Denied,Electronic_EDI,2023-03-30,2023-03-30,2023-03-30,2023-04-10,Auto_Adjudicated,11,1078527460,1325999602,225100000X,Physical Therapist,11,In_Network,OTHER,,50458085930,,5,Commercial,HMO,78,F,1.0658,2,Duplicate,64.03,45.81,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0594,none,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000001976,MBR00000203,Medical_Professional,Paid,Provider_Portal,2023-09-22,2023-09-22,2023-09-22,2023-10-15,Auto_Adjudicated,23,1797494973,1704466150,225100000X,Physical Therapist,22,In_Network,F41.1,,47562,,0,Commercial,PPO,49,F,0.3046,,,311.57,181.6,0.0,181.6,0.0,0.0,129.97,0.0,0.0,0,,0.0503,none,0,1,0,0,0,0.0,0,0,IET_Initiation_Substance_Use,FFS
CLM0000001977,MBR00000038,Medical_Professional,Paid,Electronic_EDI,2023-01-23,2023-01-23,2023-01-23,2023-02-13,Auto_Adjudicated,21,1380824221,1690197969,207RN0300X,Nephrology,21,In_Network,OTHER,J06.9|M17.11,99393,,0,Commercial,EPO,46,M,1.1295,,,259.89,172.85,77.4,38.11,38.0,19.35,87.04,0.0,0.0,0,,0.1772,controlled_substance_high_volume,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000001978,MBR00000014,Medical_Professional,Paid,Electronic_EDI,2023-03-31,2023-03-31,2023-03-31,2023-04-30,Clinical_Review,30,1484613641,1977073565,207RG0100X,Gastroenterology,22,In_Network,Z12.11,Z00.00,81001,,0,Commercial,HMO,77,M,2.8513,,,1092.04,636.57,256.3,278.19,38.0,64.08,455.47,0.0,0.0,0,,0.1163,none,0,1,0,0,0,2.4e-05,0,0,,FFS
CLM0000001979,MBR00000034,Medical_Institutional,Paid,Electronic_EDI,2023-01-15,2023-01-15,2023-01-19,2023-01-31,Auto_Adjudicated,16,1972755666,1774401124,101YP2500X,Psychologist Clinical,22,In_Network,Z00.00,OTHER|J44.1,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,35,M,0.7712,,,20483.67,7754.17,6136.54,39.49,44.0,1534.14,12729.5,0.0,0.0,0,,0.023,none,0,1,1,0,0,0.000568,0,0,,FFS
CLM0000001980,MBR00000206,Medical_Professional,Paid,Electronic_EDI,2023-08-22,2023-08-22,2023-08-22,2023-09-02,Manual_Review,11,1875632885,1133410177,207RN0300X,Nephrology,11,In_Network,M17.11,I10,47562,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,445.81,307.82,306.82,0.0,1.0,0.0,137.99,0.0,0.0,0,,0.0258,none,0,1,0,0,0,2.8e-05,0,0,PPC_Prenatal_Care,Shared_Savings
CLM0000001981,MBR00000044,Medical_Institutional,Denied,Electronic_EDI,2023-10-20,2023-10-20,2023-10-22,2023-11-09,Auto_Adjudicated,20,1881170383,1522426351,208600000X,Surgery General,24,In_Network,J20.9,,revenue_code:0360,,0,Commercial,PPO,29,M,0.7512,96,Eligibility,18142.5,10771.73,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0277,none,0,1,0,0,0,0.0,0,0,AWV_Annual_Wellness_Visit,FFS
CLM0000001982,MBR00000046,Behavioral_Health,Paid,Electronic_EDI,2023-07-09,2023-07-09,2023-07-09,2023-07-10,Manual_Review,1,1838794554,1994275960,207V00000X,Obstetrics & Gynecology,23,Out_of_Network,Z00.01,,80053,,0,Commercial,HMO,76,F,0.9613,,,202.81,84.53,0.0,84.53,0.0,0.0,118.28,0.0,0.0,0,,0.0213,none,0,1,0,0,0,0.0,1,0,COL_Colorectal_Cancer_Screening,Capitation
CLM0000001983,MBR00000073,Dental,Paid,Electronic_EDI,2023-11-22,2023-11-22,2023-11-22,2023-12-22,Auto_Adjudicated,30,1736809698,1112696614,207RC0000X,Cardiovascular Disease,23,In_Network,G47.33,Z23|M54.5,D2391,,0,Commercial,POS,79,M,1.1768,,,225.2,152.59,0.0,152.59,0.0,0.0,72.61,0.0,0.0,0,,0.2152,provider_specialty_mismatch|upcoding_pattern,0,2,0,0,0,0.0,0,0,POD_Persistence_of_Beta_Blocker,Capitation
CLM0000001984,MBR00000220,Medical_Professional,Paid,Electronic_EDI,2023-09-05,2023-09-05,2023-09-05,2023-09-26,Auto_Adjudicated,21,1954226809,1829216053,2086S0122X,Orthopedic Surgery,11,In_Network,OTHER,,99205,,0,Commercial,HMO,38,M,0.7736,,,452.62,194.48,0.0,194.48,0.0,0.0,258.14,0.0,0.0,0,,0.1242,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000001985,MBR00000061,Medical_Institutional,Paid,Electronic_EDI,2023-10-02,2023-10-02,2023-10-04,2023-10-04,Auto_Adjudicated,2,1918359820,1884259357,207RP1001X,Pulmonary Disease,23,Out_of_Network,OTHER,OTHER,revenue_code:0210,,0,Commercial,PPO,66,M,2.3575,,,13805.71,10882.82,8578.48,125.72,34.0,2144.62,2922.89,0.0,0.0,0,,0.0966,none,0,1,1,0,0,0.000794,1,0,,Shared_Savings
CLM0000001986,MBR00000011,Medical_Professional,Paid,Electronic_EDI,2023-04-23,2023-04-23,2023-04-23,2023-04-29,Auto_Adjudicated,6,1059948944,1164525386,2086S0122X,Orthopedic Surgery,22,In_Network,Z12.11,OTHER,90837,,0,Medicare_Advantage,SNP,35,F,1.0833,,,929.42,335.11,253.25,1.55,17.0,63.31,594.31,0.0,0.0,0,,0.0159,none,0,1,0,1,0,2.3e-05,0,0,,FFS
CLM0000001987,MBR00000274,Medical_Professional,Paid,Electronic_EDI,2023-11-07,2023-11-07,2023-11-07,2023-11-08,Auto_Adjudicated,1,1705084901,1321680994,207RP1001X,Pulmonary Disease,24,In_Network,Z23,OTHER|Z12.11|E11.9,99395,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,161.73,90.64,44.25,35.32,0.0,11.06,71.09,0.0,0.0,0,,0.0319,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000001988,MBR00000264,Vision,Paid,Electronic_EDI,2023-08-15,2023-08-15,2023-08-15,2023-09-05,Auto_Adjudicated,21,1510562885,1390802135,207R00000X,Internal Medicine,11,In_Network,OTHER,G47.33|N39.0|K21.0,92014,,0,ACA_Marketplace,ACA_Bronze,12,F,0.5826,,,215.93,112.59,0.0,112.59,0.0,0.0,103.34,0.0,0.0,0,,0.0985,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000001989,MBR00000058,Behavioral_Health,Paid,Electronic_EDI,2023-02-01,2023-02-01,2023-02-01,2023-02-21,Auto_Adjudicated,20,1688560518,1685903362,2086S0122X,Orthopedic Surgery,24,In_Network,OTHER,I10|E11.9,99213,,0,Commercial,PPO,56,F,1.1626,,,331.52,262.44,150.0,59.94,15.0,37.5,69.08,0.0,0.0,0,,0.1447,none,0,1,0,0,0,1.4e-05,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000001990,MBR00000081,Medical_Professional,Paid,Paper,2023-01-30,2023-01-30,2023-01-30,2023-02-04,Auto_Adjudicated,5,1340676357,1874728994,225100000X,Physical Therapist,81,In_Network,Z00.00,,97110,,0,Medicare_Advantage,SNP,66,F,2.159,,,534.05,385.5,293.63,13.46,5.0,73.41,148.55,0.0,0.0,0,,0.1052,none,0,1,0,0,0,2.7e-05,0,0,,FFS
CLM0000001991,MBR00000059,Medical_Professional,Paid,Electronic_EDI,2023-11-19,2023-11-19,2023-11-19,2023-12-06,Auto_Adjudicated,17,1315569619,1538261819,207RE0101X,Endocrinology,31,In_Network,Z00.00,,99215,,0,Medicare_Advantage,SNP,12,F,1.266,,,250.47,120.79,64.43,24.26,16.0,16.11,129.68,0.0,0.0,0,,0.0341,none,0,1,0,0,0,6e-06,0,0,,Bundled_Payment
CLM0000001992,MBR00000212,Medical_Professional,Partially_Paid,Electronic_EDI,2023-04-09,2023-04-09,2023-04-09,2023-04-24,Manual_Review,15,1469822310,1358873132,208600000X,Surgery General,32,In_Network,Z00.00,,99387,,0,Commercial,HMO,57,F,2.5456,4,Medical_Necessity,164.72,85.56,0.0,54.31,0.0,0.0,110.41,0.0,0.0,0,,0.1068,none,0,1,0,0,0,0.0,0,0,COA_Care_Transitions,P4P
CLM0000001993,MBR00000077,Medical_Institutional,Paid,Electronic_EDI,2023-06-17,2023-06-17,2023-06-21,2023-07-02,Auto_Adjudicated,15,1257723293,1983760474,207RP1001X,Pulmonary Disease,11,In_Network,F32.9,,revenue_code:0200,,0,Medicare_Advantage,MA_HMO,27,F,0.9229,,,14326.13,9572.94,7622.89,6.33,38.0,1905.72,4753.19,5468.32,1090.44,0,,0.0986,none,0,1,1,0,0,0.000706,0,0,,Shared_Savings
CLM0000001994,MBR00000281,Medical_Professional,Paid,Electronic_EDI,2023-09-30,2023-09-30,2023-09-30,2023-10-19,Auto_Adjudicated,19,1222934819,1662516615,207RP1001X,Pulmonary Disease,22,Emergency,OTHER,OTHER|I50.9|M17.11,83036,,0,Medicare_Advantage,MA_HMO,3,M,0.8531,,,305.38,254.67,200.89,0.56,3.0,50.22,50.71,0.0,0.0,0,,0.1372,none,0,1,0,1,0,1.9e-05,0,0,,FFS
CLM0000001995,MBR00000247,Medical_Professional,Paid,Electronic_EDI,2023-10-03,2023-10-03,2023-10-03,2023-10-29,Auto_Adjudicated,26,1474985672,1983760474,207RC0000X,Cardiovascular Disease,11,In_Network,Z00.01,Z00.00,99204,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,336.19,185.98,142.75,2.54,5.0,35.69,150.21,0.0,0.0,0,,0.082,none,0,1,0,0,0,1.3e-05,0,0,CCS_Cervical_Cancer_Screening,Shared_Savings
CLM0000001996,MBR00000177,Medical_Institutional,Denied,Electronic_EDI,2023-01-10,2023-01-10,2023-01-13,2023-02-07,Auto_Adjudicated,28,1532359759,1220755708,207R00000X,Internal Medicine,22,In_Network,E13.9,,revenue_code:0300,,0,Commercial,HMO,42,F,1.2774,1,Network,4910.29,3767.82,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1135,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000001997,MBR00000003,Medical_Professional,Partially_Paid,Electronic_EDI,2023-08-10,2023-08-10,2023-08-10,2023-08-15,Auto_Adjudicated,5,1172766349,1132693989,207RN0300X,Nephrology,23,In_Network,I10,Z00.01|G43.909,99282,,0,Commercial,PPO,79,F,1.3879,5,Medical_Necessity,252.17,178.77,56.76,11.7,25.0,14.19,144.52,0.0,0.0,0,,0.0483,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000001998,MBR00000267,Pharmacy,Paid,Electronic_EDI,2023-11-24,2023-11-24,2023-11-24,2023-12-23,Auto_Adjudicated,29,1097702209,1177602659,2086S0122X,Orthopedic Surgery,24,In_Network,Z00.00,,00003014960,,3,Medicare_Advantage,MA_HMO,26,F,0.2859,,,634.59,446.21,309.09,43.85,16.0,77.27,188.38,0.0,0.0,0,,0.0873,none,0,1,0,0,0,2.9e-05,0,1,,Shared_Savings
CLM0000001999,MBR00000213,Pharmacy,Paid,Paper,2023-05-06,2023-05-06,2023-05-06,2023-05-24,Auto_Adjudicated,18,1396168768,1020312030,225100000X,Physical Therapist,81,In_Network,J44.1,E78.5,00003014960,,2,Commercial,PPO,17,M,1.5857,,,241.19,113.22,0.0,113.22,0.0,0.0,127.97,0.0,0.0,0,,0.0112,none,0,1,0,0,0,0.0,0,1,MMA_Medication_Management,FFS
CLM0000002000,MBR00000233,Medical_Institutional,Denied,Electronic_EDI,2023-07-14,2023-07-14,2023-07-18,2023-07-20,Clinical_Review,6,1648123576,1811797489,101YP2500X,Psychologist Clinical,71,In_Network,J44.1,,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,87,M,0.8034,3,Network,8785.45,3205.69,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1334,none,0,1,0,1,0,0.0,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000002001,MBR00000022,Medical_Institutional,Denied,Electronic_EDI,2023-04-06,2023-04-06,2023-04-07,2023-05-04,Auto_Adjudicated,28,1843445592,1054984734,207RC0000X,Cardiovascular Disease,11,In_Network,E78.5,E78.5,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,34,M,0.9472,22,Eligibility,25946.8,15172.93,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0576,none,0,1,0,0,0,0.0,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000002002,MBR00000210,Pharmacy,Paid,Electronic_EDI,2023-09-16,2023-09-16,2023-09-16,2023-09-28,Manual_Review,12,1886549972,1884259357,2084P0800X,Psychiatry,65,In_Network,M54.5,,00078043215,,2,Medicare_Advantage,SNP,49,M,0.6952,,,100.9,66.04,26.7,14.66,18.0,6.68,34.86,0.0,0.0,0,,0.1209,none,0,1,0,0,0,2e-06,0,1,,Shared_Savings
CLM0000002003,MBR00000238,Medical_Professional,Denied,Electronic_EDI,2023-02-12,2023-02-12,2023-02-12,2023-02-26,Manual_Review,14,1319616460,1942423230,246ZN0300X,Neuropsychology,32,In_Network,J06.9,,97010,,0,Commercial,PPO,74,F,0.4382,2,Eligibility,325.91,191.9,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0221,none,0,1,0,0,0,0.0,0,0,PPC_Prenatal_Care,P4P
CLM0000002004,MBR00000290,Dental,Paid,Electronic_EDI,2023-07-06,2023-07-06,2023-07-06,2023-08-05,Auto_Adjudicated,30,1313352855,1540743888,207RN0300X,Nephrology,23,In_Network,OTHER,Z23|J45.20|M79.3,D1110,,0,Commercial,PPO,9,M,0.5261,,,281.21,152.46,0.0,152.46,0.0,0.0,128.75,0.0,0.0,0,,0.0727,upcoding_pattern,0,1,0,0,0,0.0,0,0,CBP_Controlling_BP,FFS
CLM0000002005,MBR00000175,Medical_Professional,Paid,Electronic_EDI,2023-05-29,2023-05-29,2023-05-29,2023-06-16,Auto_Adjudicated,18,1451464799,1040061910,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,E11.9|OTHER|N18.3,99204,,0,Commercial,PPO,14,F,1.5785,,,484.99,239.71,124.47,74.13,10.0,31.12,245.28,0.0,0.0,0,,0.0823,none,0,1,0,0,0,1.2e-05,0,0,,Bundled_Payment
CLM0000002006,MBR00000156,Vision,Denied,Provider_Portal,2023-08-19,2023-08-19,2023-08-19,2023-08-24,Auto_Adjudicated,5,1556434733,1025886739,207RC0000X,Cardiovascular Disease,11,In_Network,N39.0,E11.9,92012,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,1,Eligibility,471.55,367.66,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0927,npi_mismatch,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002007,MBR00000135,Medical_Professional,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-27,2023-06-30,Manual_Review,3,1930591083,1330485436,2086S0122X,Orthopedic Surgery,21,In_Network,OTHER,OTHER|N39.0,99283,,0,Commercial,PPO,58,F,2.2702,,,218.43,94.99,42.12,5.34,37.0,10.53,123.44,27.63,10.85,0,,0.1206,none,0,1,0,0,0,4e-06,0,0,,Bundled_Payment
CLM0000002008,MBR00000208,Pharmacy,Paid,Paper,2023-12-19,2023-12-19,2023-12-19,2024-01-13,Clinical_Review,25,1821999097,1540743888,2084P0800X,Psychiatry,11,Emergency,I25.10,,00169751112,,4,Medicare_Advantage,MA_HMO,66,M,2.1466,,,143.42,50.58,19.59,20.09,6.0,4.9,92.84,0.0,0.0,0,,0.1348,provider_specialty_mismatch,0,1,0,1,0,2e-06,0,0,,FFS
CLM0000002009,MBR00000277,Medical_Professional,Paid,Electronic_EDI,2023-12-19,2023-12-19,2023-12-19,2023-12-30,Auto_Adjudicated,11,1826919173,1220755708,225100000X,Physical Therapist,11,In_Network,Z00.01,Z00.00,99285,,0,Medicaid_MCO,MCO,30,M,1.8495,,,345.48,139.6,136.6,0.0,3.0,0.0,205.88,0.0,0.0,0,,0.1282,none,0,1,0,1,0,1.3e-05,0,0,,Shared_Savings
CLM0000002010,MBR00000181,Pharmacy,Paid,Provider_Portal,2023-04-13,2023-04-13,2023-04-13,2023-04-16,Auto_Adjudicated,3,1484613641,1728466420,101YP2500X,Psychologist Clinical,11,In_Network,F41.1,,00071012831,,1,Commercial,PPO,82,F,1.0432,,,1255.76,717.54,448.74,128.61,28.0,112.19,538.22,0.0,0.0,0,,0.0824,diagnosis_procedure_mismatch,0,1,0,0,0,4.2e-05,0,1,,Shared_Savings
CLM0000002011,MBR00000071,Medical_Institutional,Paid,Provider_Portal,2023-01-14,2023-01-14,2023-01-15,2023-01-16,Auto_Adjudicated,2,1159640414,1764064254,207R00000X,Internal Medicine,22,In_Network,OTHER,,revenue_code:0450,,0,Commercial,EPO,19,F,0.5699,,,9689.81,6105.22,4817.38,14.5,69.0,1204.34,3584.59,0.0,0.0,0,,0.1139,none,0,1,0,0,0,0.000446,0,0,MPT_Annual_Monitoring,Bundled_Payment
CLM0000002012,MBR00000006,Medical_Professional,Paid,Electronic_EDI,2023-06-26,2023-06-26,2023-06-26,2023-07-25,Auto_Adjudicated,29,1571330665,1788579687,225100000X,Physical Therapist,22,In_Network,G47.33,I50.9,99384,,0,Commercial,EPO,88,M,1.4365,,,558.95,390.57,258.26,34.74,33.0,64.57,168.38,0.0,0.0,0,,0.1154,none,0,1,0,0,0,2.4e-05,0,0,,FFS
CLM0000002013,MBR00000185,Pharmacy,Paid,Electronic_EDI,2023-07-31,2023-07-31,2023-07-31,2023-08-18,Auto_Adjudicated,18,1549436467,1898471307,207R00000X,Internal Medicine,11,In_Network,OTHER,OTHER|K21.0,59148001506,,1,Medicaid_MCO,MCO,73,M,1.5417,,,219.76,138.55,135.55,0.0,3.0,0.0,81.21,0.0,0.0,0,,0.1896,unusual_service_frequency,0,1,0,0,0,1.3e-05,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000002014,MBR00000262,Medical_Professional,Paid,Paper,2023-09-27,2023-09-27,2023-09-27,2023-10-13,Clinical_Review,16,1990849102,1865266296,207RG0100X,Gastroenterology,32,In_Network,N39.0,Z00.00|E11.9,90847,,0,Medicare_Advantage,PFFS,77,F,1.7452,,,1181.17,788.27,627.05,0.46,4.0,156.76,392.9,0.0,0.0,0,,0.0083,none,0,1,0,1,0,5.8e-05,0,0,,FFS
CLM0000002015,MBR00000020,Medical_Institutional,Paid,Electronic_EDI,2023-07-08,2023-07-08,2023-07-11,2023-07-26,Auto_Adjudicated,18,1019263018,1358873132,101YP2500X,Psychologist Clinical,11,In_Network,OTHER,E11.65,revenue_code:0120,,0,Medicare_Advantage,MA_PPO,63,F,0.7119,,,61915.17,25288.22,20156.93,52.06,40.0,5039.23,36626.95,0.0,0.0,1,Duplicate Billing,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|impossible_service_combo|service_date_weekend|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,1,0,0,0.001866,0,0,,Bundled_Payment
CLM0000002016,MBR00000126,Medical_Professional,Paid,Electronic_EDI,2023-07-30,2023-07-30,2023-07-30,2023-08-12,Auto_Adjudicated,13,1222934819,1188760037,2084P0800X,Psychiatry,21,In_Network,OTHER,OTHER,90837,,0,Medicaid_MCO,MLTSS,48,F,0.637,,,637.23,362.93,360.93,0.0,2.0,0.0,274.3,0.0,0.0,0,,0.0285,none,0,1,0,0,0,3.3e-05,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000002017,MBR00000285,Pharmacy,Paid,Electronic_EDI,2023-01-09,2023-01-09,2023-01-09,2023-02-07,Manual_Review,29,1199465234,1489993356,207RC0000X,Cardiovascular Disease,22,In_Network,OTHER,I10,50458085930,,3,Commercial,HDHP_HSA,56,M,0.9226,,,152.51,107.49,45.66,50.41,0.0,11.42,45.02,0.0,0.0,0,,0.0475,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000002018,MBR00000155,Dental,Paid,Electronic_EDI,2023-10-01,2023-10-01,2023-10-01,2023-10-20,Auto_Adjudicated,19,1046058495,1289435414,207Q00000X,Family Medicine,22,In_Network,OTHER,E11.9|OTHER|M47.816,D2391,,0,ACA_Marketplace,ACA_Bronze,9,F,0.8196,,,431.95,221.21,0.0,221.21,0.0,0.0,210.74,0.0,0.0,0,,0.1668,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002019,MBR00000068,Medical_Institutional,Paid,Electronic_EDI,2023-04-29,2023-04-29,2023-05-03,2023-05-19,Auto_Adjudicated,20,1012271279,1579331190,2084P0800X,Psychiatry,21,In_Network,M54.5,,revenue_code:0250,682,0,Medicare_Advantage,MA_HMO,28,F,0.8494,,,34951.1,16730.57,13343.52,11.17,40.0,3335.88,18220.53,0.0,0.0,0,,0.1759,high_oop_waiver,0,1,1,0,0,0.001235,0,0,,Shared_Savings
CLM0000002020,MBR00000112,Pharmacy,Paid,Electronic_EDI,2023-05-19,2023-05-19,2023-05-19,2023-06-15,Auto_Adjudicated,27,1055717021,1055872102,101YP2500X,Psychologist Clinical,23,In_Network,Z79.4,I10,16590051660,,2,Medicare_Advantage,MA_HMO,18,M,1.01,,,518.6,253.04,168.72,36.15,6.0,42.18,265.56,0.0,0.0,0,,0.1454,none,0,1,0,0,0,1.6e-05,0,1,,Shared_Savings
CLM0000002021,MBR00000130,Dental,Paid,Electronic_EDI,2023-06-01,2023-06-01,2023-06-01,2023-06-02,Auto_Adjudicated,1,1700802848,1747596016,208600000X,Surgery General,21,In_Network,E78.5,OTHER|J06.9|M17.11,D2140,,0,Medicare_Advantage,MA_PPO,58,M,1.3394,,,723.62,390.46,307.08,2.61,4.0,76.77,333.16,0.0,0.0,0,,0.0166,none,0,1,0,0,0,2.8e-05,0,0,,FFS
CLM0000002022,MBR00000036,Pharmacy,Paid,Electronic_EDI,2023-01-26,2023-01-26,2023-01-26,2023-02-05,Manual_Review,10,1567711165,1829216053,208600000X,Surgery General,11,In_Network,OTHER,F32.9,50458085930,,4,Commercial,EPO,17,M,2.0136,,,123.99,43.63,0.0,28.99,14.64,0.0,80.36,0.0,0.0,0,,0.0003,none,0,1,0,1,0,0.0,0,1,,FFS
CLM0000002023,MBR00000196,Medical_Professional,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-27,2023-07-22,Auto_Adjudicated,25,1310250833,1554490060,207Q00000X,Family Medicine,22,In_Network,I25.10,OTHER|E78.5,99203,,0,Commercial,PPO,16,F,1.6015,,,210.76,169.05,0.0,169.05,0.0,0.0,41.71,0.0,0.0,0,,0.0986,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002024,MBR00000178,Medical_Institutional,Paid,Electronic_EDI,2023-05-17,2023-05-17,2023-05-20,2023-05-20,Manual_Review,3,1958981650,1591405274,207RP1001X,Pulmonary Disease,11,In_Network,I10,OTHER,revenue_code:0360,,0,Medicaid_MCO,MCO,89,M,0.7057,,,5695.24,2579.72,2579.72,0.0,0.0,0.0,3115.52,0.0,0.0,0,,0.1063,none,0,1,0,0,0,0.000239,0,0,,FFS
CLM0000002025,MBR00000192,Medical_Professional,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-25,2023-04-04,Auto_Adjudicated,10,1929402739,1938465393,207RC0000X,Cardiovascular Disease,81,Out_of_Network,Z23,OTHER|J06.9|E78.5,97140,,0,Medicaid_MCO,MCO,22,F,1.1739,,,724.0,563.52,563.52,0.0,0.0,0.0,160.48,0.0,0.0,0,,0.099,none,0,1,0,0,0,5.2e-05,1,0,,Capitation
CLM0000002026,MBR00000184,Medical_Institutional,Paid,Electronic_EDI,2023-03-30,2023-03-30,2023-04-01,2023-04-04,Auto_Adjudicated,5,1069440570,1878017518,207RG0100X,Gastroenterology,22,In_Network,I10,E11.9|F32.9,revenue_code:0110,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,27785.76,10504.37,10504.37,0.0,0.0,0.0,17281.39,0.0,0.0,0,,0.0796,none,0,1,1,0,0,0.000972,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000002027,MBR00000006,Medical_Professional,Paid,Electronic_EDI,2023-01-13,2023-01-13,2023-01-13,2023-02-04,Auto_Adjudicated,22,1594587354,1163639177,246ZN0300X,Neuropsychology,11,In_Network,F32.9,E78.5,99213,,0,Commercial,EPO,88,M,1.4365,,,211.09,103.35,32.32,29.95,33.0,8.08,107.74,0.0,0.0,0,,0.075,none,0,1,0,0,0,3e-06,0,0,BCS_Breast_Cancer_Screening,P4P
CLM0000002028,MBR00000055,Pharmacy,Partially_Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-12-11,Auto_Adjudicated,26,1905691248,1133410177,207RN0300X,Nephrology,24,In_Network,Z00.00,,50458085930,,2,Commercial,PPO,68,F,1.2896,1,Medical_Necessity,155.49,96.66,0.0,56.62,0.0,0.0,98.87,0.0,0.0,0,,0.0294,none,0,1,0,1,0,0.0,0,0,AMR_Asthma_Medication_Ratio,Bundled_Payment
CLM0000002029,MBR00000052,Medical_Institutional,Paid,Electronic_EDI,2023-04-16,2023-04-16,2023-04-16,2023-04-24,Auto_Adjudicated,8,1631060535,1354959095,2086S0122X,Orthopedic Surgery,23,In_Network,OTHER,Z79.4,revenue_code:0100,,0,Commercial,PPO,0,F,1.325,,,21475.33,9067.52,6996.63,245.73,76.0,1749.16,12407.81,0.0,0.0,0,,0.107,none,0,1,1,0,0,0.000648,0,0,,Shared_Savings
CLM0000002030,MBR00000029,Medical_Institutional,Paid,Electronic_EDI,2023-11-10,2023-11-10,2023-11-10,2023-12-01,Auto_Adjudicated,21,1637260822,1705448933,207RP1001X,Pulmonary Disease,21,In_Network,J44.1,,revenue_code:0200,683,0,Medicaid_MCO,MCO,13,F,0.9053,,,8987.76,7582.19,7579.19,0.0,3.0,0.0,1405.57,0.0,0.0,0,,0.1117,none,0,1,1,0,0,0.000702,0,0,FUH_Follow_Up_Hospitalization,Shared_Savings
CLM0000002031,MBR00000215,Medical_Professional,Paid,Electronic_EDI,2023-10-28,2023-10-28,2023-10-28,2023-11-20,Auto_Adjudicated,23,1981853293,1789540567,2084P0800X,Psychiatry,81,In_Network,OTHER,,99283,,0,ACA_Marketplace,ACA_Silver,69,M,0.8895,,,254.58,160.58,0.0,160.58,0.0,0.0,94.0,0.0,0.0,0,,0.1226,none,0,1,0,0,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000002032,MBR00000037,Medical_Professional,Denied,Electronic_EDI,2023-06-14,2023-06-14,2023-06-14,2023-07-12,Auto_Adjudicated,28,1464997678,1842149518,207RG0100X,Gastroenterology,22,In_Network,I10,OTHER,90847,,0,Medicaid_MCO,MLTSS,11,M,1.043,2,Authorization,1418.01,1068.45,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0736,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002033,MBR00000198,Pharmacy,Paid,Electronic_EDI,2023-10-18,2023-10-18,2023-10-18,2023-11-15,Manual_Review,28,1220710861,1163639177,207RG0100X,Gastroenterology,11,Out_of_Network,Z12.11,OTHER,00069420020,,3,Medicaid_MCO,MCO,81,F,1.4199,,,183.44,89.68,87.68,0.0,2.0,0.0,93.76,0.0,0.0,0,,0.0445,none,0,1,0,0,0,8e-06,1,0,PCR_Plan_All_Cause_Readmission,Capitation
CLM0000002034,MBR00000056,Medical_Institutional,Paid,Electronic_EDI,2023-03-17,2023-03-17,2023-03-18,2023-03-31,Auto_Adjudicated,14,1313352855,1461075342,207RC0000X,Cardiovascular Disease,24,In_Network,OTHER,K21.0|N39.0,revenue_code:0250,,0,Commercial,EPO,74,F,1.3941,,,6275.62,2792.91,1873.51,404.02,47.0,468.38,3482.71,0.0,0.0,0,,0.1081,none,0,1,0,0,0,0.000173,0,0,,Bundled_Payment
CLM0000002035,MBR00000036,Vision,Paid,Electronic_EDI,2023-03-06,2023-03-06,2023-03-06,2023-03-09,Auto_Adjudicated,3,1963647323,1330485436,207RN0300X,Nephrology,65,Out_of_Network,M47.816,,V2115,,0,Commercial,EPO,17,M,2.0136,,,293.82,227.33,72.53,103.67,33.0,18.13,66.49,0.0,0.0,0,,0.0988,none,0,1,0,0,0,7e-06,1,0,,FFS
CLM0000002036,MBR00000052,Medical_Institutional,Paid,Electronic_EDI,2023-11-19,2023-11-19,2023-11-20,2023-12-12,Auto_Adjudicated,23,1218294278,1039962073,207RN0300X,Nephrology,11,In_Network,Z00.00,,revenue_code:0210,,0,Commercial,PPO,0,F,1.325,,,17723.86,8159.84,6434.4,40.84,76.0,1608.6,9564.02,0.0,0.0,0,,0.092,none,0,1,1,0,0,0.000596,0,0,FUM_Follow_Up_ED_Mental_Health,Bundled_Payment
CLM0000002037,MBR00000156,Medical_Professional,Paid,Electronic_EDI,2023-08-21,2023-08-21,2023-08-21,2023-09-07,Auto_Adjudicated,17,1263063839,1034732777,208600000X,Surgery General,11,In_Network,OTHER,OTHER,90837,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,3752.38,2032.06,1593.88,26.71,13.0,398.47,1720.32,0.0,0.0,0,,0.2771,benford_violation|service_date_weekend|duplicate_claim_indicator,0,2,0,0,0,0.000148,0,0,,Shared_Savings
CLM0000002038,MBR00000192,Pharmacy,Paid,Electronic_EDI,2023-09-05,2023-09-05,2023-09-05,2023-09-19,Auto_Adjudicated,14,1871417879,1368666316,207RE0101X,Endocrinology,22,In_Network,I10,Z00.00,59148001506,,3,Medicaid_MCO,MCO,22,F,1.1739,,,606.81,437.06,437.06,0.0,0.0,0.0,169.75,0.0,0.0,0,,0.153,billing_spike_recent,0,1,0,1,0,4e-05,0,0,,FFS
CLM0000002039,MBR00000241,Pharmacy,Denied,Electronic_EDI,2023-11-28,2023-11-28,2023-11-28,2023-12-15,Auto_Adjudicated,17,1426424205,1140170394,101YP2500X,Psychologist Clinical,24,In_Network,E78.5,M54.5,00071012831,,1,Medicare_Advantage,MA_HMO,77,M,1.2169,22,Timely_Filing,2314.26,1080.22,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.237,unusual_service_frequency|impossible_service_combo,0,2,0,0,0,0.0,0,1,SPC_Statin_Therapy,Capitation
CLM0000002040,MBR00000039,Medical_Professional,Paid,Provider_Portal,2023-01-06,2023-01-06,2023-01-06,2023-01-26,Auto_Adjudicated,20,1666911728,1738617370,225100000X,Physical Therapist,11,Out_of_Network,L70.0,,99284,,0,Medicaid_MCO,MCO,20,F,0.5358,,,353.9,239.74,239.74,0.0,0.0,0.0,114.16,0.0,0.0,1,Code Substitution,1.0,outlier_billing_amount|geographic_mismatch|provider_specialty_mismatch|service_date_weekend|duplicate_claim_indicator|upcoding_pattern|phantom_billing_indicator|npi_mismatch|controlled_substance_high_volume,1,5,0,0,0,2.2e-05,1,0,,Bundled_Payment
CLM0000002041,MBR00000184,Pharmacy,Paid,Electronic_EDI,2023-03-03,2023-03-03,2023-03-03,2023-03-12,Auto_Adjudicated,9,1874109311,1354265777,207RN0300X,Nephrology,81,In_Network,C50.911,,00071012831,,1,Medicaid_MCO,MLTSS,30,M,2.8302,,,623.46,516.24,514.24,0.0,2.0,0.0,107.22,0.0,0.0,0,,0.1725,benford_violation,0,1,0,0,0,4.8e-05,0,1,,Capitation
CLM0000002042,MBR00000228,Medical_Professional,Paid,Electronic_EDI,2023-12-12,2023-12-12,2023-12-12,2023-12-22,Auto_Adjudicated,10,1172766349,1554490060,208600000X,Surgery General,11,In_Network,G47.33,E11.9|OTHER,80053,,0,Commercial,PPO,55,F,0.7203,,,664.02,411.09,0.0,411.09,0.0,0.0,252.93,0.0,0.0,0,,0.2395,temporal_clustering|phantom_billing_indicator|controlled_substance_high_volume,0,2,0,0,0,0.0,0,0,,FFS
CLM0000002043,MBR00000099,Medical_Professional,Denied,Electronic_EDI,2023-02-16,2023-02-16,2023-02-16,2023-02-27,Auto_Adjudicated,11,1713741288,1985590322,207V00000X,Obstetrics & Gynecology,24,In_Network,Z00.00,,99231,,0,Commercial,HMO,10,F,0.7843,CO-45,Authorization,230.12,111.64,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1479,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002044,MBR00000024,Medical_Professional,Denied,Electronic_EDI,2023-06-11,2023-06-11,2023-06-11,2023-06-26,Auto_Adjudicated,15,1901508637,1396850418,101YP2500X,Psychologist Clinical,32,In_Network,E78.5,Z12.11,99221,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,97,Network,1067.9,875.7,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Provider Impersonation,1.0,unusual_service_frequency|geographic_mismatch|temporal_clustering|high_volume_same_code|benford_violation|service_date_weekend|billing_spike_recent|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch,1,5,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002045,MBR00000050,Medical_Institutional,Denied,Electronic_EDI,2023-01-08,2023-01-08,2023-01-11,2023-01-29,Manual_Review,21,1886537420,1133410177,2086S0122X,Orthopedic Surgery,11,In_Network,J06.9,OTHER|Z12.11|Z87.891,revenue_code:0300,,0,Medicare_Advantage,MA_PPO,12,F,0.8486,22,Duplicate,4286.08,3464.07,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1672,unusual_service_frequency,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002046,MBR00000028,Pharmacy,Paid,Electronic_EDI,2023-04-27,2023-04-27,2023-04-27,2023-04-29,Auto_Adjudicated,2,1373899620,1867389043,246ZN0300X,Neuropsychology,22,In_Network,Z23,,00310075090,,1,Commercial,HMO,3,F,2.116,,,57.93,38.36,0.0,38.36,0.0,0.0,19.57,0.0,0.0,0,,0.1129,temporal_clustering,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002047,MBR00000269,Medical_Professional,Paid,Electronic_EDI,2023-03-03,2023-03-03,2023-03-03,2023-03-12,Auto_Adjudicated,9,1164721841,1012893364,246ZN0300X,Neuropsychology,11,In_Network,Z00.00,Z12.11|F41.1,71250,,0,Commercial,EPO,10,F,0.718,,,227.98,165.41,49.21,72.89,31.0,12.3,62.57,0.0,0.0,0,,0.124,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000002048,MBR00000120,Pharmacy,Paid,Electronic_EDI,2023-04-02,2023-04-02,2023-04-02,2023-04-24,Auto_Adjudicated,22,1770738194,1040061910,246ZN0300X,Neuropsychology,23,In_Network,I50.9,M47.816|Z00.00,00169751112,,2,Commercial,PPO,62,F,1.0823,,,216.9,157.47,0.0,157.47,0.0,0.0,59.43,0.0,0.0,0,,0.1202,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,,P4P
CLM0000002049,MBR00000160,Pharmacy,Paid,Provider_Portal,2023-10-20,2023-10-20,2023-10-20,2023-10-21,Auto_Adjudicated,1,1673449362,1170002937,207RP1001X,Pulmonary Disease,22,In_Network,OTHER,N39.0,00310075090,,1,Commercial,HMO,73,M,1.9608,,,307.96,176.32,122.61,0.06,23.0,30.65,131.64,0.0,0.0,0,,0.0279,none,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000002050,MBR00000226,Medical_Institutional,Paid,Electronic_EDI,2023-04-10,2023-04-10,2023-04-13,2023-05-04,Auto_Adjudicated,24,1190558906,1187669363,2084P0800X,Psychiatry,24,In_Network,OTHER,OTHER|Z00.00|Z00.01,revenue_code:0370,,0,Medicare_Advantage,MA_PPO,84,M,1.0796,,,4991.53,2408.84,1896.11,2.7,36.0,474.03,2582.69,0.0,0.0,0,,0.1185,none,0,1,0,1,0,0.000176,0,0,,Shared_Savings
CLM0000002051,MBR00000118,Medical_Professional,Paid,Electronic_EDI,2023-10-20,2023-10-20,2023-10-20,2023-11-13,Manual_Review,24,1994365754,1175334579,2084P0800X,Psychiatry,22,Out_of_Network,OTHER,,99285,,0,Medicaid_MCO,MCO,69,M,1.2773,,,356.6,136.7,135.7,0.0,1.0,0.0,219.9,0.0,0.0,0,,0.258,temporal_clustering|upcoding_pattern,0,2,0,0,0,1.3e-05,0,0,,Bundled_Payment
CLM0000002052,MBR00000193,Medical_Professional,Paid,Electronic_EDI,2023-11-18,2023-11-18,2023-11-18,2023-11-28,Auto_Adjudicated,10,1556072255,1887266184,246ZN0300X,Neuropsychology,21,In_Network,E11.9,OTHER|Z00.00,99281,,0,Commercial,PPO,11,M,0.5266,,,355.35,132.8,9.71,90.66,30.0,2.43,222.55,0.0,0.0,0,,0.0251,none,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000002053,MBR00000024,Medical_Professional,Paid,Electronic_EDI,2023-07-14,2023-07-14,2023-07-14,2023-08-02,Auto_Adjudicated,19,1945264928,1177602659,208600000X,Surgery General,11,In_Network,M17.11,,99284,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,333.01,125.4,122.4,0.0,3.0,0.0,207.61,0.0,0.0,0,,0.0779,none,0,1,0,1,0,1.1e-05,0,0,MPT_Annual_Monitoring,Bundled_Payment
CLM0000002054,MBR00000148,Vision,Paid,Electronic_EDI,2023-07-13,2023-07-13,2023-07-13,2023-07-28,Auto_Adjudicated,15,1231231881,1447657873,207RE0101X,Endocrinology,11,In_Network,OTHER,K21.0,V2100,,0,Commercial,EPO,51,F,0.6534,,,393.37,184.7,0.0,184.7,0.0,0.0,208.67,0.0,0.0,0,,0.1302,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002055,MBR00000028,Pharmacy,Paid,Electronic_EDI,2023-04-30,2023-04-30,2023-04-30,2023-05-08,Auto_Adjudicated,8,1263063839,1694343357,207RC0000X,Cardiovascular Disease,22,In_Network,Z00.00,,59148001506,,1,Commercial,HMO,3,F,2.116,,,213.88,86.9,0.0,86.9,0.0,0.0,126.98,0.0,0.0,0,,0.0889,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000002056,MBR00000077,Medical_Professional,Paid,Electronic_EDI,2023-08-28,2023-08-28,2023-08-28,2023-09-02,Auto_Adjudicated,5,1871417879,1860951128,207RP1001X,Pulmonary Disease,65,Out_of_Network,E11.9,M54.5,99213,,0,Medicare_Advantage,MA_HMO,27,F,0.9229,,,545.24,203.82,152.98,8.59,4.0,38.25,341.42,0.0,0.0,0,,0.1776,unbundling_pattern|controlled_substance_high_volume,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000002057,MBR00000092,Medical_Institutional,Paid,Electronic_EDI,2023-10-17,2023-10-17,2023-10-18,2023-11-15,Auto_Adjudicated,29,1388662212,1301833092,101YP2500X,Psychologist Clinical,24,In_Network,E78.5,,revenue_code:0120,,0,Medicaid_MCO,MLTSS,68,F,1.3217,,,21037.23,13498.15,13489.15,0.0,9.0,0.0,7539.08,0.0,0.0,0,,0.2,high_volume_same_code,0,2,1,0,0,0.001249,0,0,,Shared_Savings
CLM0000002058,MBR00000212,Medical_Professional,Paid,Electronic_EDI,2023-11-06,2023-11-06,2023-11-06,2023-12-02,Manual_Review,26,1577859682,1811797489,2084P0800X,Psychiatry,21,In_Network,N18.3,,99385,,0,Commercial,HMO,57,F,2.5456,,,149.53,77.74,0.0,77.74,0.0,0.0,71.79,0.0,0.0,0,,0.1871,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,PPC_Prenatal_Care,FFS
CLM0000002059,MBR00000200,Medical_Professional,Paid,Electronic_EDI,2023-03-12,2023-03-12,2023-03-12,2023-04-08,Auto_Adjudicated,27,1145887050,1289435414,207RP1001X,Pulmonary Disease,81,In_Network,OTHER,,99396,,0,Commercial,HDHP_HSA,29,M,0.8011,,,702.61,596.98,112.72,456.08,0.0,28.18,105.63,97.65,13.06,0,,0.0947,diagnosis_procedure_mismatch,0,1,0,0,0,1e-05,0,0,FUM_Follow_Up_ED_Mental_Health,P4P
CLM0000002060,MBR00000219,Medical_Professional,Paid,Electronic_EDI,2023-09-04,2023-09-04,2023-09-04,2023-09-09,Auto_Adjudicated,5,1205744244,1894215172,207RN0300X,Nephrology,11,In_Network,F41.1,I10,99396,,0,Medicare_Advantage,MA_HMO,84,M,0.9513,,,173.19,118.43,76.0,23.43,0.0,19.0,54.76,0.0,0.0,0,,0.1339,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000002061,MBR00000018,Medical_Professional,Paid,Electronic_EDI,2023-02-20,2023-02-20,2023-02-20,2023-03-21,Manual_Review,29,1315569619,1705448933,2084P0800X,Psychiatry,81,In_Network,E11.65,,90837,,0,Commercial,EPO,5,F,0.5555,,,642.67,526.66,404.48,7.06,14.0,101.12,116.01,0.0,0.0,0,,0.1515,phantom_billing_indicator|controlled_substance_high_volume,0,1,0,1,0,3.7e-05,0,0,SPD_Spirometry_Testing,FFS
CLM0000002062,MBR00000299,Medical_Professional,Paid,Provider_Portal,2023-06-25,2023-06-25,2023-06-25,2023-07-14,Clinical_Review,19,1338575285,1577226132,208600000X,Surgery General,11,In_Network,M79.3,Z00.00|E78.5,99204,,0,Medicaid_MCO,MCO,74,F,0.8833,,,1003.1,383.57,381.57,0.0,2.0,0.0,619.53,0.0,0.0,0,,0.1079,none,0,1,0,0,0,3.5e-05,0,0,,Shared_Savings
CLM0000002063,MBR00000014,Medical_Professional,Paid,Paper,2023-02-02,2023-02-02,2023-02-02,2023-02-18,Auto_Adjudicated,16,1377412382,1649705287,2084P0800X,Psychiatry,11,In_Network,OTHER,R05.9,47562,,0,Commercial,HMO,77,M,2.8513,,,915.77,440.43,316.77,6.47,38.0,79.19,475.34,0.0,0.0,0,,0.0423,none,0,1,0,0,0,2.9e-05,0,0,BPD_BP_Declined,Shared_Savings
CLM0000002064,MBR00000247,Medical_Institutional,Paid,Provider_Portal,2023-07-17,2023-07-17,2023-07-21,2023-07-28,Auto_Adjudicated,11,1319616460,1884259357,246ZN0300X,Neuropsychology,31,Out_of_Network,E78.5,M54.5|E78.5,revenue_code:0360,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,5723.73,4239.21,3343.67,7.62,52.0,835.92,1484.52,0.0,0.0,0,,0.0714,none,0,1,0,0,0,0.000309,1,0,,Capitation
CLM0000002065,MBR00000217,Medical_Institutional,Paid,Electronic_EDI,2023-11-02,2023-11-02,2023-11-03,2023-11-10,Manual_Review,8,1476262171,1291071007,225100000X,Physical Therapist,22,In_Network,F33.0,Z00.01|J44.1,revenue_code:0300,,0,ACA_Marketplace,ACA_Bronze,11,F,1.1619,,,16248.45,10710.02,5599.81,1377.01,0.0,3733.2,5538.43,0.0,0.0,0,,0.1265,none,0,1,1,0,0,0.000518,0,0,,P4P
CLM0000002066,MBR00000178,Medical_Institutional,Paid,Electronic_EDI,2023-10-21,2023-10-21,2023-10-23,2023-10-31,Auto_Adjudicated,10,1167433253,1622950074,207RN0300X,Nephrology,32,In_Network,OTHER,,revenue_code:0300,,0,Medicaid_MCO,MCO,89,M,0.7057,,,19202.17,10198.1,10198.1,0.0,0.0,0.0,9004.07,0.0,0.0,0,,0.1388,none,0,1,1,0,0,0.000944,0,0,POD_Persistence_of_Beta_Blocker,FFS
CLM0000002067,MBR00000137,Medical_Professional,Paid,Electronic_EDI,2023-09-14,2023-09-14,2023-09-14,2023-09-20,Auto_Adjudicated,6,1069440570,1061113875,2084P0800X,Psychiatry,24,In_Network,OTHER,,99396,,0,Commercial,PPO,87,M,0.5201,,,309.63,238.53,131.75,48.85,25.0,32.94,71.1,117.58,10.71,0,,0.1077,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000002068,MBR00000222,Medical_Institutional,Paid,Electronic_EDI,2023-07-27,2023-07-27,2023-07-29,2023-08-20,Auto_Adjudicated,24,1374847145,1811797489,207Q00000X,Family Medicine,11,In_Network,Z12.11,L70.0|OTHER,revenue_code:0250,,0,Commercial,PPO,48,F,0.6945,,,7605.06,4564.8,3550.83,82.26,44.0,887.71,3040.26,0.0,0.0,0,,0.0934,none,0,1,0,1,0,0.000329,0,0,,FFS
CLM0000002069,MBR00000217,Medical_Institutional,Paid,Electronic_EDI,2023-08-13,2023-08-13,2023-08-15,2023-09-11,Auto_Adjudicated,29,1618564043,1291071007,207RN0300X,Nephrology,11,In_Network,Z00.01,E11.9,revenue_code:0360,,0,ACA_Marketplace,ACA_Bronze,11,F,1.1619,,,3792.63,3065.28,1126.24,1188.21,0.0,750.83,727.35,0.0,0.0,0,,0.0414,none,0,1,0,1,0,0.000104,0,0,,Shared_Savings
CLM0000002070,MBR00000042,Vision,Denied,Electronic_EDI,2023-02-05,2023-02-05,2023-02-05,2023-03-07,Auto_Adjudicated,30,1900781649,1689327034,207RG0100X,Gastroenterology,22,In_Network,OTHER,I10,92002,,0,Commercial,HMO,78,F,1.1448,PR-1,Timely_Filing,156.41,97.55,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0424,none,0,1,0,0,0,0.0,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000002071,MBR00000235,Medical_Professional,Paid,Electronic_EDI,2023-09-19,2023-09-19,2023-09-19,2023-10-16,Auto_Adjudicated,27,1706018784,1447657873,246ZN0300X,Neuropsychology,22,In_Network,OTHER,,99204,,0,Commercial,HDHP_HSA,85,F,1.4308,,,189.64,122.11,0.0,122.11,0.0,0.0,67.53,0.0,0.0,0,,0.0424,none,0,1,0,0,0,0.0,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000002072,MBR00000024,Medical_Institutional,Paid,Electronic_EDI,2023-09-02,2023-09-02,2023-09-02,2023-09-06,Auto_Adjudicated,4,1170319307,1791502603,207V00000X,Obstetrics & Gynecology,21,In_Network,Z00.01,C50.911,revenue_code:0360,247,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,38487.59,19430.84,19428.84,0.0,2.0,0.0,19056.75,0.0,0.0,0,,0.1789,temporal_clustering,0,1,1,0,0,0.001798,0,0,SPC_Statin_Therapy,Shared_Savings
CLM0000002073,MBR00000154,Medical_Professional,Denied,Electronic_EDI,2023-02-21,2023-02-21,2023-02-21,2023-03-16,Auto_Adjudicated,23,1464997678,1140170394,225100000X,Physical Therapist,11,In_Network,Z00.01,M54.5,99213,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,16,Timely_Filing,152.22,59.37,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0477,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002074,MBR00000192,Medical_Professional,Paid,Electronic_EDI,2023-08-16,2023-08-16,2023-08-16,2023-09-11,Auto_Adjudicated,26,1205349488,1004714954,207RC0000X,Cardiovascular Disease,11,In_Network,I10,M17.11|C50.911,27130,,0,Medicaid_MCO,MCO,22,F,1.1739,,,40668.29,14505.29,14505.29,0.0,0.0,0.0,26163.0,0.0,0.0,1,Kickback Arrangement,1.0,unusual_service_frequency|provider_specialty_mismatch|high_volume_same_code|impossible_service_combo|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,1,0,0,0.001343,0,0,PPC_Prenatal_Care,Shared_Savings
CLM0000002075,MBR00000245,Medical_Institutional,Paid,Paper,2023-05-19,2023-05-19,2023-05-20,2023-06-04,Auto_Adjudicated,16,1878453830,1197700958,2084P0800X,Psychiatry,22,In_Network,M79.3,Z23|Z12.11|K21.0,revenue_code:0210,,0,Medicaid_MCO,MCO,60,F,0.7502,,,21554.7,10655.57,10654.57,0.0,1.0,0.0,10899.13,0.0,0.0,0,,0.0022,none,0,1,1,0,0,0.000986,0,0,KED_ESRD_Patients,Capitation
CLM0000002076,MBR00000143,Pharmacy,Paid,Paper,2023-07-02,2023-07-02,2023-07-02,2023-07-19,Auto_Adjudicated,17,1390393668,1365397818,208600000X,Surgery General,11,In_Network,M54.5,F32.9,00078043215,,2,Commercial,POS,85,M,1.6078,,,561.19,434.99,101.86,271.67,36.0,25.46,126.2,0.0,0.0,0,,0.0987,none,0,1,0,0,0,9e-06,0,1,,FFS
CLM0000002077,MBR00000075,Behavioral_Health,Paid,Electronic_EDI,2023-10-20,2023-10-20,2023-10-20,2023-11-01,Auto_Adjudicated,12,1718336220,1591405274,207RN0300X,Nephrology,22,Out_of_Network,E11.9,Z00.00|I10,99285,,0,Medicaid_MCO,MCO,5,M,1.0573,,,164.1,85.16,81.16,0.0,4.0,0.0,78.94,0.0,0.0,0,,0.0102,none,0,1,0,0,0,8e-06,1,0,SPC_Statin_Therapy,FFS
CLM0000002078,MBR00000152,Medical_Institutional,Paid,Paper,2023-04-26,2023-04-26,2023-04-29,2023-05-21,Auto_Adjudicated,25,1735391772,1319611206,207RE0101X,Endocrinology,11,In_Network,OTHER,N18.3,revenue_code:0360,,0,Commercial,HMO,82,F,1.2506,,,21120.32,16195.92,12648.72,325.02,60.0,3162.18,4924.4,0.0,0.0,0,,0.0723,npi_mismatch,0,1,1,0,0,0.001171,0,0,MMA_Medication_Management,Capitation
CLM0000002079,MBR00000077,Medical_Professional,Partially_Paid,Electronic_EDI,2023-11-26,2023-11-26,2023-11-26,2023-12-18,Auto_Adjudicated,22,1190558906,1972530373,207RN0300X,Nephrology,32,In_Network,E11.9,Z00.00|E78.5|K21.0,99383,,0,Medicare_Advantage,MA_HMO,27,F,0.9229,22,Medical_Necessity,497.82,420.91,226.84,11.75,4.0,56.71,198.52,0.0,0.0,0,,0.1668,duplicate_claim_indicator,0,1,0,0,0,2.1e-05,0,0,,FFS
CLM0000002080,MBR00000161,Pharmacy,Paid,Electronic_EDI,2023-05-30,2023-05-30,2023-05-30,2023-06-18,Auto_Adjudicated,19,1950560596,1704466150,207R00000X,Internal Medicine,22,In_Network,OTHER,K21.0|Z00.00,00169751112,,3,Medicaid_MCO,MLTSS,9,F,0.8354,,,382.18,216.14,212.14,0.0,4.0,0.0,166.04,0.0,0.0,0,,0.1059,none,0,1,0,0,0,2e-05,0,0,,Capitation
CLM0000002081,MBR00000143,Medical_Professional,Paid,Paper,2023-07-04,2023-07-04,2023-07-04,2023-07-05,Auto_Adjudicated,1,1713741288,1368666316,101YP2500X,Psychologist Clinical,11,In_Network,K21.0,,99392,,0,Commercial,POS,85,M,1.6078,,,436.92,248.07,0.0,248.07,0.0,0.0,188.85,0.0,0.0,0,,0.1447,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002082,MBR00000231,Medical_Institutional,Paid,Provider_Portal,2023-01-11,2023-01-11,2023-01-15,2023-02-09,Manual_Review,29,1170257806,1810068286,208600000X,Surgery General,24,In_Network,Z23,,revenue_code:0100,,0,ACA_Marketplace,ACA_Silver,12,M,0.6456,,,4094.88,3176.5,2111.57,84.98,75.0,904.96,918.38,0.0,0.0,0,,0.0001,none,0,1,0,0,0,0.000195,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000002083,MBR00000075,Pharmacy,Denied,Provider_Portal,2023-02-13,2023-02-13,2023-02-13,2023-03-01,Auto_Adjudicated,16,1231954359,1034732777,207Q00000X,Family Medicine,22,In_Network,OTHER,OTHER|Z00.01|M25.511,00071012831,,1,Medicaid_MCO,MCO,5,M,1.0573,50,Eligibility,306.93,193.4,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1724,temporal_clustering|impossible_service_combo|service_date_weekend,0,1,0,1,0,0.0,0,0,,FFS
CLM0000002084,MBR00000061,Medical_Institutional,Paid,Electronic_EDI,2023-04-12,2023-04-12,2023-04-14,2023-05-11,Auto_Adjudicated,29,1756856314,1144950506,207RE0101X,Endocrinology,22,In_Network,Z00.01,I10,revenue_code:0100,,0,Commercial,PPO,66,M,2.3575,,,18613.49,14258.86,11268.96,138.66,34.0,2817.24,4354.63,0.0,0.0,0,,0.1961,provider_specialty_mismatch,0,1,1,0,0,0.001043,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000002085,MBR00000145,Medical_Institutional,Paid,Electronic_EDI,2023-12-18,2023-12-18,2023-12-18,2024-01-08,Manual_Review,21,1464997678,1396850418,207V00000X,Obstetrics & Gynecology,11,In_Network,Z00.01,Z00.00,revenue_code:0210,,0,Medicaid_MCO,MLTSS,46,M,0.5813,,,10481.49,7348.63,7347.63,0.0,1.0,0.0,3132.86,0.0,0.0,0,,0.0525,none,0,1,1,0,0,0.00068,0,0,,FFS
CLM0000002086,MBR00000014,Medical_Professional,Paid,Electronic_EDI,2023-04-04,2023-04-04,2023-04-04,2023-04-20,Auto_Adjudicated,16,1451329728,1179350099,2086S0122X,Orthopedic Surgery,21,Out_of_Network,K21.0,Z00.01|OTHER,99214,,0,Commercial,HMO,77,M,2.8513,,,206.92,111.17,0.0,111.17,0.0,0.0,95.75,0.0,0.0,0,,0.0603,none,0,1,0,0,0,0.0,1,0,,Capitation
CLM0000002087,MBR00000072,Medical_Professional,Paid,Electronic_EDI,2023-05-22,2023-05-22,2023-05-22,2023-06-14,Auto_Adjudicated,23,1068197532,1477113725,2086S0122X,Orthopedic Surgery,32,In_Network,J44.1,,12001,,0,Medicare_Advantage,MA_PPO,39,M,0.4967,,,890.95,599.41,462.71,13.02,8.0,115.68,291.54,0.0,0.0,0,,0.0801,none,0,1,0,0,0,4.3e-05,0,0,,FFS
CLM0000002088,MBR00000112,Behavioral_Health,Paid,Electronic_EDI,2023-11-03,2023-11-03,2023-11-03,2023-11-11,Auto_Adjudicated,8,1414670047,1884259357,207Q00000X,Family Medicine,11,In_Network,M17.11,OTHER|J44.1,99384,,0,Medicare_Advantage,MA_HMO,18,M,1.01,,,134.28,48.88,17.65,20.82,6.0,4.41,85.4,0.0,0.0,0,,0.0484,none,0,1,0,0,0,2e-06,0,0,,Capitation
CLM0000002089,MBR00000151,Medical_Professional,Paid,Electronic_EDI,2023-04-25,2023-04-25,2023-04-25,2023-05-09,Manual_Review,14,1403662694,1477113725,225100000X,Physical Therapist,22,In_Network,OTHER,OTHER,99396,,0,Medicare_Advantage,MA_HMO,77,M,0.8709,,,225.68,135.56,99.66,4.99,6.0,24.91,90.12,0.0,0.0,0,,0.0252,none,0,1,0,0,0,9e-06,0,0,CDC_BP_Control,Capitation
CLM0000002090,MBR00000083,Medical_Professional,Paid,Electronic_EDI,2023-10-19,2023-10-19,2023-10-19,2023-10-20,Auto_Adjudicated,1,1550698436,1643673796,246ZN0300X,Neuropsychology,11,In_Network,OTHER,OTHER|E11.65,99395,,0,Commercial,PPO,76,M,0.6621,,,448.48,177.04,110.89,19.42,19.0,27.72,271.44,76.08,19.29,0,,0.141,upcoding_pattern,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000002091,MBR00000169,Medical_Institutional,Paid,Paper,2023-02-13,2023-02-13,2023-02-17,2023-03-08,Clinical_Review,23,1965682436,1282319940,207RE0101X,Endocrinology,22,In_Network,Z00.00,OTHER,revenue_code:0370,,0,Commercial,EPO,30,M,1.4348,,,30652.34,19182.48,15108.41,235.97,61.0,3777.1,11469.86,0.0,0.0,0,,0.1806,duplicate_claim_indicator,0,1,1,0,0,0.001398,0,0,HBD_Hemoglobin_A1c_Testing,Bundled_Payment
CLM0000002092,MBR00000265,Medical_Professional,Paid,Electronic_EDI,2023-02-17,2023-02-17,2023-02-17,2023-02-27,Auto_Adjudicated,10,1639236553,1175334579,2084P0800X,Psychiatry,22,In_Network,I10,,17000,,0,Commercial,PPO,84,F,0.7969,,,910.9,688.71,393.37,172.0,25.0,98.34,222.19,0.0,0.0,0,,0.0307,none,0,1,0,0,0,3.6e-05,0,0,,Shared_Savings
CLM0000002093,MBR00000165,Medical_Professional,Paid,Electronic_EDI,2023-01-05,2023-01-05,2023-01-05,2023-01-08,Manual_Review,3,1389116733,1452088018,207R00000X,Internal Medicine,11,In_Network,J20.9,F32.9|Z23|F10.10,99204,,0,ACA_Marketplace,ACA_Bronze,55,M,0.9775,,,222.49,95.69,0.0,95.69,0.0,0.0,126.8,0.0,0.0,0,,0.0387,none,0,1,0,0,0,0.0,0,0,POD_Persistence_of_Beta_Blocker,FFS
CLM0000002094,MBR00000090,Medical_Professional,Paid,Electronic_EDI,2023-02-14,2023-02-14,2023-02-14,2023-03-10,Manual_Review,24,1326896487,1622950074,207R00000X,Internal Medicine,11,In_Network,OTHER,I48.91,90837,,0,Medicare_Advantage,MA_HMO,49,F,0.4351,,,298.54,163.5,107.35,14.32,15.0,26.84,135.04,0.0,0.0,0,,0.1837,geographic_mismatch|temporal_clustering,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000002095,MBR00000018,Medical_Institutional,Paid,Electronic_EDI,2023-08-05,2023-08-05,2023-08-07,2023-08-12,Auto_Adjudicated,7,1719850506,1930040953,246ZN0300X,Neuropsychology,22,In_Network,E78.5,J06.9|F32.9,revenue_code:0200,,0,Commercial,EPO,5,F,0.5555,,,5950.13,3707.47,2890.71,27.09,67.0,722.68,2242.66,0.0,0.0,0,,0.0167,none,0,1,0,0,0,0.000268,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000002096,MBR00000042,Medical_Institutional,Paid,Electronic_EDI,2023-02-02,2023-02-02,2023-02-04,2023-02-09,Auto_Adjudicated,7,1739169232,1330485436,207R00000X,Internal Medicine,21,In_Network,J06.9,,revenue_code:0450,248,0,Commercial,HMO,78,F,1.1448,,,38166.38,17213.13,13691.39,28.89,70.0,3422.85,20953.25,0.0,0.0,0,,0.0232,none,0,1,1,0,0,0.001267,0,0,,FFS
CLM0000002097,MBR00000169,Pharmacy,Paid,Electronic_EDI,2023-08-08,2023-08-08,2023-08-08,2023-08-13,Auto_Adjudicated,5,1945264928,1170002937,2084P0800X,Psychiatry,65,In_Network,E11.9,E11.9,00085163102,,2,Commercial,EPO,30,M,1.4348,,,210.31,77.07,0.0,77.07,0.0,0.0,133.24,0.0,0.0,0,,0.0668,benford_violation,0,1,0,0,0,0.0,0,1,,P4P
CLM0000002098,MBR00000204,Medical_Professional,Paid,Electronic_EDI,2023-08-04,2023-08-04,2023-08-04,2023-08-23,Auto_Adjudicated,19,1549436467,1977073565,101YP2500X,Psychologist Clinical,23,In_Network,OTHER,Z00.01|J06.9,90837,,0,Commercial,HMO,12,M,0.8716,,,605.24,212.27,71.38,91.05,32.0,17.84,392.97,0.0,0.0,0,,0.1222,none,0,1,0,1,0,7e-06,0,0,,Bundled_Payment
CLM0000002099,MBR00000014,Vision,Denied,Electronic_EDI,2023-03-26,2023-03-26,2023-03-26,2023-04-06,Auto_Adjudicated,11,1658094898,1061149198,207RN0300X,Nephrology,65,In_Network,I10,F41.1|I10,V2115,,0,Commercial,HMO,77,M,2.8513,18,Network,303.85,145.15,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0571,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002100,MBR00000058,Medical_Professional,Paid,Paper,2023-01-14,2023-01-14,2023-01-14,2023-02-01,Auto_Adjudicated,18,1924450526,1704466150,207RG0100X,Gastroenterology,65,In_Network,E11.65,I10|OTHER|J20.9,97140,,0,Commercial,PPO,56,F,1.1626,,,1049.6,528.36,300.04,138.31,15.0,75.01,521.24,0.0,0.0,0,,0.098,none,0,1,0,0,0,2.8e-05,0,0,,Shared_Savings
CLM0000002101,MBR00000101,Medical_Professional,Paid,Electronic_EDI,2023-02-28,2023-02-28,2023-02-28,2023-03-11,Auto_Adjudicated,11,1797494973,1685903362,207R00000X,Internal Medicine,11,In_Network,Z00.00,I10|G47.33,71250,,0,Commercial,PPO,83,M,0.3627,,,316.83,184.51,129.87,0.17,22.0,32.47,132.32,0.0,0.0,0,,0.0901,phantom_billing_indicator,0,1,0,0,0,1.2e-05,0,0,,Capitation
CLM0000002102,MBR00000102,Vision,Denied,Electronic_EDI,2023-02-21,2023-02-21,2023-02-21,2023-03-16,Manual_Review,23,1957378066,1450837722,225100000X,Physical Therapist,32,In_Network,N18.3,F41.1,92002,,0,Commercial,POS,68,M,1.6864,256,Timely_Filing,219.56,169.98,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0217,none,0,1,0,0,0,0.0,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000002103,MBR00000291,Pharmacy,Paid,Electronic_EDI,2023-07-09,2023-07-09,2023-07-09,2023-07-21,Auto_Adjudicated,12,1222934819,1623053477,225100000X,Physical Therapist,81,In_Network,Z12.11,E11.65|OTHER,00069420020,,3,Commercial,PPO,78,M,1.4773,,,301.81,168.47,0.0,168.47,0.0,0.0,133.34,0.0,0.0,0,,0.0681,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000002104,MBR00000061,Medical_Professional,Paid,Electronic_EDI,2023-12-01,2023-12-01,2023-12-01,2023-12-25,Auto_Adjudicated,24,1474985672,1039962073,225100000X,Physical Therapist,22,In_Network,E11.65,F32.9|E78.5|OTHER,74177,,0,Commercial,PPO,66,M,2.3575,,,768.79,301.17,186.29,55.3,13.0,46.57,467.62,0.0,0.0,0,,0.0577,temporal_clustering,0,1,0,0,0,1.7e-05,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000002105,MBR00000019,Medical_Professional,Paid,Provider_Portal,2023-06-06,2023-06-06,2023-06-06,2023-06-20,Auto_Adjudicated,14,1826043246,1662516615,207RP1001X,Pulmonary Disease,23,In_Network,Z00.00,I10|OTHER|M54.5,99204,,0,Commercial,PPO,77,M,0.6521,,,486.8,249.85,44.06,172.78,22.0,11.01,236.95,0.0,0.0,0,,0.0868,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000002106,MBR00000112,Pharmacy,Paid,Electronic_EDI,2023-08-16,2023-08-16,2023-08-16,2023-08-17,Auto_Adjudicated,1,1046207613,1055872102,101YP2500X,Psychologist Clinical,21,In_Network,Z00.01,OTHER|Z00.01|I10,00071012831,,1,Medicare_Advantage,MA_HMO,18,M,1.01,,,328.87,165.42,98.03,36.88,6.0,24.51,163.45,0.0,0.0,0,,0.0192,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000002107,MBR00000042,Medical_Professional,Paid,Provider_Portal,2023-04-20,2023-04-20,2023-04-20,2023-05-04,Auto_Adjudicated,14,1918578486,1267212691,207RG0100X,Gastroenterology,11,Emergency,Z00.01,F41.1|J20.9,99214,,0,Commercial,HMO,78,F,1.1448,,,190.33,120.85,64.92,19.7,20.0,16.23,69.48,0.0,0.0,0,,0.1099,none,0,1,0,0,0,6e-06,0,0,DDE_Diabetes_Short_Term_Complications,Bundled_Payment
CLM0000002108,MBR00000038,Medical_Professional,Paid,Electronic_EDI,2023-02-02,2023-02-02,2023-02-02,2023-02-10,Auto_Adjudicated,8,1170257806,1685903362,2084P0800X,Psychiatry,11,In_Network,OTHER,J06.9|Z00.00,70553,,0,Commercial,EPO,46,M,1.1295,,,62.85,42.38,0.0,42.38,0.0,0.0,20.47,0.0,0.0,0,,0.1151,none,0,1,0,1,0,0.0,0,0,W30_Well_Child_Visit,P4P
CLM0000002109,MBR00000130,Medical_Institutional,Paid,Electronic_EDI,2023-03-20,2023-03-20,2023-03-22,2023-04-04,Manual_Review,15,1804302686,1012893364,225100000X,Physical Therapist,11,In_Network,G43.909,K21.0,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,58,M,1.3394,,,14422.06,5051.36,4014.43,9.32,24.0,1003.61,9370.7,0.0,0.0,0,,0.064,none,0,1,0,0,0,0.000372,0,0,,Shared_Savings
CLM0000002110,MBR00000097,Pharmacy,Paid,Electronic_EDI,2023-06-22,2023-06-22,2023-06-22,2023-06-26,Manual_Review,4,1243052462,1985590322,207RN0300X,Nephrology,22,In_Network,I10,E78.5,00310075090,,2,Commercial,EPO,34,M,1.3765,,,78.0,48.35,0.0,48.35,0.0,0.0,29.65,0.0,0.0,0,,0.1433,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002111,MBR00000028,Medical_Institutional,Paid,Electronic_EDI,2023-11-05,2023-11-05,2023-11-09,2023-11-28,Auto_Adjudicated,23,1981623199,1579331190,246ZN0300X,Neuropsychology,23,In_Network,M54.5,K21.0|E78.5,revenue_code:0370,,0,Commercial,HMO,3,F,2.116,,,18948.88,8965.32,6982.27,158.48,79.0,1745.57,9983.56,0.0,0.0,0,,0.1381,none,0,1,1,0,0,0.000646,0,0,CDC_BP_Control,FFS
CLM0000002112,MBR00000182,Medical_Institutional,Paid,Electronic_EDI,2023-03-31,2023-03-31,2023-03-31,2023-04-19,Auto_Adjudicated,19,1633089013,1419347445,225100000X,Physical Therapist,11,In_Network,K21.0,,revenue_code:0300,,0,Commercial,HMO,82,F,0.8489,,,50216.6,36695.91,29157.92,214.51,34.0,7289.48,13520.69,0.0,0.0,0,,0.1796,outlier_billing_amount|npi_mismatch,0,1,1,0,0,0.002699,0,0,,Capitation
CLM0000002113,MBR00000155,Vision,Denied,Electronic_EDI,2023-12-20,2023-12-20,2023-12-20,2023-12-25,Auto_Adjudicated,5,1888245409,1860951128,208600000X,Surgery General,11,In_Network,Z00.01,K21.0,92002,,0,ACA_Marketplace,ACA_Bronze,9,F,0.8196,2,Duplicate,167.33,86.8,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0962,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002114,MBR00000024,Medical_Professional,Paid,Electronic_EDI,2023-08-18,2023-08-18,2023-08-18,2023-09-17,Auto_Adjudicated,30,1770738194,1163639177,207RE0101X,Endocrinology,11,In_Network,OTHER,J44.1,84443,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,1021.98,825.63,822.63,0.0,3.0,0.0,196.35,0.0,0.0,0,,0.1953,upcoding_pattern,0,1,0,0,0,7.6e-05,0,0,,FFS
CLM0000002115,MBR00000261,Pharmacy,Paid,Electronic_EDI,2023-05-08,2023-05-08,2023-05-08,2023-05-19,Auto_Adjudicated,11,1956215244,1004714954,207RC0000X,Cardiovascular Disease,81,In_Network,J06.9,,50458085930,,1,Medicare_Advantage,MA_PPO,13,F,0.4259,,,361.1,198.13,143.2,18.13,1.0,35.8,162.97,0.0,0.0,0,,0.1423,none,0,1,0,0,0,1.3e-05,0,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000002116,MBR00000089,Medical_Professional,Paid,Electronic_EDI,2023-08-12,2023-08-12,2023-08-12,2023-08-19,Clinical_Review,7,1099247356,1977073565,207V00000X,Obstetrics & Gynecology,24,In_Network,I50.9,J06.9|E11.9,97012,,0,Commercial,PPO,14,M,0.5668,,,827.97,434.87,299.83,26.08,34.0,74.96,393.1,0.0,0.0,0,,0.0526,none,0,1,0,0,0,2.8e-05,0,0,,FFS
CLM0000002117,MBR00000291,Pharmacy,Paid,Provider_Portal,2023-09-08,2023-09-08,2023-09-08,2023-09-09,Auto_Adjudicated,1,1633089013,1747596016,207RG0100X,Gastroenterology,11,In_Network,M79.3,Z12.11,00310075090,,3,Commercial,PPO,78,M,1.4773,,,233.99,97.63,0.0,97.63,0.0,0.0,136.36,0.0,0.0,0,,0.1819,unusual_service_frequency|impossible_service_combo,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000002118,MBR00000281,Medical_Institutional,Paid,Electronic_EDI,2023-09-04,2023-09-04,2023-09-05,2023-09-12,Auto_Adjudicated,8,1918160357,1930040953,207V00000X,Obstetrics & Gynecology,31,In_Network,OTHER,E78.5,revenue_code:0370,,0,Medicare_Advantage,MA_HMO,3,M,0.8531,,,1851.74,809.97,622.66,1.64,30.0,155.67,1041.77,0.0,0.0,0,,0.0942,none,0,1,0,0,0,5.8e-05,0,0,,Capitation
CLM0000002119,MBR00000136,Medical_Professional,Paid,Electronic_EDI,2023-11-07,2023-11-07,2023-11-07,2023-11-08,Manual_Review,1,1114266188,1133410177,207RP1001X,Pulmonary Disease,31,In_Network,J45.20,Z00.00,97140,,0,Commercial,POS,2,F,1.2611,,,680.52,467.55,306.29,74.69,10.0,76.57,212.97,0.0,0.0,0,,0.1011,none,0,1,0,0,0,2.8e-05,0,0,,Capitation
CLM0000002120,MBR00000072,Medical_Institutional,Paid,Electronic_EDI,2023-08-26,2023-08-26,2023-08-30,2023-09-10,Auto_Adjudicated,15,1734752728,1164525386,207Q00000X,Family Medicine,24,In_Network,Z00.00,Z79.4|M54.5,revenue_code:0120,,0,Medicare_Advantage,MA_PPO,39,M,0.4967,,,11906.66,7569.64,6014.26,25.82,26.0,1503.56,4337.02,0.0,0.0,0,,0.0974,none,0,1,1,0,0,0.000557,0,0,,Capitation
CLM0000002121,MBR00000249,Dental,Paid,Electronic_EDI,2023-01-10,2023-01-10,2023-01-10,2023-01-29,Auto_Adjudicated,19,1404237143,1643673796,207Q00000X,Family Medicine,32,Out_of_Network,I10,,D2140,,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,657.06,410.73,128.2,197.59,30.0,54.94,246.33,0.0,0.0,0,,0.1023,diagnosis_procedure_mismatch,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000002122,MBR00000114,Medical_Institutional,Denied,Electronic_EDI,2023-05-16,2023-05-16,2023-05-17,2023-05-28,Auto_Adjudicated,12,1356331863,1691162131,207RE0101X,Endocrinology,22,In_Network,K21.0,OTHER,revenue_code:0300,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,16,COB,28470.22,11858.23,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0753,none,0,1,0,0,0,0.0,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000002123,MBR00000052,Medical_Professional,Paid,Electronic_EDI,2023-11-22,2023-11-22,2023-11-22,2023-12-19,Auto_Adjudicated,27,1055717021,1477113725,225100000X,Physical Therapist,11,In_Network,Z00.01,,99213,,0,Commercial,PPO,0,F,1.325,,,216.94,87.41,20.16,30.21,32.0,5.04,129.53,0.0,0.0,0,,0.0249,none,0,1,0,0,0,2e-06,0,0,,Capitation
CLM0000002124,MBR00000166,Medical_Professional,Paid,Electronic_EDI,2023-03-16,2023-03-16,2023-03-16,2023-04-14,Auto_Adjudicated,29,1594322174,1887266184,2086S0122X,Orthopedic Surgery,32,In_Network,Z12.11,OTHER|F32.9|Z12.11,99386,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,108.29,61.63,0.0,61.63,0.0,0.0,46.66,0.0,0.0,0,,0.0612,none,0,1,0,0,0,0.0,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000002125,MBR00000152,Medical_Institutional,Denied,Electronic_EDI,2023-06-29,2023-06-29,2023-07-03,2023-07-09,Clinical_Review,10,1068197532,1388050552,2084P0800X,Psychiatry,31,In_Network,OTHER,,revenue_code:0200,,0,Commercial,HMO,82,F,1.2506,3,COB,2853.36,2358.77,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1205,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002126,MBR00000255,Pharmacy,Denied,Electronic_EDI,2023-06-29,2023-06-29,2023-06-29,2023-07-19,Auto_Adjudicated,20,1175252466,1804282800,207RP1001X,Pulmonary Disease,11,In_Network,E11.9,E13.9|J44.1|I50.9,00310075090,,2,Medicare_Advantage,MA_HMO,21,M,0.6945,16,Network,555.53,311.23,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1115,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000002127,MBR00000214,Medical_Institutional,Paid,Electronic_EDI,2023-07-19,2023-07-19,2023-07-20,2023-08-01,Auto_Adjudicated,13,1560886857,1408846353,208600000X,Surgery General,22,In_Network,Z87.891,,revenue_code:0360,,0,Commercial,HDHP_HSA,76,M,1.7526,,,11193.63,8976.07,6703.61,596.56,0.0,1675.9,2217.56,0.0,0.0,0,,0.1386,none,0,1,1,1,0,0.00062,0,0,,FFS
CLM0000002128,MBR00000264,Medical_Professional,Paid,Electronic_EDI,2023-11-08,2023-11-08,2023-11-08,2023-11-17,Auto_Adjudicated,9,1864546991,1622950074,207RC0000X,Cardiovascular Disease,22,In_Network,E78.5,,99214,,0,ACA_Marketplace,ACA_Bronze,12,F,0.5826,,,135.84,113.26,0.0,113.26,0.0,0.0,22.58,0.0,0.0,0,,0.0724,high_volume_same_code,0,1,0,0,0,0.0,0,0,DAE_Drug_Alcohol_Dependence,Shared_Savings
CLM0000002129,MBR00000215,Pharmacy,Partially_Paid,Electronic_EDI,2023-07-13,2023-07-13,2023-07-13,2023-07-20,Auto_Adjudicated,7,1484613641,1013600387,2086S0122X,Orthopedic Surgery,22,In_Network,Z00.00,K21.0|I10|OTHER,00071015523,,2,ACA_Marketplace,ACA_Silver,69,M,0.8895,97,Medical_Necessity,62.5,25.35,0.0,18.68,0.0,0.0,43.82,0.0,0.0,0,,0.0694,none,0,1,0,1,0,0.0,0,0,W30_Well_Child_Visit,FFS
CLM0000002130,MBR00000191,Medical_Professional,Paid,Provider_Portal,2023-01-01,2023-01-01,2023-01-01,2023-01-17,Auto_Adjudicated,16,1102590784,1587454801,207RG0100X,Gastroenterology,22,Out_of_Network,Z00.01,Z12.11,99283,,0,Commercial,POS,85,F,0.9729,,,314.25,255.24,96.99,96.0,38.0,24.25,59.01,0.0,0.0,0,,0.0861,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000002131,MBR00000154,Medical_Professional,Paid,Electronic_EDI,2023-03-29,2023-03-29,2023-03-29,2023-04-03,Manual_Review,5,1958171947,1013600387,225100000X,Physical Therapist,11,Out_of_Network,Z00.01,N18.3,99203,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,297.46,211.41,161.73,9.24,0.0,40.43,86.05,0.0,0.0,0,,0.1588,npi_mismatch,0,1,0,0,0,1.5e-05,1,0,AWV_Annual_Wellness_Visit,Capitation
CLM0000002132,MBR00000297,Medical_Institutional,Paid,Electronic_EDI,2023-08-15,2023-08-15,2023-08-17,2023-09-05,Auto_Adjudicated,21,1956215244,1540743888,2084P0800X,Psychiatry,22,In_Network,M54.5,Z12.11,revenue_code:0210,,0,Commercial,HMO,88,M,1.5311,,,53261.37,21174.53,16894.95,16.84,39.0,4223.74,32086.84,14517.86,1288.31,0,,0.174,outlier_billing_amount,0,1,1,0,0,0.001564,0,0,,FFS
CLM0000002133,MBR00000291,Medical_Institutional,Paid,Paper,2023-10-08,2023-10-08,2023-10-08,2023-11-04,Clinical_Review,27,1253087808,1577226132,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,,revenue_code:0360,,0,Commercial,PPO,78,M,1.4773,,,11164.27,7970.16,6114.03,251.62,76.0,1528.51,3194.11,0.0,0.0,0,,0.0633,none,0,1,1,0,0,0.000566,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000002134,MBR00000255,Vision,Paid,Provider_Portal,2023-08-21,2023-08-21,2023-08-21,2023-09-02,Auto_Adjudicated,12,1222934819,1469881892,246ZN0300X,Neuropsychology,11,In_Network,F33.0,,92004,,0,Medicare_Advantage,MA_HMO,21,M,0.6945,,,339.64,202.64,144.6,3.89,18.0,36.15,137.0,0.0,0.0,0,,0.1331,none,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000002135,MBR00000229,Medical_Institutional,Paid,Paper,2023-09-20,2023-09-20,2023-09-23,2023-10-08,Auto_Adjudicated,18,1879212418,1985590322,2084P0800X,Psychiatry,22,In_Network,I10,,revenue_code:0300,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,11555.73,4851.98,3837.69,0.86,54.0,959.42,6703.75,0.0,0.0,0,,0.07,none,0,1,0,0,0,0.000355,0,0,DDE_Diabetes_Short_Term_Complications,P4P
CLM0000002136,MBR00000174,Medical_Professional,Paid,Paper,2023-03-28,2023-03-28,2023-03-28,2023-04-27,Clinical_Review,30,1120678352,1564691686,207RC0000X,Cardiovascular Disease,21,In_Network,Z00.00,,99384,,0,Medicare_Advantage,MA_HMO,85,M,0.3901,,,421.68,197.79,138.31,6.91,18.0,34.58,223.89,0.0,0.0,0,,0.1426,none,0,1,0,0,0,1.3e-05,0,0,,Shared_Savings
CLM0000002137,MBR00000081,Pharmacy,Paid,Electronic_EDI,2023-02-04,2023-02-04,2023-02-04,2023-02-26,Auto_Adjudicated,22,1331829614,1542515060,2086S0122X,Orthopedic Surgery,21,In_Network,OTHER,,50458085930,,2,Medicare_Advantage,SNP,66,F,2.159,,,735.83,518.16,400.41,12.64,5.0,100.1,217.67,0.0,0.0,0,,0.0498,none,0,1,0,0,0,3.7e-05,0,1,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000002138,MBR00000264,Medical_Professional,Paid,Electronic_EDI,2023-12-07,2023-12-07,2023-12-07,2023-12-20,Auto_Adjudicated,13,1208538971,1170002937,207Q00000X,Family Medicine,11,In_Network,I10,F41.1,99395,,0,ACA_Marketplace,ACA_Bronze,12,F,0.5826,,,449.0,228.8,0.0,228.8,0.0,0.0,220.2,0.0,0.0,0,,0.1268,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002139,MBR00000004,Vision,Paid,Electronic_EDI,2023-07-22,2023-07-22,2023-07-22,2023-08-18,Auto_Adjudicated,27,1325430913,1965244699,101YP2500X,Psychologist Clinical,22,In_Network,E78.5,M79.3|I25.10,V2115,,0,Medicare_Advantage,MA_PPO,68,M,1.23,,,750.17,619.63,470.33,23.71,8.0,117.58,130.54,365.22,79.82,0,,0.0258,none,0,1,0,0,0,4.4e-05,0,0,,FFS
CLM0000002140,MBR00000071,Medical_Professional,Paid,Electronic_EDI,2023-09-23,2023-09-23,2023-09-23,2023-09-25,Auto_Adjudicated,2,1007414142,1741177636,207RN0300X,Nephrology,11,In_Network,OTHER,I10,97140,,0,Commercial,EPO,19,F,0.5699,,,949.22,721.51,551.05,10.7,22.0,137.76,227.71,469.4,52.34,0,,0.0941,none,0,1,0,1,0,5.1e-05,0,0,BPD_BP_Declined,Bundled_Payment
CLM0000002141,MBR00000128,Dental,Denied,Electronic_EDI,2023-12-10,2023-12-10,2023-12-10,2023-12-28,Auto_Adjudicated,18,1557212800,1809122260,208600000X,Surgery General,11,In_Network,J20.9,E11.9,D0150,,0,Commercial,PPO,13,F,1.4203,96,COB,135.14,84.73,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.044,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002142,MBR00000176,Dental,Paid,Electronic_EDI,2023-03-07,2023-03-07,2023-03-07,2023-03-15,Auto_Adjudicated,8,1078527460,1938465393,207V00000X,Obstetrics & Gynecology,24,In_Network,E11.9,,D2391,,0,Commercial,POS,4,M,0.8792,,,213.47,141.51,0.0,141.51,0.0,0.0,71.96,0.0,0.0,0,,0.1492,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002143,MBR00000169,Dental,Paid,Electronic_EDI,2023-11-09,2023-11-09,2023-11-09,2023-11-15,Manual_Review,6,1882720848,1148659045,2084P0800X,Psychiatry,23,In_Network,G47.33,I10|I25.10|Z12.11,D0150,,0,Commercial,EPO,30,M,1.4348,,,572.75,463.63,307.67,57.04,22.0,76.92,109.12,0.0,0.0,0,,0.1454,none,0,1,0,0,0,2.8e-05,0,0,,Shared_Savings
CLM0000002144,MBR00000055,Medical_Professional,Paid,Electronic_EDI,2023-05-12,2023-05-12,2023-05-12,2023-05-28,Auto_Adjudicated,16,1421421733,1220755708,2086S0122X,Orthopedic Surgery,22,In_Network,Z12.11,,99213,,0,Commercial,PPO,68,F,1.2896,,,248.18,126.64,89.25,5.08,10.0,22.31,121.54,0.0,0.0,0,,0.0857,none,0,1,0,1,0,8e-06,0,0,,P4P
CLM0000002145,MBR00000032,Pharmacy,Paid,Electronic_EDI,2023-08-13,2023-08-13,2023-08-13,2023-09-04,Auto_Adjudicated,22,1213747973,1643673796,101YP2500X,Psychologist Clinical,22,In_Network,I25.10,E11.9,00071012831,,1,Medicaid_MCO,FFS_Medicaid,87,M,0.4839,,,180.27,136.02,134.02,0.0,2.0,0.0,44.25,0.0,0.0,0,,0.1427,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000002146,MBR00000069,Pharmacy,Paid,Electronic_EDI,2023-05-19,2023-05-19,2023-05-19,2023-06-11,Auto_Adjudicated,23,1642333103,1977073565,207RG0100X,Gastroenterology,21,Out_of_Network,Z00.01,Z00.00|OTHER|J06.9,00310075090,,3,Medicare_Advantage,MA_PPO,2,M,0.5765,,,94.15,54.08,0.0,49.63,4.45,0.0,40.07,0.0,0.0,0,,0.2027,impossible_service_combo,0,2,0,0,0,0.0,0,0,,FFS
CLM0000002147,MBR00000110,Medical_Professional,Paid,Electronic_EDI,2023-03-13,2023-03-13,2023-03-13,2023-04-05,Auto_Adjudicated,23,1928139578,1738617370,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,F32.9,74177,,0,Medicare_Advantage,MA_HMO,83,F,1.127,,,1786.6,1403.67,1110.37,6.71,9.0,277.59,382.93,666.37,258.74,0,,0.1258,none,0,1,0,0,0,0.000103,0,0,TRC_Transition_of_Care,FFS
CLM0000002148,MBR00000005,Medical_Institutional,Paid,Electronic_EDI,2023-11-12,2023-11-12,2023-11-13,2023-11-21,Auto_Adjudicated,9,1141106555,1945682535,101YP2500X,Psychologist Clinical,21,In_Network,J44.1,F32.9,revenue_code:0370,871,0,Medicare_Advantage,MA_PPO,8,M,0.566,,,47616.86,18218.36,14554.72,3.96,21.0,3638.68,29398.5,11007.02,2398.33,0,,0.0758,outlier_billing_amount,0,1,1,0,0,0.001347,0,0,,FFS
CLM0000002149,MBR00000206,Medical_Institutional,Paid,Electronic_EDI,2023-05-05,2023-05-05,2023-05-09,2023-05-18,Auto_Adjudicated,13,1542851144,1390802135,207RC0000X,Cardiovascular Disease,24,In_Network,Z00.00,I10|C50.911,revenue_code:0450,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,9765.07,6923.05,6918.05,0.0,5.0,0.0,2842.02,0.0,0.0,0,,0.0841,none,0,1,1,0,0,0.00064,0,0,,Capitation
CLM0000002150,MBR00000077,Vision,Paid,Electronic_EDI,2023-01-09,2023-01-09,2023-01-09,2023-01-13,Auto_Adjudicated,4,1542851144,1977073565,225100000X,Physical Therapist,22,In_Network,E11.65,,V2115,,0,Medicare_Advantage,MA_HMO,27,F,0.9229,,,250.93,189.26,142.06,7.68,4.0,35.52,61.67,0.0,0.0,0,,0.0863,geographic_mismatch,0,1,0,0,0,1.3e-05,0,0,CDC_BP_Control,Bundled_Payment
CLM0000002151,MBR00000111,Pharmacy,Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-23,2023-03-14,Auto_Adjudicated,19,1501282310,1825450791,207RC0000X,Cardiovascular Disease,24,In_Network,J06.9,E11.9,00071015523,,1,Medicare_Advantage,MA_PPO,44,M,0.7462,,,499.34,327.89,248.33,1.47,16.0,62.08,171.45,216.6,17.99,0,,0.2465,temporal_clustering|upcoding_pattern,0,2,0,0,0,2.3e-05,0,1,,FFS
CLM0000002152,MBR00000106,Medical_Institutional,Paid,Electronic_EDI,2023-12-12,2023-12-12,2023-12-12,2024-01-06,Auto_Adjudicated,25,1901054209,1765164601,207RE0101X,Endocrinology,65,In_Network,OTHER,Z79.4,revenue_code:0360,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,30765.25,15282.89,12179.76,23.19,35.0,3044.94,15482.36,0.0,0.0,0,,0.1413,geographic_mismatch,0,1,1,0,0,0.001127,0,0,CCS_Cervical_Cancer_Screening,Bundled_Payment
CLM0000002153,MBR00000157,Medical_Institutional,Paid,Electronic_EDI,2023-10-23,2023-10-23,2023-10-23,2023-11-07,Manual_Review,15,1878453830,1577226132,207RP1001X,Pulmonary Disease,11,Out_of_Network,I10,Z12.11|N39.0|K21.0,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,26,F,0.9164,,,2765.03,1172.35,912.45,3.79,28.0,228.11,1592.68,756.9,134.75,0,,0.1052,none,0,1,0,1,0,8.4e-05,0,0,TRC_Transition_of_Care,Capitation
CLM0000002154,MBR00000259,Medical_Professional,Partially_Paid,Electronic_EDI,2023-08-27,2023-08-27,2023-08-27,2023-09-06,Clinical_Review,10,1650193199,1220755708,207RC0000X,Cardiovascular Disease,65,In_Network,J06.9,OTHER|J06.9|I10,11200,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,16,Medical_Necessity,1045.88,752.56,402.31,0.57,7.0,100.58,535.43,0.0,0.0,0,,0.0963,unusual_service_frequency,0,1,0,0,0,3.7e-05,0,0,PPC_Prenatal_Care,Shared_Savings
CLM0000002155,MBR00000047,Medical_Institutional,Paid,Electronic_EDI,2023-10-07,2023-10-07,2023-10-09,2023-10-17,Manual_Review,10,1734752728,1151295616,2086S0122X,Orthopedic Surgery,23,In_Network,OTHER,J06.9,revenue_code:0450,,0,Commercial,PPO,37,M,0.565,,,18748.73,7763.18,5985.13,237.76,44.0,1496.28,10985.55,0.0,0.0,0,,0.1205,none,0,1,1,1,0,0.000554,0,0,,Capitation
CLM0000002156,MBR00000107,Pharmacy,Denied,Electronic_EDI,2023-08-21,2023-08-21,2023-08-21,2023-09-10,Manual_Review,20,1124477249,1705448933,2084P0800X,Psychiatry,22,Out_of_Network,E11.9,M17.11,59148001506,,1,Medicare_Advantage,MA_PPO,44,M,1.0439,5,Medical_Necessity,208.99,161.37,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0684,none,0,1,0,1,0,0.0,0,0,,P4P
CLM0000002157,MBR00000206,Medical_Institutional,Denied,Electronic_EDI,2023-11-23,2023-11-23,2023-11-23,2023-12-14,Manual_Review,21,1015096289,1228356980,207Q00000X,Family Medicine,22,Out_of_Network,M54.5,Z00.00,revenue_code:0210,,0,Medicaid_MCO,MLTSS,21,M,1.4038,4,Eligibility,5447.0,3271.26,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0439,none,0,1,0,1,0,0.0,1,0,MPT_Annual_Monitoring,FFS
CLM0000002158,MBR00000013,Pharmacy,Paid,Electronic_EDI,2023-02-05,2023-02-05,2023-02-05,2023-02-20,Auto_Adjudicated,15,1321381114,1390802135,207RC0000X,Cardiovascular Disease,22,In_Network,OTHER,OTHER|E11.9|J06.9,00169751112,,1,Commercial,PPO,64,F,1.428,,,90.77,49.11,0.0,49.11,0.0,0.0,41.66,0.0,0.0,0,,0.0138,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002159,MBR00000248,Medical_Institutional,Denied,Electronic_EDI,2023-01-23,2023-01-23,2023-01-24,2023-01-31,Auto_Adjudicated,8,1732726112,1007652766,208600000X,Surgery General,11,In_Network,N40.0,J20.9|K57.30,revenue_code:0370,,0,Commercial,PPO,40,F,0.6665,4,Authorization,738.04,345.65,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1606,upcoding_pattern,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002160,MBR00000291,Medical_Professional,Paid,Electronic_EDI,2023-09-07,2023-09-07,2023-09-07,2023-09-20,Auto_Adjudicated,13,1813729693,1765164601,207R00000X,Internal Medicine,11,In_Network,J06.9,,90834,,0,Commercial,PPO,78,M,1.4773,,,410.54,147.05,14.07,115.46,14.0,3.52,263.49,0.0,0.0,0,,0.1264,none,0,1,0,0,0,1e-06,0,0,,Capitation
CLM0000002161,MBR00000183,Pharmacy,Partially_Paid,Electronic_EDI,2023-12-13,2023-12-13,2023-12-13,2023-12-23,Auto_Adjudicated,10,1832660692,1704466150,101YP2500X,Psychologist Clinical,21,In_Network,F32.9,Z00.00|Z23|E78.5,00310075090,,1,Commercial,PPO,51,M,0.8463,50,Medical_Necessity,37.2,29.86,0.0,23.43,0.0,0.0,13.77,0.0,0.0,0,,0.0231,none,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000002162,MBR00000290,Medical_Professional,Paid,Electronic_EDI,2023-07-28,2023-07-28,2023-07-28,2023-07-31,Auto_Adjudicated,3,1923332120,1170002937,208600000X,Surgery General,11,In_Network,J20.9,I10|I50.9|N18.3,27447,,0,Commercial,PPO,9,M,0.5261,,,12326.47,8039.25,6097.21,378.73,39.0,1524.3,4287.22,0.0,0.0,0,,0.0487,none,0,1,1,0,0,0.000564,0,0,MPT_Annual_Monitoring,Capitation
CLM0000002163,MBR00000131,Behavioral_Health,Paid,Electronic_EDI,2023-12-13,2023-12-13,2023-12-13,2023-12-26,Auto_Adjudicated,13,1231231881,1287935251,207RN0300X,Nephrology,11,In_Network,OTHER,,97110,,0,Commercial,EPO,15,F,0.9228,,,269.0,188.42,0.0,188.42,0.0,0.0,80.58,0.0,0.0,0,,0.0314,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002164,MBR00000132,Vision,Paid,Electronic_EDI,2023-05-24,2023-05-24,2023-05-24,2023-06-19,Auto_Adjudicated,26,1741980770,1489993356,207RE0101X,Endocrinology,11,In_Network,G47.33,Z12.11|OTHER,V2103,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,,,156.17,130.69,99.17,0.73,6.0,24.79,25.48,0.0,0.0,0,,0.1692,billing_spike_recent,0,1,0,0,0,9e-06,0,0,,Shared_Savings
CLM0000002165,MBR00000033,Dental,Paid,Provider_Portal,2023-08-31,2023-08-31,2023-08-31,2023-09-19,Auto_Adjudicated,19,1424643153,1148659045,207V00000X,Obstetrics & Gynecology,81,In_Network,J44.1,OTHER|Z00.00,D0150,,0,Medicare_Advantage,PFFS,31,F,0.821,,,778.28,357.5,248.0,42.51,5.0,62.0,420.78,0.0,0.0,0,,0.1412,none,0,1,0,0,0,2.3e-05,0,0,,FFS
CLM0000002166,MBR00000011,Dental,Paid,Electronic_EDI,2023-07-02,2023-07-02,2023-07-02,2023-07-07,Auto_Adjudicated,5,1915327071,1553094822,207R00000X,Internal Medicine,11,Emergency,OTHER,,D0150,,0,Medicare_Advantage,SNP,35,F,1.0833,,,1131.72,431.59,329.62,2.57,17.0,82.4,700.13,0.0,0.0,0,,0.0759,unusual_service_frequency,0,1,0,0,0,3.1e-05,0,0,PPC_Prenatal_Care,FFS
CLM0000002167,MBR00000076,Medical_Institutional,Paid,Electronic_EDI,2023-11-13,2023-11-13,2023-11-16,2023-12-09,Manual_Review,26,1006962798,1912895973,207RC0000X,Cardiovascular Disease,81,In_Network,M54.5,OTHER|I10|F32.9,revenue_code:0200,,0,Commercial,HMO,26,M,2.1785,,,14851.98,8797.7,6982.9,29.07,40.0,1745.73,6054.28,0.0,0.0,0,,0.0832,none,0,1,1,0,0,0.000646,0,0,,FFS
CLM0000002168,MBR00000147,Medical_Institutional,Denied,Electronic_EDI,2023-08-21,2023-08-21,2023-08-23,2023-08-28,Auto_Adjudicated,7,1364214492,1942423230,207RG0100X,Gastroenterology,22,In_Network,K21.0,,revenue_code:0200,,0,Commercial,PPO,31,F,0.7098,22,Coding_Error,20751.14,11631.65,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1069,high_oop_waiver,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002169,MBR00000156,Pharmacy,Paid,Electronic_EDI,2023-06-07,2023-06-07,2023-06-07,2023-06-26,Auto_Adjudicated,19,1532359759,1930040953,2084P0800X,Psychiatry,11,Emergency,E13.9,OTHER,00071012831,,2,Medicare_Advantage,MA_PPO,66,F,1.8933,,,49.31,18.83,0.0,13.7,5.13,0.0,30.48,0.0,0.0,0,,0.1239,billing_spike_recent,0,1,0,0,0,0.0,0,1,FUH_Follow_Up_Hospitalization,Shared_Savings
CLM0000002170,MBR00000067,Medical_Professional,Paid,Electronic_EDI,2023-03-29,2023-03-29,2023-03-29,2023-04-16,Auto_Adjudicated,18,1929402739,1884259357,101YP2500X,Psychologist Clinical,11,Emergency,Z23,E78.5|H52.4|E11.9,99231,,0,Medicaid_MCO,MCO,55,M,0.4175,,,306.89,179.88,177.88,0.0,2.0,0.0,127.01,0.0,0.0,0,,0.0342,none,0,1,0,0,0,1.6e-05,0,0,,Shared_Savings
CLM0000002171,MBR00000184,Pharmacy,Paid,Paper,2023-04-23,2023-04-23,2023-04-23,2023-05-15,Auto_Adjudicated,22,1375098560,1688513262,101YP2500X,Psychologist Clinical,11,In_Network,F41.1,OTHER|K21.0|E11.9,59148001506,,3,Medicaid_MCO,MLTSS,30,M,2.8302,,,58.49,36.3,34.3,0.0,2.0,0.0,22.19,0.0,0.0,0,,0.1119,none,0,1,0,0,0,3e-06,0,0,,Shared_Savings
CLM0000002172,MBR00000056,Medical_Professional,Paid,Electronic_EDI,2023-01-27,2023-01-27,2023-01-27,2023-02-19,Auto_Adjudicated,23,1151127621,1649705287,207R00000X,Internal Medicine,21,In_Network,I10,,71046,,0,Commercial,EPO,74,F,1.3941,,,194.45,79.41,0.0,79.41,0.0,0.0,115.04,0.0,0.0,0,,0.1146,high_volume_same_code,0,1,0,0,0,0.0,0,0,,P4P
CLM0000002173,MBR00000103,Dental,Paid,Electronic_EDI,2023-02-25,2023-02-25,2023-02-25,2023-03-06,Manual_Review,9,1124477249,1157814306,207RP1001X,Pulmonary Disease,11,In_Network,N18.3,Z00.00|N18.3,D1110,,0,Medicaid_MCO,MCO,24,M,0.4785,,,163.75,114.24,113.24,0.0,1.0,0.0,49.51,0.0,0.0,0,,0.0603,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000002174,MBR00000060,Medical_Institutional,Paid,Electronic_EDI,2023-07-02,2023-07-02,2023-07-04,2023-07-26,Auto_Adjudicated,24,1664872214,1986847322,207RN0300X,Nephrology,31,In_Network,M79.3,K57.30|F41.1,revenue_code:0120,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,15580.8,8146.6,4019.93,1446.71,0.0,2679.95,7434.2,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|geographic_mismatch|temporal_clustering|high_volume_same_code|benford_violation|service_date_weekend|billing_spike_recent|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|npi_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.000372,0,0,,Shared_Savings
CLM0000002175,MBR00000207,Pharmacy,Paid,Electronic_EDI,2023-01-12,2023-01-12,2023-01-12,2023-01-30,Manual_Review,18,1683650935,1951488764,207RN0300X,Nephrology,21,In_Network,OTHER,Z23|F33.0,00006001954,,1,Medicaid_MCO,MLTSS,11,F,1.6522,,,169.82,107.36,107.36,0.0,0.0,0.0,62.46,0.0,0.0,0,,0.1221,controlled_substance_high_volume,0,1,0,0,0,1e-05,0,0,,Shared_Savings
CLM0000002176,MBR00000158,Medical_Institutional,Paid,Electronic_EDI,2023-06-19,2023-06-19,2023-06-19,2023-06-30,Auto_Adjudicated,11,1039678579,1330485436,246ZN0300X,Neuropsychology,22,In_Network,Z00.01,Z00.00,revenue_code:0110,,0,Commercial,HMO,65,M,1.5361,,,4210.25,2814.75,2211.12,0.85,50.0,552.78,1395.5,0.0,0.0,0,,0.1872,npi_mismatch,0,1,0,1,0,0.000205,0,0,,Bundled_Payment
CLM0000002177,MBR00000215,Medical_Institutional,Paid,Electronic_EDI,2023-01-16,2023-01-16,2023-01-19,2023-01-20,Clinical_Review,4,1274357072,1355732274,207RN0300X,Nephrology,22,In_Network,OTHER,E11.9|E78.5|OTHER,revenue_code:0370,,0,ACA_Marketplace,ACA_Silver,69,M,0.8895,,,13202.99,6985.75,4055.32,1118.43,74.0,1738.0,6217.24,0.0,0.0,0,,0.1415,unbundling_pattern,0,1,0,0,0,0.000375,0,0,,P4P
CLM0000002178,MBR00000016,Vision,Paid,Provider_Portal,2023-02-28,2023-02-28,2023-02-28,2023-03-18,Auto_Adjudicated,18,1089569577,1884259357,207RN0300X,Nephrology,23,In_Network,Z00.01,K21.0|Z00.00,V2320,,0,Commercial,HDHP_HSA,20,F,0.5843,,,197.77,141.95,0.0,141.95,0.0,0.0,55.82,0.0,0.0,0,,0.1557,impossible_service_combo,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002179,MBR00000134,Medical_Institutional,Denied,Electronic_EDI,2023-09-06,2023-09-06,2023-09-06,2023-09-20,Manual_Review,14,1373899620,1040061910,207R00000X,Internal Medicine,81,In_Network,J45.20,OTHER|Z12.11,revenue_code:0360,,0,Medicare_Advantage,MA_PPO,33,M,1.115,16,Medical_Necessity,13473.67,9130.35,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2053,phantom_billing_indicator,0,2,0,0,0,0.0,0,0,COL_Colorectal_Cancer_Screening,Capitation
CLM0000002180,MBR00000293,Medical_Professional,Paid,Electronic_EDI,2023-01-11,2023-01-11,2023-01-11,2023-01-26,Auto_Adjudicated,15,1770431137,1304018750,208600000X,Surgery General,22,In_Network,J44.1,Z00.00,27447,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,15259.32,5780.18,4589.58,32.2,11.0,1147.4,9479.14,0.0,0.0,0,,0.1151,none,0,1,0,0,0,0.000425,0,0,,FFS
CLM0000002181,MBR00000014,Medical_Professional,Paid,Provider_Portal,2023-05-01,2023-05-01,2023-05-01,2023-05-22,Auto_Adjudicated,21,1804302686,1878017518,2084P0800X,Psychiatry,21,In_Network,Z23,Z23,99385,,0,Commercial,HMO,77,M,2.8513,,,308.39,128.62,0.0,128.62,0.0,0.0,179.77,0.0,0.0,1,Medically Unnecessary Services,1.0,outlier_billing_amount|geographic_mismatch|temporal_clustering|benford_violation|impossible_service_combo|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|unbundling_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,1,0,0.0,0,0,,Shared_Savings
CLM0000002182,MBR00000132,Medical_Institutional,Paid,Electronic_EDI,2023-03-10,2023-03-10,2023-03-12,2023-04-01,Auto_Adjudicated,22,1456447970,1419347445,2086S0122X,Orthopedic Surgery,81,In_Network,OTHER,,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,,,19584.55,7293.69,5814.84,1.14,24.0,1453.71,12290.86,0.0,0.0,0,,0.0246,none,0,1,1,0,0,0.000538,0,0,CCS_Cervical_Cancer_Screening,Bundled_Payment
CLM0000002183,MBR00000012,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-01-20,2023-01-20,2023-01-23,2023-01-26,Auto_Adjudicated,6,1677021292,1114756459,207RE0101X,Endocrinology,81,In_Network,F32.9,,revenue_code:0370,,0,Commercial,HMO,84,M,1.3904,16,Medical_Necessity,25526.32,20034.3,12120.44,16.28,56.0,3030.11,10303.5,0.0,0.0,0,,0.1136,none,0,1,1,0,0,0.001122,0,0,PPC_Prenatal_Care,FFS
CLM0000002184,MBR00000046,Medical_Institutional,Paid,Paper,2023-03-16,2023-03-16,2023-03-19,2023-03-25,Auto_Adjudicated,9,1167433253,1461075342,207RN0300X,Nephrology,24,In_Network,Z00.00,OTHER|J44.1|E11.65,revenue_code:0200,,0,Commercial,HMO,76,F,0.9613,,,3960.02,2077.43,1591.98,46.46,41.0,397.99,1882.59,0.0,0.0,0,,0.0192,none,0,1,0,0,0,0.000147,0,0,,Shared_Savings
CLM0000002185,MBR00000143,Medical_Professional,Paid,Electronic_EDI,2023-02-10,2023-02-10,2023-02-10,2023-03-10,Auto_Adjudicated,28,1155203600,1538261819,225100000X,Physical Therapist,24,Out_of_Network,N39.0,M17.11,74177,,0,Commercial,POS,85,M,1.6078,,,380.72,234.29,0.0,234.29,0.0,0.0,146.43,0.0,0.0,0,,0.0735,none,0,1,0,0,0,0.0,1,0,,FFS
CLM0000002186,MBR00000050,Medical_Professional,Paid,Electronic_EDI,2023-01-29,2023-01-29,2023-01-29,2023-02-16,Auto_Adjudicated,18,1495592428,1842149518,246ZN0300X,Neuropsychology,21,In_Network,N39.0,OTHER,99382,,0,Medicare_Advantage,MA_PPO,12,F,0.8486,,,223.89,137.5,107.63,2.96,0.0,26.91,86.39,85.12,19.32,0,,0.0766,phantom_billing_indicator,0,1,0,0,0,1e-05,0,0,,Shared_Savings
CLM0000002187,MBR00000159,Dental,Denied,Electronic_EDI,2023-08-27,2023-08-27,2023-08-27,2023-09-09,Auto_Adjudicated,13,1477762002,1619587398,207RN0300X,Nephrology,22,In_Network,J45.20,OTHER,D3310,,0,Commercial,PPO,70,F,1.2009,18,Authorization,706.87,414.58,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2345,unusual_service_frequency|controlled_substance_high_volume,0,2,0,0,0,0.0,0,0,,FFS
CLM0000002188,MBR00000279,Pharmacy,Paid,Electronic_EDI,2023-02-14,2023-02-14,2023-02-14,2023-03-16,Auto_Adjudicated,30,1321381114,1691162131,2084P0800X,Psychiatry,21,In_Network,J06.9,J06.9|K21.0,00085163102,,1,Medicare_Advantage,MA_PPO,81,M,1.6817,,,261.98,144.04,85.11,28.65,9.0,21.28,117.94,0.0,0.0,0,,0.1992,benford_violation,0,1,0,0,0,8e-06,0,0,LCS_Lung_Cancer_Screening,Capitation
CLM0000002189,MBR00000061,Medical_Professional,Paid,Electronic_EDI,2023-12-03,2023-12-03,2023-12-03,2023-12-24,Auto_Adjudicated,21,1218294278,1938465393,2086S0122X,Orthopedic Surgery,22,In_Network,Z00.00,E11.9,80053,,0,Commercial,PPO,66,M,2.3575,,,265.34,138.69,63.07,46.85,13.0,15.77,126.65,0.0,0.0,0,,0.0405,none,0,1,0,0,0,6e-06,0,0,,Capitation
CLM0000002190,MBR00000033,Medical_Professional,Paid,Electronic_EDI,2023-06-24,2023-06-24,2023-06-24,2023-07-20,Manual_Review,26,1263063839,1865266296,207RN0300X,Nephrology,31,Out_of_Network,J06.9,E13.9|I10,71046,,0,Medicare_Advantage,PFFS,31,F,0.821,,,917.31,439.92,322.59,31.68,5.0,80.65,477.39,0.0,0.0,0,,0.1151,none,0,1,0,1,0,3e-05,1,0,PCR_Plan_All_Cause_Readmission,Bundled_Payment
CLM0000002191,MBR00000246,Medical_Professional,Paid,Provider_Portal,2023-05-27,2023-05-27,2023-05-27,2023-06-11,Auto_Adjudicated,15,1897701389,1938465393,208600000X,Surgery General,21,Emergency,N18.3,,99214,,0,Commercial,PPO,80,F,0.7925,,,528.03,247.25,170.1,4.63,30.0,42.52,280.78,0.0,0.0,0,,0.0221,none,0,1,0,0,0,1.6e-05,0,0,FUM_Follow_Up_ED_Mental_Health,Shared_Savings
CLM0000002192,MBR00000143,Pharmacy,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-11-16,Auto_Adjudicated,5,1468401280,1791502603,2086S0122X,Orthopedic Surgery,22,In_Network,J20.9,,00071015523,,3,Commercial,POS,85,M,1.6078,,,214.02,144.03,30.26,70.21,36.0,7.56,69.99,0.0,0.0,0,,0.1411,temporal_clustering,0,1,0,0,0,3e-06,0,0,,Shared_Savings
CLM0000002193,MBR00000266,Pharmacy,Paid,Electronic_EDI,2023-10-07,2023-10-07,2023-10-07,2023-10-29,Auto_Adjudicated,22,1019263018,1148659045,246ZN0300X,Neuropsychology,24,In_Network,OTHER,,59148001506,,1,Commercial,EPO,14,M,1.075,,,96.83,67.91,0.0,67.91,0.0,0.0,28.92,0.0,0.0,0,,0.0737,none,0,1,0,0,0,0.0,0,1,,Capitation
CLM0000002194,MBR00000097,Medical_Institutional,Denied,Electronic_EDI,2023-05-31,2023-05-31,2023-06-01,2023-06-25,Auto_Adjudicated,25,1033622184,1689327034,207RN0300X,Nephrology,11,In_Network,E78.5,,revenue_code:0300,,0,Commercial,EPO,34,M,1.3765,96,Coding_Error,25745.73,12146.72,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0298,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002195,MBR00000186,Medical_Institutional,Paid,Electronic_EDI,2023-12-16,2023-12-16,2023-12-16,2024-01-03,Manual_Review,18,1046207613,1662516615,207RC0000X,Cardiovascular Disease,22,In_Network,E11.65,F32.9|OTHER,revenue_code:0110,,0,Commercial,PPO,65,M,1.6983,,,14173.82,5929.97,4546.63,196.69,50.0,1136.66,8243.85,3228.99,1016.03,0,,0.1481,phantom_billing_indicator,0,1,0,0,0,0.000421,0,0,,Bundled_Payment
CLM0000002196,MBR00000279,Dental,Denied,Electronic_EDI,2023-07-10,2023-07-10,2023-07-10,2023-07-23,Auto_Adjudicated,13,1205349488,1827839595,101YP2500X,Psychologist Clinical,24,In_Network,OTHER,F32.9|Z00.00,D7140,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,PR-1,Authorization,301.31,221.75,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0693,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002197,MBR00000054,Medical_Professional,Paid,Electronic_EDI,2023-09-12,2023-09-12,2023-09-12,2023-09-16,Manual_Review,4,1496340237,1055872102,207R00000X,Internal Medicine,11,In_Network,M54.5,Z00.00,99397,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,,,437.62,169.32,131.52,3.92,1.0,32.88,268.3,0.0,0.0,0,,0.0746,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000002198,MBR00000236,Medical_Professional,Paid,Electronic_EDI,2023-12-15,2023-12-15,2023-12-15,2023-12-23,Auto_Adjudicated,8,1211372728,1579331190,207Q00000X,Family Medicine,11,In_Network,K21.0,OTHER|C50.911,99395,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,279.45,174.89,171.89,0.0,3.0,0.0,104.56,0.0,0.0,0,,0.1329,unbundling_pattern,0,1,0,1,0,1.6e-05,0,0,,FFS
CLM0000002199,MBR00000187,Medical_Institutional,Paid,Electronic_EDI,2023-09-17,2023-09-17,2023-09-21,2023-10-15,Auto_Adjudicated,28,1051254008,1029818813,246ZN0300X,Neuropsychology,11,In_Network,OTHER,C50.911|Z12.11|M17.11,revenue_code:0370,,0,Medicaid_MCO,MCO,36,F,1.191,,,12903.83,7650.21,7643.21,0.0,7.0,0.0,5253.62,0.0,0.0,0,,0.1062,billing_spike_recent,0,1,1,0,0,0.000707,0,0,,Shared_Savings
CLM0000002200,MBR00000241,Behavioral_Health,Paid,Electronic_EDI,2023-08-01,2023-08-01,2023-08-01,2023-08-07,Auto_Adjudicated,6,1292920374,1672803287,207RN0300X,Nephrology,11,In_Network,I10,E11.65|OTHER,99202,,0,Medicare_Advantage,MA_HMO,77,M,1.2169,,,338.23,236.15,166.09,11.54,17.0,41.52,102.08,0.0,0.0,0,,0.1374,temporal_clustering,0,1,0,0,0,1.5e-05,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000002201,MBR00000054,Medical_Institutional,Paid,Electronic_EDI,2023-08-10,2023-08-10,2023-08-11,2023-08-30,Clinical_Review,20,1679629515,1489993356,246ZN0300X,Neuropsychology,22,In_Network,I25.10,M17.11|M54.5,revenue_code:0360,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,,,7644.85,5719.23,4539.27,0.14,45.0,1134.82,1925.62,0.0,0.0,0,,0.0598,high_oop_waiver,0,1,0,0,0,0.00042,0,0,,FFS
CLM0000002202,MBR00000136,Medical_Institutional,Paid,Electronic_EDI,2023-08-23,2023-08-23,2023-08-25,2023-09-12,Auto_Adjudicated,20,1864546991,1789540567,207R00000X,Internal Medicine,23,In_Network,Z12.11,N39.0,revenue_code:0450,,0,Commercial,POS,2,F,1.2611,,,4238.49,3437.51,2326.64,457.21,72.0,581.66,800.98,0.0,0.0,0,,0.0688,none,0,1,0,1,0,0.000215,0,0,,FFS
CLM0000002203,MBR00000039,Pharmacy,Paid,Electronic_EDI,2023-12-17,2023-12-17,2023-12-17,2024-01-01,Auto_Adjudicated,15,1864546991,1132693989,207RE0101X,Endocrinology,21,In_Network,Z00.00,K57.30,00071012831,,1,Medicaid_MCO,MCO,20,F,0.5358,,,233.49,113.69,113.69,0.0,0.0,0.0,119.8,0.0,0.0,0,,0.1463,none,0,1,0,0,0,1.1e-05,0,0,,Capitation
CLM0000002204,MBR00000291,Medical_Professional,Paid,Provider_Portal,2023-09-09,2023-09-09,2023-09-09,2023-10-09,Manual_Review,30,1580443769,1538261819,246ZN0300X,Neuropsychology,22,In_Network,OTHER,,99231,,0,Commercial,PPO,78,M,1.4773,,,609.84,225.17,0.0,225.17,0.0,0.0,384.67,0.0,0.0,0,,0.0845,none,0,1,0,0,0,0.0,0,0,SPD_Spirometry_Testing,Shared_Savings
CLM0000002205,MBR00000019,Medical_Institutional,Paid,Electronic_EDI,2023-04-18,2023-04-18,2023-04-19,2023-05-09,Manual_Review,21,1101385540,1622950074,207RC0000X,Cardiovascular Disease,11,In_Network,E11.9,,revenue_code:0360,,0,Commercial,PPO,77,M,0.6521,,,1549.36,983.33,643.03,144.54,35.0,160.76,566.03,0.0,0.0,0,,0.1959,provider_specialty_mismatch,0,1,0,0,0,6e-05,0,0,,Shared_Savings
CLM0000002206,MBR00000020,Medical_Institutional,Paid,Paper,2023-01-08,2023-01-08,2023-01-08,2023-02-07,Manual_Review,30,1346717076,1607833568,2086S0122X,Orthopedic Surgery,31,In_Network,OTHER,,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,63,F,0.7119,,,23218.73,12572.89,10001.1,31.52,40.0,2500.27,10645.84,0.0,0.0,0,,0.0256,none,0,1,1,0,0,0.000926,0,0,,FFS
CLM0000002207,MBR00000273,Behavioral_Health,Paid,Electronic_EDI,2023-10-09,2023-10-09,2023-10-09,2023-10-17,Auto_Adjudicated,8,1958171947,1878017518,207RG0100X,Gastroenterology,21,In_Network,Z23,Z00.00,99213,,0,ACA_Marketplace,ACA_Bronze,4,M,1.3569,,,223.86,128.06,0.0,128.06,0.0,0.0,95.8,0.0,0.0,0,,0.0668,none,0,1,0,0,0,0.0,0,0,SPD_Spirometry_Testing,Capitation
CLM0000002208,MBR00000095,Medical_Professional,Partially_Paid,Electronic_EDI,2023-06-25,2023-06-25,2023-06-25,2023-07-18,Manual_Review,23,1560886857,1040061910,2084P0800X,Psychiatry,23,Out_of_Network,I10,,99282,,0,Commercial,HMO,28,M,0.5827,96,Medical_Necessity,214.37,165.15,28.45,34.6,22.0,7.11,122.21,0.0,0.0,0,,0.0053,none,0,1,0,0,0,3e-06,1,0,MPT_Annual_Monitoring,P4P
CLM0000002209,MBR00000180,Medical_Institutional,Paid,Electronic_EDI,2023-05-30,2023-05-30,2023-06-01,2023-06-23,Manual_Review,24,1901508637,1509799493,207RC0000X,Cardiovascular Disease,11,In_Network,E11.9,F32.9,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,72,F,1.1909,,,6707.38,3558.28,2804.84,1.23,51.0,701.21,3149.1,0.0,0.0,0,,0.1099,provider_specialty_mismatch,0,1,0,0,0,0.00026,0,0,,Capitation
CLM0000002210,MBR00000090,Dental,Paid,Electronic_EDI,2023-12-02,2023-12-02,2023-12-02,2023-12-30,Manual_Review,28,1770738194,1289435414,246ZN0300X,Neuropsychology,31,In_Network,OTHER,J06.9|OTHER,D4341,,0,Medicare_Advantage,MA_HMO,49,F,0.4351,,,601.67,372.84,274.12,15.19,15.0,68.53,228.83,0.0,0.0,0,,0.1278,none,0,1,0,0,0,2.5e-05,0,0,,Shared_Savings
CLM0000002211,MBR00000192,Pharmacy,Paid,Electronic_EDI,2023-02-25,2023-02-25,2023-02-25,2023-03-10,Auto_Adjudicated,13,1929402739,1005335812,207RP1001X,Pulmonary Disease,22,In_Network,Z12.11,Z12.11,50458085930,,3,Medicaid_MCO,MCO,22,F,1.1739,,,310.09,129.56,129.56,0.0,0.0,0.0,180.53,0.0,0.0,0,,0.0726,none,0,1,0,1,0,1.2e-05,0,0,LCS_Lung_Cancer_Screening,Shared_Savings
CLM0000002212,MBR00000060,Medical_Institutional,Paid,Electronic_EDI,2023-01-14,2023-01-14,2023-01-16,2023-01-24,Auto_Adjudicated,10,1151127621,1688513262,225100000X,Physical Therapist,81,Out_of_Network,E78.5,Z79.4,revenue_code:0100,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,4718.62,3521.54,2003.0,183.2,0.0,1335.34,1197.08,0.0,0.0,0,,0.0967,none,0,1,0,1,0,0.000185,1,0,,Bundled_Payment
CLM0000002213,MBR00000142,Medical_Professional,Denied,Electronic_EDI,2023-09-23,2023-09-23,2023-09-23,2023-10-18,Auto_Adjudicated,25,1976612978,1469642907,207RG0100X,Gastroenterology,21,In_Network,E78.5,F32.9,99222,,0,ACA_Marketplace,ACA_Silver,48,M,1.3761,16,COB,326.07,193.99,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0014,none,0,1,0,0,0,0.0,0,0,DDE_Diabetes_Short_Term_Complications,Bundled_Payment
CLM0000002214,MBR00000162,Medical_Professional,Denied,Electronic_EDI,2023-11-28,2023-11-28,2023-11-28,2023-12-20,Auto_Adjudicated,22,1741980770,1694343357,207RN0300X,Nephrology,32,In_Network,I25.10,OTHER,99223,,0,Medicaid_MCO,MLTSS,84,F,1.324,2,Duplicate,556.1,285.29,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0859,none,0,1,0,0,0,0.0,0,0,CDC_BP_Control,FFS
CLM0000002215,MBR00000105,Medical_Professional,Paid,Electronic_EDI,2023-10-25,2023-10-25,2023-10-25,2023-11-03,Auto_Adjudicated,9,1170257806,1706603847,207RP1001X,Pulmonary Disease,21,In_Network,E78.5,,12001,,0,Commercial,HMO,74,M,1.1834,,,1059.09,602.17,256.43,266.63,15.0,64.11,456.92,0.0,0.0,0,,0.1875,unusual_service_frequency,0,1,0,0,0,2.4e-05,0,0,CBP_Controlling_BP,Shared_Savings
CLM0000002216,MBR00000078,Medical_Professional,Paid,Electronic_EDI,2023-11-09,2023-11-09,2023-11-09,2023-11-19,Auto_Adjudicated,10,1272115456,1691162131,207RG0100X,Gastroenterology,11,In_Network,OTHER,OTHER,99387,,0,Commercial,EPO,65,F,1.3174,,,121.61,57.15,0.0,57.15,0.0,0.0,64.46,0.0,0.0,0,,0.0448,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002217,MBR00000044,Pharmacy,Paid,Electronic_EDI,2023-11-07,2023-11-07,2023-11-07,2023-12-01,Auto_Adjudicated,24,1176378924,1123879500,208600000X,Surgery General,23,In_Network,Z00.00,,00069420020,,2,Commercial,PPO,29,M,0.7512,,,301.8,190.5,0.0,175.34,15.16,0.0,111.3,0.0,0.0,0,,0.0633,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000002218,MBR00000208,Pharmacy,Paid,Electronic_EDI,2023-09-04,2023-09-04,2023-09-04,2023-09-22,Auto_Adjudicated,18,1648123576,1489434038,225100000X,Physical Therapist,11,In_Network,I10,Z00.01,00071012831,,1,Medicare_Advantage,MA_HMO,66,M,2.1466,,,66.35,30.7,9.26,13.12,6.0,2.32,35.65,0.0,0.0,0,,0.2547,unbundling_pattern|diagnosis_procedure_mismatch,0,2,0,0,0,1e-06,0,1,,FFS
CLM0000002219,MBR00000053,Pharmacy,Paid,Electronic_EDI,2023-11-27,2023-11-27,2023-11-27,2023-12-25,Auto_Adjudicated,28,1924450526,1477113725,246ZN0300X,Neuropsychology,24,In_Network,K21.0,Z00.00,59148001506,,3,Medicaid_MCO,MLTSS,74,F,0.9277,,,214.31,113.44,113.44,0.0,0.0,0.0,100.87,0.0,0.0,0,,0.1659,benford_violation,0,1,0,0,0,1e-05,0,1,ACR_Urine_Protein,FFS
CLM0000002220,MBR00000091,Medical_Professional,Paid,Electronic_EDI,2023-05-03,2023-05-03,2023-05-03,2023-05-22,Auto_Adjudicated,19,1735391772,1764064254,207RE0101X,Endocrinology,21,In_Network,E11.9,Z87.891,43239,,0,Commercial,PPO,13,F,1.2451,,,385.14,151.48,0.0,151.48,0.0,0.0,233.66,0.0,0.0,0,,0.077,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002221,MBR00000106,Medical_Professional,Paid,Electronic_EDI,2023-09-25,2023-09-25,2023-09-25,2023-10-25,Auto_Adjudicated,30,1878057972,1055872102,225100000X,Physical Therapist,24,In_Network,OTHER,Z79.4|J20.9|K21.0,99386,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,342.42,171.25,126.73,6.84,6.0,31.68,171.17,0.0,0.0,0,,0.0682,none,0,1,0,0,0,1.2e-05,0,0,,Shared_Savings
CLM0000002222,MBR00000141,Pharmacy,Paid,Electronic_EDI,2023-02-03,2023-02-03,2023-02-03,2023-02-13,Auto_Adjudicated,10,1508520529,1706603847,207RE0101X,Endocrinology,22,In_Network,OTHER,,16590051660,,1,Commercial,HMO,47,F,0.6724,,,105.34,56.97,5.72,23.83,26.0,1.43,48.37,0.0,0.0,0,,0.078,none,0,1,0,1,0,1e-06,0,1,,Bundled_Payment
CLM0000002223,MBR00000208,Medical_Professional,Paid,Electronic_EDI,2023-07-09,2023-07-09,2023-07-09,2023-08-02,Auto_Adjudicated,24,1201027197,1312595355,207RG0100X,Gastroenterology,22,In_Network,J44.1,M25.511,27447,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,8653.05,6395.34,5091.62,24.82,6.0,1272.9,2257.71,0.0,0.0,0,,0.0662,none,0,1,1,0,0,0.000471,0,0,POD_Persistence_of_Beta_Blocker,Bundled_Payment
CLM0000002224,MBR00000135,Medical_Professional,Paid,Electronic_EDI,2023-04-15,2023-04-15,2023-04-15,2023-04-21,Auto_Adjudicated,6,1886537420,1388050552,225100000X,Physical Therapist,24,Out_of_Network,OTHER,,27447,,0,Commercial,PPO,58,F,2.2702,,,22439.16,15130.2,12072.39,2.71,37.0,3018.1,7308.96,0.0,0.0,0,,0.0144,none,0,1,1,0,0,0.001117,1,0,,Bundled_Payment
CLM0000002225,MBR00000263,Medical_Professional,Paid,Electronic_EDI,2023-12-03,2023-12-03,2023-12-03,2023-12-25,Auto_Adjudicated,22,1771383741,1061149198,208600000X,Surgery General,23,In_Network,OTHER,Z87.891|Z23|M54.5,99394,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,,,296.63,121.33,74.63,9.04,19.0,18.66,175.3,0.0,0.0,0,,0.0836,none,0,1,0,0,0,7e-06,0,0,COL_Colorectal_Cancer_Screening,Shared_Savings
CLM0000002226,MBR00000201,Medical_Professional,Paid,Electronic_EDI,2023-06-06,2023-06-06,2023-06-06,2023-06-19,Auto_Adjudicated,13,1505049857,1884259357,207RC0000X,Cardiovascular Disease,23,In_Network,I10,,99395,,0,Medicare_Advantage,MA_PPO,74,M,1.1575,,,422.25,274.88,203.91,13.99,6.0,50.98,147.37,0.0,0.0,0,,0.1439,none,0,1,0,0,0,1.9e-05,0,0,,FFS
CLM0000002227,MBR00000251,Medical_Professional,Paid,Provider_Portal,2023-03-17,2023-03-17,2023-03-17,2023-04-02,Auto_Adjudicated,16,1878057972,1576271272,101YP2500X,Psychologist Clinical,23,In_Network,Z00.00,OTHER,99395,,0,Commercial,PPO,65,M,0.7737,,,214.79,122.71,0.0,122.71,0.0,0.0,92.08,0.0,0.0,0,,0.0312,none,0,1,0,0,0,0.0,0,0,POD_Persistence_of_Beta_Blocker,Capitation
CLM0000002228,MBR00000212,Medical_Professional,Paid,Electronic_EDI,2023-07-24,2023-07-24,2023-07-24,2023-08-18,Auto_Adjudicated,25,1435110996,1764064254,207RN0300X,Nephrology,22,In_Network,Z79.4,Z23,90832,,0,Commercial,HMO,57,F,2.5456,,,225.25,125.66,0.0,125.66,0.0,0.0,99.59,0.0,0.0,0,,0.1242,unusual_service_frequency,0,1,0,1,0,0.0,0,0,,FFS
CLM0000002229,MBR00000047,Dental,Paid,Electronic_EDI,2023-01-28,2023-01-28,2023-01-28,2023-02-01,Auto_Adjudicated,4,1826043246,1318978078,208600000X,Surgery General,24,In_Network,OTHER,E11.9|OTHER|C50.911,D2140,,0,Commercial,PPO,37,M,0.565,,,525.09,211.11,0.0,211.11,0.0,0.0,313.98,0.0,0.0,0,,0.0951,none,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,Capitation
CLM0000002230,MBR00000295,Medical_Professional,Paid,Electronic_EDI,2023-02-15,2023-02-15,2023-02-15,2023-02-22,Auto_Adjudicated,7,1774425033,1312595355,101YP2500X,Psychologist Clinical,11,In_Network,OTHER,E11.65,85025,,0,Commercial,HDHP_HSA,78,F,0.8618,,,1789.7,1149.55,847.66,89.97,0.0,211.92,640.15,0.0,0.0,0,,0.1974,service_date_weekend|upcoding_pattern,0,1,0,0,0,7.8e-05,0,0,MPT_Annual_Monitoring,Shared_Savings
CLM0000002231,MBR00000233,Medical_Institutional,Paid,Electronic_EDI,2023-06-04,2023-06-04,2023-06-07,2023-06-21,Auto_Adjudicated,17,1097600151,1880530717,207R00000X,Internal Medicine,11,In_Network,F33.0,OTHER,revenue_code:0100,,0,Medicare_Advantage,MA_PPO,87,M,0.8034,,,7134.01,3119.89,2412.46,56.31,48.0,603.12,4014.12,0.0,0.0,0,,0.0741,none,0,1,0,0,0,0.000223,0,0,,FFS
CLM0000002232,MBR00000172,Medical_Institutional,Paid,Electronic_EDI,2023-08-15,2023-08-15,2023-08-18,2023-08-28,Auto_Adjudicated,13,1905691248,1170002937,2086S0122X,Orthopedic Surgery,24,Out_of_Network,Z00.01,E11.9,revenue_code:0110,,0,Medicaid_MCO,MCO,50,F,0.2787,,,18586.44,9099.71,9091.71,0.0,8.0,0.0,9486.73,0.0,0.0,0,,0.096,none,0,1,1,1,0,0.000842,1,0,COL_Colorectal_Cancer_Screening,Shared_Savings
CLM0000002233,MBR00000052,Medical_Institutional,Paid,Electronic_EDI,2023-07-29,2023-07-29,2023-08-02,2023-08-15,Auto_Adjudicated,17,1084831484,1965244699,207RC0000X,Cardiovascular Disease,22,In_Network,OTHER,E11.65|E78.5,revenue_code:0250,,0,Commercial,PPO,0,F,1.325,,,9064.53,6886.85,5244.86,254.77,76.0,1311.22,2177.68,0.0,0.0,0,,0.1347,none,0,1,1,1,0,0.000485,0,0,,Bundled_Payment
CLM0000002234,MBR00000055,Medical_Institutional,Paid,Electronic_EDI,2023-01-20,2023-01-20,2023-01-24,2023-02-02,Auto_Adjudicated,13,1035707913,1406199453,207RC0000X,Cardiovascular Disease,65,In_Network,K57.30,,revenue_code:0120,,0,Commercial,PPO,68,F,1.2896,,,68319.59,25870.99,20550.06,109.42,74.0,5137.51,42448.6,17696.38,2512.28,0,,0.1123,outlier_billing_amount,0,1,1,0,0,0.001902,0,0,,Capitation
CLM0000002235,MBR00000184,Medical_Professional,Paid,Electronic_EDI,2023-09-02,2023-09-02,2023-09-02,2023-09-04,Clinical_Review,2,1980039511,1643673796,2084P0800X,Psychiatry,81,In_Network,OTHER,,99231,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,215.26,159.25,157.25,0.0,2.0,0.0,56.01,134.6,13.93,0,,0.1432,none,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000002236,MBR00000132,Medical_Professional,Paid,Electronic_EDI,2023-01-21,2023-01-21,2023-01-21,2023-02-19,Auto_Adjudicated,29,1075661656,1356856197,207V00000X,Obstetrics & Gynecology,32,In_Network,C50.911,,99205,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,,,273.62,149.08,113.58,1.11,6.0,28.39,124.54,0.0,0.0,0,,0.1343,none,0,1,0,0,0,1.1e-05,0,0,,Capitation
CLM0000002237,MBR00000200,Medical_Institutional,Paid,Electronic_EDI,2023-10-20,2023-10-20,2023-10-22,2023-11-10,Auto_Adjudicated,21,1364746046,1356856197,207RC0000X,Cardiovascular Disease,22,In_Network,Z00.01,OTHER,revenue_code:0360,,0,Commercial,HDHP_HSA,29,M,0.8011,,,1944.61,957.29,390.57,469.08,0.0,97.64,987.32,0.0,0.0,0,,0.0776,upcoding_pattern,0,1,0,0,0,3.6e-05,0,0,,FFS
CLM0000002238,MBR00000118,Vision,Denied,Electronic_EDI,2023-01-15,2023-01-15,2023-01-15,2023-02-03,Auto_Adjudicated,19,1315569619,1912895973,2086S0122X,Orthopedic Surgery,24,In_Network,N18.3,I10,V2100,,0,Medicaid_MCO,MCO,69,M,1.2773,2,Coding_Error,614.82,370.25,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1644,temporal_clustering,0,1,0,0,0,0.0,0,0,,P4P
CLM0000002239,MBR00000158,Medical_Institutional,Denied,Paper,2023-01-10,2023-01-10,2023-01-11,2023-01-15,Auto_Adjudicated,5,1089569577,1522426351,207RN0300X,Nephrology,21,In_Network,Z23,E11.9|K21.0|I10,revenue_code:0450,292,0,Commercial,HMO,65,M,1.5361,CO-45,Medical_Necessity,7418.53,3581.99,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0732,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002240,MBR00000059,Medical_Institutional,Denied,Electronic_EDI,2023-07-05,2023-07-05,2023-07-08,2023-07-11,Auto_Adjudicated,6,1577859682,1469642907,207RC0000X,Cardiovascular Disease,11,Out_of_Network,Z23,J20.9,revenue_code:0450,,0,Medicare_Advantage,SNP,12,F,1.266,2,COB,38610.75,29789.32,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0443,none,0,1,0,0,0,0.0,0,0,AWV_Annual_Wellness_Visit,Bundled_Payment
CLM0000002241,MBR00000049,Behavioral_Health,Paid,Electronic_EDI,2023-10-15,2023-10-15,2023-10-15,2023-11-02,Auto_Adjudicated,18,1389116733,1187669363,207Q00000X,Family Medicine,24,In_Network,Z79.4,,99387,,0,Medicare_Advantage,PFFS,67,M,0.978,,,157.36,58.6,34.44,11.55,4.0,8.61,98.76,0.0,0.0,0,,0.1334,none,0,1,0,1,0,3e-06,0,0,PPC_Prenatal_Care,Capitation
CLM0000002242,MBR00000024,Pharmacy,Paid,Electronic_EDI,2023-10-02,2023-10-02,2023-10-02,2023-10-04,Auto_Adjudicated,2,1453331651,1356856197,207RN0300X,Nephrology,24,In_Network,OTHER,L70.0,00071015523,,1,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,169.01,115.83,112.83,0.0,3.0,0.0,53.18,0.0,0.0,0,,0.1087,unbundling_pattern,0,1,0,0,0,1e-05,0,1,,FFS
CLM0000002243,MBR00000244,Pharmacy,Paid,Electronic_EDI,2023-08-04,2023-08-04,2023-08-04,2023-08-19,Auto_Adjudicated,15,1377412382,1144950506,208600000X,Surgery General,11,In_Network,OTHER,Z00.00,50458085930,,2,Commercial,PPO,52,M,0.6677,,,96.34,72.53,0.0,72.53,0.0,0.0,23.81,0.0,0.0,0,,0.1219,service_date_weekend,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000002244,MBR00000168,Medical_Institutional,Denied,Electronic_EDI,2023-03-06,2023-03-06,2023-03-08,2023-04-02,Auto_Adjudicated,27,1943769986,1738617370,207RC0000X,Cardiovascular Disease,31,Out_of_Network,Z00.00,OTHER,revenue_code:0100,,0,Commercial,HMO,76,M,1.2791,97,Coding_Error,5174.45,2366.32,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0205,none,0,1,0,0,0,0.0,1,0,,FFS
CLM0000002245,MBR00000287,Dental,Paid,Provider_Portal,2023-12-09,2023-12-09,2023-12-09,2024-01-05,Auto_Adjudicated,27,1889525696,1274911960,225100000X,Physical Therapist,32,In_Network,I10,OTHER,D1110,,0,Commercial,PPO,4,M,0.7685,,,293.56,215.92,43.83,135.13,26.0,10.96,77.64,0.0,0.0,0,,0.1436,duplicate_claim_indicator,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000002246,MBR00000220,Medical_Institutional,Paid,Electronic_EDI,2023-01-08,2023-01-08,2023-01-09,2023-01-24,Auto_Adjudicated,16,1356562955,1148612764,208600000X,Surgery General,21,In_Network,J06.9,Z00.00|N18.3,revenue_code:0100,683,0,Commercial,HMO,38,M,0.7736,,,10593.8,6097.05,4702.75,163.61,55.0,1175.69,4496.75,0.0,0.0,0,,0.1491,billing_spike_recent,0,1,0,0,0,0.000435,0,0,CCS_Cervical_Cancer_Screening,Bundled_Payment
CLM0000002247,MBR00000226,Pharmacy,Paid,Electronic_EDI,2023-05-05,2023-05-05,2023-05-05,2023-05-12,Manual_Review,7,1637260822,1177602659,207R00000X,Internal Medicine,11,In_Network,E13.9,M54.5|F41.1|E11.65,00006001954,,1,Medicare_Advantage,MA_PPO,84,M,1.0796,,,134.44,113.54,82.43,0.5,10.0,20.61,20.9,0.0,0.0,0,,0.141,none,0,1,0,0,0,8e-06,0,1,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000002248,MBR00000156,Pharmacy,Paid,Provider_Portal,2023-09-28,2023-09-28,2023-09-28,2023-10-01,Auto_Adjudicated,3,1636337876,1564636990,207RN0300X,Nephrology,32,In_Network,Z79.4,,00071012831,,2,Medicare_Advantage,MA_PPO,66,F,1.8933,,,53.27,28.68,0.0,23.31,5.37,0.0,24.59,0.0,0.0,0,,0.0702,none,0,1,0,0,0,0.0,0,0,MMA_Medication_Management,FFS
CLM0000002249,MBR00000242,Medical_Institutional,Paid,Electronic_EDI,2023-08-10,2023-08-10,2023-08-10,2023-08-16,Auto_Adjudicated,6,1470105939,1148612764,207V00000X,Obstetrics & Gynecology,11,In_Network,M17.11,M79.3|L70.0,revenue_code:0110,,0,Medicaid_MCO,MLTSS,75,F,0.7104,,,15490.21,7915.2,7913.2,0.0,2.0,0.0,7575.01,0.0,0.0,0,,0.1095,none,0,1,1,0,0,0.000732,0,0,,Shared_Savings
CLM0000002250,MBR00000285,Vision,Paid,Electronic_EDI,2023-10-11,2023-10-11,2023-10-11,2023-10-20,Auto_Adjudicated,9,1898658234,1291071007,207RN0300X,Nephrology,11,Out_of_Network,K21.0,OTHER|N18.3,92012,,0,Commercial,HDHP_HSA,56,M,0.9226,,,105.26,83.84,0.0,83.84,0.0,0.0,21.42,0.0,0.0,0,,0.1237,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002251,MBR00000212,Behavioral_Health,Paid,Electronic_EDI,2023-10-03,2023-10-03,2023-10-03,2023-10-20,Auto_Adjudicated,17,1943769986,1004714954,101YP2500X,Psychologist Clinical,22,In_Network,OTHER,,97110,,0,Commercial,HMO,57,F,2.5456,,,185.8,126.31,0.0,126.31,0.0,0.0,59.49,0.0,0.0,0,,0.0973,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002252,MBR00000032,Medical_Institutional,Paid,Electronic_EDI,2023-12-04,2023-12-04,2023-12-06,2023-12-26,Manual_Review,22,1172766349,1764064254,207RP1001X,Pulmonary Disease,31,In_Network,Z00.01,Z00.01|I10,revenue_code:0210,,0,Medicaid_MCO,FFS_Medicaid,87,M,0.4839,,,2893.57,2129.48,2123.48,0.0,6.0,0.0,764.09,1618.4,390.98,0,,0.0413,none,0,1,0,0,0,0.000197,0,0,AWV_Annual_Wellness_Visit,Capitation
CLM0000002253,MBR00000194,Medical_Professional,Denied,Electronic_EDI,2023-07-05,2023-07-05,2023-07-05,2023-07-19,Auto_Adjudicated,14,1706018784,1672803287,207R00000X,Internal Medicine,24,In_Network,J44.1,,99232,,0,Commercial,PPO,77,M,0.9783,256,Medical_Necessity,439.19,245.03,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1163,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002254,MBR00000037,Pharmacy,Paid,Electronic_EDI,2023-10-22,2023-10-22,2023-10-22,2023-11-16,Auto_Adjudicated,25,1923937825,1643323506,2084P0800X,Psychiatry,23,In_Network,OTHER,N18.3,00006001954,,5,Medicaid_MCO,MLTSS,11,M,1.043,,,482.34,287.54,286.54,0.0,1.0,0.0,194.8,0.0,0.0,0,,0.1267,none,0,1,0,0,0,2.7e-05,0,0,,Bundled_Payment
CLM0000002255,MBR00000024,Medical_Professional,Paid,Electronic_EDI,2023-02-25,2023-02-25,2023-02-25,2023-03-02,Auto_Adjudicated,5,1257723293,1105733833,2084P0800X,Psychiatry,31,In_Network,E78.5,C50.911,97110,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,983.67,827.4,824.4,0.0,3.0,0.0,156.27,525.53,223.89,0,,0.1126,none,0,1,0,0,0,7.6e-05,0,0,,FFS
CLM0000002256,MBR00000206,Medical_Institutional,Paid,Electronic_EDI,2023-03-04,2023-03-04,2023-03-06,2023-03-17,Auto_Adjudicated,13,1513407277,1951488764,207RC0000X,Cardiovascular Disease,23,In_Network,E11.9,,revenue_code:0120,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,7816.9,4847.55,4842.55,0.0,5.0,0.0,2969.35,0.0,0.0,0,,0.027,none,0,1,0,0,0,0.000448,0,0,,FFS
CLM0000002257,MBR00000249,Medical_Professional,Paid,Electronic_EDI,2023-01-18,2023-01-18,2023-01-18,2023-02-06,Auto_Adjudicated,19,1012271279,1406199453,207Q00000X,Family Medicine,23,Emergency,I50.9,Z00.121,99383,,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,193.26,139.79,0.0,139.79,0.0,0.0,53.47,0.0,0.0,0,,0.0315,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002258,MBR00000051,Pharmacy,Paid,Electronic_EDI,2023-03-15,2023-03-15,2023-03-15,2023-03-17,Auto_Adjudicated,2,1986485249,1498781755,207R00000X,Internal Medicine,11,Emergency,I10,M17.11,00006001954,,4,Medicare_Advantage,MA_PPO,17,F,1.0695,,,146.94,123.39,51.05,45.57,14.0,12.76,23.55,0.0,0.0,0,,0.0129,none,0,1,0,0,0,5e-06,0,0,DDE_Diabetes_Short_Term_Complications,Shared_Savings
CLM0000002259,MBR00000023,Vision,Paid,Electronic_EDI,2023-02-09,2023-02-09,2023-02-09,2023-03-09,Clinical_Review,28,1542851144,1811797489,207RG0100X,Gastroenterology,22,In_Network,F41.1,,V2115,,0,Medicare_Advantage,MA_PPO,87,M,1.084,,,272.43,194.32,131.92,14.41,15.0,32.98,78.11,0.0,0.0,0,,0.0448,none,0,1,0,0,0,1.2e-05,0,0,SPC_Statin_Therapy,FFS
CLM0000002260,MBR00000269,Medical_Professional,Paid,Electronic_EDI,2023-10-23,2023-10-23,2023-10-23,2023-11-22,Manual_Review,30,1866366547,1564636990,207RE0101X,Endocrinology,22,In_Network,OTHER,J44.1,99284,,0,Commercial,EPO,10,F,0.718,,,894.13,632.45,424.86,70.37,31.0,106.22,261.68,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|benford_violation|impossible_service_combo|duplicate_claim_indicator|phantom_billing_indicator|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,3.9e-05,0,0,FUM_Follow_Up_ED_Mental_Health,Capitation
CLM0000002261,MBR00000041,Pharmacy,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-27,2023-07-20,Auto_Adjudicated,23,1490172833,1553094822,208600000X,Surgery General,11,Out_of_Network,Z00.00,OTHER,00071012831,,2,Commercial,PPO,42,F,0.8283,,,35.24,14.37,0.0,14.37,0.0,0.0,20.87,0.0,0.0,0,,0.0066,none,0,1,0,1,0,0.0,1,1,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000002262,MBR00000011,Dental,Paid,Electronic_EDI,2023-06-09,2023-06-09,2023-06-09,2023-07-01,Auto_Adjudicated,22,1636337876,1320546364,207RC0000X,Cardiovascular Disease,21,In_Network,OTHER,,D7140,,0,Medicare_Advantage,SNP,35,F,1.0833,,,520.72,237.38,175.24,1.32,17.0,43.81,283.34,0.0,0.0,0,,0.1663,high_oop_waiver,0,1,0,0,0,1.6e-05,0,0,AMR_Asthma_Medication_Ratio,Bundled_Payment
CLM0000002263,MBR00000212,Medical_Professional,Partially_Paid,Electronic_EDI,2023-08-18,2023-08-18,2023-08-18,2023-08-25,Auto_Adjudicated,7,1873731689,1688513262,101YP2500X,Psychologist Clinical,11,In_Network,I10,J06.9|E11.9,10060,,0,Commercial,HMO,57,F,2.5456,CO-45,Medical_Necessity,851.41,630.89,111.03,339.83,18.0,27.76,354.8,0.0,0.0,0,,0.0688,temporal_clustering,0,1,0,0,0,1e-05,0,0,,P4P
CLM0000002264,MBR00000254,Medical_Professional,Paid,Electronic_EDI,2023-05-10,2023-05-10,2023-05-10,2023-05-16,Auto_Adjudicated,6,1965682436,1554490060,101YP2500X,Psychologist Clinical,11,In_Network,F41.1,OTHER|Z00.00|J06.9,97035,,0,Commercial,PPO,22,F,0.9285,,,376.04,316.39,203.64,33.83,28.0,50.91,59.65,0.0,0.0,0,,0.0828,none,0,1,0,0,0,1.9e-05,0,0,,Shared_Savings
CLM0000002265,MBR00000158,Medical_Professional,Paid,Electronic_EDI,2023-07-24,2023-07-24,2023-07-24,2023-08-01,Auto_Adjudicated,8,1379875145,1188760037,207RG0100X,Gastroenterology,22,In_Network,I10,H52.4,71250,,0,Commercial,HMO,65,M,1.5361,,,330.21,187.19,0.0,187.19,0.0,0.0,143.02,0.0,0.0,0,,0.1488,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002266,MBR00000164,Pharmacy,Denied,Electronic_EDI,2023-01-02,2023-01-02,2023-01-02,2023-01-07,Auto_Adjudicated,5,1560886857,1694343357,207RN0300X,Nephrology,11,In_Network,C50.911,I10|Z00.00|Z79.4,00085163102,,1,ACA_Marketplace,ACA_Silver,3,F,0.7155,97,Timely_Filing,189.1,138.18,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1232,none,0,1,0,0,0,0.0,0,1,,Capitation
CLM0000002267,MBR00000106,Medical_Institutional,Paid,Electronic_EDI,2023-09-13,2023-09-13,2023-09-17,2023-09-30,Clinical_Review,17,1159268684,1728466420,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,E11.9|E78.5|Z00.00,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,14111.3,5017.31,3970.36,19.35,35.0,992.59,9093.99,0.0,0.0,0,,0.1053,high_volume_same_code,0,1,0,0,0,0.000367,0,0,,Capitation
CLM0000002268,MBR00000075,Medical_Professional,Paid,Electronic_EDI,2023-11-09,2023-11-09,2023-11-09,2023-12-08,Auto_Adjudicated,29,1252009836,1132693989,2084P0800X,Psychiatry,24,In_Network,M54.5,G43.909,71046,,0,Medicaid_MCO,MCO,5,M,1.0573,,,300.53,123.84,119.84,0.0,4.0,0.0,176.69,0.0,0.0,0,,0.071,service_date_weekend,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000002269,MBR00000221,Medical_Professional,Paid,Electronic_EDI,2023-01-14,2023-01-14,2023-01-14,2023-02-04,Clinical_Review,21,1943769986,1616762819,225100000X,Physical Therapist,24,In_Network,OTHER,OTHER|H52.4|I10,99233,,0,Commercial,HDHP_HSA,28,M,1.6683,,,288.28,112.24,30.44,74.19,0.0,7.61,176.04,0.0,0.0,0,,0.159,impossible_service_combo,0,1,0,0,0,3e-06,0,0,,Bundled_Payment
CLM0000002270,MBR00000255,Medical_Institutional,Paid,Electronic_EDI,2023-01-29,2023-01-29,2023-02-02,2023-02-25,Auto_Adjudicated,27,1878057972,1489434038,207RP1001X,Pulmonary Disease,23,In_Network,L70.0,OTHER|E11.9,revenue_code:0360,,0,Medicare_Advantage,MA_HMO,21,M,0.6945,,,14167.68,5710.19,4544.76,5.23,24.0,1136.19,8457.49,0.0,0.0,0,,0.0607,none,0,1,0,1,0,0.000421,0,0,COA_Care_Transitions,FFS
CLM0000002271,MBR00000102,Medical_Professional,Paid,Electronic_EDI,2023-02-18,2023-02-18,2023-02-18,2023-03-20,Auto_Adjudicated,30,1513407277,1986847322,207R00000X,Internal Medicine,11,In_Network,OTHER,OTHER|K21.0,90847,,0,Commercial,POS,68,M,1.6864,,,1185.13,448.99,12.56,401.29,32.0,3.14,736.14,0.0,0.0,0,,0.1251,none,0,1,0,0,0,1e-06,0,0,,Shared_Savings
CLM0000002272,MBR00000085,Medical_Institutional,Denied,Electronic_EDI,2023-08-07,2023-08-07,2023-08-08,2023-08-27,Auto_Adjudicated,20,1076251878,1747596016,207R00000X,Internal Medicine,23,In_Network,I50.9,,revenue_code:0250,,0,Medicare_Advantage,SNP,2,M,0.7823,97,COB,10858.94,3935.11,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0456,none,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000002273,MBR00000083,Medical_Professional,Paid,Electronic_EDI,2023-10-01,2023-10-01,2023-10-01,2023-10-05,Auto_Adjudicated,4,1208538971,1301869102,207RN0300X,Nephrology,23,In_Network,K57.30,Z00.00|I25.10,99396,,0,Commercial,PPO,76,M,0.6621,,,101.57,69.61,0.0,69.61,0.0,0.0,31.96,0.0,0.0,0,,0.0105,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002274,MBR00000014,Pharmacy,Paid,Electronic_EDI,2023-10-23,2023-10-23,2023-10-23,2023-11-20,Auto_Adjudicated,28,1963647323,1274911960,207RG0100X,Gastroenterology,11,In_Network,OTHER,,00069420020,,3,Commercial,HMO,77,M,2.8513,,,220.21,125.5,0.0,125.5,0.0,0.0,94.71,0.0,0.0,0,,0.0718,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002275,MBR00000088,Pharmacy,Paid,Electronic_EDI,2023-10-08,2023-10-08,2023-10-08,2023-10-25,Clinical_Review,17,1007266616,1542515060,207RG0100X,Gastroenterology,11,In_Network,G43.909,N39.0|OTHER,00169751112,,2,ACA_Marketplace,ACA_Silver,45,M,1.4166,,,46.55,28.91,0.0,28.91,0.0,0.0,17.64,0.0,0.0,0,,0.0424,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000002276,MBR00000008,Dental,Paid,Electronic_EDI,2023-07-27,2023-07-27,2023-07-27,2023-08-13,Auto_Adjudicated,17,1731980913,1321680994,207RN0300X,Nephrology,21,In_Network,OTHER,,D2391,,0,Medicaid_MCO,MCO,74,M,0.8375,,,210.18,109.37,108.37,0.0,1.0,0.0,100.81,0.0,0.0,0,,0.0122,none,0,1,0,0,0,1e-05,0,0,,Shared_Savings
CLM0000002277,MBR00000233,Medical_Professional,Denied,Electronic_EDI,2023-09-10,2023-09-10,2023-09-10,2023-10-10,Auto_Adjudicated,30,1638309014,1591405274,207RG0100X,Gastroenterology,21,In_Network,E78.5,J06.9|OTHER,99212,,0,Medicare_Advantage,MA_PPO,87,M,0.8034,170,Eligibility,142.51,78.46,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.131,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002278,MBR00000079,Medical_Institutional,Paid,Paper,2023-04-11,2023-04-11,2023-04-11,2023-05-02,Auto_Adjudicated,21,1213747973,1301833092,207RN0300X,Nephrology,11,In_Network,I10,OTHER|Z00.00,revenue_code:0370,,0,Medicaid_MCO,MLTSS,55,F,0.5016,,,18716.16,8045.52,8040.52,0.0,5.0,0.0,10670.64,0.0,0.0,0,,0.1421,none,0,1,1,0,0,0.000744,0,0,,FFS
CLM0000002279,MBR00000206,Pharmacy,Paid,Electronic_EDI,2023-09-25,2023-09-25,2023-09-25,2023-09-29,Auto_Adjudicated,4,1864546991,1688513262,207RP1001X,Pulmonary Disease,11,In_Network,M79.3,I50.9,00006001954,,2,Medicaid_MCO,MLTSS,21,M,1.4038,,,75.49,50.66,49.66,0.0,1.0,0.0,24.83,0.0,0.0,0,,0.1392,none,0,1,0,0,0,5e-06,0,0,,Shared_Savings
CLM0000002280,MBR00000165,Medical_Institutional,Paid,Electronic_EDI,2023-03-07,2023-03-07,2023-03-10,2023-03-30,Clinical_Review,23,1558692441,1811797489,207RN0300X,Nephrology,22,In_Network,E78.5,F41.1,revenue_code:0210,,0,ACA_Marketplace,ACA_Bronze,55,M,0.9775,,,29497.3,12291.37,6473.9,1501.53,0.0,4315.93,17205.93,0.0,0.0,0,,0.1354,none,0,1,1,0,0,0.000599,0,0,,Shared_Savings
CLM0000002281,MBR00000250,Medical_Professional,Paid,Electronic_EDI,2023-12-12,2023-12-12,2023-12-12,2024-01-11,Auto_Adjudicated,30,1976612978,1027261156,207R00000X,Internal Medicine,22,Emergency,K21.0,,99385,,0,Commercial,PPO,41,M,0.9245,,,156.93,124.07,0.0,122.22,1.85,0.0,32.86,0.0,0.0,0,,0.0422,none,0,1,0,0,0,0.0,0,0,DDE_Diabetes_Short_Term_Complications,Capitation
CLM0000002282,MBR00000291,Medical_Professional,Paid,Electronic_EDI,2023-01-15,2023-01-15,2023-01-15,2023-01-23,Auto_Adjudicated,8,1243052462,1112696614,246ZN0300X,Neuropsychology,22,In_Network,OTHER,,90837,,0,Commercial,PPO,78,M,1.4773,,,158.78,78.0,0.0,78.0,0.0,0.0,80.78,0.0,0.0,0,,0.0713,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002283,MBR00000116,Medical_Institutional,Paid,Electronic_EDI,2023-12-05,2023-12-05,2023-12-07,2023-12-19,Auto_Adjudicated,14,1211372728,1972530373,246ZN0300X,Neuropsychology,81,In_Network,Z79.4,E11.9|Z23|OTHER,revenue_code:0200,,0,Medicaid_MCO,MLTSS,79,F,0.4614,,,8773.89,4216.0,4208.0,0.0,8.0,0.0,4557.89,0.0,0.0,0,,0.0683,none,0,1,0,0,0,0.000389,0,0,MPT_Annual_Monitoring,FFS
CLM0000002284,MBR00000027,Medical_Institutional,Paid,Electronic_EDI,2023-06-15,2023-06-15,2023-06-15,2023-06-19,Auto_Adjudicated,4,1216417633,1706603847,207RN0300X,Nephrology,11,In_Network,OTHER,E13.9|Z79.4,revenue_code:0300,,0,Medicare_Advantage,MA_HMO,45,M,0.6886,,,3632.03,1628.94,1250.01,18.42,48.0,312.5,2003.09,990.73,200.01,0,,0.0263,none,0,1,0,0,0,0.000116,0,0,,Shared_Savings
CLM0000002285,MBR00000220,Vision,Paid,Electronic_EDI,2023-08-20,2023-08-20,2023-08-20,2023-09-11,Auto_Adjudicated,22,1190787795,1643673796,207RP1001X,Pulmonary Disease,24,In_Network,J06.9,Z00.01|I50.9,V2115,,0,Commercial,HMO,38,M,0.7736,,,540.82,218.33,40.91,132.2,35.0,10.23,322.49,0.0,0.0,0,,0.1265,high_volume_same_code|impossible_service_combo,0,1,0,0,0,4e-06,0,0,,Shared_Savings
CLM0000002286,MBR00000007,Pharmacy,Paid,Electronic_EDI,2023-02-27,2023-02-27,2023-02-27,2023-03-04,Auto_Adjudicated,5,1907932706,1765164601,207RP1001X,Pulmonary Disease,21,In_Network,E78.5,OTHER|N18.3,50458085930,,2,Commercial,HDHP_HSA,72,F,0.7578,,,104.51,49.69,0.0,49.69,0.0,0.0,54.82,0.0,0.0,0,,0.0337,none,0,1,0,0,0,0.0,0,0,AWV_Annual_Wellness_Visit,Capitation
CLM0000002287,MBR00000069,Pharmacy,Paid,Electronic_EDI,2023-04-25,2023-04-25,2023-04-25,2023-05-08,Auto_Adjudicated,13,1183801932,1040061910,207RN0300X,Nephrology,24,In_Network,E11.9,Z00.00,50458085930,,4,Medicare_Advantage,MA_PPO,2,M,0.5765,,,453.19,384.68,294.57,8.47,8.0,73.64,68.51,262.12,21.47,0,,0.1449,none,0,1,0,0,0,2.7e-05,0,0,,FFS
CLM0000002288,MBR00000014,Behavioral_Health,Paid,Electronic_EDI,2023-11-06,2023-11-06,2023-11-06,2023-11-26,Auto_Adjudicated,20,1192302048,1489434038,207V00000X,Obstetrics & Gynecology,24,In_Network,OTHER,OTHER,97035,,0,Commercial,HMO,77,M,2.8513,,,188.8,68.36,0.0,67.94,0.42,0.0,120.44,0.0,0.0,0,,0.0453,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002289,MBR00000273,Pharmacy,Paid,Electronic_EDI,2023-01-06,2023-01-06,2023-01-06,2023-02-01,Auto_Adjudicated,26,1462532026,1666461892,225100000X,Physical Therapist,22,Out_of_Network,K21.0,OTHER,00006001954,,1,ACA_Marketplace,ACA_Bronze,4,M,1.3569,,,239.34,142.77,0.0,142.77,0.0,0.0,96.57,0.0,0.0,0,,0.0678,none,0,1,0,0,0,0.0,1,1,SPD_Spirometry_Testing,FFS
CLM0000002290,MBR00000003,Medical_Professional,Paid,Electronic_EDI,2023-03-10,2023-03-10,2023-03-10,2023-03-20,Auto_Adjudicated,10,1457568950,1575884274,207RN0300X,Nephrology,23,Out_of_Network,OTHER,,99395,,0,Commercial,PPO,79,F,1.3879,,,214.89,113.29,65.91,5.9,25.0,16.48,101.6,0.0,0.0,0,,0.0668,none,0,1,0,0,0,6e-06,1,0,,Shared_Savings
CLM0000002291,MBR00000153,Medical_Professional,Paid,Electronic_EDI,2023-08-15,2023-08-15,2023-08-15,2023-09-12,Auto_Adjudicated,28,1380824221,1691162131,207V00000X,Obstetrics & Gynecology,23,In_Network,J06.9,Z00.00|N40.0,99211,,0,Commercial,POS,12,F,0.6525,,,919.07,679.32,461.67,77.23,25.0,115.42,239.75,0.0,0.0,0,,0.033,none,0,1,0,0,0,4.3e-05,0,0,,FFS
CLM0000002292,MBR00000134,Pharmacy,Paid,Electronic_EDI,2023-10-16,2023-10-16,2023-10-16,2023-10-17,Clinical_Review,1,1456447970,1649705287,207V00000X,Obstetrics & Gynecology,24,In_Network,E78.5,M54.5|N18.3,00071015523,,1,Medicare_Advantage,MA_PPO,33,M,1.115,,,71.8,47.22,0.75,33.28,13.0,0.19,24.58,0.0,0.0,0,,0.1256,none,0,1,0,1,0,0.0,0,0,CDC_HbA1c_Poor_Control,Shared_Savings
CLM0000002293,MBR00000194,Medical_Professional,Paid,Electronic_EDI,2023-06-04,2023-06-04,2023-06-04,2023-06-09,Clinical_Review,5,1966338974,1811797489,101YP2500X,Psychologist Clinical,11,Out_of_Network,OTHER,E78.5,97110,,0,Commercial,PPO,77,M,0.9783,,,76.74,28.01,0.0,28.01,0.0,0.0,48.73,0.0,0.0,0,,0.0928,phantom_billing_indicator,0,1,0,0,0,0.0,1,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000002294,MBR00000091,Vision,Denied,Electronic_EDI,2023-02-01,2023-02-01,2023-02-01,2023-02-05,Auto_Adjudicated,4,1788188920,1287935251,2086S0122X,Orthopedic Surgery,21,In_Network,F33.0,L70.0,92014,,0,Commercial,PPO,13,F,1.2451,16,Timely_Filing,318.9,124.42,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0269,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002295,MBR00000263,Medical_Professional,Paid,Electronic_EDI,2023-02-22,2023-02-22,2023-02-22,2023-03-17,Auto_Adjudicated,23,1205349488,1112696614,207R00000X,Internal Medicine,31,In_Network,N39.0,I10,83036,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,,,317.19,215.38,148.58,10.65,19.0,37.15,101.81,0.0,0.0,0,,0.1602,provider_specialty_mismatch,0,1,0,0,0,1.4e-05,0,0,,Shared_Savings
CLM0000002296,MBR00000214,Medical_Professional,Paid,Electronic_EDI,2023-11-16,2023-11-16,2023-11-16,2023-11-27,Auto_Adjudicated,11,1211612843,1887266184,246ZN0300X,Neuropsychology,22,In_Network,K21.0,OTHER|Z00.00,70553,,0,Commercial,HDHP_HSA,76,M,1.7526,,,749.93,521.24,280.24,170.94,0.0,70.06,228.69,240.23,28.74,0,,0.1883,geographic_mismatch,0,1,0,0,0,2.6e-05,0,0,,FFS
CLM0000002297,MBR00000135,Pharmacy,Denied,Electronic_EDI,2023-03-19,2023-03-19,2023-03-19,2023-03-20,Auto_Adjudicated,1,1091395764,1318978078,207Q00000X,Family Medicine,11,In_Network,F32.9,Z00.00,00069420020,,3,Commercial,PPO,58,F,2.2702,3,Timely_Filing,170.29,113.88,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0276,none,0,1,0,0,0,0.0,0,1,,P4P
CLM0000002298,MBR00000113,Pharmacy,Paid,Electronic_EDI,2023-07-27,2023-07-27,2023-07-27,2023-08-20,Auto_Adjudicated,24,1210349885,1767402068,207RE0101X,Endocrinology,81,In_Network,OTHER,,00006001954,,5,Medicaid_MCO,MLTSS,29,F,1.1621,,,117.85,79.86,78.86,0.0,1.0,0.0,37.99,0.0,0.0,0,,0.0206,none,0,1,0,0,0,7e-06,0,0,,Shared_Savings
CLM0000002299,MBR00000242,Dental,Denied,Electronic_EDI,2023-12-03,2023-12-03,2023-12-03,2023-12-12,Auto_Adjudicated,9,1205744244,1068662623,207RN0300X,Nephrology,81,In_Network,I10,I10|Z12.11,D2140,,0,Medicaid_MCO,MLTSS,75,F,0.7104,CO-45,Medical_Necessity,274.17,210.49,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1148,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,MMA_Medication_Management,FFS
CLM0000002300,MBR00000222,Medical_Professional,Paid,Electronic_EDI,2023-05-15,2023-05-15,2023-05-15,2023-06-05,Auto_Adjudicated,21,1039678579,1867626800,207Q00000X,Family Medicine,22,In_Network,Z00.00,R05.9|F41.1,90847,,0,Commercial,PPO,48,F,0.6945,,,865.62,468.58,168.23,219.29,39.0,42.06,397.04,0.0,0.0,0,,0.1208,diagnosis_procedure_mismatch,0,1,0,0,0,1.6e-05,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000002301,MBR00000127,Medical_Professional,Paid,Electronic_EDI,2023-01-24,2023-01-24,2023-01-24,2023-02-10,Auto_Adjudicated,17,1881170383,1688513262,207RE0101X,Endocrinology,22,Emergency,Z00.00,,99384,,0,Commercial,HMO,31,F,0.3336,,,233.73,119.04,0.0,119.04,0.0,0.0,114.69,0.0,0.0,0,,0.0739,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002302,MBR00000107,Medical_Institutional,Denied,Electronic_EDI,2023-10-19,2023-10-19,2023-10-22,2023-10-23,Auto_Adjudicated,4,1117755591,1930040953,207RC0000X,Cardiovascular Disease,11,In_Network,F41.1,F32.9,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,44,M,1.0439,22,Network,10458.59,7952.44,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0562,none,0,1,0,0,0,0.0,0,0,CDC_BP_Control,FFS
CLM0000002303,MBR00000012,Dental,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-10,2023-10-29,Auto_Adjudicated,19,1017424540,1588993671,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,OTHER,D3310,,0,Commercial,HMO,84,M,1.3904,,,259.63,134.16,0.0,134.16,0.0,0.0,125.47,0.0,0.0,0,,0.0774,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002304,MBR00000025,Medical_Professional,Denied,Electronic_EDI,2023-08-22,2023-08-22,2023-08-22,2023-09-17,Auto_Adjudicated,26,1008470017,1098360555,225100000X,Physical Therapist,81,In_Network,I50.9,E11.65|M17.11,99215,,0,Commercial,POS,74,M,1.3309,1,Medical_Necessity,632.06,524.24,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1325,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000002305,MBR00000014,Medical_Institutional,Paid,Electronic_EDI,2023-11-20,2023-11-20,2023-11-21,2023-12-01,Auto_Adjudicated,11,1413983739,1320546364,207RN0300X,Nephrology,11,In_Network,OTHER,Z23|OTHER|E11.9,revenue_code:0360,,0,Commercial,HMO,77,M,2.8513,,,38999.44,27701.41,22090.08,53.81,35.0,5522.52,11298.03,0.0,0.0,0,,0.1929,npi_mismatch,0,1,1,1,0,0.002045,0,0,,Capitation
CLM0000002306,MBR00000008,Medical_Professional,Denied,Electronic_EDI,2023-10-06,2023-10-06,2023-10-06,2023-11-01,Auto_Adjudicated,26,1825861601,1188760037,2084P0800X,Psychiatry,11,In_Network,N18.3,I10,99281,,0,Medicaid_MCO,MCO,74,M,0.8375,1,Timely_Filing,134.1,94.01,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.071,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002307,MBR00000049,Pharmacy,Paid,Electronic_EDI,2023-09-05,2023-09-05,2023-09-05,2023-09-14,Auto_Adjudicated,9,1338575285,1477113725,207RG0100X,Gastroenterology,65,In_Network,M17.11,F41.1,00071012831,,1,Medicare_Advantage,PFFS,67,M,0.978,,,180.37,144.96,95.13,22.05,4.0,23.78,35.41,0.0,0.0,0,,0.2936,benford_violation|impossible_service_combo|duplicate_claim_indicator,0,2,0,0,0,9e-06,0,0,,Capitation
CLM0000002308,MBR00000259,Medical_Professional,Paid,Electronic_EDI,2023-04-30,2023-04-30,2023-04-30,2023-05-09,Auto_Adjudicated,9,1793406356,1296566243,207RG0100X,Gastroenterology,21,In_Network,I25.10,K57.30|Z00.00|OTHER,99396,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,186.33,136.64,97.39,7.9,7.0,24.35,49.69,0.0,0.0,0,,0.0867,none,0,1,0,1,0,9e-06,0,0,,Bundled_Payment
CLM0000002309,MBR00000236,Behavioral_Health,Paid,Electronic_EDI,2023-01-23,2023-01-23,2023-01-23,2023-01-29,Auto_Adjudicated,6,1804302686,1938465393,101YP2500X,Psychologist Clinical,81,In_Network,OTHER,,80053,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,118.04,43.85,40.85,0.0,3.0,0.0,74.19,0.0,0.0,0,,0.0459,none,0,1,0,0,0,4e-06,0,0,,Capitation
CLM0000002310,MBR00000254,Medical_Professional,Paid,Electronic_EDI,2023-09-18,2023-09-18,2023-09-18,2023-09-25,Clinical_Review,7,1856989511,1282319940,2086S0122X,Orthopedic Surgery,21,In_Network,Z00.00,E78.5,97110,,0,Commercial,PPO,22,F,0.9285,,,69.28,40.12,0.0,24.04,16.08,0.0,29.16,0.0,0.0,0,,0.1419,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002311,MBR00000186,Pharmacy,Paid,Paper,2023-10-31,2023-10-31,2023-10-31,2023-11-08,Manual_Review,8,1006539337,1391074619,207RN0300X,Nephrology,11,In_Network,F32.9,M79.3,00071012831,,5,Commercial,PPO,65,M,1.6983,,,138.74,74.78,41.91,10.4,12.0,10.48,63.96,0.0,0.0,0,,0.1422,none,0,1,0,0,0,4e-06,0,0,KED_ESRD_Patients,FFS
CLM0000002312,MBR00000186,Pharmacy,Paid,Electronic_EDI,2023-09-07,2023-09-07,2023-09-07,2023-09-27,Auto_Adjudicated,20,1373899620,1452088018,246ZN0300X,Neuropsychology,71,In_Network,Z23,,16590051660,,2,Commercial,PPO,65,M,1.6983,,,147.53,83.01,0.0,83.01,0.0,0.0,64.52,0.0,0.0,0,,0.142,billing_spike_recent,0,1,0,0,0,0.0,0,0,FLU_Flu_Vaccination,FFS
CLM0000002313,MBR00000038,Medical_Professional,Denied,Electronic_EDI,2023-08-23,2023-08-23,2023-08-23,2023-08-27,Auto_Adjudicated,4,1344162462,1406199453,208600000X,Surgery General,11,In_Network,OTHER,I10|OTHER,85025,,0,Commercial,EPO,46,M,1.1295,96,Authorization,1679.25,824.14,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1389,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,Bundled_Payment
CLM0000002314,MBR00000207,Medical_Professional,Paid,Electronic_EDI,2023-09-15,2023-09-15,2023-09-15,2023-10-02,Auto_Adjudicated,17,1838794554,1133410177,246ZN0300X,Neuropsychology,23,In_Network,I10,,74177,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,1353.13,623.37,623.37,0.0,0.0,0.0,729.76,0.0,0.0,0,,0.1187,none,0,1,0,0,0,5.8e-05,0,0,COA_Care_Transitions,FFS
CLM0000002315,MBR00000088,Medical_Institutional,Denied,Electronic_EDI,2023-04-10,2023-04-10,2023-04-10,2023-04-18,Auto_Adjudicated,8,1611521069,1354265777,101YP2500X,Psychologist Clinical,11,In_Network,Z00.00,J06.9|I10,revenue_code:0110,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,97,Timely_Filing,18681.92,11610.21,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1116,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002316,MBR00000159,Medical_Institutional,Paid,Electronic_EDI,2023-02-11,2023-02-11,2023-02-14,2023-02-16,Auto_Adjudicated,5,1042080259,1450837722,207R00000X,Internal Medicine,24,Out_of_Network,Z79.4,Z00.00|M54.5,revenue_code:0200,,0,Commercial,PPO,70,F,1.2009,,,23313.14,16819.5,13360.6,47.75,71.0,3340.15,6493.64,0.0,0.0,0,,0.0186,none,0,1,1,0,0,0.001237,1,0,,FFS
CLM0000002317,MBR00000289,Pharmacy,Paid,Electronic_EDI,2023-08-15,2023-08-15,2023-08-15,2023-09-09,Auto_Adjudicated,25,1113370285,1575884274,207RN0300X,Nephrology,11,In_Network,F33.0,Z12.11|Z00.00,00003014960,,1,Commercial,POS,51,M,1.0534,,,355.79,157.29,78.68,19.94,39.0,19.67,198.5,0.0,0.0,0,,0.1283,none,0,1,0,0,0,7e-06,0,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000002318,MBR00000263,Medical_Institutional,Paid,Electronic_EDI,2023-12-05,2023-12-05,2023-12-08,2023-12-22,Auto_Adjudicated,17,1424416273,1706603847,207RP1001X,Pulmonary Disease,24,In_Network,M54.5,,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,,,18610.89,9082.4,7213.5,31.52,34.0,1803.38,9528.49,0.0,0.0,0,,0.1291,none,0,1,1,0,0,0.000668,0,0,,Shared_Savings
CLM0000002319,MBR00000073,Medical_Professional,Paid,Electronic_EDI,2023-02-19,2023-02-19,2023-02-19,2023-02-28,Auto_Adjudicated,9,1424104563,1325999602,246ZN0300X,Neuropsychology,81,In_Network,J20.9,J20.9,90837,,0,Commercial,POS,79,M,1.1768,,,1713.52,1169.28,819.08,112.42,33.0,204.77,544.24,0.0,0.0,0,,0.1434,none,0,1,0,0,0,7.6e-05,0,0,,Capitation
CLM0000002320,MBR00000215,Vision,Paid,Electronic_EDI,2023-01-26,2023-01-26,2023-01-26,2023-02-15,Auto_Adjudicated,20,1577859682,1144950506,207V00000X,Obstetrics & Gynecology,11,In_Network,J44.1,F32.9|F41.1|I10,V2115,,0,ACA_Marketplace,ACA_Silver,69,M,0.8895,,,148.41,101.53,0.0,101.53,0.0,0.0,46.88,0.0,0.0,0,,0.0534,none,0,1,0,0,0,0.0,0,0,CCS_Cervical_Cancer_Screening,Bundled_Payment
CLM0000002321,MBR00000032,Medical_Professional,Paid,Electronic_EDI,2023-09-12,2023-09-12,2023-09-12,2023-10-10,Manual_Review,28,1577859682,1575884274,207RE0101X,Endocrinology,21,In_Network,J06.9,Z12.11,99203,,0,Medicaid_MCO,FFS_Medicaid,87,M,0.4839,,,219.44,86.25,84.25,0.0,2.0,0.0,133.19,0.0,0.0,0,,0.1347,none,0,1,0,0,0,8e-06,0,0,,Bundled_Payment
CLM0000002322,MBR00000009,Medical_Institutional,Paid,Electronic_EDI,2023-06-01,2023-06-01,2023-06-04,2023-06-10,Auto_Adjudicated,9,1175252466,1579331190,208600000X,Surgery General,23,In_Network,Z23,,revenue_code:0300,,0,Commercial,HMO,11,F,0.5327,,,6815.09,2649.44,1780.32,382.04,42.0,445.08,4165.65,0.0,0.0,0,,0.0791,none,0,1,0,0,0,0.000165,0,0,TRC_Transition_of_Care,FFS
CLM0000002323,MBR00000010,Vision,Paid,Electronic_EDI,2023-11-21,2023-11-21,2023-11-21,2023-11-29,Auto_Adjudicated,8,1147452455,1114756459,207RG0100X,Gastroenterology,81,In_Network,I10,OTHER|J06.9,V2320,,0,Medicare_Advantage,MA_HMO,44,F,1.4631,,,212.52,127.23,60.17,48.01,4.0,15.04,85.29,0.0,0.0,0,,0.0115,none,0,1,0,0,0,6e-06,0,0,DAE_Drug_Alcohol_Dependence,FFS
CLM0000002324,MBR00000054,Dental,Paid,Provider_Portal,2023-06-19,2023-06-19,2023-06-19,2023-07-10,Auto_Adjudicated,21,1156265220,1764064254,225100000X,Physical Therapist,21,Out_of_Network,OTHER,OTHER|I10,D3310,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,,,319.56,245.53,189.87,7.19,1.0,47.47,74.03,0.0,0.0,0,,0.1132,none,0,1,0,0,0,1.8e-05,0,0,,FFS
CLM0000002325,MBR00000207,Medical_Professional,Paid,Electronic_EDI,2023-07-07,2023-07-07,2023-07-07,2023-07-22,Auto_Adjudicated,15,1099247356,1396850418,207R00000X,Internal Medicine,81,In_Network,Z12.11,I10,83036,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,2038.1,939.51,939.51,0.0,0.0,0.0,1098.59,0.0,0.0,0,,0.0585,none,0,1,0,0,0,8.7e-05,0,0,,FFS
CLM0000002326,MBR00000114,Medical_Professional,Paid,Electronic_EDI,2023-01-23,2023-01-23,2023-01-23,2023-02-13,Auto_Adjudicated,21,1257723293,1706603847,207RC0000X,Cardiovascular Disease,65,In_Network,M79.3,OTHER,11200,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,1216.48,1033.0,790.2,26.25,19.0,197.55,183.48,0.0,0.0,0,,0.0795,none,0,1,0,0,0,7.3e-05,0,0,,Capitation
CLM0000002327,MBR00000006,Medical_Institutional,Paid,Provider_Portal,2023-12-08,2023-12-08,2023-12-09,2023-12-14,Auto_Adjudicated,6,1272115456,1607833568,207RE0101X,Endocrinology,23,In_Network,Z23,R05.9,revenue_code:0250,,0,Commercial,EPO,88,M,1.4365,,,36079.26,30649.72,24459.07,14.89,61.0,6114.77,5429.54,0.0,0.0,0,,0.202,billing_spike_recent,0,2,1,0,0,0.002264,0,0,,Bundled_Payment
CLM0000002328,MBR00000297,Medical_Professional,Paid,Electronic_EDI,2023-04-29,2023-04-29,2023-04-29,2023-05-27,Auto_Adjudicated,28,1528602428,1643323506,207V00000X,Obstetrics & Gynecology,21,In_Network,I10,,99393,,0,Commercial,HMO,88,M,1.5311,,,269.3,175.45,105.86,16.12,27.0,26.47,93.85,0.0,0.0,0,,0.1366,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000002329,MBR00000162,Pharmacy,Paid,Electronic_EDI,2023-06-07,2023-06-07,2023-06-07,2023-06-08,Manual_Review,1,1374847145,1623053477,207Q00000X,Family Medicine,22,In_Network,Z87.891,G47.33,00006001954,,2,Medicaid_MCO,MLTSS,84,F,1.324,,,163.11,135.43,134.43,0.0,1.0,0.0,27.68,95.99,20.91,0,,0.149,none,0,1,0,0,0,1.2e-05,0,1,,FFS
CLM0000002330,MBR00000125,Medical_Institutional,Paid,Electronic_EDI,2023-08-14,2023-08-14,2023-08-16,2023-08-23,Auto_Adjudicated,9,1898865801,1942423230,101YP2500X,Psychologist Clinical,23,In_Network,Z23,Z23|OTHER|Z00.00,revenue_code:0300,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,20195.11,11035.2,8786.31,7.31,45.0,2196.58,9159.91,0.0,0.0,0,,0.0998,none,0,1,1,0,0,0.000813,0,0,,Shared_Savings
CLM0000002331,MBR00000159,Medical_Professional,Denied,Electronic_EDI,2023-11-04,2023-11-04,2023-11-04,2023-11-23,Auto_Adjudicated,19,1631060535,1301833092,207RG0100X,Gastroenterology,23,In_Network,I10,I10|OTHER,11200,,0,Commercial,PPO,70,F,1.2009,18,Eligibility,879.55,528.47,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2239,impossible_service_combo|diagnosis_procedure_mismatch,0,2,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002332,MBR00000159,Medical_Institutional,Denied,Electronic_EDI,2023-10-13,2023-10-13,2023-10-15,2023-10-29,Auto_Adjudicated,16,1838794554,1574982369,225100000X,Physical Therapist,11,In_Network,OTHER,Z00.00|J06.9,revenue_code:0210,,0,Commercial,PPO,70,F,1.2009,3,Network,17693.68,12414.27,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0642,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002333,MBR00000144,Pharmacy,Paid,Provider_Portal,2023-10-05,2023-10-05,2023-10-05,2023-10-16,Auto_Adjudicated,11,1963647323,1575884274,207Q00000X,Family Medicine,22,In_Network,OTHER,Z00.01,00085163102,,2,Commercial,HDHP_HSA,56,F,2.5926,,,1150.18,443.21,0.0,443.21,0.0,0.0,706.97,0.0,0.0,0,,0.0856,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000002334,MBR00000184,Pharmacy,Denied,Electronic_EDI,2023-02-07,2023-02-07,2023-02-07,2023-03-09,Manual_Review,30,1176378924,1114756459,207RN0300X,Nephrology,31,In_Network,G43.909,Z23|K21.0,50458085930,,2,Medicaid_MCO,MLTSS,30,M,2.8302,CO-45,COB,287.62,211.26,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0571,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002335,MBR00000269,Medical_Professional,Paid,Electronic_EDI,2023-02-01,2023-02-01,2023-02-01,2023-02-12,Auto_Adjudicated,11,1706018784,1209882852,208600000X,Surgery General,22,In_Network,I25.10,I10,90837,,0,Commercial,EPO,10,F,0.718,,,374.65,306.59,183.5,46.21,31.0,45.88,68.06,0.0,0.0,0,,0.1488,none,0,1,0,0,0,1.7e-05,0,0,MPT_Annual_Monitoring,FFS
CLM0000002336,MBR00000095,Medical_Professional,Paid,Electronic_EDI,2023-10-26,2023-10-26,2023-10-26,2023-11-16,Manual_Review,21,1617928396,1691162131,207RN0300X,Nephrology,22,In_Network,F33.0,Z00.01|Z23,99203,,0,Commercial,HMO,28,M,0.5827,,,196.93,125.07,66.52,19.92,22.0,16.63,71.86,0.0,0.0,0,,0.1843,service_date_weekend|upcoding_pattern,0,1,0,0,0,6e-06,0,0,,Capitation
CLM0000002337,MBR00000151,Medical_Professional,Denied,Electronic_EDI,2023-11-24,2023-11-24,2023-11-24,2023-12-07,Auto_Adjudicated,13,1102040918,1995553359,207RP1001X,Pulmonary Disease,21,In_Network,J06.9,M17.11,99384,,0,Medicare_Advantage,MA_HMO,77,M,0.8709,18,Authorization,426.55,196.01,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0409,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002338,MBR00000002,Medical_Institutional,Paid,Electronic_EDI,2023-08-12,2023-08-12,2023-08-16,2023-08-26,Manual_Review,14,1887698203,1301833092,208600000X,Surgery General,11,In_Network,E78.5,,revenue_code:0450,,0,Commercial,PPO,42,F,0.9012,,,23862.55,9905.62,7854.43,51.58,36.0,1963.61,13956.93,0.0,0.0,0,,0.1103,none,0,1,1,0,0,0.000727,0,0,IET_Initiation_Substance_Use,FFS
CLM0000002339,MBR00000259,Pharmacy,Paid,Electronic_EDI,2023-11-23,2023-11-23,2023-11-23,2023-12-17,Manual_Review,24,1064567615,1643673796,207RN0300X,Nephrology,11,In_Network,J44.1,H52.4,00169751112,,1,Medicare_Advantage,MA_PPO,5,M,1.6554,,,393.84,180.73,130.73,10.32,7.0,32.68,213.11,0.0,0.0,0,,0.0693,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000002340,MBR00000097,Dental,Paid,Electronic_EDI,2023-04-25,2023-04-25,2023-04-25,2023-05-06,Manual_Review,11,1793630905,1878017518,207RN0300X,Nephrology,21,In_Network,K29.70,,D3310,,0,Commercial,EPO,34,M,1.3765,,,478.41,215.62,0.0,215.62,0.0,0.0,262.79,0.0,0.0,0,,0.1119,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002341,MBR00000084,Vision,Paid,Electronic_EDI,2023-05-07,2023-05-07,2023-05-07,2023-05-19,Auto_Adjudicated,12,1183801932,1288028182,2084P0800X,Psychiatry,23,Emergency,F41.1,G43.909,V2103,,0,Medicare_Advantage,MA_HMO,15,F,0.8004,,,166.46,129.85,80.53,18.19,11.0,20.13,36.61,0.0,0.0,0,,0.1222,benford_violation,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000002342,MBR00000300,Medical_Institutional,Denied,Electronic_EDI,2023-03-03,2023-03-03,2023-03-03,2023-03-27,Manual_Review,24,1670125610,1049766043,207RG0100X,Gastroenterology,24,In_Network,OTHER,Z00.00|K21.0,revenue_code:0200,,0,Commercial,PPO,64,F,1.0393,22,Medical_Necessity,47842.89,20022.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2503,outlier_billing_amount|diagnosis_procedure_mismatch,0,2,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002343,MBR00000176,Dental,Paid,Electronic_EDI,2023-10-12,2023-10-12,2023-10-12,2023-10-15,Auto_Adjudicated,3,1379875145,1705448933,225100000X,Physical Therapist,11,In_Network,Z12.11,OTHER|J44.1,D1110,,0,Commercial,POS,4,M,0.8792,,,783.41,654.18,188.74,397.25,21.0,47.19,129.23,0.0,0.0,0,,0.0119,none,0,1,0,0,0,1.7e-05,0,0,,Capitation
CLM0000002344,MBR00000037,Medical_Professional,Denied,Electronic_EDI,2023-08-29,2023-08-29,2023-08-29,2023-09-11,Auto_Adjudicated,13,1159268684,1588993671,2086S0122X,Orthopedic Surgery,21,In_Network,Z12.11,,97110,,0,Medicaid_MCO,MLTSS,11,M,1.043,3,Eligibility,496.23,366.9,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0624,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002345,MBR00000081,Medical_Institutional,Paid,Electronic_EDI,2023-03-22,2023-03-22,2023-03-26,2023-03-31,Auto_Adjudicated,9,1956215244,1447186817,225100000X,Physical Therapist,24,In_Network,Z23,OTHER|E78.5,revenue_code:0210,,0,Medicare_Advantage,SNP,66,F,2.159,,,16689.07,11953.09,9516.79,13.1,44.0,2379.2,4735.98,0.0,0.0,0,,0.0045,none,0,1,1,0,0,0.000881,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000002346,MBR00000112,Medical_Institutional,Denied,Electronic_EDI,2023-12-25,2023-12-25,2023-12-26,2024-01-09,Auto_Adjudicated,15,1451464799,1452088018,207RN0300X,Nephrology,11,In_Network,Z87.891,,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,18,M,1.01,3,Network,14184.24,9342.7,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0502,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002347,MBR00000297,Pharmacy,Denied,Paper,2023-01-11,2023-01-11,2023-01-11,2023-01-29,Clinical_Review,18,1898865801,1068662623,246ZN0300X,Neuropsychology,81,In_Network,Z00.00,I10,50458085930,,2,Commercial,HMO,88,M,1.5311,256,Medical_Necessity,133.72,49.8,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2215,phantom_billing_indicator|high_oop_waiver,0,2,0,0,0,0.0,0,1,,Capitation
CLM0000002348,MBR00000135,Pharmacy,Denied,Provider_Portal,2023-10-04,2023-10-04,2023-10-04,2023-10-17,Manual_Review,13,1958981650,1809122260,207Q00000X,Family Medicine,23,In_Network,J06.9,Z00.01,00069420020,,2,Commercial,PPO,58,F,2.2702,1,Coding_Error,71.21,50.51,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1464,service_date_weekend,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002349,MBR00000073,Medical_Professional,Paid,Provider_Portal,2023-03-16,2023-03-16,2023-03-16,2023-04-15,Manual_Review,30,1006962798,1887266184,207RN0300X,Nephrology,71,In_Network,J45.20,I10,99385,,0,Commercial,POS,79,M,1.1768,,,373.17,202.0,0.0,202.0,0.0,0.0,171.17,0.0,0.0,0,,0.0657,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002350,MBR00000170,Dental,Paid,Electronic_EDI,2023-10-09,2023-10-09,2023-10-09,2023-11-06,Auto_Adjudicated,28,1950560596,1007652766,101YP2500X,Psychologist Clinical,24,In_Network,J20.9,K57.30|Z00.01,D4341,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,142.99,58.88,17.4,34.13,3.0,4.35,84.11,0.0,0.0,0,,0.0966,none,0,1,0,0,0,2e-06,0,0,,Shared_Savings
CLM0000002351,MBR00000129,Dental,Denied,Electronic_EDI,2023-06-23,2023-06-23,2023-06-23,2023-06-28,Auto_Adjudicated,5,1642333103,1579331190,207RN0300X,Nephrology,81,In_Network,M54.5,,D7140,,0,Medicare_Advantage,MA_PPO,9,F,0.8196,1,COB,244.86,187.56,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1667,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002352,MBR00000014,Vision,Denied,Provider_Portal,2023-03-26,2023-03-26,2023-03-26,2023-04-15,Auto_Adjudicated,20,1994365754,1986847322,207RG0100X,Gastroenterology,23,In_Network,R05.9,OTHER|G47.33,V2103,,0,Commercial,HMO,77,M,2.8513,5,Duplicate,658.99,340.52,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0582,none,0,1,0,0,0,0.0,0,0,COA_Care_Transitions,Shared_Savings
CLM0000002353,MBR00000259,Medical_Institutional,Paid,Electronic_EDI,2023-01-21,2023-01-21,2023-01-24,2023-01-31,Auto_Adjudicated,10,1154652946,1704466150,207R00000X,Internal Medicine,11,Out_of_Network,OTHER,OTHER|E11.65,revenue_code:0120,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,17454.82,11366.69,9063.51,1.31,36.0,2265.88,6088.13,0.0,0.0,0,,0.038,none,0,1,1,0,0,0.000839,0,0,,Capitation
CLM0000002354,MBR00000005,Behavioral_Health,Paid,Electronic_EDI,2023-08-12,2023-08-12,2023-08-12,2023-09-03,Auto_Adjudicated,22,1882720848,1847196500,246ZN0300X,Neuropsychology,24,In_Network,M17.11,E11.9|I10,99204,,0,Medicare_Advantage,MA_PPO,8,M,0.566,,,266.46,114.11,59.75,34.42,5.0,14.94,152.35,0.0,0.0,0,,0.1001,geographic_mismatch,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000002355,MBR00000273,Pharmacy,Paid,Electronic_EDI,2023-02-27,2023-02-27,2023-02-27,2023-03-14,Auto_Adjudicated,15,1642333103,1538261819,2086S0122X,Orthopedic Surgery,11,In_Network,K29.70,OTHER|Z00.00|Z00.01,00169751112,,1,ACA_Marketplace,ACA_Bronze,4,M,1.3569,,,142.21,58.87,0.0,58.87,0.0,0.0,83.34,0.0,0.0,0,,0.1398,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002356,MBR00000235,Pharmacy,Denied,Electronic_EDI,2023-06-11,2023-06-11,2023-06-11,2023-07-10,Auto_Adjudicated,29,1176378924,1330485436,208600000X,Surgery General,22,In_Network,E11.9,N18.3,00078043215,,3,Commercial,HDHP_HSA,85,F,1.4308,50,Coding_Error,51.62,29.59,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1106,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000002357,MBR00000024,Medical_Institutional,Paid,Electronic_EDI,2023-12-08,2023-12-08,2023-12-10,2024-01-06,Auto_Adjudicated,29,1375098560,1301833092,225100000X,Physical Therapist,21,Out_of_Network,F32.9,,revenue_code:0110,683,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,17422.48,6472.42,6470.42,0.0,2.0,0.0,10950.06,0.0,0.0,0,,0.1387,none,0,1,1,0,0,0.000599,0,0,PCR_Plan_All_Cause_Readmission,Bundled_Payment
CLM0000002358,MBR00000213,Pharmacy,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-11-17,Auto_Adjudicated,2,1907932706,1055872102,225100000X,Physical Therapist,24,In_Network,E78.5,Z12.11|N18.3,00006001954,,1,Commercial,PPO,17,M,1.5857,,,268.29,176.33,0.0,176.33,0.0,0.0,91.96,0.0,0.0,0,,0.1048,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002359,MBR00000227,Pharmacy,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-27,2023-07-01,Auto_Adjudicated,4,1331903993,1352413270,207RE0101X,Endocrinology,24,In_Network,OTHER,OTHER,59148001506,,1,Medicare_Advantage,MA_PPO,2,F,0.7835,,,339.78,132.31,94.51,0.18,14.0,23.63,207.47,0.0,0.0,0,,0.035,none,0,1,0,0,0,9e-06,0,1,,FFS
CLM0000002360,MBR00000182,Medical_Institutional,Denied,Electronic_EDI,2023-09-20,2023-09-20,2023-09-21,2023-09-21,Auto_Adjudicated,1,1780111559,1625992541,101YP2500X,Psychologist Clinical,31,In_Network,E11.9,Z00.01|OTHER,revenue_code:0200,,0,Commercial,HMO,82,F,0.8489,170,Medical_Necessity,8427.96,5152.55,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0655,none,0,1,0,0,0,0.0,0,0,COL_Colorectal_Cancer_Screening,Bundled_Payment
CLM0000002361,MBR00000174,Behavioral_Health,Paid,Electronic_EDI,2023-10-23,2023-10-23,2023-10-23,2023-11-16,Auto_Adjudicated,24,1288855406,1938465393,207RE0101X,Endocrinology,11,In_Network,OTHER,J44.1|Z12.11,47562,,0,Medicare_Advantage,MA_HMO,85,M,0.3901,,,179.34,95.1,44.41,21.58,18.0,11.1,84.24,0.0,0.0,0,,0.0232,none,0,1,0,0,0,4e-06,0,0,,Capitation
CLM0000002362,MBR00000014,Medical_Professional,Denied,Electronic_EDI,2023-08-06,2023-08-06,2023-08-06,2023-08-13,Auto_Adjudicated,7,1976304517,1522426351,246ZN0300X,Neuropsychology,81,In_Network,Z23,OTHER|I10,43239,,0,Commercial,HMO,77,M,2.8513,256,Duplicate,967.42,495.15,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.147,impossible_service_combo,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000002363,MBR00000017,Medical_Institutional,Paid,Electronic_EDI,2023-03-16,2023-03-16,2023-03-17,2023-04-07,Auto_Adjudicated,22,1878057972,1978943761,207RN0300X,Nephrology,24,In_Network,F41.1,Z00.01,revenue_code:0250,,0,Commercial,PPO,55,F,0.6174,,,3868.41,2841.66,2174.46,56.58,67.0,543.62,1026.75,0.0,0.0,0,,0.0662,geographic_mismatch,0,1,0,0,0,0.000201,0,0,,FFS
CLM0000002364,MBR00000213,Medical_Professional,Paid,Electronic_EDI,2023-10-19,2023-10-19,2023-10-19,2023-10-29,Manual_Review,10,1208538971,1942423230,2086S0122X,Orthopedic Surgery,21,In_Network,N39.0,OTHER,90847,,0,Commercial,PPO,17,M,1.5857,,,1148.4,674.27,308.44,260.72,28.0,77.11,474.13,0.0,0.0,0,,0.0165,none,0,1,0,0,0,2.9e-05,0,0,TRC_Transition_of_Care,P4P
CLM0000002365,MBR00000032,Medical_Institutional,Paid,Electronic_EDI,2023-02-01,2023-02-01,2023-02-02,2023-02-11,Auto_Adjudicated,10,1871348663,1977073565,207V00000X,Obstetrics & Gynecology,11,Emergency,E11.9,I25.10|F32.9|Z00.00,revenue_code:0120,,0,Medicaid_MCO,FFS_Medicaid,87,M,0.4839,,,10388.25,4641.27,4635.27,0.0,6.0,0.0,5746.98,0.0,0.0,0,,0.1936,phantom_billing_indicator|diagnosis_procedure_mismatch,0,1,0,0,0,0.000429,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000002366,MBR00000076,Medical_Professional,Paid,Electronic_EDI,2023-07-07,2023-07-07,2023-07-07,2023-07-26,Auto_Adjudicated,19,1454749898,1811797489,2084P0800X,Psychiatry,21,In_Network,E11.9,J20.9,12001,,0,Commercial,HMO,26,M,2.1785,,,797.99,433.8,287.33,42.63,32.0,71.83,364.19,0.0,0.0,0,,0.0313,none,0,1,0,0,0,2.7e-05,0,0,,Bundled_Payment
CLM0000002367,MBR00000154,Medical_Professional,Paid,Electronic_EDI,2023-10-08,2023-10-08,2023-10-08,2023-11-01,Manual_Review,24,1167433253,1289435414,208600000X,Surgery General,11,Out_of_Network,Z12.11,E78.5,81001,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,3269.4,1775.53,1413.02,9.26,0.0,353.25,1493.87,0.0,0.0,0,,0.0086,none,0,1,0,0,0,0.000131,0,0,,Bundled_Payment
CLM0000002368,MBR00000052,Medical_Professional,Paid,Electronic_EDI,2023-07-24,2023-07-24,2023-07-24,2023-08-10,Auto_Adjudicated,17,1274357072,1288028182,2086S0122X,Orthopedic Surgery,22,In_Network,J45.20,E11.9|Z12.11,97012,,0,Commercial,PPO,0,F,1.325,,,537.34,330.2,97.81,175.94,32.0,24.45,207.14,0.0,0.0,0,,0.1371,temporal_clustering|impossible_service_combo,0,1,0,0,0,9e-06,0,0,,Bundled_Payment
CLM0000002369,MBR00000234,Medical_Professional,Paid,Electronic_EDI,2023-05-06,2023-05-06,2023-05-06,2023-05-24,Auto_Adjudicated,18,1133514780,1538261819,246ZN0300X,Neuropsychology,11,In_Network,Z87.891,,99393,,0,Medicare_Advantage,MA_HMO,59,M,0.395,,,300.2,202.12,157.07,5.78,0.0,39.27,98.08,0.0,0.0,0,,0.0977,geographic_mismatch,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000002370,MBR00000239,Medical_Professional,Denied,Electronic_EDI,2023-05-30,2023-05-30,2023-05-30,2023-06-22,Manual_Review,23,1769163673,1509799493,2086S0122X,Orthopedic Surgery,21,In_Network,OTHER,Z00.00|J44.1,99213,,0,Commercial,HMO,1,F,1.1193,5,Medical_Necessity,284.23,143.01,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1247,none,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000002371,MBR00000252,Pharmacy,Paid,Paper,2023-06-15,2023-06-15,2023-06-15,2023-06-21,Clinical_Review,6,1292994726,1133410177,207V00000X,Obstetrics & Gynecology,23,In_Network,Z00.01,,59148001506,,1,Medicare_Advantage,MA_HMO,80,M,0.7173,,,36.96,18.74,0.24,3.45,15.0,0.06,18.22,0.0,0.0,0,,0.0599,none,0,1,0,0,0,0.0,0,1,CDC_BP_Control,Shared_Savings
CLM0000002372,MBR00000014,Medical_Professional,Paid,Electronic_EDI,2023-09-25,2023-09-25,2023-09-25,2023-10-13,Auto_Adjudicated,18,1520692162,1983760474,207RG0100X,Gastroenterology,22,Out_of_Network,OTHER,F33.0|M47.816|Z00.00,99395,,0,Commercial,HMO,77,M,2.8513,,,380.13,284.01,9.56,234.06,38.0,2.39,96.12,0.0,0.0,0,,0.142,none,0,1,0,1,0,1e-06,1,0,,FFS
CLM0000002373,MBR00000135,Medical_Professional,Denied,Electronic_EDI,2023-12-23,2023-12-23,2023-12-23,2024-01-01,Clinical_Review,9,1055717021,1510751265,225100000X,Physical Therapist,32,In_Network,E11.9,I10,99385,,0,Commercial,PPO,58,F,2.2702,2,COB,87.0,38.29,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0703,billing_spike_recent,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002374,MBR00000254,Medical_Professional,Paid,Provider_Portal,2023-10-07,2023-10-07,2023-10-07,2023-10-12,Manual_Review,5,1015411732,1054984734,246ZN0300X,Neuropsychology,11,In_Network,M17.11,,71250,,0,Commercial,PPO,22,F,0.9285,,,1104.56,747.94,559.65,20.38,28.0,139.91,356.62,0.0,0.0,0,,0.1022,diagnosis_procedure_mismatch,0,1,0,0,0,5.2e-05,0,0,,Shared_Savings
CLM0000002375,MBR00000114,Medical_Professional,Paid,Electronic_EDI,2023-04-24,2023-04-24,2023-04-24,2023-05-04,Auto_Adjudicated,10,1097702209,1577226132,2084P0800X,Psychiatry,22,In_Network,E11.9,OTHER|I25.10,99394,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,198.14,167.24,99.31,24.11,19.0,24.83,30.9,0.0,0.0,0,,0.0541,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000002376,MBR00000207,Medical_Professional,Paid,Electronic_EDI,2023-02-09,2023-02-09,2023-02-09,2023-02-15,Auto_Adjudicated,6,1495592428,1689327034,246ZN0300X,Neuropsychology,65,In_Network,OTHER,Z00.00|L70.0,27130,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,10735.98,7956.12,7956.12,0.0,0.0,0.0,2779.86,0.0,0.0,0,,0.1192,none,0,1,1,0,0,0.000736,0,0,,FFS
CLM0000002377,MBR00000177,Vision,Paid,Provider_Portal,2023-06-19,2023-06-19,2023-06-19,2023-06-29,Auto_Adjudicated,10,1001149267,1330485436,208600000X,Surgery General,21,In_Network,M17.11,,92002,,0,Commercial,HMO,42,F,1.2774,,,274.67,132.8,27.78,71.07,27.0,6.95,141.87,0.0,0.0,0,,0.1734,upcoding_pattern,0,1,0,0,0,3e-06,0,0,,Bundled_Payment
CLM0000002378,MBR00000110,Medical_Institutional,Denied,Electronic_EDI,2023-11-05,2023-11-05,2023-11-08,2023-11-06,Manual_Review,1,1641779816,1287935251,207R00000X,Internal Medicine,22,Out_of_Network,F32.9,,revenue_code:0300,,0,Medicare_Advantage,MA_HMO,83,F,1.127,PR-1,Authorization,3638.88,1334.9,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1449,phantom_billing_indicator,0,1,0,0,0,0.0,1,0,,FFS
CLM0000002379,MBR00000086,Medical_Professional,Paid,Electronic_EDI,2023-08-16,2023-08-16,2023-08-16,2023-09-08,Auto_Adjudicated,23,1735391772,1509799493,207R00000X,Internal Medicine,65,In_Network,M54.5,Z23,99233,,0,Medicare_Advantage,MA_PPO,8,M,0.5427,,,264.75,130.91,98.25,0.09,8.0,24.56,133.84,0.0,0.0,0,,0.0909,none,0,1,0,0,0,9e-06,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000002380,MBR00000194,Medical_Institutional,Denied,Electronic_EDI,2023-04-26,2023-04-26,2023-04-29,2023-05-07,Auto_Adjudicated,11,1325430913,1039962073,207RE0101X,Endocrinology,22,In_Network,K21.0,E78.5,revenue_code:0250,,0,Commercial,PPO,77,M,0.9783,22,Network,4475.49,1573.61,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2433,unusual_service_frequency|upcoding_pattern,0,2,0,1,0,0.0,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000002381,MBR00000041,Medical_Professional,Denied,Electronic_EDI,2023-02-01,2023-02-01,2023-02-01,2023-02-21,Auto_Adjudicated,20,1288855406,1689327034,2084P0800X,Psychiatry,31,In_Network,Z00.01,,97140,,0,Commercial,PPO,42,F,0.8283,3,Medical_Necessity,263.6,169.42,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0686,billing_spike_recent,0,1,0,0,0,0.0,0,0,CCS_Cervical_Cancer_Screening,Bundled_Payment
CLM0000002382,MBR00000259,Pharmacy,Paid,Electronic_EDI,2023-04-01,2023-04-01,2023-04-01,2023-04-24,Auto_Adjudicated,23,1433357203,1196833348,208600000X,Surgery General,71,In_Network,E13.9,Z00.121,00071015523,,2,Medicare_Advantage,MA_PPO,5,M,1.6554,,,151.14,87.57,56.14,10.4,7.0,14.03,63.57,0.0,0.0,0,,0.0204,none,0,1,0,1,0,5e-06,0,1,,FFS
CLM0000002383,MBR00000173,Vision,Paid,Electronic_EDI,2023-09-15,2023-09-15,2023-09-15,2023-10-10,Auto_Adjudicated,25,1958171947,1579331190,207RC0000X,Cardiovascular Disease,11,In_Network,E11.65,J06.9,92004,,0,Medicare_Advantage,PFFS,23,F,1.0279,,,516.23,335.84,243.96,16.89,14.0,60.99,180.39,171.95,36.18,0,,0.11,none,0,1,0,0,0,2.3e-05,0,0,,Shared_Savings
CLM0000002384,MBR00000035,Medical_Professional,Paid,Electronic_EDI,2023-08-29,2023-08-29,2023-08-29,2023-09-01,Auto_Adjudicated,3,1954226809,1825450791,207RC0000X,Cardiovascular Disease,24,In_Network,Z00.01,F32.9|OTHER,99283,,0,ACA_Marketplace,ACA_Platinum,46,M,0.6598,,,401.78,299.58,0.0,299.58,0.0,0.0,102.2,0.0,0.0,0,,0.1987,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,CBP_Controlling_BP,FFS
CLM0000002385,MBR00000208,Medical_Professional,Paid,Electronic_EDI,2023-06-12,2023-06-12,2023-06-12,2023-06-28,Manual_Review,16,1404237143,1690197969,207Q00000X,Family Medicine,23,In_Network,Z00.01,I10|E11.65,99203,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,213.34,99.37,60.98,17.15,6.0,15.24,113.97,0.0,0.0,0,,0.1839,unusual_service_frequency|npi_mismatch,0,1,0,1,0,6e-06,0,0,,Bundled_Payment
CLM0000002386,MBR00000135,Medical_Institutional,Paid,Paper,2023-04-30,2023-04-30,2023-05-03,2023-05-13,Auto_Adjudicated,13,1389116733,1623053477,225100000X,Physical Therapist,81,In_Network,M54.5,,revenue_code:0450,,0,Commercial,PPO,58,F,2.2702,,,10355.95,5551.94,4392.67,2.11,59.0,1098.17,4804.01,0.0,0.0,0,,0.039,none,0,1,0,0,0,0.000407,0,0,,FFS
CLM0000002387,MBR00000061,Medical_Professional,Paid,Electronic_EDI,2023-03-04,2023-03-04,2023-03-04,2023-03-15,Auto_Adjudicated,11,1346717076,1252125670,207RE0101X,Endocrinology,22,In_Network,F32.9,Z00.01|OTHER,43239,,0,Commercial,PPO,66,M,2.3575,,,444.47,258.05,67.5,160.67,13.0,16.88,186.42,0.0,0.0,0,,0.0604,none,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000002388,MBR00000291,Medical_Professional,Paid,Electronic_EDI,2023-12-16,2023-12-16,2023-12-16,2024-01-10,Manual_Review,25,1394029346,1365397818,207RP1001X,Pulmonary Disease,24,In_Network,E11.9,M54.5,99392,,0,Commercial,PPO,78,M,1.4773,,,154.11,113.2,71.46,9.87,14.0,17.87,40.91,0.0,0.0,0,,0.0644,none,0,1,0,0,0,7e-06,0,0,,Shared_Savings
CLM0000002389,MBR00000212,Pharmacy,Paid,Electronic_EDI,2023-06-04,2023-06-04,2023-06-04,2023-06-07,Auto_Adjudicated,3,1549436467,1767402068,2086S0122X,Orthopedic Surgery,21,In_Network,I10,OTHER,00069420020,,5,Commercial,HMO,57,F,2.5456,,,77.88,44.99,0.0,44.99,0.0,0.0,32.89,0.0,0.0,0,,0.0525,none,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000002390,MBR00000178,Medical_Institutional,Paid,Electronic_EDI,2023-10-03,2023-10-03,2023-10-06,2023-10-13,Auto_Adjudicated,10,1803277343,1542515060,2084P0800X,Psychiatry,22,In_Network,Z00.01,,revenue_code:0370,,0,Medicaid_MCO,MCO,89,M,0.7057,,,27269.17,12422.25,12422.25,0.0,0.0,0.0,14846.92,10530.16,1096.14,1,Duplicate Billing,1.0,outlier_billing_amount|provider_specialty_mismatch|temporal_clustering|impossible_service_combo|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,1,0,0,0.00115,0,0,,FFS
CLM0000002391,MBR00000255,Medical_Professional,Paid,Electronic_EDI,2023-06-15,2023-06-15,2023-06-15,2023-07-09,Clinical_Review,24,1555292468,1447657873,207RE0101X,Endocrinology,24,In_Network,M54.5,J06.9|OTHER,99391,,0,Medicare_Advantage,MA_HMO,21,M,0.6945,,,271.64,216.75,151.26,9.67,18.0,37.82,54.89,0.0,0.0,0,,0.0754,none,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000002392,MBR00000165,Pharmacy,Paid,Paper,2023-07-24,2023-07-24,2023-07-24,2023-08-05,Auto_Adjudicated,12,1078527460,1352413270,207Q00000X,Family Medicine,81,In_Network,Z79.4,OTHER|E11.9,00071015523,,1,ACA_Marketplace,ACA_Bronze,55,M,0.9775,,,79.55,30.34,0.0,30.34,0.0,0.0,49.21,0.0,0.0,0,,0.1307,unbundling_pattern,0,1,0,0,0,0.0,0,1,,FFS
CLM0000002393,MBR00000138,Medical_Professional,Paid,Electronic_EDI,2023-08-19,2023-08-19,2023-08-19,2023-08-22,Manual_Review,3,1299958874,1842149518,207R00000X,Internal Medicine,11,In_Network,K57.30,,43239,,0,Commercial,HDHP_HSA,47,M,0.996,,,1131.4,757.69,597.32,11.04,0.0,149.33,373.71,0.0,0.0,0,,0.0772,npi_mismatch,0,1,0,1,0,5.5e-05,0,0,BPD_BP_Declined,Capitation
CLM0000002394,MBR00000059,Medical_Professional,Paid,Electronic_EDI,2023-05-08,2023-05-08,2023-05-08,2023-05-14,Auto_Adjudicated,6,1899326088,1788579687,207RG0100X,Gastroenterology,11,In_Network,E78.5,,90847,,0,Medicare_Advantage,SNP,12,F,1.266,,,1016.65,511.12,373.79,27.88,16.0,93.45,505.53,0.0,0.0,0,,0.0361,none,0,1,0,1,0,3.5e-05,0,0,,Shared_Savings
CLM0000002395,MBR00000049,Pharmacy,Paid,Electronic_EDI,2023-12-03,2023-12-03,2023-12-03,2023-12-13,Auto_Adjudicated,10,1490172833,1689327034,208600000X,Surgery General,81,Emergency,K21.0,M79.3,00085163102,,2,Medicare_Advantage,PFFS,67,M,0.978,,,625.32,371.36,277.67,20.27,4.0,69.42,253.96,0.0,0.0,0,,0.0988,none,0,1,0,0,0,2.6e-05,0,0,,Shared_Savings
CLM0000002396,MBR00000135,Medical_Institutional,Paid,Electronic_EDI,2023-06-14,2023-06-14,2023-06-14,2023-06-22,Auto_Adjudicated,8,1893886964,1175334579,101YP2500X,Psychologist Clinical,22,Out_of_Network,Z79.4,E11.9|Z00.00|M54.5,revenue_code:0250,,0,Commercial,PPO,58,F,2.2702,,,40868.21,34059.61,27199.0,1.86,59.0,6799.75,6808.6,0.0,0.0,0,,0.1417,unbundling_pattern|phantom_billing_indicator,0,1,1,0,0,0.002518,1,0,,FFS
CLM0000002397,MBR00000142,Medical_Institutional,Paid,Paper,2023-10-02,2023-10-02,2023-10-03,2023-10-23,Auto_Adjudicated,21,1231231881,1188760037,207RC0000X,Cardiovascular Disease,11,In_Network,J06.9,C50.911|I10,revenue_code:0250,,0,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,5235.33,3387.48,2284.27,43.23,81.0,978.97,1847.85,0.0,0.0,0,,0.1984,high_oop_waiver,0,1,0,0,0,0.000211,0,0,,FFS
CLM0000002398,MBR00000214,Pharmacy,Paid,Electronic_EDI,2023-11-25,2023-11-25,2023-11-25,2023-12-01,Auto_Adjudicated,6,1513278494,1880530717,225100000X,Physical Therapist,22,In_Network,OTHER,,00169751112,,3,Commercial,HDHP_HSA,76,M,1.7526,,,90.47,62.09,0.0,62.09,0.0,0.0,28.38,0.0,0.0,0,,0.1276,none,0,1,0,0,0,0.0,0,1,,P4P
CLM0000002399,MBR00000138,Medical_Institutional,Paid,Electronic_EDI,2023-05-18,2023-05-18,2023-05-19,2023-06-10,Manual_Review,23,1490172833,1978943761,207R00000X,Internal Medicine,65,In_Network,M47.816,Z79.4|OTHER,revenue_code:0370,,0,Commercial,HDHP_HSA,47,M,0.996,,,16463.36,11126.26,8648.85,315.19,0.0,2162.21,5337.1,0.0,0.0,0,,0.1278,service_date_weekend,0,1,1,0,0,0.000801,0,0,ACR_Urine_Protein,FFS
CLM0000002400,MBR00000179,Dental,Paid,Electronic_EDI,2023-03-26,2023-03-26,2023-03-26,2023-04-05,Auto_Adjudicated,10,1175252466,1197700958,207RG0100X,Gastroenterology,81,In_Network,I25.10,M54.5,D3310,,0,Medicare_Advantage,SNP,82,F,0.5266,,,205.64,145.87,99.16,4.92,17.0,24.79,59.77,0.0,0.0,0,,0.1141,none,0,1,0,0,0,9e-06,0,0,,Shared_Savings
CLM0000002401,MBR00000249,Medical_Institutional,Paid,Electronic_EDI,2023-12-15,2023-12-15,2023-12-16,2023-12-18,Auto_Adjudicated,3,1114266188,1513198866,101YP2500X,Psychologist Clinical,21,In_Network,F41.1,Z00.01,revenue_code:0370,292,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,14829.58,8482.68,5668.73,296.5,88.0,2429.45,6346.9,0.0,0.0,0,,0.1314,unbundling_pattern,0,1,1,0,0,0.000525,0,0,,FFS
CLM0000002402,MBR00000298,Medical_Institutional,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-11,2023-10-11,Auto_Adjudicated,1,1501282310,1489993356,207RC0000X,Cardiovascular Disease,24,In_Network,F41.1,,revenue_code:0120,,0,Medicaid_MCO,MCO,75,M,0.8324,,,8787.34,3151.11,3151.11,0.0,0.0,0.0,5636.23,0.0,0.0,0,,0.194,diagnosis_procedure_mismatch,0,1,0,0,0,0.000292,0,0,W30_Well_Child_Visit,FFS
CLM0000002403,MBR00000102,Pharmacy,Paid,Electronic_EDI,2023-10-11,2023-10-11,2023-10-11,2023-10-30,Auto_Adjudicated,19,1905691248,1896197144,2086S0122X,Orthopedic Surgery,22,In_Network,E78.5,,00003014960,,1,Commercial,POS,68,M,1.6864,,,374.75,297.89,0.0,297.89,0.0,0.0,76.86,0.0,0.0,0,,0.0271,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002404,MBR00000273,Medical_Professional,Denied,Electronic_EDI,2023-12-06,2023-12-06,2023-12-06,2023-12-29,Auto_Adjudicated,23,1832660692,1390802135,225100000X,Physical Therapist,21,In_Network,Z00.00,J44.1,99214,,0,ACA_Marketplace,ACA_Bronze,4,M,1.3569,3,Medical_Necessity,449.18,283.3,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1839,benford_violation,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002405,MBR00000239,Pharmacy,Denied,Electronic_EDI,2023-01-11,2023-01-11,2023-01-11,2023-01-16,Manual_Review,5,1111846258,1489434038,246ZN0300X,Neuropsychology,24,In_Network,OTHER,I10|Z00.00,00069420020,,4,Commercial,HMO,1,F,1.1193,2,Medical_Necessity,140.87,113.63,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1005,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000002406,MBR00000021,Medical_Professional,Paid,Electronic_EDI,2023-12-06,2023-12-06,2023-12-06,2023-12-16,Auto_Adjudicated,10,1670125610,1804282800,207RE0101X,Endocrinology,11,In_Network,OTHER,I10|E78.5,99205,,0,Commercial,POS,72,M,0.6126,,,112.18,80.57,0.0,80.57,0.0,0.0,31.61,0.0,0.0,0,,0.0612,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002407,MBR00000105,Medical_Institutional,Paid,Electronic_EDI,2023-02-11,2023-02-11,2023-02-11,2023-03-06,Auto_Adjudicated,23,1054449469,1197700958,207RC0000X,Cardiovascular Disease,21,In_Network,OTHER,K57.30|M54.5|OTHER,revenue_code:0300,439,0,Commercial,HMO,74,M,1.1834,,,29791.96,21646.59,16893.03,480.3,50.0,4223.26,8145.37,0.0,0.0,0,,0.1085,none,0,1,1,0,0,0.001564,0,0,,Shared_Savings
CLM0000002408,MBR00000068,Pharmacy,Paid,Electronic_EDI,2023-02-22,2023-02-22,2023-02-22,2023-03-21,Auto_Adjudicated,27,1887363539,1196833348,2084P0800X,Psychiatry,11,In_Network,Z23,J45.20,00071012831,,4,Medicare_Advantage,MA_HMO,28,F,0.8494,,,110.4,74.66,50.14,3.98,8.0,12.54,35.74,0.0,0.0,0,,0.09,none,0,1,0,0,0,5e-06,0,0,,Capitation
CLM0000002409,MBR00000197,Medical_Institutional,Denied,Paper,2023-03-20,2023-03-20,2023-03-24,2023-04-11,Auto_Adjudicated,22,1901508637,1175334579,208600000X,Surgery General,11,In_Network,OTHER,OTHER,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,59,M,1.1414,1,Authorization,11749.1,9761.26,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1275,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000002410,MBR00000168,Medical_Professional,Paid,Provider_Portal,2023-02-10,2023-02-10,2023-02-10,2023-03-01,Auto_Adjudicated,19,1963647323,1930040953,207RN0300X,Nephrology,21,In_Network,Z87.891,G47.33,99215,,0,Commercial,HMO,76,M,1.2791,,,261.5,195.38,0.0,195.38,0.0,0.0,66.12,0.0,0.0,0,,0.0753,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002411,MBR00000154,Medical_Institutional,Denied,Electronic_EDI,2023-01-30,2023-01-30,2023-01-30,2023-02-22,Auto_Adjudicated,23,1542851144,1978943761,207R00000X,Internal Medicine,81,In_Network,Z23,Z00.00,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,3,Eligibility,16955.9,9626.5,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0575,none,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000002412,MBR00000224,Pharmacy,Paid,Electronic_EDI,2023-02-14,2023-02-14,2023-02-14,2023-02-23,Manual_Review,9,1394029346,1296566243,2086S0122X,Orthopedic Surgery,21,In_Network,OTHER,,59148001506,,1,Medicaid_MCO,MCO,86,F,1.3289,,,109.4,53.25,50.25,0.0,3.0,0.0,56.15,0.0,0.0,0,,0.1252,none,0,1,0,0,0,5e-06,0,0,,Bundled_Payment
CLM0000002413,MBR00000105,Behavioral_Health,Paid,Electronic_EDI,2023-06-24,2023-06-24,2023-06-24,2023-06-26,Manual_Review,2,1055717021,1320546364,208600000X,Surgery General,23,In_Network,OTHER,I10|E78.5,99282,,0,Commercial,HMO,74,M,1.1834,,,167.48,91.72,0.0,91.72,0.0,0.0,75.76,0.0,0.0,1,Kickback Arrangement,1.0,geographic_mismatch|temporal_clustering|high_volume_same_code|benford_violation|service_date_weekend|upcoding_pattern|unbundling_pattern|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002414,MBR00000121,Medical_Institutional,Denied,Electronic_EDI,2023-05-14,2023-05-14,2023-05-16,2023-05-31,Auto_Adjudicated,17,1519595029,1013600387,207RN0300X,Nephrology,11,Emergency,N39.0,,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,58,M,1.226,16,Network,25248.15,11131.68,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0635,high_volume_same_code,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002415,MBR00000262,Medical_Professional,Paid,Electronic_EDI,2023-05-03,2023-05-03,2023-05-03,2023-05-20,Auto_Adjudicated,17,1331264469,1148612764,246ZN0300X,Neuropsychology,32,In_Network,OTHER,Z87.891|M79.3|E11.9,99385,,0,Medicare_Advantage,PFFS,77,F,1.7452,,,263.27,123.5,94.89,0.89,4.0,23.72,139.77,0.0,0.0,0,,0.0312,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000002416,MBR00000293,Medical_Professional,Paid,Electronic_EDI,2023-03-03,2023-03-03,2023-03-03,2023-03-28,Auto_Adjudicated,25,1133514780,1197700958,207RN0300X,Nephrology,22,In_Network,OTHER,M47.816|E78.5,99282,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,262.87,113.35,78.34,4.42,11.0,19.59,149.52,0.0,0.0,0,,0.0312,none,0,1,0,1,0,7e-06,0,0,,Shared_Savings
CLM0000002417,MBR00000229,Medical_Institutional,Denied,Electronic_EDI,2023-12-16,2023-12-16,2023-12-18,2023-12-24,Manual_Review,8,1710668368,1447657873,225100000X,Physical Therapist,71,In_Network,N18.3,,revenue_code:0120,,0,Medicare_Advantage,PFFS,63,M,1.1626,CO-45,Timely_Filing,4124.89,1561.36,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0956,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002418,MBR00000066,Medical_Professional,Paid,Electronic_EDI,2023-04-30,2023-04-30,2023-04-30,2023-05-27,Auto_Adjudicated,27,1918359820,1469881892,207Q00000X,Family Medicine,21,Out_of_Network,Z23,,11200,,0,Medicaid_MCO,MCO,54,M,0.6083,,,931.52,509.11,506.11,0.0,3.0,0.0,422.41,0.0,0.0,0,,0.0521,none,0,1,0,0,0,4.7e-05,1,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000002419,MBR00000035,Dental,Paid,Electronic_EDI,2023-06-19,2023-06-19,2023-06-19,2023-07-04,Auto_Adjudicated,15,1263063839,1175334579,2086S0122X,Orthopedic Surgery,22,In_Network,I10,I50.9|M54.5,D4341,,0,ACA_Marketplace,ACA_Platinum,46,M,0.6598,,,497.58,363.06,167.72,117.41,36.0,41.93,134.52,0.0,0.0,0,,0.0495,none,0,1,0,1,0,1.6e-05,0,0,,Capitation
CLM0000002420,MBR00000064,Medical_Institutional,Paid,Electronic_EDI,2023-02-21,2023-02-21,2023-02-24,2023-03-07,Auto_Adjudicated,14,1906448800,1986847322,101YP2500X,Psychologist Clinical,11,In_Network,OTHER,E11.9,revenue_code:0450,,0,Medicare_Advantage,SNP,73,M,1.0644,,,10895.81,4190.8,3309.17,1.34,53.0,827.29,6705.01,0.0,0.0,0,,0.0192,none,0,1,0,0,0,0.000306,0,0,,FFS
CLM0000002421,MBR00000134,Medical_Institutional,Paid,Electronic_EDI,2023-03-18,2023-03-18,2023-03-22,2023-04-17,Auto_Adjudicated,30,1710617771,1867389043,207RN0300X,Nephrology,11,In_Network,Z00.00,F41.1,revenue_code:0370,,0,Medicare_Advantage,MA_PPO,33,M,1.115,,,4992.75,3349.64,2628.05,42.58,22.0,657.01,1643.11,0.0,0.0,0,,0.1965,high_oop_waiver,0,1,0,0,0,0.000243,0,0,,P4P
CLM0000002422,MBR00000075,Medical_Professional,Paid,Electronic_EDI,2023-03-26,2023-03-26,2023-03-26,2023-04-12,Auto_Adjudicated,17,1580443769,1643323506,207RP1001X,Pulmonary Disease,22,In_Network,I10,,99396,,0,Medicaid_MCO,MCO,5,M,1.0573,,,291.69,244.99,240.99,0.0,4.0,0.0,46.7,0.0,0.0,0,,0.0001,none,0,1,0,0,0,2.2e-05,0,0,,Capitation
CLM0000002423,MBR00000273,Medical_Professional,Paid,Electronic_EDI,2023-12-15,2023-12-15,2023-12-15,2023-12-18,Auto_Adjudicated,3,1584745499,1321680994,207RN0300X,Nephrology,24,In_Network,Z12.11,OTHER|M79.3,99283,,0,ACA_Marketplace,ACA_Bronze,4,M,1.3569,,,304.21,175.58,0.0,175.58,0.0,0.0,128.63,0.0,0.0,0,,0.0228,none,0,1,0,0,0,0.0,0,0,MMA_Medication_Management,Capitation
CLM0000002424,MBR00000199,Medical_Institutional,Paid,Electronic_EDI,2023-03-05,2023-03-05,2023-03-08,2023-03-13,Auto_Adjudicated,8,1637260822,1252125670,2084P0800X,Psychiatry,11,In_Network,Z12.11,J06.9,revenue_code:0370,,0,Medicaid_MCO,MLTSS,17,F,1.0776,,,11565.5,5647.76,5647.76,0.0,0.0,0.0,5917.74,0.0,0.0,0,,0.1499,none,0,1,1,1,0,0.000523,0,0,,Shared_Savings
CLM0000002425,MBR00000132,Medical_Institutional,Paid,Electronic_EDI,2023-07-04,2023-07-04,2023-07-07,2023-07-22,Auto_Adjudicated,18,1396168768,1912895973,207RP1001X,Pulmonary Disease,23,In_Network,E78.5,M17.11,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,,,4527.15,2992.9,2374.88,0.3,24.0,593.72,1534.25,0.0,0.0,0,,0.1386,none,0,1,0,0,0,0.00022,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000002426,MBR00000085,Medical_Professional,Paid,Electronic_EDI,2023-07-15,2023-07-15,2023-07-15,2023-07-22,Auto_Adjudicated,7,1850379080,1878017518,207RP1001X,Pulmonary Disease,23,In_Network,Z00.00,K21.0|Z00.00|I50.9,99222,,0,Medicare_Advantage,SNP,2,M,0.7823,,,317.86,219.92,143.19,25.94,15.0,35.8,97.94,0.0,0.0,0,,0.0828,none,0,1,0,0,0,1.3e-05,0,0,,Bundled_Payment
CLM0000002427,MBR00000121,Pharmacy,Paid,Electronic_EDI,2023-01-27,2023-01-27,2023-01-27,2023-02-01,Manual_Review,5,1932483309,1330485436,2086S0122X,Orthopedic Surgery,22,In_Network,OTHER,E11.9|N39.0,00071012831,,1,Medicare_Advantage,MA_PPO,58,M,1.226,,,205.02,101.82,52.07,18.73,18.0,13.02,103.2,0.0,0.0,0,,0.164,service_date_weekend,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000002428,MBR00000146,Medical_Institutional,Paid,Electronic_EDI,2023-05-06,2023-05-06,2023-05-07,2023-05-15,Auto_Adjudicated,9,1091395764,1489993356,2084P0800X,Psychiatry,24,In_Network,M17.11,Z00.00|OTHER,revenue_code:0370,,0,Medicaid_MCO,MCO,24,M,0.6484,,,17492.84,9612.83,9603.83,0.0,9.0,0.0,7880.01,0.0,0.0,0,,0.1106,none,0,1,1,0,0,0.000889,0,0,,Bundled_Payment
CLM0000002429,MBR00000211,Medical_Institutional,Paid,Electronic_EDI,2023-01-30,2023-01-30,2023-02-03,2023-02-15,Manual_Review,16,1064567615,1577226132,2086S0122X,Orthopedic Surgery,22,In_Network,OTHER,Z00.00|M54.5,revenue_code:0200,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,,,10614.92,8701.26,6937.77,0.05,29.0,1734.44,1913.66,0.0,0.0,0,,0.0938,none,0,1,1,0,0,0.000642,0,0,,Capitation
CLM0000002430,MBR00000027,Dental,Paid,Electronic_EDI,2023-03-04,2023-03-04,2023-03-04,2023-03-07,Auto_Adjudicated,3,1710668368,1747596016,207RC0000X,Cardiovascular Disease,71,In_Network,OTHER,Z12.11|OTHER|I10,D0150,,0,Medicare_Advantage,MA_HMO,45,M,0.6886,,,756.02,463.69,369.74,1.51,0.0,92.44,292.33,0.0,0.0,0,,0.0923,none,0,1,0,0,0,3.4e-05,0,0,,Capitation
CLM0000002431,MBR00000255,Medical_Professional,Paid,Electronic_EDI,2023-08-31,2023-08-31,2023-08-31,2023-09-16,Auto_Adjudicated,16,1211612843,1746676564,2086S0122X,Orthopedic Surgery,24,Out_of_Network,F41.1,I10|F33.0,99386,,0,Medicare_Advantage,MA_HMO,21,M,0.6945,,,279.73,235.93,167.91,8.05,18.0,41.98,43.8,0.0,0.0,0,,0.0681,none,0,1,0,0,0,1.6e-05,1,0,,Bundled_Payment
CLM0000002432,MBR00000039,Medical_Professional,Paid,Paper,2023-07-24,2023-07-24,2023-07-24,2023-08-15,Auto_Adjudicated,22,1393200616,1894215172,207RN0300X,Nephrology,32,Out_of_Network,Z12.11,E11.9|Z00.00,99282,,0,Medicaid_MCO,MCO,20,F,0.5358,,,562.45,339.96,339.96,0.0,0.0,0.0,222.49,0.0,0.0,0,,0.1256,none,0,1,0,0,0,3.1e-05,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000002433,MBR00000081,Dental,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-27,2023-07-11,Manual_Review,14,1746688640,1685903362,2084P0800X,Psychiatry,21,In_Network,E78.5,,D3310,,0,Medicare_Advantage,SNP,66,F,2.159,,,400.08,172.81,126.3,9.93,5.0,31.58,227.27,0.0,0.0,0,,0.0017,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000002434,MBR00000298,Medical_Professional,Paid,Electronic_EDI,2023-03-18,2023-03-18,2023-03-18,2023-04-08,Auto_Adjudicated,21,1124477249,1365397818,207RE0101X,Endocrinology,24,In_Network,OTHER,E11.9|I25.10,99221,,0,Medicaid_MCO,MCO,75,M,0.8324,,,156.9,117.59,117.59,0.0,0.0,0.0,39.31,0.0,0.0,0,,0.0467,none,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000002435,MBR00000059,Medical_Institutional,Paid,Electronic_EDI,2023-08-13,2023-08-13,2023-08-13,2023-09-02,Auto_Adjudicated,20,1897701389,1896197144,2086S0122X,Orthopedic Surgery,81,In_Network,N18.3,K21.0|J06.9,revenue_code:0450,,0,Medicare_Advantage,SNP,12,F,1.266,,,25460.77,19843.96,15841.18,9.49,33.0,3960.29,5616.81,0.0,0.0,0,,0.0593,none,0,1,1,0,0,0.001466,0,0,,Shared_Savings
CLM0000002436,MBR00000030,Pharmacy,Partially_Paid,Electronic_EDI,2023-11-21,2023-11-21,2023-11-21,2023-12-06,Manual_Review,15,1909649019,1406199453,207Q00000X,Family Medicine,11,In_Network,OTHER,E78.5,00069420020,,3,Medicaid_MCO,MCO,67,M,0.4581,50,Medical_Necessity,134.5,49.12,23.25,0.0,3.0,0.0,108.25,17.79,4.8,0,,0.0462,none,0,1,0,0,0,2e-06,0,1,,Capitation
CLM0000002437,MBR00000189,Medical_Institutional,Paid,Electronic_EDI,2023-11-02,2023-11-02,2023-11-05,2023-12-02,Auto_Adjudicated,30,1176378924,1574982369,207Q00000X,Family Medicine,22,In_Network,OTHER,E78.5|OTHER,revenue_code:0370,,0,Medicaid_MCO,MCO,71,F,0.9722,,,8046.31,3755.91,3748.91,0.0,7.0,0.0,4290.4,2519.86,762.35,0,,0.1144,billing_spike_recent,0,1,0,0,0,0.000347,0,0,,P4P
CLM0000002438,MBR00000125,Vision,Paid,Electronic_EDI,2023-03-04,2023-03-04,2023-03-04,2023-03-23,Manual_Review,19,1886549972,1689327034,207RE0101X,Endocrinology,31,In_Network,E11.9,F32.9,V2100,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,470.52,270.63,204.33,4.22,11.0,51.08,199.89,0.0,0.0,0,,0.1476,upcoding_pattern,0,1,0,0,0,1.9e-05,0,0,,Capitation
CLM0000002439,MBR00000028,Medical_Institutional,Paid,Electronic_EDI,2023-09-02,2023-09-02,2023-09-02,2023-09-27,Manual_Review,25,1374361443,1763260577,207V00000X,Obstetrics & Gynecology,21,In_Network,OTHER,OTHER,revenue_code:0360,193,0,Commercial,HMO,3,F,2.116,,,9306.47,7539.68,5670.23,372.9,79.0,1417.56,1766.79,0.0,0.0,1,Medically Unnecessary Services,1.0,outlier_billing_amount|geographic_mismatch|temporal_clustering|high_volume_same_code|benford_violation|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,1,0,0,0.000525,0,0,CBP_Controlling_BP,Capitation
CLM0000002440,MBR00000002,Medical_Institutional,Paid,Electronic_EDI,2023-03-29,2023-03-29,2023-03-30,2023-04-18,Clinical_Review,20,1560886857,1355732274,207RE0101X,Endocrinology,22,Out_of_Network,OTHER,,revenue_code:0200,,0,Commercial,PPO,42,F,0.9012,,,9852.25,7804.85,6194.2,26.09,36.0,1548.55,2047.4,0.0,0.0,0,,0.0949,none,0,1,1,0,0,0.000573,1,0,,FFS
CLM0000002441,MBR00000024,Medical_Professional,Paid,Electronic_EDI,2023-11-06,2023-11-06,2023-11-06,2023-12-05,Auto_Adjudicated,29,1631060535,1951488764,2086S0122X,Orthopedic Surgery,24,In_Network,F32.9,OTHER|F41.1,99284,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,325.55,220.35,217.35,0.0,3.0,0.0,105.2,0.0,0.0,0,,0.0791,benford_violation,0,1,0,0,0,2e-05,0,0,,FFS
CLM0000002442,MBR00000160,Medical_Professional,Paid,Electronic_EDI,2023-06-19,2023-06-19,2023-06-19,2023-07-02,Auto_Adjudicated,13,1176378924,1498781755,207RC0000X,Cardiovascular Disease,31,In_Network,OTHER,OTHER,70553,,0,Commercial,HMO,73,M,1.9608,,,1193.04,873.06,598.49,101.95,23.0,149.62,319.98,0.0,0.0,0,,0.0305,none,0,1,0,0,0,5.5e-05,0,0,,Shared_Savings
CLM0000002443,MBR00000073,Medical_Institutional,Paid,Electronic_EDI,2023-09-24,2023-09-24,2023-09-28,2023-09-30,Auto_Adjudicated,6,1147937670,1860951128,208600000X,Surgery General,11,In_Network,J44.1,I10,revenue_code:0250,,0,Commercial,POS,79,M,1.1768,,,13670.88,5773.3,4553.2,9.8,72.0,1138.3,7897.58,0.0,0.0,0,,0.077,none,0,1,0,1,0,0.000421,0,0,CBP_Controlling_BP,FFS
CLM0000002444,MBR00000229,Medical_Professional,Paid,Electronic_EDI,2023-07-13,2023-07-13,2023-07-13,2023-07-19,Auto_Adjudicated,6,1220710861,1522426351,208600000X,Surgery General,21,In_Network,Z12.11,M54.5|G47.33|E11.9,90837,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,134.49,85.23,23.1,42.36,14.0,5.77,49.26,0.0,0.0,0,,0.1201,none,0,1,0,0,0,2e-06,0,0,,Bundled_Payment
CLM0000002445,MBR00000259,Medical_Institutional,Paid,Provider_Portal,2023-08-31,2023-08-31,2023-09-03,2023-09-30,Auto_Adjudicated,30,1683650935,1301869102,207RN0300X,Nephrology,21,In_Network,I10,,revenue_code:0360,291,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,5007.89,3711.89,2938.31,3.0,36.0,734.58,1296.0,0.0,0.0,0,,0.1043,none,0,1,0,1,0,0.000272,0,0,,P4P
CLM0000002446,MBR00000045,Medical_Professional,Paid,Electronic_EDI,2023-12-02,2023-12-02,2023-12-02,2023-12-26,Auto_Adjudicated,24,1496340237,1157814306,207Q00000X,Family Medicine,11,In_Network,G43.909,J44.1|OTHER|Z12.11,90834,,0,Commercial,HMO,78,F,1.0658,,,269.13,125.88,52.8,27.88,32.0,13.2,143.25,0.0,0.0,0,,0.1375,none,0,1,0,0,0,5e-06,0,0,BCS_Breast_Cancer_Screening,Bundled_Payment
CLM0000002447,MBR00000106,Medical_Professional,Paid,Electronic_EDI,2023-02-18,2023-02-18,2023-02-18,2023-02-28,Manual_Review,10,1954226809,1402472115,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,H52.4,17000,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,173.7,71.68,36.38,20.21,6.0,9.09,102.02,0.0,0.0,0,,0.039,none,0,1,0,0,0,3e-06,0,0,,Shared_Savings
CLM0000002448,MBR00000046,Medical_Institutional,Paid,Provider_Portal,2023-11-21,2023-11-21,2023-11-24,2023-12-05,Manual_Review,14,1901508637,1985590322,207RE0101X,Endocrinology,24,Out_of_Network,E11.9,N18.3|Z23|J06.9,revenue_code:0210,,0,Commercial,HMO,76,F,0.9613,,,10296.11,6691.84,5285.87,43.51,41.0,1321.47,3604.27,0.0,0.0,0,,0.0511,none,0,1,1,1,0,0.000489,1,0,,FFS
CLM0000002449,MBR00000090,Medical_Institutional,Paid,Electronic_EDI,2023-06-23,2023-06-23,2023-06-27,2023-06-25,Clinical_Review,2,1907932706,1662516615,2086S0122X,Orthopedic Surgery,31,In_Network,Z12.11,,revenue_code:0210,,0,Medicare_Advantage,MA_HMO,49,F,0.4351,,,19005.43,15392.09,12251.32,19.94,58.0,3062.83,3613.34,0.0,0.0,0,,0.1174,none,0,1,1,0,0,0.001134,0,0,,P4P
CLM0000002450,MBR00000075,Medical_Professional,Paid,Electronic_EDI,2023-02-21,2023-02-21,2023-02-21,2023-03-22,Auto_Adjudicated,29,1932483309,1884259357,207RG0100X,Gastroenterology,71,In_Network,Z00.00,,90847,,0,Medicaid_MCO,MCO,5,M,1.0573,,,1282.83,1073.52,1069.52,0.0,4.0,0.0,209.31,0.0,0.0,0,,0.1253,none,0,1,0,0,0,9.9e-05,0,0,,FFS
CLM0000002451,MBR00000233,Pharmacy,Paid,Electronic_EDI,2023-06-05,2023-06-05,2023-06-05,2023-06-19,Auto_Adjudicated,14,1456447970,1774401124,207R00000X,Internal Medicine,71,In_Network,E11.65,F33.0,59148001506,,1,Medicare_Advantage,MA_PPO,87,M,0.8034,,,267.76,150.76,114.23,4.97,3.0,28.56,117.0,0.0,0.0,0,,0.0868,none,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000002452,MBR00000109,Medical_Professional,Paid,Electronic_EDI,2023-01-21,2023-01-21,2023-01-21,2023-02-02,Auto_Adjudicated,12,1415701059,1522426351,207RG0100X,Gastroenterology,81,Out_of_Network,J44.1,J06.9,90847,,0,Commercial,HMO,8,F,0.5723,,,439.8,256.7,103.27,89.61,38.0,25.82,183.1,0.0,0.0,0,,0.0265,none,0,1,0,1,0,1e-05,0,0,IET_Initiation_Substance_Use,Shared_Savings
CLM0000002453,MBR00000154,Medical_Professional,Paid,Paper,2023-07-14,2023-07-14,2023-07-14,2023-07-22,Auto_Adjudicated,8,1035707913,1469697158,2084P0800X,Psychiatry,11,In_Network,OTHER,I48.91|I10,99204,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,481.05,319.0,245.41,12.24,0.0,61.35,162.05,0.0,0.0,0,,0.1954,diagnosis_procedure_mismatch,0,1,0,0,0,2.3e-05,0,0,,Bundled_Payment
CLM0000002454,MBR00000200,Vision,Paid,Electronic_EDI,2023-06-19,2023-06-19,2023-06-19,2023-06-22,Auto_Adjudicated,3,1929402739,1287472731,2086S0122X,Orthopedic Surgery,21,In_Network,Z00.00,F10.10,92002,,0,Commercial,HDHP_HSA,29,M,0.8011,,,252.04,92.95,0.0,92.95,0.0,0.0,159.09,0.0,0.0,0,,0.1954,unbundling_pattern,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002455,MBR00000245,Vision,Denied,Electronic_EDI,2023-05-21,2023-05-21,2023-05-21,2023-06-13,Auto_Adjudicated,23,1164721841,1355732274,207R00000X,Internal Medicine,11,Out_of_Network,Z00.01,M17.11,V2103,,0,Medicaid_MCO,MCO,60,F,0.7502,1,Timely_Filing,673.0,418.1,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Duplicate Billing,0.9129,unusual_service_frequency|provider_specialty_mismatch|high_volume_same_code|benford_violation|impossible_service_combo|upcoding_pattern|unbundling_pattern|phantom_billing_indicator,1,5,0,0,0,0.0,1,0,,FFS
CLM0000002456,MBR00000095,Medical_Institutional,Paid,Electronic_EDI,2023-06-09,2023-06-09,2023-06-10,2023-06-16,Auto_Adjudicated,7,1260336577,1157814306,2086S0122X,Orthopedic Surgery,23,Out_of_Network,Z00.00,Z00.01|OTHER|J20.9,revenue_code:0200,,0,Commercial,HMO,28,M,0.5827,,,9625.06,6389.59,5027.5,50.21,55.0,1256.88,3235.47,0.0,0.0,0,,0.0086,none,0,1,1,1,0,0.000465,0,0,DAE_Drug_Alcohol_Dependence,Shared_Savings
CLM0000002457,MBR00000064,Medical_Institutional,Denied,Electronic_EDI,2023-08-11,2023-08-11,2023-08-14,2023-08-14,Auto_Adjudicated,3,1170319307,1576271272,2084P0800X,Psychiatry,81,In_Network,OTHER,H52.4,revenue_code:0120,,0,Medicare_Advantage,SNP,73,M,1.0644,97,Coding_Error,8214.0,3388.29,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0471,none,0,1,0,0,0,0.0,0,0,CBP_Controlling_BP,FFS
CLM0000002458,MBR00000295,Dental,Paid,Electronic_EDI,2023-10-24,2023-10-24,2023-10-24,2023-11-23,Auto_Adjudicated,30,1898658234,1764064254,207RC0000X,Cardiovascular Disease,11,In_Network,M17.11,,D4341,,0,Commercial,HDHP_HSA,78,F,0.8618,,,152.78,116.81,0.0,116.81,0.0,0.0,35.97,0.0,0.0,0,,0.1491,none,0,1,0,0,0,0.0,0,0,MMA_Medication_Management,FFS
CLM0000002459,MBR00000102,Medical_Institutional,Denied,Electronic_EDI,2023-05-21,2023-05-21,2023-05-22,2023-06-07,Auto_Adjudicated,17,1210349885,1903401648,2086S0122X,Orthopedic Surgery,22,Out_of_Network,E11.9,I10|OTHER,revenue_code:0360,,0,Commercial,POS,68,M,1.6864,50,Medical_Necessity,21289.98,13151.03,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1052,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,1,0,,Capitation
CLM0000002460,MBR00000199,Medical_Professional,Paid,Paper,2023-01-07,2023-01-07,2023-01-07,2023-01-10,Manual_Review,3,1051254008,1527857018,207RP1001X,Pulmonary Disease,22,In_Network,Z00.00,F32.9,99387,,0,Medicaid_MCO,MLTSS,17,F,1.0776,,,838.99,657.97,655.97,0.0,2.0,0.0,181.02,459.35,144.93,1,DME Fraud,1.0,geographic_mismatch|provider_specialty_mismatch|high_volume_same_code|benford_violation|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,6.1e-05,0,0,,FFS
CLM0000002461,MBR00000201,Medical_Professional,Paid,Paper,2023-07-20,2023-07-20,2023-07-20,2023-07-29,Auto_Adjudicated,9,1373899620,1867626800,2084P0800X,Psychiatry,11,In_Network,Z00.01,M54.5,99213,,0,Medicare_Advantage,MA_PPO,74,M,1.1575,,,453.88,284.69,209.99,16.2,6.0,52.5,169.19,0.0,0.0,1,DME Fraud,0.9527,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|billing_spike_recent|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch,1,5,0,1,0,1.9e-05,0,0,PCR_Plan_All_Cause_Readmission,P4P
CLM0000002462,MBR00000158,Medical_Professional,Paid,Electronic_EDI,2023-12-06,2023-12-06,2023-12-06,2023-12-23,Auto_Adjudicated,17,1429653002,1469697158,207RP1001X,Pulmonary Disease,31,In_Network,F10.10,M17.11,70553,,0,Commercial,HMO,65,M,1.5361,,,216.77,109.27,0.0,109.27,0.0,0.0,107.5,0.0,0.0,0,,0.092,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000002463,MBR00000072,Pharmacy,Paid,Electronic_EDI,2023-05-22,2023-05-22,2023-05-22,2023-05-29,Auto_Adjudicated,7,1633089013,1274911960,2084P0800X,Psychiatry,21,In_Network,F41.1,,00310075090,,1,Medicare_Advantage,MA_PPO,39,M,0.4967,,,402.03,216.02,136.47,37.43,8.0,34.12,186.01,0.0,0.0,1,Duplicate Billing,1.0,geographic_mismatch|high_volume_same_code|benford_violation|impossible_service_combo|service_date_weekend|billing_spike_recent|phantom_billing_indicator|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,1.3e-05,0,1,,P4P
CLM0000002464,MBR00000044,Medical_Institutional,Paid,Provider_Portal,2023-02-14,2023-02-14,2023-02-16,2023-03-16,Auto_Adjudicated,30,1477762002,1432077493,246ZN0300X,Neuropsychology,21,In_Network,H52.4,Z12.11,revenue_code:0360,439,0,Commercial,PPO,29,M,0.7512,,,4712.7,3899.99,2889.93,214.58,73.0,722.48,812.71,0.0,0.0,0,,0.0893,none,0,1,0,0,0,0.000267,0,0,,Capitation
CLM0000002465,MBR00000151,Medical_Professional,Paid,Electronic_EDI,2023-11-20,2023-11-20,2023-11-20,2023-12-17,Auto_Adjudicated,27,1145887050,1489993356,207RN0300X,Nephrology,81,In_Network,E78.5,,99384,,0,Medicare_Advantage,MA_HMO,77,M,0.8709,,,489.39,281.67,218.36,2.72,6.0,54.59,207.72,0.0,0.0,0,,0.0787,none,0,1,0,0,0,2e-05,0,0,TRC_Transition_of_Care,FFS
CLM0000002466,MBR00000157,Medical_Professional,Paid,Electronic_EDI,2023-05-31,2023-05-31,2023-05-31,2023-06-27,Auto_Adjudicated,27,1067329999,1643673796,207RN0300X,Nephrology,11,In_Network,K21.0,,11200,,0,Medicare_Advantage,MA_HMO,26,F,0.9164,,,1935.09,1169.19,917.61,5.18,17.0,229.4,765.9,0.0,0.0,0,,0.0553,none,0,1,0,0,0,8.5e-05,0,0,,Bundled_Payment
CLM0000002467,MBR00000228,Medical_Professional,Paid,Electronic_EDI,2023-05-15,2023-05-15,2023-05-15,2023-05-31,Auto_Adjudicated,16,1145860509,1643673796,2084P0800X,Psychiatry,21,In_Network,F33.0,OTHER,11200,,0,Commercial,PPO,55,F,0.7203,,,434.67,316.98,38.0,230.48,39.0,9.5,117.69,0.0,0.0,0,,0.049,none,0,1,0,1,0,4e-06,0,0,,FFS
CLM0000002468,MBR00000210,Pharmacy,Paid,Electronic_EDI,2023-04-17,2023-04-17,2023-04-17,2023-05-17,Auto_Adjudicated,30,1900781649,1054984734,207V00000X,Obstetrics & Gynecology,24,In_Network,E11.9,,00071012831,,5,Medicare_Advantage,SNP,49,M,0.6952,,,573.91,434.78,301.61,39.77,18.0,75.4,139.13,0.0,0.0,0,,0.1348,diagnosis_procedure_mismatch,0,1,0,0,0,2.8e-05,0,0,,FFS
CLM0000002469,MBR00000275,Dental,Paid,Provider_Portal,2023-09-20,2023-09-20,2023-09-20,2023-09-30,Auto_Adjudicated,10,1988579666,1013600387,207R00000X,Internal Medicine,22,In_Network,E78.5,E11.9|N39.0,D2391,,0,Medicare_Advantage,MA_PPO,67,M,0.8169,,,126.08,102.14,58.55,13.95,15.0,14.64,23.94,0.0,0.0,0,,0.1288,none,0,1,0,0,0,5e-06,0,0,COA_Care_Transitions,Capitation
CLM0000002470,MBR00000293,Medical_Institutional,Paid,Paper,2023-02-22,2023-02-22,2023-02-24,2023-03-11,Auto_Adjudicated,17,1264432433,1489993356,207R00000X,Internal Medicine,22,In_Network,I10,M54.5|I10,revenue_code:0210,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,10614.99,7392.21,5872.16,20.01,32.0,1468.04,3222.78,0.0,0.0,0,,0.1381,controlled_substance_high_volume,0,1,1,0,0,0.000544,0,0,AMR_Asthma_Medication_Ratio,Shared_Savings
CLM0000002471,MBR00000213,Pharmacy,Paid,Electronic_EDI,2023-08-09,2023-08-09,2023-08-09,2023-09-01,Auto_Adjudicated,23,1597245892,1811797489,101YP2500X,Psychologist Clinical,22,In_Network,C50.911,,00006001954,,1,Commercial,PPO,17,M,1.5857,,,22.23,11.09,0.0,11.09,0.0,0.0,11.14,0.0,0.0,0,,0.0282,none,0,1,0,0,0,0.0,0,1,AMR_Asthma_Medication_Ratio,Capitation
CLM0000002472,MBR00000024,Medical_Professional,Paid,Electronic_EDI,2023-05-06,2023-05-06,2023-05-06,2023-05-22,Auto_Adjudicated,16,1170257806,1903401648,207Q00000X,Family Medicine,11,In_Network,I25.10,K57.30,99213,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,445.69,189.3,186.3,0.0,3.0,0.0,256.39,0.0,0.0,0,,0.0582,none,0,1,0,0,0,1.7e-05,0,0,POD_Persistence_of_Beta_Blocker,FFS
CLM0000002473,MBR00000129,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-05-19,2023-05-19,2023-05-22,2023-06-14,Auto_Adjudicated,26,1216417633,1741177636,207V00000X,Obstetrics & Gynecology,11,Emergency,K21.0,I10,revenue_code:0100,,0,Medicare_Advantage,MA_PPO,9,F,0.8196,170,Medical_Necessity,3027.06,1754.4,740.88,10.55,59.0,185.22,2031.41,0.0,0.0,0,,0.1048,benford_violation,0,1,0,0,0,6.9e-05,0,0,AMR_Asthma_Medication_Ratio,Capitation
CLM0000002474,MBR00000184,Medical_Institutional,Paid,Electronic_EDI,2023-03-19,2023-03-19,2023-03-19,2023-03-23,Auto_Adjudicated,4,1797494973,1831337866,208600000X,Surgery General,31,In_Network,E11.65,,revenue_code:0300,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,2072.62,823.21,823.21,0.0,0.0,0.0,1249.41,0.0,0.0,0,,0.1059,none,0,1,0,0,0,7.6e-05,0,0,,FFS
CLM0000002475,MBR00000177,Medical_Professional,Denied,Paper,2023-10-17,2023-10-17,2023-10-17,2023-10-31,Auto_Adjudicated,14,1793630905,1607833568,207RP1001X,Pulmonary Disease,11,In_Network,I10,,99395,,0,Commercial,HMO,42,F,1.2774,1,Authorization,319.24,257.63,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0322,none,0,1,0,0,0,0.0,0,0,SPD_Spirometry_Testing,FFS
CLM0000002476,MBR00000056,Medical_Institutional,Denied,Electronic_EDI,2023-06-12,2023-06-12,2023-06-12,2023-07-07,Manual_Review,25,1068197532,1339359594,207Q00000X,Family Medicine,81,In_Network,OTHER,E78.5|F41.1,revenue_code:0300,,0,Commercial,EPO,74,F,1.3941,1,Eligibility,30494.91,25613.69,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0661,upcoding_pattern,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002477,MBR00000175,Pharmacy,Paid,Electronic_EDI,2023-11-29,2023-11-29,2023-11-29,2023-12-05,Auto_Adjudicated,6,1205349488,1540743888,207RC0000X,Cardiovascular Disease,11,In_Network,Z00.121,,00085163102,,3,Commercial,PPO,14,F,1.5785,,,130.24,79.52,0.0,72.46,7.06,0.0,50.72,0.0,0.0,0,,0.127,impossible_service_combo,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002478,MBR00000110,Medical_Professional,Paid,Electronic_EDI,2023-10-25,2023-10-25,2023-10-25,2023-11-06,Manual_Review,12,1256824549,1267212691,2084P0800X,Psychiatry,32,In_Network,I10,Z23|OTHER,85025,,0,Medicare_Advantage,MA_HMO,83,F,1.127,,,715.07,264.13,198.42,7.11,9.0,49.6,450.94,0.0,0.0,0,,0.0645,none,0,1,0,1,0,1.8e-05,0,0,,Shared_Savings
CLM0000002479,MBR00000106,Medical_Institutional,Paid,Paper,2023-10-01,2023-10-01,2023-10-01,2023-10-31,Auto_Adjudicated,30,1299958874,1564691686,225100000X,Physical Therapist,71,In_Network,OTHER,R05.9|Z00.00,revenue_code:0450,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,58593.23,29178.3,23300.86,17.22,35.0,5825.22,29414.93,0.0,0.0,0,,0.0965,outlier_billing_amount,0,1,1,0,0,0.002157,0,0,,Capitation
CLM0000002480,MBR00000249,Dental,Denied,Electronic_EDI,2023-06-11,2023-06-11,2023-06-11,2023-06-30,Auto_Adjudicated,19,1918359820,1564691686,2084P0800X,Psychiatry,11,In_Network,Z12.11,I10|I25.10,D3310,,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,CO-45,Eligibility,197.85,107.67,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0914,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002481,MBR00000134,Pharmacy,Paid,Provider_Portal,2023-12-07,2023-12-07,2023-12-07,2023-12-18,Auto_Adjudicated,11,1231231881,1865266296,207V00000X,Obstetrics & Gynecology,23,In_Network,F32.9,E11.9|OTHER,50458085930,,2,Medicare_Advantage,MA_PPO,33,M,1.115,,,82.09,44.77,0.0,32.58,12.19,0.0,37.32,0.0,0.0,0,,0.0217,none,0,1,0,0,0,0.0,0,0,FLU_Flu_Vaccination,FFS
CLM0000002482,MBR00000160,Medical_Institutional,Denied,Electronic_EDI,2023-07-29,2023-07-29,2023-07-30,2023-08-09,Auto_Adjudicated,11,1122148537,1105871325,207V00000X,Obstetrics & Gynecology,24,In_Network,N39.0,,revenue_code:0300,,0,Commercial,HMO,73,M,1.9608,256,Eligibility,31879.62,22364.96,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1372,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002483,MBR00000169,Medical_Professional,Paid,Electronic_EDI,2023-06-06,2023-06-06,2023-06-06,2023-06-13,Auto_Adjudicated,7,1331903993,1179350099,208600000X,Surgery General,22,In_Network,OTHER,C50.911,99396,,0,Commercial,EPO,30,M,1.4348,,,313.24,263.35,0.0,263.35,0.0,0.0,49.89,0.0,0.0,0,,0.1488,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002484,MBR00000169,Pharmacy,Denied,Electronic_EDI,2023-05-05,2023-05-05,2023-05-05,2023-05-28,Auto_Adjudicated,23,1793406356,1025886739,246ZN0300X,Neuropsychology,32,In_Network,I10,,00071012831,,2,Commercial,EPO,30,M,1.4348,5,Authorization,562.75,203.87,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0121,none,0,1,0,0,0,0.0,0,1,,P4P
CLM0000002485,MBR00000065,Medical_Professional,Paid,Electronic_EDI,2023-11-25,2023-11-25,2023-11-25,2023-11-29,Auto_Adjudicated,4,1309817189,1133410177,207RG0100X,Gastroenterology,11,In_Network,E78.5,M54.5,71046,,0,Commercial,HDHP_HSA,63,M,0.7795,,,262.42,218.54,0.0,218.54,0.0,0.0,43.88,0.0,0.0,0,,0.0044,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002486,MBR00000181,Medical_Professional,Denied,Electronic_EDI,2023-04-02,2023-04-02,2023-04-02,2023-04-09,Auto_Adjudicated,7,1850379080,1564636990,208600000X,Surgery General,71,In_Network,OTHER,Z00.00,90837,,0,Commercial,PPO,82,F,1.0432,CO-45,Medical_Necessity,185.82,150.23,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1348,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002487,MBR00000105,Medical_Professional,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-11-15,Auto_Adjudicated,4,1905691248,1020312030,207RN0300X,Nephrology,22,In_Network,OTHER,,99394,,0,Commercial,HMO,74,M,1.1834,,,136.69,106.35,0.0,106.35,0.0,0.0,30.34,0.0,0.0,0,,0.0392,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002488,MBR00000195,Medical_Institutional,Denied,Electronic_EDI,2023-03-24,2023-03-24,2023-03-26,2023-04-16,Auto_Adjudicated,23,1557212800,1688513262,207RN0300X,Nephrology,21,In_Network,OTHER,OTHER|I25.10,revenue_code:0120,291,0,Commercial,PPO,13,F,0.5967,50,Timely_Filing,22667.94,12878.32,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0852,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000002489,MBR00000046,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-10-01,2023-10-01,2023-10-01,2023-10-30,Auto_Adjudicated,29,1522998767,1391074619,101YP2500X,Psychologist Clinical,22,In_Network,I10,M54.5,revenue_code:0200,,0,Commercial,HMO,76,F,0.9613,18,Medical_Necessity,35353.97,19295.8,9481.51,96.04,41.0,2370.38,23365.04,0.0,0.0,0,,0.0835,duplicate_claim_indicator,0,1,1,0,0,0.000878,0,0,,P4P
CLM0000002490,MBR00000299,Pharmacy,Denied,Electronic_EDI,2023-04-12,2023-04-12,2023-04-12,2023-04-15,Auto_Adjudicated,3,1086690796,1527857018,207R00000X,Internal Medicine,21,In_Network,J44.1,,16590051660,,1,Medicaid_MCO,MCO,74,F,0.8833,22,Medical_Necessity,423.9,249.99,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.183,benford_violation,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002491,MBR00000227,Medical_Institutional,Paid,Electronic_EDI,2023-10-27,2023-10-27,2023-10-31,2023-11-25,Auto_Adjudicated,29,1597649716,1829216053,207RC0000X,Cardiovascular Disease,22,In_Network,K21.0,N39.0|OTHER,revenue_code:0360,,0,Medicare_Advantage,MA_PPO,2,F,0.7835,,,19781.94,13388.2,10678.39,0.21,40.0,2669.6,6393.74,0.0,0.0,0,,0.131,geographic_mismatch,0,1,1,0,0,0.000988,0,0,,FFS
CLM0000002492,MBR00000132,Behavioral_Health,Paid,Electronic_EDI,2023-10-27,2023-10-27,2023-10-27,2023-11-24,Clinical_Review,28,1510562885,1304018750,207RE0101X,Endocrinology,11,In_Network,Z00.00,,99213,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,,,411.59,198.18,153.02,0.9,6.0,38.26,213.41,0.0,0.0,0,,0.016,none,0,1,0,1,0,1.4e-05,0,0,,Shared_Savings
CLM0000002493,MBR00000095,Medical_Institutional,Paid,Electronic_EDI,2023-09-20,2023-09-20,2023-09-22,2023-10-06,Auto_Adjudicated,16,1897146144,1415734567,246ZN0300X,Neuropsychology,31,In_Network,Z00.00,,revenue_code:0360,,0,Commercial,HMO,28,M,0.5827,,,6946.6,3821.29,2968.59,55.55,55.0,742.15,3125.31,0.0,0.0,0,,0.0343,none,0,1,0,0,0,0.000275,0,0,,P4P
CLM0000002494,MBR00000123,Medical_Institutional,Paid,Electronic_EDI,2023-12-23,2023-12-23,2023-12-24,2023-12-25,Auto_Adjudicated,2,1617928396,1616762819,207RG0100X,Gastroenterology,21,In_Network,OTHER,,revenue_code:0120,439,0,ACA_Marketplace,ACA_Bronze,7,M,0.2444,,,2009.03,1667.08,911.14,148.51,0.0,607.43,341.95,0.0,0.0,0,,0.1142,none,0,1,0,1,0,8.4e-05,0,0,,P4P
CLM0000002495,MBR00000212,Medical_Professional,Paid,Paper,2023-07-03,2023-07-03,2023-07-03,2023-07-24,Auto_Adjudicated,21,1299958874,1847196500,101YP2500X,Psychologist Clinical,22,In_Network,Z00.01,Z00.00,20610,,0,Commercial,HMO,57,F,2.5456,,,209.59,81.06,0.0,81.06,0.0,0.0,128.53,0.0,0.0,0,,0.2048,geographic_mismatch,0,2,0,1,0,0.0,0,0,,FFS
CLM0000002496,MBR00000195,Medical_Professional,Paid,Electronic_EDI,2023-10-29,2023-10-29,2023-10-29,2023-11-14,Auto_Adjudicated,16,1175978429,1738617370,207RG0100X,Gastroenterology,65,In_Network,E78.5,L70.0|OTHER,97110,,0,Commercial,PPO,13,F,0.5967,,,235.03,106.05,55.3,23.92,13.0,13.83,128.98,0.0,0.0,0,,0.143,none,0,1,0,1,0,5e-06,0,0,,Bundled_Payment
CLM0000002497,MBR00000208,Medical_Institutional,Paid,Electronic_EDI,2023-07-18,2023-07-18,2023-07-22,2023-08-12,Auto_Adjudicated,25,1014995735,1643673796,2086S0122X,Orthopedic Surgery,65,In_Network,I10,N39.0|OTHER,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,2102.84,779.57,567.85,15.75,54.0,141.96,1323.27,0.0,0.0,0,,0.1458,none,0,1,0,0,0,5.3e-05,0,0,,Bundled_Payment
CLM0000002498,MBR00000270,Pharmacy,Paid,Electronic_EDI,2023-01-14,2023-01-14,2023-01-14,2023-01-23,Auto_Adjudicated,9,1661091022,1187669363,207Q00000X,Family Medicine,24,In_Network,I25.10,E11.9|F10.10,00169751112,,1,Commercial,POS,1,F,1.6363,,,60.62,39.2,0.0,39.2,0.0,0.0,21.42,0.0,0.0,0,,0.1541,service_date_weekend|upcoding_pattern,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002499,MBR00000142,Medical_Professional,Paid,Electronic_EDI,2023-05-30,2023-05-30,2023-05-30,2023-06-16,Auto_Adjudicated,17,1159640414,1291071007,225100000X,Physical Therapist,11,In_Network,OTHER,Z23,99202,,0,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,176.28,107.5,0.0,107.5,0.0,0.0,68.78,0.0,0.0,0,,0.0451,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002500,MBR00000198,Medical_Institutional,Paid,Electronic_EDI,2023-01-12,2023-01-12,2023-01-12,2023-02-08,Clinical_Review,27,1327415110,1607833568,207RG0100X,Gastroenterology,65,In_Network,E78.5,Z12.11|Z79.4,revenue_code:0120,,0,Medicaid_MCO,MCO,81,F,1.4199,,,20718.09,7928.86,7926.86,0.0,2.0,0.0,12789.23,0.0,0.0,0,,0.0114,none,0,1,1,0,0,0.000734,0,0,,Bundled_Payment
CLM0000002501,MBR00000138,Medical_Professional,Paid,Provider_Portal,2023-08-27,2023-08-27,2023-08-27,2023-09-17,Manual_Review,21,1679629515,1469881892,207R00000X,Internal Medicine,11,In_Network,OTHER,N18.3|J06.9,82947,,0,Commercial,HDHP_HSA,47,M,0.996,,,798.7,464.01,215.73,194.35,0.0,53.93,334.69,0.0,0.0,0,,0.0596,none,0,1,0,0,0,2e-05,0,0,MMA_Medication_Management,Capitation
CLM0000002502,MBR00000189,Medical_Institutional,Denied,Electronic_EDI,2023-02-24,2023-02-24,2023-02-24,2023-03-16,Auto_Adjudicated,20,1159640414,1738617370,101YP2500X,Psychologist Clinical,22,In_Network,I10,Z12.11|F41.1,revenue_code:0210,,0,Medicaid_MCO,MCO,71,F,0.9722,3,Authorization,46643.66,20881.63,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0104,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000002503,MBR00000145,Medical_Professional,Paid,Electronic_EDI,2023-04-27,2023-04-27,2023-04-27,2023-05-27,Manual_Review,30,1588313061,1133410177,207RP1001X,Pulmonary Disease,65,In_Network,J06.9,,99284,,0,Medicaid_MCO,MLTSS,46,M,0.5813,,,150.65,101.39,98.39,0.0,3.0,0.0,49.26,0.0,0.0,0,,0.0596,none,0,1,0,0,0,9e-06,0,0,MMA_Medication_Management,Capitation
CLM0000002504,MBR00000229,Medical_Professional,Paid,Electronic_EDI,2023-11-09,2023-11-09,2023-11-09,2023-11-24,Auto_Adjudicated,15,1006962798,1301869102,207RP1001X,Pulmonary Disease,11,In_Network,E11.9,OTHER,70553,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,844.01,636.52,485.57,15.55,14.0,121.39,207.49,342.99,96.84,0,,0.1578,high_volume_same_code,0,1,0,0,0,4.5e-05,0,0,,FFS
CLM0000002505,MBR00000003,Medical_Professional,Paid,Electronic_EDI,2023-09-23,2023-09-23,2023-09-23,2023-09-29,Auto_Adjudicated,6,1068197532,1061113875,2084P0800X,Psychiatry,11,Out_of_Network,F32.9,,99213,,0,Commercial,PPO,79,F,1.3879,,,540.68,218.19,153.75,1.01,25.0,38.44,322.49,0.0,0.0,0,,0.1366,none,0,1,0,0,0,1.4e-05,1,0,FUH_Follow_Up_Hospitalization,P4P
CLM0000002506,MBR00000066,Dental,Paid,Paper,2023-05-01,2023-05-01,2023-05-01,2023-05-31,Manual_Review,30,1706046899,1995553359,207RN0300X,Nephrology,22,In_Network,OTHER,OTHER,D7140,,0,Medicaid_MCO,MCO,54,M,0.6083,,,257.6,187.4,184.4,0.0,3.0,0.0,70.2,0.0,0.0,0,,0.0578,high_oop_waiver,0,1,0,0,0,1.7e-05,0,0,TRC_Transition_of_Care,Capitation
CLM0000002507,MBR00000092,Pharmacy,Paid,Electronic_EDI,2023-07-01,2023-07-01,2023-07-01,2023-07-06,Manual_Review,5,1110312325,1358873132,2084P0800X,Psychiatry,22,In_Network,H52.4,J06.9|OTHER,00078043215,,2,Medicaid_MCO,MLTSS,68,F,1.3217,,,126.06,71.91,68.91,0.0,3.0,0.0,54.15,0.0,0.0,0,,0.133,none,0,1,0,1,0,6e-06,0,1,,FFS
CLM0000002508,MBR00000286,Medical_Professional,Denied,Electronic_EDI,2023-07-28,2023-07-28,2023-07-28,2023-08-14,Auto_Adjudicated,17,1164721841,1765164601,207Q00000X,Family Medicine,21,In_Network,E11.9,OTHER|R05.9,74177,,0,Medicare_Advantage,PFFS,40,F,1.2751,2,Network,1709.9,1037.08,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.035,none,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000002509,MBR00000156,Medical_Professional,Denied,Paper,2023-05-07,2023-05-07,2023-05-07,2023-05-30,Manual_Review,23,1963647323,1811797489,208600000X,Surgery General,24,In_Network,OTHER,N40.0|Z00.00,90837,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,1,Coding_Error,506.67,291.19,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0957,billing_spike_recent,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002510,MBR00000115,Medical_Institutional,Paid,Electronic_EDI,2023-09-27,2023-09-27,2023-09-28,2023-10-21,Auto_Adjudicated,24,1119160702,1452088018,207Q00000X,Family Medicine,32,Out_of_Network,K57.30,Z00.01,revenue_code:0200,,0,Commercial,PPO,15,F,0.7398,,,43589.36,30876.38,24489.7,217.26,47.0,6122.42,12712.98,0.0,0.0,0,,0.1094,unusual_service_frequency,0,1,1,0,0,0.002267,0,0,,FFS
CLM0000002511,MBR00000129,Medical_Professional,Denied,Electronic_EDI,2023-02-22,2023-02-22,2023-02-22,2023-03-16,Auto_Adjudicated,22,1519736600,1622950074,207V00000X,Obstetrics & Gynecology,81,In_Network,F32.9,M54.5,99211,,0,Medicare_Advantage,MA_PPO,9,F,0.8196,18,Medical_Necessity,133.49,94.25,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1201,none,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,P4P
CLM0000002512,MBR00000140,Pharmacy,Paid,Electronic_EDI,2023-06-03,2023-06-03,2023-06-03,2023-06-16,Manual_Review,13,1451464799,1809122260,207RE0101X,Endocrinology,11,Emergency,OTHER,F32.9|C50.911|OTHER,59148001506,,1,Medicare_Advantage,MA_HMO,7,M,1.3997,,,657.39,423.05,311.54,21.63,12.0,77.88,234.34,0.0,0.0,0,,0.1472,service_date_weekend,0,1,0,0,0,2.9e-05,0,0,,Bundled_Payment
CLM0000002513,MBR00000262,Medical_Institutional,Paid,Provider_Portal,2023-04-02,2023-04-02,2023-04-02,2023-04-08,Auto_Adjudicated,6,1943769986,1055872102,207RP1001X,Pulmonary Disease,23,In_Network,OTHER,,revenue_code:0450,,0,Medicare_Advantage,PFFS,77,F,1.7452,,,37210.24,17232.75,13760.96,0.55,31.0,3440.24,19977.49,0.0,0.0,0,,0.1632,unbundling_pattern,0,1,1,0,0,0.001274,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000002514,MBR00000292,Dental,Denied,Electronic_EDI,2023-09-01,2023-09-01,2023-09-01,2023-09-03,Auto_Adjudicated,2,1067329999,1509799493,2084P0800X,Psychiatry,32,In_Network,L70.0,,D3310,,0,Medicare_Advantage,MA_HMO,4,M,1.1779,96,Network,197.18,106.49,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1472,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002515,MBR00000253,Medical_Professional,Paid,Electronic_EDI,2023-08-18,2023-08-18,2023-08-18,2023-08-28,Manual_Review,10,1921056264,1144950506,207RN0300X,Nephrology,11,In_Network,E11.9,OTHER,97140,,0,Commercial,EPO,44,M,0.3882,,,523.86,396.6,202.88,123.0,20.0,50.72,127.26,0.0,0.0,0,,0.0253,none,0,1,0,0,0,1.9e-05,0,0,,Shared_Savings
CLM0000002516,MBR00000252,Behavioral_Health,Paid,Electronic_EDI,2023-10-17,2023-10-17,2023-10-17,2023-11-16,Auto_Adjudicated,30,1556434733,1354959095,207RC0000X,Cardiovascular Disease,22,In_Network,I10,E78.5|I48.91,99212,,0,Medicare_Advantage,MA_HMO,80,M,0.7173,,,118.28,59.91,34.92,1.26,15.0,8.73,58.37,0.0,0.0,0,,0.181,high_volume_same_code,0,1,0,0,0,3e-06,0,0,,Capitation
CLM0000002517,MBR00000061,Pharmacy,Paid,Paper,2023-05-13,2023-05-13,2023-05-13,2023-06-03,Auto_Adjudicated,21,1324272690,1560230600,2084P0800X,Psychiatry,11,In_Network,OTHER,OTHER,59148001506,,2,Commercial,PPO,66,M,2.3575,,,121.28,98.12,0.0,98.12,0.0,0.0,23.16,0.0,0.0,0,,0.0844,geographic_mismatch,0,1,0,0,0,0.0,0,1,DDE_Diabetes_Short_Term_Complications,Capitation
CLM0000002518,MBR00000083,Pharmacy,Paid,Electronic_EDI,2023-03-24,2023-03-24,2023-03-24,2023-04-06,Auto_Adjudicated,13,1426424205,1985590322,207R00000X,Internal Medicine,11,In_Network,K57.30,,50458085930,,1,Commercial,PPO,76,M,0.6621,,,51.52,25.45,0.0,19.31,6.14,0.0,26.07,0.0,0.0,0,,0.1056,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002519,MBR00000180,Vision,Denied,Electronic_EDI,2023-01-12,2023-01-12,2023-01-12,2023-01-27,Auto_Adjudicated,15,1469822310,1297948643,207RE0101X,Endocrinology,11,Emergency,OTHER,E11.9|Z00.00,V2115,,0,Medicare_Advantage,MA_PPO,72,F,1.1909,50,COB,114.98,71.88,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0223,none,0,1,0,0,0,0.0,0,0,COA_Care_Transitions,FFS
CLM0000002520,MBR00000196,Medical_Institutional,Paid,Electronic_EDI,2023-11-05,2023-11-05,2023-11-08,2023-11-16,Manual_Review,11,1110312325,1965244699,208600000X,Surgery General,23,In_Network,OTHER,OTHER|I10,revenue_code:0250,,0,Commercial,PPO,16,F,1.6015,,,3882.18,2545.54,1777.23,288.0,36.0,444.31,1336.64,1354.27,320.06,0,,0.0444,none,0,1,0,0,0,0.000164,0,0,,Shared_Savings
CLM0000002521,MBR00000061,Medical_Professional,Denied,Provider_Portal,2023-04-29,2023-04-29,2023-04-29,2023-05-26,Auto_Adjudicated,27,1756856314,1473869105,207RP1001X,Pulmonary Disease,22,In_Network,OTHER,F10.10,99214,,0,Commercial,PPO,66,M,2.3575,5,Medical_Necessity,470.22,204.24,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0929,benford_violation,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,Bundled_Payment
CLM0000002522,MBR00000219,Medical_Institutional,Paid,Paper,2023-09-28,2023-09-28,2023-10-01,2023-10-12,Auto_Adjudicated,14,1864546991,1554490060,208600000X,Surgery General,11,In_Network,Z12.11,,revenue_code:0360,,0,Medicare_Advantage,MA_HMO,84,M,0.9513,,,2249.68,1341.39,1032.38,27.92,23.0,258.09,908.29,0.0,0.0,0,,0.1222,unusual_service_frequency|provider_specialty_mismatch,0,1,0,0,0,9.6e-05,0,0,MPT_Annual_Monitoring,FFS
CLM0000002523,MBR00000061,Pharmacy,Paid,Electronic_EDI,2023-05-12,2023-05-12,2023-05-12,2023-06-07,Auto_Adjudicated,26,1453331651,1450837722,207R00000X,Internal Medicine,22,In_Network,J06.9,,00169751112,,2,Commercial,PPO,66,M,2.3575,,,539.79,259.41,175.83,26.63,13.0,43.96,280.38,0.0,0.0,0,,0.1642,duplicate_claim_indicator,0,1,0,0,0,1.6e-05,0,0,,Bundled_Payment
CLM0000002524,MBR00000081,Dental,Paid,Electronic_EDI,2023-04-30,2023-04-30,2023-04-30,2023-05-02,Auto_Adjudicated,2,1389534304,1054984734,207RG0100X,Gastroenterology,11,In_Network,E11.9,Z12.11,D0150,,0,Medicare_Advantage,SNP,66,F,2.159,,,605.87,284.47,212.11,14.33,5.0,53.03,321.4,0.0,0.0,0,,0.1134,upcoding_pattern,0,1,0,0,0,2e-05,0,0,,FFS
CLM0000002525,MBR00000097,Medical_Institutional,Paid,Electronic_EDI,2023-03-26,2023-03-26,2023-03-27,2023-04-10,Auto_Adjudicated,15,1878453830,1151295616,208600000X,Surgery General,11,In_Network,Z00.01,J06.9,revenue_code:0300,,0,Commercial,EPO,34,M,1.3765,,,39274.47,23322.52,18556.49,69.91,57.0,4639.12,15951.95,0.0,0.0,0,,0.0326,none,0,1,1,0,0,0.001718,0,0,CBP_Controlling_BP,Capitation
CLM0000002526,MBR00000254,Pharmacy,Paid,Electronic_EDI,2023-10-08,2023-10-08,2023-10-08,2023-10-27,Auto_Adjudicated,19,1966338974,1196833348,207RP1001X,Pulmonary Disease,65,In_Network,F41.1,,00310075090,,5,Commercial,PPO,22,F,0.9285,,,237.16,118.34,55.21,21.32,28.0,13.8,118.82,0.0,0.0,0,,0.1337,none,0,1,0,0,0,5e-06,0,0,LCS_Lung_Cancer_Screening,Shared_Savings
CLM0000002527,MBR00000214,Medical_Professional,Denied,Electronic_EDI,2023-04-13,2023-04-13,2023-04-13,2023-05-04,Auto_Adjudicated,21,1086690796,1827839595,101YP2500X,Psychologist Clinical,22,In_Network,F41.1,OTHER|J06.9,99285,,0,Commercial,HDHP_HSA,76,M,1.7526,2,Authorization,638.65,412.93,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.076,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,SPD_Spirometry_Testing,Shared_Savings
CLM0000002528,MBR00000161,Medical_Professional,Paid,Electronic_EDI,2023-04-17,2023-04-17,2023-04-17,2023-04-18,Auto_Adjudicated,1,1193571728,1354959095,207Q00000X,Family Medicine,24,In_Network,Z00.01,Z23|Z00.00|I10,99387,,0,Medicaid_MCO,MLTSS,9,F,0.8354,,,136.68,96.29,92.29,0.0,4.0,0.0,40.39,0.0,0.0,0,,0.1336,none,0,1,0,1,0,9e-06,0,0,KED_ESRD_Patients,Shared_Savings
CLM0000002529,MBR00000244,Medical_Institutional,Paid,Electronic_EDI,2023-09-11,2023-09-11,2023-09-15,2023-10-01,Auto_Adjudicated,20,1055717021,1282319940,101YP2500X,Psychologist Clinical,21,In_Network,N18.3,,revenue_code:0250,872,0,Commercial,PPO,52,M,0.6677,,,41116.7,29361.06,23335.64,133.51,58.0,5833.91,11755.64,0.0,0.0,0,,0.0696,none,0,1,1,0,0,0.00216,0,0,,FFS
CLM0000002530,MBR00000241,Medical_Institutional,Denied,Electronic_EDI,2023-07-05,2023-07-05,2023-07-05,2023-07-31,Auto_Adjudicated,26,1597649716,1994275960,101YP2500X,Psychologist Clinical,11,Out_of_Network,J06.9,J06.9,revenue_code:0200,,0,Medicare_Advantage,MA_HMO,77,M,1.2169,96,Eligibility,185342.46,84236.21,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1432,outlier_billing_amount,0,1,0,1,0,0.0,1,0,CDC_HbA1c_Poor_Control,Shared_Savings
CLM0000002531,MBR00000125,Medical_Professional,Paid,Electronic_EDI,2023-09-25,2023-09-25,2023-09-25,2023-09-28,Auto_Adjudicated,3,1207523397,1291071007,2086S0122X,Orthopedic Surgery,32,In_Network,F32.9,G47.33,99394,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,245.44,127.21,89.15,4.78,11.0,22.29,118.23,0.0,0.0,0,,0.1216,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000002532,MBR00000231,Pharmacy,Paid,Electronic_EDI,2023-02-07,2023-02-07,2023-02-07,2023-02-17,Auto_Adjudicated,10,1881170383,1985590322,207Q00000X,Family Medicine,11,In_Network,M17.11,Z00.00,16590051660,,5,ACA_Marketplace,ACA_Silver,12,M,0.6456,,,172.2,143.78,0.0,143.78,0.0,0.0,28.42,0.0,0.0,0,,0.3192,high_volume_same_code|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,0,2,0,0,0,0.0,0,0,,Capitation
CLM0000002533,MBR00000062,Medical_Institutional,Paid,Electronic_EDI,2023-12-11,2023-12-11,2023-12-13,2023-12-24,Auto_Adjudicated,13,1082088479,1649705287,207RE0101X,Endocrinology,21,In_Network,M54.5,J06.9,revenue_code:0370,683,0,Commercial,HMO,46,F,0.5516,,,5236.4,4230.4,3340.39,21.91,33.0,835.1,1006.0,0.0,0.0,0,,0.1636,unusual_service_frequency|temporal_clustering,0,1,0,0,0,0.000309,0,0,,Capitation
CLM0000002534,MBR00000155,Medical_Institutional,Paid,Electronic_EDI,2023-03-26,2023-03-26,2023-03-29,2023-04-03,Auto_Adjudicated,8,1033622184,1865266296,207RE0101X,Endocrinology,23,In_Network,E13.9,J06.9,revenue_code:0100,,0,ACA_Marketplace,ACA_Bronze,9,F,0.8196,,,12738.8,10320.64,5712.04,800.57,0.0,3808.03,2418.16,0.0,0.0,0,,0.109,unbundling_pattern,0,1,1,0,0,0.000529,0,0,,FFS
CLM0000002535,MBR00000036,Medical_Professional,Paid,Paper,2023-02-12,2023-02-12,2023-02-12,2023-02-26,Auto_Adjudicated,14,1205744244,1705448933,207V00000X,Obstetrics & Gynecology,22,Out_of_Network,M17.11,OTHER,27447,,0,Commercial,EPO,17,M,2.0136,,,20505.09,13414.59,10593.55,139.65,33.0,2648.39,7090.5,0.0,0.0,0,,0.1496,none,0,1,1,0,0,0.000981,1,0,IET_Initiation_Substance_Use,FFS
CLM0000002536,MBR00000135,Medical_Professional,Paid,Electronic_EDI,2023-02-09,2023-02-09,2023-02-09,2023-03-08,Auto_Adjudicated,27,1592228076,1354959095,207RG0100X,Gastroenterology,65,Out_of_Network,K21.0,,97010,,0,Commercial,PPO,58,F,2.2702,,,124.32,78.27,29.08,4.92,37.0,7.27,46.05,0.0,0.0,0,,0.0668,none,0,1,0,0,0,3e-06,1,0,W30_Well_Child_Visit,Bundled_Payment
CLM0000002537,MBR00000159,Pharmacy,Paid,Electronic_EDI,2023-04-22,2023-04-22,2023-04-22,2023-05-19,Auto_Adjudicated,27,1170319307,1098360555,2086S0122X,Orthopedic Surgery,81,Emergency,Z23,E78.5|OTHER,00085163102,,2,Commercial,PPO,70,F,1.2009,,,293.71,180.97,101.64,39.92,14.0,25.41,112.74,0.0,0.0,0,,0.0503,none,0,1,0,0,0,9e-06,0,1,,Bundled_Payment
CLM0000002538,MBR00000024,Dental,Paid,Electronic_EDI,2023-06-02,2023-06-02,2023-06-02,2023-06-21,Clinical_Review,19,1878453830,1055872102,2084P0800X,Psychiatry,11,In_Network,Z00.00,OTHER,D0120,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,681.09,487.05,484.05,0.0,3.0,0.0,194.04,0.0,0.0,0,,0.0906,none,0,1,0,0,0,4.5e-05,0,0,,FFS
CLM0000002539,MBR00000143,Medical_Professional,Paid,Electronic_EDI,2023-01-28,2023-01-28,2023-01-28,2023-02-24,Auto_Adjudicated,27,1115589144,1587454801,207Q00000X,Family Medicine,11,In_Network,OTHER,,97110,,0,Commercial,POS,85,M,1.6078,,,350.78,130.91,0.0,130.91,0.0,0.0,219.87,0.0,0.0,0,,0.138,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002540,MBR00000194,Pharmacy,Partially_Paid,Electronic_EDI,2023-08-12,2023-08-12,2023-08-12,2023-09-06,Auto_Adjudicated,25,1014995735,1300957944,101YP2500X,Psychologist Clinical,23,In_Network,OTHER,E11.9,00310075090,,2,Commercial,PPO,77,M,0.9783,18,Medical_Necessity,128.18,55.15,0.0,40.5,0.0,0.0,87.68,0.0,0.0,0,,0.1016,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002541,MBR00000184,Pharmacy,Partially_Paid,Electronic_EDI,2023-08-09,2023-08-09,2023-08-09,2023-08-11,Auto_Adjudicated,2,1519736600,1112696614,101YP2500X,Psychologist Clinical,11,In_Network,I10,,16590051660,,5,Medicaid_MCO,MLTSS,30,M,2.8302,18,Medical_Necessity,354.79,172.21,91.17,0.0,2.0,0.0,261.62,0.0,0.0,0,,0.0063,none,0,1,0,1,0,8e-06,0,1,,Capitation
CLM0000002542,MBR00000014,Pharmacy,Paid,Electronic_EDI,2023-10-06,2023-10-06,2023-10-06,2023-10-18,Auto_Adjudicated,12,1567711165,1477113725,207Q00000X,Family Medicine,22,In_Network,E78.5,Z12.11,00078043215,,5,Commercial,HMO,77,M,2.8513,,,85.59,57.51,0.0,57.51,0.0,0.0,28.08,0.0,0.0,0,,0.0351,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002543,MBR00000028,Medical_Institutional,Paid,Electronic_EDI,2023-01-06,2023-01-06,2023-01-07,2023-02-01,Auto_Adjudicated,26,1826567270,1829216053,207RN0300X,Nephrology,21,Out_of_Network,OTHER,,revenue_code:0100,193,0,Commercial,HMO,3,F,2.116,,,23425.97,11296.3,8641.67,415.21,79.0,2160.42,12129.67,0.0,0.0,0,,0.0581,none,0,1,1,0,0,0.0008,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000002544,MBR00000111,Medical_Professional,Paid,Electronic_EDI,2023-02-04,2023-02-04,2023-02-04,2023-02-18,Auto_Adjudicated,14,1002224900,1419347445,101YP2500X,Psychologist Clinical,32,In_Network,C50.911,H52.4,43239,,0,Medicare_Advantage,MA_PPO,44,M,0.7462,,,794.11,333.7,238.13,20.04,16.0,59.53,460.41,0.0,0.0,0,,0.0605,none,0,1,0,0,0,2.2e-05,0,0,,FFS
CLM0000002545,MBR00000252,Pharmacy,Paid,Electronic_EDI,2023-03-15,2023-03-15,2023-03-15,2023-04-03,Auto_Adjudicated,19,1454749898,1650774392,2084P0800X,Psychiatry,65,In_Network,M54.5,E78.5,16590051660,,1,Medicare_Advantage,MA_HMO,80,M,0.7173,,,1165.46,464.56,353.6,7.56,15.0,88.4,700.9,0.0,0.0,0,,0.0766,none,0,1,0,0,0,3.3e-05,0,0,,FFS
CLM0000002546,MBR00000262,Medical_Institutional,Paid,Electronic_EDI,2023-06-07,2023-06-07,2023-06-11,2023-06-20,Auto_Adjudicated,13,1443292773,1576271272,207RP1001X,Pulmonary Disease,11,In_Network,R05.9,OTHER,revenue_code:0360,,0,Medicare_Advantage,PFFS,77,F,1.7452,,,10692.45,8533.38,6801.05,1.06,31.0,1700.26,2159.07,0.0,0.0,0,,0.0518,none,0,1,1,0,0,0.00063,0,0,SPD_Spirometry_Testing,Shared_Savings
CLM0000002547,MBR00000098,Medical_Professional,Denied,Electronic_EDI,2023-07-30,2023-07-30,2023-07-30,2023-07-31,Auto_Adjudicated,1,1124477249,1513198866,2086S0122X,Orthopedic Surgery,11,Emergency,OTHER,OTHER,90853,,0,Medicare_Advantage,MA_HMO,7,M,0.511,CO-45,Medical_Necessity,447.33,307.68,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0274,none,0,1,0,0,0,0.0,0,0,TRC_Transition_of_Care,Capitation
CLM0000002548,MBR00000212,Medical_Institutional,Paid,Electronic_EDI,2023-03-14,2023-03-14,2023-03-16,2023-03-31,Auto_Adjudicated,17,1084831484,1027261156,207RP1001X,Pulmonary Disease,81,In_Network,E11.9,Z79.4|I10,revenue_code:0360,,0,Commercial,HMO,57,F,2.5456,,,14989.13,8402.76,6513.79,192.52,68.0,1628.45,6586.37,0.0,0.0,0,,0.1248,none,0,1,1,0,0,0.000603,0,0,TRC_Transition_of_Care,FFS
CLM0000002549,MBR00000174,Medical_Institutional,Denied,Electronic_EDI,2023-05-09,2023-05-09,2023-05-13,2023-05-21,Auto_Adjudicated,12,1986485249,1163639177,225100000X,Physical Therapist,11,In_Network,K57.30,Z00.00|Z23,revenue_code:0210,,0,Medicare_Advantage,MA_HMO,85,M,0.3901,22,Medical_Necessity,13316.56,5315.49,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0151,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002550,MBR00000296,Medical_Institutional,Paid,Provider_Portal,2023-07-04,2023-07-04,2023-07-07,2023-07-28,Clinical_Review,24,1269720844,1140170394,2084P0800X,Psychiatry,11,In_Network,OTHER,E11.9,revenue_code:0450,,0,Commercial,HMO,83,F,1.4969,,,52125.84,34820.73,27736.5,107.1,43.0,6934.13,17305.11,0.0,0.0,0,,0.1769,outlier_billing_amount,0,1,1,1,0,0.002567,0,0,,Bundled_Payment
CLM0000002551,MBR00000028,Dental,Paid,Electronic_EDI,2023-07-15,2023-07-15,2023-07-15,2023-08-11,Auto_Adjudicated,27,1183801932,1157814306,207RN0300X,Nephrology,11,In_Network,Z00.01,OTHER,D7140,,0,Commercial,HMO,3,F,2.116,,,902.9,596.19,431.0,43.44,14.0,107.75,306.71,0.0,0.0,0,,0.0596,none,0,1,0,0,0,4e-05,0,0,,Bundled_Payment
CLM0000002552,MBR00000166,Medical_Institutional,Paid,Electronic_EDI,2023-07-08,2023-07-08,2023-07-09,2023-07-12,Auto_Adjudicated,4,1207523397,1898471307,208600000X,Surgery General,21,In_Network,OTHER,F32.9|Z79.4,revenue_code:0450,247,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,6223.27,2200.81,1164.0,470.96,67.0,498.86,4022.46,0.0,0.0,0,,0.0257,none,0,1,0,0,0,0.000108,0,0,IET_Initiation_Substance_Use,FFS
CLM0000002553,MBR00000178,Medical_Professional,Partially_Paid,Electronic_EDI,2023-08-18,2023-08-18,2023-08-18,2023-08-29,Clinical_Review,11,1928139578,1291071007,207RE0101X,Endocrinology,11,In_Network,OTHER,N18.3,33510,,0,Medicaid_MCO,MCO,89,M,0.7057,CO-45,Medical_Necessity,568.17,290.13,188.31,0.0,3.0,0.0,376.86,0.0,0.0,0,,0.0707,none,0,1,0,0,0,1.7e-05,0,0,,FFS
CLM0000002554,MBR00000097,Vision,Denied,Provider_Portal,2023-09-29,2023-09-29,2023-09-29,2023-10-11,Manual_Review,12,1924450526,1358873132,207R00000X,Internal Medicine,21,In_Network,L70.0,Z00.00,92004,,0,Commercial,EPO,34,M,1.3765,256,Eligibility,197.84,145.04,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0935,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002555,MBR00000014,Medical_Professional,Paid,Electronic_EDI,2023-10-29,2023-10-29,2023-10-29,2023-11-19,Auto_Adjudicated,21,1218294278,1554490060,207RG0100X,Gastroenterology,11,In_Network,M17.11,C50.911|OTHER,99284,,0,Commercial,HMO,77,M,2.8513,,,181.08,141.65,0.0,141.65,0.0,0.0,39.43,0.0,0.0,0,,0.0588,upcoding_pattern,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002556,MBR00000014,Medical_Professional,Paid,Electronic_EDI,2023-12-13,2023-12-13,2023-12-13,2023-12-25,Auto_Adjudicated,12,1346717076,1098360555,207RP1001X,Pulmonary Disease,24,In_Network,N18.3,F32.9,99204,,0,Commercial,HMO,77,M,2.8513,,,54.84,26.15,0.0,26.15,0.0,0.0,28.69,0.0,0.0,0,,0.1413,service_date_weekend,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002557,MBR00000141,Pharmacy,Denied,Electronic_EDI,2023-05-22,2023-05-22,2023-05-22,2023-06-08,Auto_Adjudicated,17,1192302048,1433350836,225100000X,Physical Therapist,11,In_Network,R05.9,,59148001506,,1,Commercial,HMO,47,F,0.6724,97,COB,695.08,398.41,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0502,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002558,MBR00000206,Vision,Paid,Electronic_EDI,2023-04-28,2023-04-28,2023-04-28,2023-05-26,Manual_Review,28,1262622669,1896197144,207RE0101X,Endocrinology,31,In_Network,I10,I25.10|I10,V2320,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,200.26,147.49,146.49,0.0,1.0,0.0,52.77,0.0,0.0,0,,0.0963,none,0,1,0,0,0,1.4e-05,0,0,CDC_BP_Control,Capitation
CLM0000002559,MBR00000208,Pharmacy,Paid,Paper,2023-04-11,2023-04-11,2023-04-11,2023-04-29,Auto_Adjudicated,18,1588313061,1325999602,207RG0100X,Gastroenterology,23,In_Network,M54.5,G47.33,00078043215,,5,Medicare_Advantage,MA_HMO,66,M,2.1466,,,125.97,81.66,49.63,13.63,6.0,12.41,44.31,0.0,0.0,0,,0.1389,none,0,1,0,0,0,5e-06,0,1,,FFS
CLM0000002560,MBR00000056,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-05-06,2023-05-06,2023-05-10,2023-05-09,Auto_Adjudicated,3,1918578486,1390802135,207Q00000X,Family Medicine,22,In_Network,Z00.01,OTHER,revenue_code:0200,,0,Commercial,EPO,74,F,1.3941,5,Medical_Necessity,145190.45,76456.78,31967.45,243.98,47.0,7991.86,104940.16,19558.47,8233.55,0,,0.1166,outlier_billing_amount|impossible_service_combo,0,1,1,0,0,0.002959,0,0,,Capitation
CLM0000002561,MBR00000259,Medical_Institutional,Paid,Electronic_EDI,2023-07-13,2023-07-13,2023-07-13,2023-07-28,Auto_Adjudicated,15,1699014308,1388050552,207RC0000X,Cardiovascular Disease,81,In_Network,Z12.11,,revenue_code:0100,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,6744.53,5637.07,4479.03,2.28,36.0,1119.76,1107.46,0.0,0.0,0,,0.0716,unusual_service_frequency,0,1,0,0,0,0.000415,0,0,,FFS
CLM0000002562,MBR00000120,Pharmacy,Paid,Electronic_EDI,2023-08-05,2023-08-05,2023-08-05,2023-09-01,Auto_Adjudicated,27,1017424540,1391074619,207V00000X,Obstetrics & Gynecology,21,In_Network,J45.20,C50.911|Z00.00|M54.5,00169751112,,3,Commercial,PPO,62,F,1.0823,,,155.48,94.09,0.0,94.09,0.0,0.0,61.39,0.0,0.0,0,,0.0717,impossible_service_combo,0,1,0,0,0,0.0,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000002563,MBR00000292,Dental,Denied,Electronic_EDI,2023-01-26,2023-01-26,2023-01-26,2023-02-10,Auto_Adjudicated,15,1462532026,1688513262,207V00000X,Obstetrics & Gynecology,11,In_Network,OTHER,OTHER|I50.9,D2140,,0,Medicare_Advantage,MA_HMO,4,M,1.1779,4,Network,410.85,272.41,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1397,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000002564,MBR00000036,Medical_Professional,Paid,Electronic_EDI,2023-12-25,2023-12-25,2023-12-25,2024-01-24,Auto_Adjudicated,30,1913217838,1527857018,207V00000X,Obstetrics & Gynecology,22,In_Network,Z12.11,M54.5,99393,,0,Commercial,EPO,17,M,2.0136,,,331.57,199.54,34.78,123.07,33.0,8.69,132.03,30.68,3.67,0,,0.0444,none,0,1,0,0,0,3e-06,0,0,,FFS
CLM0000002565,MBR00000250,Dental,Paid,Electronic_EDI,2023-01-16,2023-01-16,2023-01-16,2023-02-13,Auto_Adjudicated,28,1588313061,1522426351,246ZN0300X,Neuropsychology,11,In_Network,F33.0,,D3310,,0,Commercial,PPO,41,M,0.9245,,,241.47,100.04,0.0,100.04,0.0,0.0,141.43,0.0,0.0,0,,0.0635,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002566,MBR00000274,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-05-24,2023-05-24,2023-05-24,2023-06-01,Auto_Adjudicated,8,1324142620,1034732777,246ZN0300X,Neuropsychology,11,In_Network,J44.1,J44.1,revenue_code:0370,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,3,Medical_Necessity,32978.72,20543.46,10590.68,5.29,46.0,2647.67,19689.08,6520.98,2642.66,0,,0.0197,none,0,1,1,0,0,0.00098,0,0,TRC_Transition_of_Care,Capitation
CLM0000002567,MBR00000245,Medical_Professional,Paid,Electronic_EDI,2023-06-12,2023-06-12,2023-06-12,2023-06-25,Auto_Adjudicated,13,1976612978,1746676564,207RC0000X,Cardiovascular Disease,65,In_Network,F32.9,,99386,,0,Medicaid_MCO,MCO,60,F,0.7502,,,303.41,148.67,146.67,0.0,2.0,0.0,154.74,0.0,0.0,0,,0.0966,none,0,1,0,0,0,1.4e-05,0,0,,Shared_Savings
CLM0000002568,MBR00000240,Medical_Professional,Paid,Electronic_EDI,2023-05-04,2023-05-04,2023-05-04,2023-05-10,Auto_Adjudicated,6,1907932706,1433350836,207RE0101X,Endocrinology,32,In_Network,M47.816,I10,99232,,0,Medicaid_MCO,MCO,9,F,0.386,,,296.18,107.21,105.21,0.0,2.0,0.0,188.97,0.0,0.0,0,,0.1376,none,0,1,0,0,0,1e-05,0,0,AWV_Annual_Wellness_Visit,Capitation
CLM0000002569,MBR00000114,Medical_Professional,Paid,Provider_Portal,2023-03-20,2023-03-20,2023-03-20,2023-03-26,Auto_Adjudicated,6,1026612378,1896197144,207V00000X,Obstetrics & Gynecology,22,Out_of_Network,I10,OTHER|Z12.11|E11.9,97110,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,405.59,174.8,109.78,18.57,19.0,27.45,230.79,0.0,0.0,0,,0.0715,none,0,1,0,0,0,1e-05,1,0,,Shared_Savings
CLM0000002570,MBR00000211,Vision,Paid,Electronic_EDI,2023-07-10,2023-07-10,2023-07-10,2023-07-22,Manual_Review,12,1216417633,1098360555,101YP2500X,Psychologist Clinical,22,In_Network,Z00.00,Z00.00|I50.9,92012,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,,,262.3,213.26,160.73,0.34,12.0,40.18,49.04,0.0,0.0,0,,0.1182,phantom_billing_indicator,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000002571,MBR00000175,Medical_Institutional,Paid,Electronic_EDI,2023-01-03,2023-01-03,2023-01-06,2023-01-16,Clinical_Review,13,1323379997,1810068286,207RG0100X,Gastroenterology,22,Out_of_Network,J06.9,K57.30|G47.33|M54.5,revenue_code:0120,,0,Commercial,PPO,14,F,1.5785,,,28851.05,21646.43,17271.9,8.56,48.0,4317.97,7204.62,0.0,0.0,0,,0.102,none,0,1,1,0,0,0.001599,1,0,,Bundled_Payment
CLM0000002572,MBR00000134,Pharmacy,Paid,Electronic_EDI,2023-09-24,2023-09-24,2023-09-24,2023-10-05,Clinical_Review,11,1443292773,1396850418,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,OTHER,59148001506,,3,Medicare_Advantage,MA_PPO,33,M,1.115,,,393.61,142.12,101.94,1.7,13.0,25.48,251.49,0.0,0.0,0,,0.0816,none,0,1,0,0,0,9e-06,0,1,,FFS
CLM0000002573,MBR00000298,Medical_Professional,Denied,Electronic_EDI,2023-09-01,2023-09-01,2023-09-01,2023-09-23,Auto_Adjudicated,22,1220235547,1985590322,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,,20610,,0,Medicaid_MCO,MCO,75,M,0.8324,CO-45,Authorization,481.35,315.17,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.093,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002574,MBR00000091,Pharmacy,Paid,Electronic_EDI,2023-10-04,2023-10-04,2023-10-04,2023-10-09,Auto_Adjudicated,5,1683650935,1012893364,2084P0800X,Psychiatry,22,In_Network,Z79.4,OTHER|N18.3|F33.0,00078043215,,3,Commercial,PPO,13,F,1.2451,,,96.91,62.43,0.0,62.43,0.0,0.0,34.48,0.0,0.0,0,,0.1221,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002575,MBR00000131,Medical_Institutional,Paid,Paper,2023-10-20,2023-10-20,2023-10-24,2023-11-04,Auto_Adjudicated,15,1120678352,1690197969,207R00000X,Internal Medicine,21,In_Network,I25.10,E11.9|OTHER,revenue_code:0210,871,0,Commercial,EPO,15,F,0.9228,,,26458.56,15489.49,12171.01,237.72,38.0,3042.75,10969.07,0.0,0.0,0,,0.162,npi_mismatch,0,1,1,0,0,0.001127,0,0,IET_Initiation_Substance_Use,FFS
CLM0000002576,MBR00000274,Vision,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-12-12,Manual_Review,27,1901547390,1643323506,207RG0100X,Gastroenterology,11,In_Network,Z79.4,Z00.01,92002,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,325.53,137.38,82.37,34.42,0.0,20.59,188.15,0.0,0.0,0,,0.0162,none,0,1,0,0,0,8e-06,0,0,,Capitation
CLM0000002577,MBR00000091,Medical_Institutional,Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-24,2023-03-17,Manual_Review,22,1462532026,1847196500,207RN0300X,Nephrology,23,In_Network,K21.0,,revenue_code:0370,,0,Commercial,PPO,13,F,1.2451,,,26418.48,21606.06,17157.15,125.62,34.0,4289.29,4812.42,0.0,0.0,0,,0.0511,none,0,1,1,0,0,0.001588,0,0,,FFS
CLM0000002578,MBR00000049,Pharmacy,Denied,Electronic_EDI,2023-10-27,2023-10-27,2023-10-27,2023-11-03,Auto_Adjudicated,7,1083045036,1878017518,207RN0300X,Nephrology,22,In_Network,E78.5,OTHER|Z23,00069420020,,2,Medicare_Advantage,PFFS,67,M,0.978,16,Coding_Error,82.92,50.58,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0586,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002579,MBR00000098,Medical_Institutional,Paid,Electronic_EDI,2023-07-22,2023-07-22,2023-07-25,2023-07-30,Auto_Adjudicated,8,1688560518,1415734567,207V00000X,Obstetrics & Gynecology,21,Out_of_Network,Z00.00,,revenue_code:0200,439,0,Medicare_Advantage,MA_HMO,7,M,0.511,,,11770.43,8432.68,6692.21,27.42,40.0,1673.05,3337.75,0.0,0.0,0,,0.0408,none,0,1,1,1,1,0.000619,1,0,,Capitation
CLM0000002580,MBR00000223,Medical_Institutional,Paid,Paper,2023-02-14,2023-02-14,2023-02-17,2023-03-14,Auto_Adjudicated,28,1501282310,1542515060,208600000X,Surgery General,65,In_Network,Z00.00,Z00.01|Z00.00|OTHER,revenue_code:0300,,0,Commercial,PPO,65,F,0.3534,,,26477.67,20513.59,16361.05,22.27,40.0,4090.26,5964.08,0.0,0.0,0,,0.0496,none,0,1,1,0,0,0.001514,0,0,,Shared_Savings
CLM0000002581,MBR00000259,Vision,Paid,Electronic_EDI,2023-12-20,2023-12-20,2023-12-20,2024-01-07,Auto_Adjudicated,18,1542851144,1356856197,207RE0101X,Endocrinology,24,In_Network,OTHER,E11.65|K21.0,V2103,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,196.12,163.06,116.03,11.02,7.0,29.01,33.06,0.0,0.0,0,,0.155,diagnosis_procedure_mismatch,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000002582,MBR00000036,Medical_Institutional,Paid,Electronic_EDI,2023-10-19,2023-10-19,2023-10-22,2023-11-15,Auto_Adjudicated,27,1826043246,1510751265,207RN0300X,Nephrology,22,In_Network,J45.20,,revenue_code:0300,,0,Commercial,EPO,17,M,2.0136,,,65591.55,26542.36,21166.89,43.74,40.0,5291.72,39049.19,13510.95,3906.0,0,,0.2335,outlier_billing_amount|service_date_weekend,0,2,1,0,0,0.001959,0,0,,Bundled_Payment
CLM0000002583,MBR00000185,Dental,Paid,Provider_Portal,2023-04-07,2023-04-07,2023-04-07,2023-05-03,Auto_Adjudicated,26,1404237143,1175334579,2084P0800X,Psychiatry,11,In_Network,E13.9,,D4341,,0,Medicaid_MCO,MCO,73,M,1.5417,,,930.82,504.62,501.62,0.0,3.0,0.0,426.2,0.0,0.0,0,,0.046,none,0,1,0,1,0,4.6e-05,0,0,,Bundled_Payment
CLM0000002584,MBR00000170,Medical_Professional,Denied,Electronic_EDI,2023-11-16,2023-11-16,2023-11-16,2023-11-30,Auto_Adjudicated,14,1208538971,1985590322,207RG0100X,Gastroenterology,23,In_Network,OTHER,,74177,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,170,Medical_Necessity,563.56,345.31,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1045,none,0,1,0,0,0,0.0,0,0,LCS_Lung_Cancer_Screening,Capitation
CLM0000002585,MBR00000198,Pharmacy,Paid,Electronic_EDI,2023-09-20,2023-09-20,2023-09-20,2023-10-06,Auto_Adjudicated,16,1424104563,1477113725,208600000X,Surgery General,23,In_Network,N18.3,OTHER|F32.9,50458085930,,3,Medicaid_MCO,MCO,81,F,1.4199,,,153.79,98.29,96.29,0.0,2.0,0.0,55.5,0.0,0.0,0,,0.1962,provider_specialty_mismatch,0,1,0,0,0,9e-06,0,1,PCR_Plan_All_Cause_Readmission,Bundled_Payment
CLM0000002586,MBR00000199,Dental,Paid,Provider_Portal,2023-06-10,2023-06-10,2023-06-10,2023-06-22,Auto_Adjudicated,12,1019263018,1619587398,207Q00000X,Family Medicine,22,In_Network,I50.9,,D2140,,0,Medicaid_MCO,MLTSS,17,F,1.0776,,,424.38,341.68,339.68,0.0,2.0,0.0,82.7,0.0,0.0,0,,0.0343,none,0,1,0,1,0,3.1e-05,0,0,,Shared_Savings
CLM0000002587,MBR00000291,Dental,Denied,Paper,2023-02-28,2023-02-28,2023-02-28,2023-03-20,Auto_Adjudicated,20,1650193199,1321680994,207Q00000X,Family Medicine,23,In_Network,OTHER,OTHER,D2140,,0,Commercial,PPO,78,M,1.4773,CO-45,Eligibility,387.58,228.93,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0259,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002588,MBR00000109,Medical_Institutional,Denied,Electronic_EDI,2023-09-20,2023-09-20,2023-09-24,2023-10-10,Auto_Adjudicated,20,1636337876,1574982369,207RN0300X,Nephrology,11,Out_of_Network,I10,OTHER,revenue_code:0210,,0,Commercial,HMO,8,F,0.5723,CO-45,Medical_Necessity,35803.69,26250.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0819,none,0,1,0,0,0,0.0,1,0,,Shared_Savings
CLM0000002589,MBR00000094,Medical_Institutional,Paid,Electronic_EDI,2023-12-01,2023-12-01,2023-12-01,2023-12-22,Auto_Adjudicated,21,1556072255,1148659045,2086S0122X,Orthopedic Surgery,21,In_Network,I10,M25.511,revenue_code:0450,292,0,Commercial,POS,36,F,0.3997,,,5431.19,3122.32,2185.26,324.74,66.0,546.32,2308.87,0.0,0.0,0,,0.0915,none,0,1,0,1,0,0.000202,0,0,,Shared_Savings
CLM0000002590,MBR00000175,Pharmacy,Denied,Paper,2023-03-11,2023-03-11,2023-03-11,2023-04-06,Auto_Adjudicated,26,1310400164,1809122260,207RN0300X,Nephrology,32,In_Network,E11.65,Z00.01|OTHER,00310075090,,3,Commercial,PPO,14,F,1.5785,3,Timely_Filing,89.73,48.64,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0526,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002591,MBR00000135,Medical_Professional,Paid,Electronic_EDI,2023-01-01,2023-01-01,2023-01-01,2023-01-24,Auto_Adjudicated,23,1896279539,1977073565,101YP2500X,Psychologist Clinical,11,Out_of_Network,Z00.01,,99391,,0,Commercial,PPO,58,F,2.2702,,,320.63,153.9,90.65,3.59,37.0,22.66,166.73,0.0,0.0,0,,0.0705,none,0,1,0,0,0,8e-06,1,0,,FFS
CLM0000002592,MBR00000145,Vision,Denied,Electronic_EDI,2023-03-24,2023-03-24,2023-03-24,2023-03-28,Manual_Review,4,1177281088,1689327034,207RE0101X,Endocrinology,22,In_Network,G47.33,,92014,,0,Medicaid_MCO,MLTSS,46,M,0.5813,97,Eligibility,358.62,179.96,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0053,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002593,MBR00000022,Medical_Professional,Paid,Electronic_EDI,2023-04-16,2023-04-16,2023-04-16,2023-04-27,Auto_Adjudicated,11,1338575285,1498781755,208600000X,Surgery General,65,In_Network,OTHER,Z79.4,99396,,0,Medicare_Advantage,MA_HMO,34,M,0.9472,,,275.02,183.75,111.58,28.27,16.0,27.9,91.27,0.0,0.0,0,,0.0052,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000002594,MBR00000046,Medical_Professional,Paid,Electronic_EDI,2023-05-17,2023-05-17,2023-05-17,2023-06-04,Manual_Review,18,1891821845,1884259357,2084P0800X,Psychiatry,11,In_Network,OTHER,Z23|OTHER|Z00.00,99202,,0,Commercial,HMO,76,F,0.9613,,,438.14,165.49,62.11,52.86,35.0,15.53,272.65,0.0,0.0,0,,0.08,unusual_service_frequency,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000002595,MBR00000282,Pharmacy,Paid,Electronic_EDI,2023-12-17,2023-12-17,2023-12-17,2024-01-05,Auto_Adjudicated,19,1317654726,1774401124,207RN0300X,Nephrology,81,In_Network,M54.5,I10,00169751112,,2,Medicare_Advantage,MA_HMO,16,M,0.7304,,,537.45,272.03,171.18,40.05,18.0,42.8,265.42,0.0,0.0,0,,0.1008,none,0,1,0,0,0,1.6e-05,0,1,,Capitation
CLM0000002596,MBR00000021,Medical_Institutional,Denied,Electronic_EDI,2023-12-12,2023-12-12,2023-12-12,2024-01-07,Auto_Adjudicated,26,1102040918,1005335812,225100000X,Physical Therapist,32,In_Network,E11.9,,revenue_code:0450,,0,Commercial,POS,72,M,0.6126,2,COB,23507.87,16158.83,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1016,upcoding_pattern,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,Shared_Savings
CLM0000002597,MBR00000177,Medical_Professional,Paid,Electronic_EDI,2023-08-29,2023-08-29,2023-08-29,2023-09-11,Auto_Adjudicated,13,1658094898,1847196500,207RE0101X,Endocrinology,23,In_Network,OTHER,K57.30,74178,,0,Commercial,HMO,42,F,1.2774,,,842.88,332.75,52.54,240.08,27.0,13.13,510.13,0.0,0.0,0,,0.107,none,0,1,0,0,0,5e-06,0,0,DAE_Drug_Alcohol_Dependence,Bundled_Payment
CLM0000002598,MBR00000221,Medical_Professional,Paid,Electronic_EDI,2023-03-20,2023-03-20,2023-03-20,2023-04-14,Auto_Adjudicated,25,1368580443,1325999602,207Q00000X,Family Medicine,23,In_Network,OTHER,,73721,,0,Commercial,HDHP_HSA,28,M,1.6683,,,558.57,346.45,0.0,346.45,0.0,0.0,212.12,0.0,0.0,0,,0.1273,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002599,MBR00000004,Behavioral_Health,Paid,Electronic_EDI,2023-03-18,2023-03-18,2023-03-18,2023-03-30,Auto_Adjudicated,12,1952322604,1690197969,2086S0122X,Orthopedic Surgery,32,In_Network,M54.5,Z79.4|N39.0,17000,,0,Medicare_Advantage,MA_PPO,68,M,1.23,,,228.41,132.39,82.54,21.21,8.0,20.64,96.02,0.0,0.0,0,,0.0741,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000002600,MBR00000069,Medical_Institutional,Paid,Electronic_EDI,2023-01-30,2023-01-30,2023-02-03,2023-02-04,Auto_Adjudicated,5,1478458171,1643673796,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,I50.9,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,2,M,0.5765,,,3508.79,1342.33,1012.71,39.44,37.0,253.18,2166.46,0.0,0.0,0,,0.0936,none,0,1,0,0,0,9.4e-05,0,0,POD_Persistence_of_Beta_Blocker,Shared_Savings
CLM0000002601,MBR00000120,Behavioral_Health,Paid,Electronic_EDI,2023-10-12,2023-10-12,2023-10-12,2023-10-27,Manual_Review,15,1461820376,1061113875,208600000X,Surgery General,23,In_Network,OTHER,OTHER|I10|J06.9,27447,,0,Commercial,PPO,62,F,1.0823,,,121.37,47.12,0.0,47.12,0.0,0.0,74.25,0.0,0.0,0,,0.0858,high_volume_same_code,0,1,0,0,0,0.0,0,0,DAE_Drug_Alcohol_Dependence,FFS
CLM0000002602,MBR00000156,Medical_Professional,Paid,Electronic_EDI,2023-03-21,2023-03-21,2023-03-21,2023-03-26,Auto_Adjudicated,5,1319616460,1672803287,208600000X,Surgery General,21,In_Network,J06.9,M54.5,17000,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,1568.81,1020.37,782.71,28.98,13.0,195.68,548.44,0.0,0.0,0,,0.0265,none,0,1,0,0,0,7.2e-05,0,0,,FFS
CLM0000002603,MBR00000107,Medical_Institutional,Denied,Electronic_EDI,2023-11-19,2023-11-19,2023-11-21,2023-12-02,Manual_Review,13,1124477249,1894215172,246ZN0300X,Neuropsychology,32,In_Network,J06.9,OTHER,revenue_code:0360,,0,Medicare_Advantage,MA_PPO,44,M,1.0439,18,COB,58157.77,35709.33,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2071,outlier_billing_amount|duplicate_claim_indicator,0,2,0,0,0,0.0,0,0,,Capitation
CLM0000002604,MBR00000193,Medical_Professional,Denied,Electronic_EDI,2023-08-04,2023-08-04,2023-08-04,2023-08-12,Auto_Adjudicated,8,1542851144,1312595355,2084P0800X,Psychiatry,22,In_Network,OTHER,,99396,,0,Commercial,PPO,11,M,0.5266,256,Timely_Filing,141.41,100.45,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0326,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002605,MBR00000071,Medical_Institutional,Paid,Electronic_EDI,2023-06-24,2023-06-24,2023-06-26,2023-06-25,Auto_Adjudicated,1,1830816512,1450837722,207RP1001X,Pulmonary Disease,24,Out_of_Network,J45.20,,revenue_code:0210,,0,Commercial,EPO,19,F,0.5699,,,19624.24,12994.14,10324.44,19.59,69.0,2581.11,6630.1,0.0,0.0,0,,0.0734,service_date_weekend,0,1,1,0,0,0.000956,1,0,,FFS
CLM0000002606,MBR00000008,Medical_Professional,Paid,Electronic_EDI,2023-11-30,2023-11-30,2023-11-30,2023-12-20,Auto_Adjudicated,20,1464997678,1522426351,246ZN0300X,Neuropsychology,11,In_Network,F33.0,,99395,,0,Medicaid_MCO,MCO,74,M,0.8375,,,130.65,77.88,76.88,0.0,1.0,0.0,52.77,0.0,0.0,0,,0.1393,none,0,1,0,0,0,7e-06,0,0,FLU_Flu_Vaccination,Shared_Savings
CLM0000002607,MBR00000001,Medical_Professional,Paid,Electronic_EDI,2023-02-26,2023-02-26,2023-02-26,2023-03-21,Auto_Adjudicated,23,1874914200,1994275960,2084P0800X,Psychiatry,11,In_Network,OTHER,I10|J06.9,99214,,0,Commercial,EPO,73,M,0.6527,,,638.28,361.21,184.65,102.4,28.0,46.16,277.07,0.0,0.0,0,,0.0963,none,0,1,0,1,0,1.7e-05,0,0,,Capitation
CLM0000002608,MBR00000109,Medical_Institutional,Paid,Electronic_EDI,2023-06-16,2023-06-16,2023-06-18,2023-06-20,Manual_Review,4,1229304423,1747935894,207V00000X,Obstetrics & Gynecology,31,In_Network,OTHER,OTHER|I50.9|Z00.00,revenue_code:0110,,0,Commercial,HMO,8,F,0.5723,,,11821.2,6019.17,4732.47,48.58,55.0,1183.12,5802.03,0.0,0.0,0,,0.0513,none,0,1,0,1,0,0.000438,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000002609,MBR00000114,Pharmacy,Paid,Electronic_EDI,2023-04-03,2023-04-03,2023-04-03,2023-04-21,Auto_Adjudicated,18,1519736600,1884259357,2084P0800X,Psychiatry,21,In_Network,Z00.00,,00310075090,,2,Medicare_Advantage,MA_PPO,57,F,1.0712,,,1350.7,499.83,373.6,13.83,19.0,93.4,850.87,0.0,0.0,0,,0.0027,none,0,1,0,0,0,3.5e-05,0,0,COA_Care_Transitions,FFS
CLM0000002610,MBR00000287,Medical_Institutional,Paid,Electronic_EDI,2023-03-07,2023-03-07,2023-03-08,2023-03-23,Auto_Adjudicated,16,1731980913,1767402068,207RP1001X,Pulmonary Disease,22,In_Network,F41.1,OTHER|Z00.00|N39.0,revenue_code:0250,,0,Commercial,PPO,4,M,0.7685,,,6766.23,2632.73,1919.81,175.97,57.0,479.95,4133.5,0.0,0.0,0,,0.103,unbundling_pattern,0,1,0,0,0,0.000178,0,0,,FFS
CLM0000002611,MBR00000013,Medical_Institutional,Paid,Provider_Portal,2023-12-05,2023-12-05,2023-12-06,2023-12-10,Auto_Adjudicated,5,1211612843,1187669363,207V00000X,Obstetrics & Gynecology,23,Out_of_Network,OTHER,E11.9,revenue_code:0450,,0,Commercial,PPO,64,F,1.428,,,7584.76,4846.95,3804.31,55.56,36.0,951.08,2737.81,0.0,0.0,0,,0.1184,high_volume_same_code|duplicate_claim_indicator,0,1,0,0,0,0.000352,0,0,,Shared_Savings
CLM0000002612,MBR00000161,Medical_Institutional,Paid,Electronic_EDI,2023-08-06,2023-08-06,2023-08-07,2023-08-25,Clinical_Review,19,1732726112,1452088018,246ZN0300X,Neuropsychology,11,In_Network,Z00.01,Z79.4|E78.5,revenue_code:0120,,0,Medicaid_MCO,MLTSS,9,F,0.8354,,,17193.57,11001.04,10996.04,0.0,5.0,0.0,6192.53,0.0,0.0,0,,0.0928,none,0,1,1,0,0,0.001018,0,0,,Capitation
CLM0000002613,MBR00000174,Medical_Institutional,Paid,Provider_Portal,2023-02-27,2023-02-27,2023-02-27,2023-03-07,Auto_Adjudicated,8,1739169232,1356856197,207RE0101X,Endocrinology,11,In_Network,Z00.00,OTHER|E11.65|M54.5,revenue_code:0300,,0,Medicare_Advantage,MA_HMO,85,M,0.3901,,,72995.35,27197.47,21706.04,6.92,58.0,5426.51,45797.88,0.0,0.0,1,DME Fraud,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|high_volume_same_code|impossible_service_combo|service_date_weekend|upcoding_pattern|diagnosis_procedure_mismatch|high_oop_waiver,1,5,1,0,0,0.002009,0,0,KED_ESRD_Patients,FFS
CLM0000002614,MBR00000208,Pharmacy,Denied,Electronic_EDI,2023-02-08,2023-02-08,2023-02-08,2023-03-05,Manual_Review,25,1033622184,1175334579,207RC0000X,Cardiovascular Disease,21,Out_of_Network,OTHER,OTHER|F41.1|J06.9,00169751112,,1,Medicare_Advantage,MA_HMO,66,M,2.1466,50,Authorization,392.35,222.63,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1308,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002615,MBR00000189,Pharmacy,Paid,Electronic_EDI,2023-04-22,2023-04-22,2023-04-22,2023-05-11,Manual_Review,19,1484613641,1489434038,208600000X,Surgery General,65,In_Network,OTHER,F32.9,00069420020,,1,Medicaid_MCO,MCO,71,F,0.9722,,,150.23,123.9,119.9,0.0,4.0,0.0,26.33,0.0,0.0,0,,0.1474,diagnosis_procedure_mismatch,0,1,0,0,0,1.1e-05,0,0,W30_Well_Child_Visit,Shared_Savings
CLM0000002616,MBR00000003,Pharmacy,Denied,Electronic_EDI,2023-10-27,2023-10-27,2023-10-27,2023-10-31,Auto_Adjudicated,4,1067329999,1666461892,207RP1001X,Pulmonary Disease,11,In_Network,I10,J20.9,00006001954,,3,Commercial,PPO,79,F,1.3879,97,Medical_Necessity,395.98,175.82,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0716,unusual_service_frequency,0,1,0,0,0,0.0,0,0,TRC_Transition_of_Care,Bundled_Payment
CLM0000002617,MBR00000187,Medical_Professional,Paid,Electronic_EDI,2023-02-22,2023-02-22,2023-02-22,2023-03-10,Auto_Adjudicated,16,1905691248,1396850418,207RN0300X,Nephrology,21,In_Network,I10,OTHER|Z00.00,99212,,0,Medicaid_MCO,MCO,36,F,1.191,,,851.13,624.79,621.79,0.0,3.0,0.0,226.34,0.0,0.0,0,,0.1894,impossible_service_combo,0,1,0,0,0,5.8e-05,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000002618,MBR00000102,Medical_Institutional,Paid,Paper,2023-09-24,2023-09-24,2023-09-25,2023-09-28,Auto_Adjudicated,4,1711104790,1587454801,101YP2500X,Psychologist Clinical,81,In_Network,OTHER,,revenue_code:0110,,0,Commercial,POS,68,M,1.6864,,,47835.41,28895.9,22952.8,139.9,65.0,5738.2,18939.51,0.0,0.0,1,Code Substitution,0.8033,outlier_billing_amount|unusual_service_frequency|temporal_clustering|service_date_weekend|unbundling_pattern|high_oop_waiver,1,5,1,0,0,0.002124,0,0,,Capitation
CLM0000002619,MBR00000228,Pharmacy,Denied,Provider_Portal,2023-02-07,2023-02-07,2023-02-07,2023-03-01,Auto_Adjudicated,22,1567711165,1763260577,2086S0122X,Orthopedic Surgery,31,Out_of_Network,E11.9,Z12.11,00071012831,,3,Commercial,PPO,55,F,0.7203,18,Authorization,253.29,187.16,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0616,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002620,MBR00000059,Vision,Paid,Electronic_EDI,2023-05-01,2023-05-01,2023-05-01,2023-05-10,Clinical_Review,9,1177281088,1623053477,246ZN0300X,Neuropsychology,23,In_Network,I10,M25.511|OTHER,92004,,0,Medicare_Advantage,SNP,12,F,1.266,,,105.21,51.12,14.74,16.69,16.0,3.69,54.09,0.0,0.0,0,,0.0101,none,0,1,0,0,0,1e-06,0,0,,Capitation
CLM0000002621,MBR00000212,Medical_Institutional,Paid,Electronic_EDI,2023-07-07,2023-07-07,2023-07-11,2023-07-22,Auto_Adjudicated,15,1658094898,1994275960,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,,revenue_code:0120,,0,Commercial,HMO,57,F,2.5456,,,22579.25,19016.77,15084.26,93.44,68.0,3771.07,3562.48,0.0,0.0,0,,0.1731,geographic_mismatch,0,1,1,0,0,0.001396,0,0,,Shared_Savings
CLM0000002622,MBR00000186,Medical_Institutional,Paid,Electronic_EDI,2023-02-16,2023-02-16,2023-02-16,2023-03-09,Auto_Adjudicated,21,1288855406,1509799493,2084P0800X,Psychiatry,31,In_Network,OTHER,I10,revenue_code:0250,,0,Commercial,PPO,65,M,1.6983,,,2675.72,1418.12,964.15,162.93,50.0,241.04,1257.6,0.0,0.0,0,,0.1453,none,0,1,0,0,0,8.9e-05,0,0,,FFS
CLM0000002623,MBR00000194,Pharmacy,Paid,Electronic_EDI,2023-05-23,2023-05-23,2023-05-23,2023-06-18,Auto_Adjudicated,26,1719850506,1132693989,246ZN0300X,Neuropsychology,71,In_Network,Z23,Z00.00,00078043215,,1,Commercial,PPO,77,M,0.9783,,,319.76,212.13,121.15,42.69,18.0,30.29,107.63,0.0,0.0,0,,0.0858,none,0,1,0,0,0,1.1e-05,0,0,,Capitation
CLM0000002624,MBR00000055,Behavioral_Health,Paid,Electronic_EDI,2023-04-07,2023-04-07,2023-04-07,2023-04-23,Auto_Adjudicated,16,1346717076,1705448933,207RC0000X,Cardiovascular Disease,65,In_Network,F33.0,OTHER,90853,,0,Commercial,PPO,68,F,1.2896,,,215.61,149.16,48.84,78.11,10.0,12.21,66.45,0.0,0.0,0,,0.0341,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000002625,MBR00000198,Medical_Institutional,Paid,Paper,2023-01-17,2023-01-17,2023-01-20,2023-01-20,Auto_Adjudicated,3,1636337876,1867389043,207RE0101X,Endocrinology,23,In_Network,K21.0,,revenue_code:0370,,0,Medicaid_MCO,MCO,81,F,1.4199,,,29643.0,20165.78,20163.78,0.0,2.0,0.0,9477.22,0.0,0.0,0,,0.0544,none,0,1,1,1,0,0.001866,0,0,,FFS
CLM0000002626,MBR00000215,Medical_Professional,Denied,Provider_Portal,2023-01-01,2023-01-01,2023-01-01,2023-01-09,Manual_Review,8,1272115456,1390802135,207RN0300X,Nephrology,23,In_Network,E78.5,OTHER|N40.0|J20.9,74177,,0,ACA_Marketplace,ACA_Silver,69,M,0.8895,1,Coding_Error,672.46,413.46,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0567,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002627,MBR00000152,Pharmacy,Paid,Electronic_EDI,2023-02-22,2023-02-22,2023-02-22,2023-03-13,Manual_Review,19,1713343912,1898471307,225100000X,Physical Therapist,24,In_Network,OTHER,E11.9|OTHER,50458085930,,4,Commercial,HMO,82,F,1.2506,,,557.57,383.76,93.91,249.37,17.0,23.48,173.81,0.0,0.0,0,,0.0913,none,0,1,0,0,0,9e-06,0,1,,FFS
CLM0000002628,MBR00000106,Pharmacy,Paid,Electronic_EDI,2023-09-26,2023-09-26,2023-09-26,2023-09-28,Auto_Adjudicated,2,1086690796,1388050552,207RN0300X,Nephrology,24,In_Network,J20.9,,59148001506,,3,Medicare_Advantage,MA_PPO,69,M,1.7254,,,284.56,196.25,123.72,35.6,6.0,30.93,88.31,0.0,0.0,0,,0.122,none,0,1,0,1,0,1.1e-05,0,0,,FFS
CLM0000002629,MBR00000052,Medical_Professional,Paid,Electronic_EDI,2023-01-14,2023-01-14,2023-01-14,2023-01-26,Auto_Adjudicated,12,1887322427,1574982369,207V00000X,Obstetrics & Gynecology,24,In_Network,M79.3,F10.10,99213,,0,Commercial,PPO,0,F,1.325,,,485.71,349.15,139.32,142.99,32.0,34.83,136.56,0.0,0.0,0,,0.0618,duplicate_claim_indicator,0,1,0,1,0,1.3e-05,0,0,,FFS
CLM0000002630,MBR00000091,Medical_Professional,Denied,Electronic_EDI,2023-07-01,2023-07-01,2023-07-01,2023-07-11,Auto_Adjudicated,10,1061181028,1133410177,2086S0122X,Orthopedic Surgery,11,Out_of_Network,Z23,,71250,,0,Commercial,PPO,13,F,1.2451,5,Timely_Filing,496.76,354.24,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0705,none,0,1,0,1,0,0.0,1,0,,FFS
CLM0000002631,MBR00000224,Medical_Institutional,Paid,Electronic_EDI,2023-01-09,2023-01-09,2023-01-09,2023-01-19,Auto_Adjudicated,10,1954226809,1865266296,207RG0100X,Gastroenterology,24,In_Network,M17.11,,revenue_code:0200,,0,Medicaid_MCO,MCO,86,F,1.3289,,,8099.82,5561.29,5552.29,0.0,9.0,0.0,2538.53,0.0,0.0,0,,0.1252,none,0,1,1,0,0,0.000514,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000002632,MBR00000130,Pharmacy,Paid,Electronic_EDI,2023-03-19,2023-03-19,2023-03-19,2023-04-17,Auto_Adjudicated,29,1413983739,1977073565,2086S0122X,Orthopedic Surgery,21,In_Network,E78.5,M47.816,00071012831,,1,Medicare_Advantage,MA_PPO,58,M,1.3394,,,59.02,47.53,29.15,7.09,4.0,7.29,11.49,0.0,0.0,0,,0.1581,duplicate_claim_indicator,0,1,0,0,0,3e-06,0,1,,FFS
CLM0000002633,MBR00000208,Pharmacy,Partially_Paid,Electronic_EDI,2023-03-06,2023-03-06,2023-03-06,2023-04-04,Auto_Adjudicated,29,1571330665,1581533104,207RP1001X,Pulmonary Disease,11,In_Network,K21.0,OTHER,00071012831,,1,Medicare_Advantage,MA_HMO,66,M,2.1466,PR-1,Medical_Necessity,72.45,57.9,11.73,22.48,6.0,2.93,29.3,0.0,0.0,0,,0.1613,phantom_billing_indicator,0,1,0,0,0,1e-06,0,1,MMA_Medication_Management,Capitation
CLM0000002634,MBR00000217,Medical_Professional,Paid,Electronic_EDI,2023-05-03,2023-05-03,2023-05-03,2023-05-30,Clinical_Review,27,1874914200,1354959095,207RG0100X,Gastroenterology,11,In_Network,Z79.4,OTHER,99385,,0,ACA_Marketplace,ACA_Bronze,11,F,1.1619,,,293.91,109.13,0.0,109.13,0.0,0.0,184.78,0.0,0.0,0,,0.04,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002635,MBR00000200,Medical_Professional,Denied,Electronic_EDI,2023-09-24,2023-09-24,2023-09-24,2023-10-20,Auto_Adjudicated,26,1747318937,1829216053,246ZN0300X,Neuropsychology,11,In_Network,OTHER,,99283,,0,Commercial,HDHP_HSA,29,M,0.8011,CO-45,Duplicate,289.32,243.18,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0582,none,0,1,0,0,0,0.0,0,0,MMA_Medication_Management,P4P
CLM0000002636,MBR00000200,Pharmacy,Paid,Electronic_EDI,2023-06-01,2023-06-01,2023-06-01,2023-06-28,Auto_Adjudicated,27,1207523397,1358873132,207RC0000X,Cardiovascular Disease,22,In_Network,OTHER,Z00.00,00310075090,,4,Commercial,HDHP_HSA,29,M,0.8011,,,248.29,185.49,4.71,179.6,0.0,1.18,62.8,0.0,0.0,0,,0.0965,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002637,MBR00000184,Medical_Professional,Denied,Electronic_EDI,2023-01-06,2023-01-06,2023-01-06,2023-01-12,Auto_Adjudicated,6,1324142620,1689327034,207RP1001X,Pulmonary Disease,11,In_Network,Z00.00,Z00.00|E11.9|OTHER,99382,,0,Medicaid_MCO,MLTSS,30,M,2.8302,50,Duplicate,198.4,128.31,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1961,upcoding_pattern,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002638,MBR00000159,Medical_Institutional,Paid,Electronic_EDI,2023-02-21,2023-02-21,2023-02-24,2023-03-05,Auto_Adjudicated,12,1897146144,1860951128,207RC0000X,Cardiovascular Disease,23,In_Network,N39.0,N39.0|R05.9,revenue_code:0100,,0,Commercial,PPO,70,F,1.2009,,,13986.48,9149.63,7253.48,11.79,71.0,1813.37,4836.85,0.0,0.0,0,,0.1403,none,0,1,1,0,0,0.000671,0,0,ACR_Urine_Protein,Capitation
CLM0000002639,MBR00000061,Medical_Institutional,Paid,Provider_Portal,2023-04-20,2023-04-20,2023-04-21,2023-04-22,Manual_Review,2,1207523397,1098360555,207Q00000X,Family Medicine,81,In_Network,Z12.11,,revenue_code:0370,,0,Commercial,PPO,66,M,2.3575,,,40319.81,21948.94,17393.98,172.47,34.0,4348.49,18370.87,0.0,0.0,0,,0.0469,none,0,1,1,0,0,0.00161,0,0,,Shared_Savings
CLM0000002640,MBR00000252,Medical_Professional,Paid,Electronic_EDI,2023-04-10,2023-04-10,2023-04-10,2023-05-04,Auto_Adjudicated,24,1055717021,1473869105,207RG0100X,Gastroenterology,11,In_Network,N18.3,J06.9,99386,,0,Medicare_Advantage,MA_HMO,80,M,0.7173,,,347.82,196.59,133.22,15.06,15.0,33.31,151.23,0.0,0.0,0,,0.0007,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000002641,MBR00000292,Pharmacy,Paid,Provider_Portal,2023-07-22,2023-07-22,2023-07-22,2023-08-18,Auto_Adjudicated,27,1080383191,1995553359,2084P0800X,Psychiatry,11,In_Network,OTHER,,00078043215,,1,Medicare_Advantage,MA_HMO,4,M,1.1779,,,185.87,100.28,67.94,12.35,3.0,16.99,85.59,0.0,0.0,0,,0.0412,none,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000002642,MBR00000144,Medical_Professional,Paid,Paper,2023-05-06,2023-05-06,2023-05-06,2023-05-07,Auto_Adjudicated,1,1617763056,1575884274,207RG0100X,Gastroenterology,11,In_Network,OTHER,Z23|M54.5,90837,,0,Commercial,HDHP_HSA,56,F,2.5926,,,794.13,654.82,314.96,261.12,0.0,78.74,139.31,0.0,0.0,0,,0.1149,unbundling_pattern,0,1,0,0,0,2.9e-05,0,0,,Shared_Savings
CLM0000002643,MBR00000281,Pharmacy,Denied,Electronic_EDI,2023-09-24,2023-09-24,2023-09-24,2023-09-30,Manual_Review,6,1510562885,1825450791,101YP2500X,Psychologist Clinical,24,In_Network,M54.5,OTHER|Z23,00003014960,,1,Medicare_Advantage,MA_HMO,3,M,0.8531,96,Network,486.94,316.04,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0944,geographic_mismatch,0,1,0,0,0,0.0,0,1,,Capitation
CLM0000002644,MBR00000300,Medical_Institutional,Denied,Electronic_EDI,2023-04-01,2023-04-01,2023-04-04,2023-04-07,Auto_Adjudicated,6,1220235547,1880530717,207R00000X,Internal Medicine,11,In_Network,K29.70,OTHER|I10,revenue_code:0110,,0,Commercial,PPO,64,F,1.0393,16,Timely_Filing,14035.29,6027.42,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2484,impossible_service_combo|high_oop_waiver,0,2,0,0,0,0.0,0,0,,Capitation
CLM0000002645,MBR00000151,Medical_Institutional,Paid,Electronic_EDI,2023-09-01,2023-09-01,2023-09-03,2023-09-29,Auto_Adjudicated,28,1887363539,1694343357,208600000X,Surgery General,11,In_Network,Z00.01,M54.5|I10,revenue_code:0210,,0,Medicare_Advantage,MA_HMO,77,M,0.8709,,,7519.62,5528.37,4384.53,10.71,37.0,1096.13,1991.25,0.0,0.0,0,,0.0034,none,0,1,0,0,0,0.000406,0,0,,FFS
CLM0000002646,MBR00000213,Dental,Paid,Electronic_EDI,2023-02-06,2023-02-06,2023-02-06,2023-03-02,Auto_Adjudicated,24,1594587354,1054984734,207R00000X,Internal Medicine,11,In_Network,I10,M54.5|I50.9,D2391,,0,Commercial,PPO,17,M,1.5857,,,257.83,179.75,0.0,179.75,0.0,0.0,78.08,0.0,0.0,0,,0.0887,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002647,MBR00000191,Medical_Professional,Denied,Electronic_EDI,2023-12-21,2023-12-21,2023-12-21,2023-12-30,Auto_Adjudicated,9,1454749898,1978943761,246ZN0300X,Neuropsychology,11,In_Network,E11.9,,99211,,0,Commercial,POS,85,F,0.9729,4,Duplicate,213.31,142.2,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1323,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002648,MBR00000075,Pharmacy,Paid,Electronic_EDI,2023-12-21,2023-12-21,2023-12-21,2023-12-23,Auto_Adjudicated,2,1334227781,1527857018,101YP2500X,Psychologist Clinical,23,In_Network,Z23,I10|N39.0,00071015523,,1,Medicaid_MCO,MCO,5,M,1.0573,,,114.16,55.03,51.03,0.0,4.0,0.0,59.13,0.0,0.0,0,,0.0736,none,0,1,0,0,0,5e-06,0,1,,Shared_Savings
CLM0000002649,MBR00000014,Medical_Professional,Paid,Electronic_EDI,2023-04-09,2023-04-09,2023-04-09,2023-04-22,Auto_Adjudicated,13,1522998767,1625992541,225100000X,Physical Therapist,23,In_Network,M17.11,,82947,,0,Commercial,HMO,77,M,2.8513,,,1129.76,744.88,285.01,350.61,38.0,71.25,384.88,0.0,0.0,0,,0.0812,none,0,1,0,0,0,2.6e-05,0,0,,FFS
CLM0000002650,MBR00000141,Behavioral_Health,Paid,Provider_Portal,2023-03-26,2023-03-26,2023-03-26,2023-04-13,Auto_Adjudicated,18,1466922283,1831337866,101YP2500X,Psychologist Clinical,11,Emergency,Z12.11,,99285,,0,Commercial,HMO,47,F,0.6724,,,514.87,390.36,256.03,44.33,26.0,64.01,124.51,0.0,0.0,0,,0.1595,impossible_service_combo,0,1,0,0,0,2.4e-05,0,0,HBD_Hemoglobin_A1c_Testing,Shared_Savings
CLM0000002651,MBR00000233,Medical_Professional,Paid,Electronic_EDI,2023-01-01,2023-01-01,2023-01-01,2023-01-03,Auto_Adjudicated,2,1592228076,1105871325,207RN0300X,Nephrology,22,In_Network,Z79.4,Z00.00,81001,,0,Medicare_Advantage,MA_PPO,87,M,0.8034,,,488.32,211.74,164.55,3.05,3.0,41.14,276.58,0.0,0.0,0,,0.0953,none,0,1,0,0,0,1.5e-05,0,0,,Capitation
CLM0000002652,MBR00000103,Medical_Institutional,Paid,Electronic_EDI,2023-12-17,2023-12-17,2023-12-20,2024-01-01,Manual_Review,15,1091395764,1163639177,207RN0300X,Nephrology,23,In_Network,I10,,revenue_code:0100,,0,Medicaid_MCO,MCO,24,M,0.4785,,,5327.89,3322.91,3317.91,0.0,5.0,0.0,2004.98,0.0,0.0,0,,0.1486,none,0,1,0,0,0,0.000307,0,0,,Capitation
CLM0000002653,MBR00000232,Medical_Professional,Paid,Electronic_EDI,2023-01-14,2023-01-14,2023-01-14,2023-01-31,Auto_Adjudicated,17,1519595029,1148659045,246ZN0300X,Neuropsychology,81,In_Network,N39.0,,97010,,0,Medicaid_MCO,MCO,40,M,1.1083,,,267.13,121.41,119.41,0.0,2.0,0.0,145.72,0.0,0.0,0,,0.0071,none,0,1,0,0,0,1.1e-05,0,0,AMR_Asthma_Medication_Ratio,Bundled_Payment
CLM0000002654,MBR00000195,Medical_Institutional,Paid,Electronic_EDI,2023-01-01,2023-01-01,2023-01-04,2023-01-31,Manual_Review,30,1325430913,1177602659,207RP1001X,Pulmonary Disease,24,In_Network,E78.5,,revenue_code:0110,,0,Commercial,PPO,13,F,0.5967,,,56752.22,35537.4,28352.94,64.23,32.0,7088.23,21214.82,0.0,0.0,0,,0.1847,outlier_billing_amount|high_oop_waiver,0,1,1,0,0,0.002624,0,0,,FFS
CLM0000002655,MBR00000207,Medical_Professional,Denied,Electronic_EDI,2023-02-05,2023-02-05,2023-02-05,2023-02-11,Auto_Adjudicated,6,1478783612,1287935251,2084P0800X,Psychiatry,24,In_Network,J06.9,OTHER|Z00.00|Z00.121,99285,,0,Medicaid_MCO,MLTSS,11,F,1.6522,5,Duplicate,1219.32,818.22,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Provider Impersonation,0.966,outlier_billing_amount|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|service_date_weekend|upcoding_pattern|npi_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.0,0,0,,FFS
CLM0000002656,MBR00000089,Medical_Professional,Paid,Electronic_EDI,2023-04-16,2023-04-16,2023-04-16,2023-04-22,Auto_Adjudicated,6,1059948944,1831337866,207RE0101X,Endocrinology,81,In_Network,M17.11,,99205,,0,Commercial,PPO,14,M,0.5668,,,300.35,226.88,137.36,21.18,34.0,34.34,73.47,0.0,0.0,0,,0.0496,none,0,1,0,0,0,1.3e-05,0,0,PPC_Prenatal_Care,FFS
CLM0000002657,MBR00000144,Medical_Professional,Paid,Electronic_EDI,2023-12-17,2023-12-17,2023-12-17,2023-12-30,Auto_Adjudicated,13,1526973051,1860951128,207Q00000X,Family Medicine,21,In_Network,I10,OTHER,97110,,0,Commercial,HDHP_HSA,56,F,2.5926,,,1735.52,1039.95,210.63,776.66,0.0,52.66,695.57,0.0,0.0,0,,0.1136,none,0,1,0,0,0,1.9e-05,0,0,,FFS
CLM0000002658,MBR00000057,Medical_Professional,Denied,Paper,2023-03-01,2023-03-01,2023-03-01,2023-03-11,Auto_Adjudicated,10,1428403730,1320546364,207Q00000X,Family Medicine,11,In_Network,Z12.11,,80053,,0,Medicare_Advantage,MA_PPO,45,M,0.6701,97,Authorization,1127.3,918.98,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Duplicate Billing,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|benford_violation|impossible_service_combo|unbundling_pattern|phantom_billing_indicator|controlled_substance_high_volume|high_oop_waiver,1,5,0,1,0,0.0,0,0,POD_Persistence_of_Beta_Blocker,Shared_Savings
CLM0000002659,MBR00000076,Pharmacy,Paid,Electronic_EDI,2023-07-24,2023-07-24,2023-07-24,2023-08-21,Manual_Review,28,1470105939,1527857018,207RG0100X,Gastroenterology,24,In_Network,OTHER,OTHER|R05.9|N18.3,50458085930,,2,Commercial,HMO,26,M,2.1785,,,158.87,128.0,73.98,3.52,32.0,18.5,30.87,0.0,0.0,0,,0.1577,service_date_weekend,0,1,0,0,0,7e-06,0,0,AWV_Annual_Wellness_Visit,FFS
CLM0000002660,MBR00000027,Medical_Institutional,Paid,Electronic_EDI,2023-08-22,2023-08-22,2023-08-24,2023-09-15,Auto_Adjudicated,24,1356408757,1788579687,207RE0101X,Endocrinology,11,Out_of_Network,E78.5,,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,45,M,0.6886,,,9198.18,6976.28,5521.37,26.57,48.0,1380.34,2221.9,0.0,0.0,0,,0.0255,none,0,1,1,0,0,0.000511,1,0,,Capitation
CLM0000002661,MBR00000038,Medical_Professional,Paid,Electronic_EDI,2023-10-14,2023-10-14,2023-10-14,2023-10-22,Auto_Adjudicated,8,1661091022,1825450791,246ZN0300X,Neuropsychology,22,In_Network,OTHER,E11.65,99382,,0,Commercial,EPO,46,M,1.1295,,,74.47,46.74,0.0,46.74,0.0,0.0,27.73,0.0,0.0,0,,0.094,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002662,MBR00000064,Vision,Paid,Paper,2023-09-09,2023-09-09,2023-09-09,2023-09-20,Auto_Adjudicated,11,1390393668,1690197969,246ZN0300X,Neuropsychology,24,In_Network,E11.9,OTHER,V2320,,0,Medicare_Advantage,SNP,73,M,1.0644,,,228.72,101.71,72.17,1.5,10.0,18.04,127.01,0.0,0.0,0,,0.0639,upcoding_pattern,0,1,0,0,0,7e-06,0,0,,Bundled_Payment
CLM0000002663,MBR00000175,Pharmacy,Paid,Electronic_EDI,2023-12-20,2023-12-20,2023-12-20,2024-01-09,Clinical_Review,20,1903785749,1433350836,208600000X,Surgery General,22,In_Network,Z00.121,OTHER|N39.0,16590051660,,2,Commercial,PPO,14,F,1.5785,,,117.22,79.17,48.99,7.93,10.0,12.25,38.05,0.0,0.0,0,,0.1046,high_oop_waiver,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000002664,MBR00000138,Medical_Professional,Denied,Electronic_EDI,2023-08-26,2023-08-26,2023-08-26,2023-09-22,Auto_Adjudicated,27,1774425033,1304018750,207RN0300X,Nephrology,21,In_Network,E11.9,F10.10|OTHER,90834,,0,Commercial,HDHP_HSA,47,M,0.996,50,COB,935.67,657.76,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0403,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002665,MBR00000082,Medical_Institutional,Paid,Electronic_EDI,2023-10-31,2023-10-31,2023-11-03,2023-11-07,Auto_Adjudicated,7,1099247356,1304018750,207RC0000X,Cardiovascular Disease,22,In_Network,OTHER,,revenue_code:0360,,0,Medicare_Advantage,MA_HMO,39,F,0.5376,,,15024.4,8974.31,7143.45,0.99,44.0,1785.86,6050.09,0.0,0.0,0,,0.0915,none,0,1,1,0,0,0.000661,0,0,,FFS
CLM0000002666,MBR00000259,Medical_Institutional,Paid,Electronic_EDI,2023-04-25,2023-04-25,2023-04-29,2023-05-04,Auto_Adjudicated,9,1832660692,1289435414,207RE0101X,Endocrinology,11,In_Network,I10,,revenue_code:0360,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,14337.85,11950.22,9523.05,10.41,36.0,2380.76,2387.63,0.0,0.0,0,,0.1862,unbundling_pattern,0,1,1,1,0,0.000881,0,0,,FFS
CLM0000002667,MBR00000160,Medical_Institutional,Paid,Electronic_EDI,2023-05-27,2023-05-27,2023-05-29,2023-06-15,Auto_Adjudicated,19,1175978429,1688513262,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,Z00.01,revenue_code:0360,,0,Commercial,HMO,73,M,1.9608,,,28280.41,11270.35,8859.9,155.48,40.0,2214.97,17010.06,0.0,0.0,0,,0.0687,provider_specialty_mismatch,0,1,1,0,0,0.00082,0,0,,FFS
CLM0000002668,MBR00000279,Dental,Denied,Electronic_EDI,2023-09-22,2023-09-22,2023-09-22,2023-10-18,Auto_Adjudicated,26,1718336220,1325999602,207RN0300X,Nephrology,21,In_Network,E11.9,J44.1,D7140,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,16,COB,86.1,66.91,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.138,geographic_mismatch,0,1,0,0,0,0.0,0,0,COA_Care_Transitions,Bundled_Payment
CLM0000002669,MBR00000188,Medical_Institutional,Denied,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-11-20,Auto_Adjudicated,9,1549436467,1878017518,207RN0300X,Nephrology,11,Out_of_Network,C50.911,Z00.00|K21.0,revenue_code:0360,,0,Commercial,HMO,8,F,1.5853,96,Timely_Filing,11477.09,9203.43,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1293,none,0,1,0,0,0,0.0,1,0,,Capitation
CLM0000002670,MBR00000005,Behavioral_Health,Paid,Provider_Portal,2023-01-02,2023-01-02,2023-01-02,2023-01-17,Auto_Adjudicated,15,1603037534,1396850418,101YP2500X,Psychologist Clinical,81,In_Network,M54.5,,99215,,0,Medicare_Advantage,MA_PPO,8,M,0.566,,,122.58,81.4,34.44,33.35,5.0,8.61,41.18,0.0,0.0,0,,0.1046,none,0,1,0,0,0,3e-06,0,0,,Capitation
CLM0000002671,MBR00000276,Pharmacy,Paid,Electronic_EDI,2023-06-05,2023-06-05,2023-06-05,2023-06-26,Auto_Adjudicated,21,1122148537,1938465393,207RP1001X,Pulmonary Disease,22,In_Network,Z00.01,G43.909|Z12.11,50458085930,,4,Commercial,POS,38,M,0.8085,,,66.14,52.51,8.04,7.46,35.0,2.01,13.63,0.0,0.0,0,,0.1783,impossible_service_combo,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000002672,MBR00000259,Behavioral_Health,Paid,Electronic_EDI,2023-10-16,2023-10-16,2023-10-16,2023-10-29,Auto_Adjudicated,13,1034110592,1810068286,2086S0122X,Orthopedic Surgery,32,In_Network,Z00.00,,33510,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,190.25,86.76,62.08,2.16,7.0,15.52,103.49,0.0,0.0,0,,0.0961,none,0,1,0,0,0,6e-06,0,0,IET_Initiation_Substance_Use,Shared_Savings
CLM0000002673,MBR00000188,Medical_Institutional,Paid,Electronic_EDI,2023-02-10,2023-02-10,2023-02-10,2023-03-06,Manual_Review,24,1209940651,1878874025,2084P0800X,Psychiatry,71,In_Network,I10,,revenue_code:0360,,0,Commercial,HMO,8,F,1.5853,,,12236.05,6394.88,5037.14,52.45,46.0,1259.29,5841.17,0.0,0.0,0,,0.1405,duplicate_claim_indicator,0,1,1,0,0,0.000466,0,0,,FFS
CLM0000002674,MBR00000162,Pharmacy,Paid,Electronic_EDI,2023-05-07,2023-05-07,2023-05-07,2023-05-23,Auto_Adjudicated,16,1469009511,1433350836,2084P0800X,Psychiatry,22,Emergency,Z23,Z00.01|OTHER,00078043215,,4,Medicaid_MCO,MLTSS,84,F,1.324,,,269.03,118.56,117.56,0.0,1.0,0.0,150.47,0.0,0.0,0,,0.0074,none,0,1,0,0,0,1.1e-05,0,0,,Shared_Savings
CLM0000002675,MBR00000141,Pharmacy,Partially_Paid,Electronic_EDI,2023-07-16,2023-07-16,2023-07-16,2023-08-12,Manual_Review,27,1514646292,1513198866,2084P0800X,Psychiatry,21,Emergency,I25.10,E11.9|M17.11,00071012831,,4,Commercial,HMO,47,F,0.6724,1,Medical_Necessity,255.13,129.29,14.91,45.34,26.0,3.73,165.15,0.0,0.0,0,,0.0248,none,0,1,0,0,0,1e-06,0,0,SPC_Statin_Therapy,Shared_Savings
CLM0000002676,MBR00000148,Pharmacy,Paid,Electronic_EDI,2023-01-30,2023-01-30,2023-01-30,2023-02-18,Auto_Adjudicated,19,1618564043,1643323506,225100000X,Physical Therapist,32,In_Network,F41.1,,59148001506,,2,Commercial,EPO,51,F,0.6534,,,92.92,40.2,0.0,40.2,0.0,0.0,52.72,0.0,0.0,0,,0.0723,none,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000002677,MBR00000226,Medical_Professional,Denied,Electronic_EDI,2023-11-25,2023-11-25,2023-11-25,2023-12-23,Manual_Review,28,1327415110,1827839595,207V00000X,Obstetrics & Gynecology,11,In_Network,Z79.4,I10|OTHER|Z12.11,99232,,0,Medicare_Advantage,MA_PPO,84,M,1.0796,16,Timely_Filing,253.73,109.59,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1147,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002678,MBR00000158,Medical_Professional,Paid,Electronic_EDI,2023-05-13,2023-05-13,2023-05-13,2023-06-08,Manual_Review,26,1564110057,1489434038,207RE0101X,Endocrinology,22,In_Network,Z00.01,,83036,,0,Commercial,HMO,65,M,1.5361,,,1777.42,649.47,295.75,265.79,14.0,73.94,1127.95,0.0,0.0,0,,0.1059,none,0,1,0,0,0,2.7e-05,0,0,FLU_Flu_Vaccination,FFS
CLM0000002679,MBR00000055,Medical_Professional,Paid,Electronic_EDI,2023-10-09,2023-10-09,2023-10-09,2023-10-17,Clinical_Review,8,1313587359,1741177636,207RC0000X,Cardiovascular Disease,11,In_Network,K57.30,OTHER|Z12.11,97010,,0,Commercial,PPO,68,F,1.2896,,,2011.65,1453.11,1079.45,93.79,10.0,269.86,558.54,0.0,0.0,0,,0.0071,none,0,1,0,0,0,0.0001,0,0,,FFS
CLM0000002680,MBR00000016,Medical_Professional,Paid,Electronic_EDI,2023-06-03,2023-06-03,2023-06-03,2023-06-30,Manual_Review,27,1170319307,1564691686,207Q00000X,Family Medicine,24,In_Network,OTHER,,80053,,0,Commercial,HDHP_HSA,20,F,0.5843,,,524.34,262.73,166.52,54.58,0.0,41.63,261.61,0.0,0.0,0,,0.0618,provider_specialty_mismatch,0,1,0,0,0,1.5e-05,0,0,MPT_Annual_Monitoring,Capitation
CLM0000002681,MBR00000038,Dental,Denied,Electronic_EDI,2023-05-25,2023-05-25,2023-05-25,2023-05-29,Auto_Adjudicated,4,1706065807,1831337866,246ZN0300X,Neuropsychology,31,In_Network,E11.9,,D1110,,0,Commercial,EPO,46,M,1.1295,18,Eligibility,370.05,242.58,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0046,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002682,MBR00000078,Pharmacy,Paid,Electronic_EDI,2023-12-13,2023-12-13,2023-12-13,2023-12-22,Auto_Adjudicated,9,1388566092,1691162131,207RE0101X,Endocrinology,22,In_Network,OTHER,J06.9|E11.9,16590051660,,1,Commercial,EPO,65,F,1.3174,,,87.88,61.27,6.37,16.31,37.0,1.59,26.61,0.0,0.0,0,,0.0913,benford_violation,0,1,0,0,0,1e-06,0,0,FUM_Follow_Up_ED_Mental_Health,Shared_Savings
CLM0000002683,MBR00000116,Medical_Professional,Paid,Electronic_EDI,2023-11-03,2023-11-03,2023-11-03,2023-11-05,Manual_Review,2,1683650935,1576271272,207R00000X,Internal Medicine,21,In_Network,E78.5,,84443,,0,Medicaid_MCO,MLTSS,79,F,0.4614,,,1334.18,914.66,911.66,0.0,3.0,0.0,419.52,0.0,0.0,0,,0.0083,none,0,1,0,0,0,8.4e-05,0,0,,Bundled_Payment
CLM0000002684,MBR00000270,Medical_Institutional,Denied,Electronic_EDI,2023-07-05,2023-07-05,2023-07-07,2023-07-09,Auto_Adjudicated,4,1231954359,1704466150,207RN0300X,Nephrology,22,In_Network,K21.0,Z23,revenue_code:0300,,0,Commercial,POS,1,F,1.6363,3,Authorization,96478.66,78665.3,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1101,outlier_billing_amount,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,Capitation
CLM0000002685,MBR00000075,Medical_Professional,Partially_Paid,Electronic_EDI,2023-06-16,2023-06-16,2023-06-16,2023-07-08,Auto_Adjudicated,22,1897701389,1977073565,2086S0122X,Orthopedic Surgery,22,In_Network,OTHER,OTHER|G47.33,99213,,0,Medicaid_MCO,MCO,5,M,1.0573,22,Medical_Necessity,214.26,152.1,112.34,0.0,4.0,0.0,97.92,0.0,0.0,0,,0.0884,npi_mismatch,0,1,0,1,0,1e-05,0,0,,Shared_Savings
CLM0000002686,MBR00000102,Pharmacy,Paid,Electronic_EDI,2023-10-08,2023-10-08,2023-10-08,2023-10-12,Auto_Adjudicated,4,1089569577,1196833348,101YP2500X,Psychologist Clinical,23,In_Network,E13.9,,00310075090,,1,Commercial,POS,68,M,1.6864,,,461.25,303.48,0.0,303.48,0.0,0.0,157.77,0.0,0.0,0,,0.0955,billing_spike_recent,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002687,MBR00000069,Dental,Paid,Provider_Portal,2023-09-03,2023-09-03,2023-09-03,2023-09-09,Manual_Review,6,1528834564,1643673796,246ZN0300X,Neuropsychology,65,In_Network,M17.11,Z00.00|J20.9,D3310,,0,Medicare_Advantage,MA_PPO,2,M,0.5765,,,544.52,226.61,136.95,47.42,8.0,34.24,317.91,0.0,0.0,0,,0.0042,none,0,1,0,0,0,1.3e-05,0,0,,Shared_Savings
CLM0000002688,MBR00000166,Medical_Professional,Paid,Electronic_EDI,2023-12-18,2023-12-18,2023-12-18,2023-12-31,Auto_Adjudicated,13,1558692441,1884259357,207RC0000X,Cardiovascular Disease,11,In_Network,Z12.11,F41.1,90834,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,577.96,208.43,0.0,208.43,0.0,0.0,369.53,0.0,0.0,0,,0.1469,billing_spike_recent,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002689,MBR00000184,Medical_Institutional,Paid,Electronic_EDI,2023-04-30,2023-04-30,2023-05-02,2023-05-25,Manual_Review,25,1918160357,1356856197,2086S0122X,Orthopedic Surgery,11,In_Network,E11.65,,revenue_code:0450,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,12869.76,9170.81,9170.81,0.0,0.0,0.0,3698.95,0.0,0.0,1,Kickback Arrangement,1.0,provider_specialty_mismatch|temporal_clustering|high_volume_same_code|benford_violation|impossible_service_combo|service_date_weekend|billing_spike_recent|upcoding_pattern|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,1,0,0,0.000849,0,0,CDC_HbA1c_Poor_Control,Bundled_Payment
CLM0000002690,MBR00000162,Vision,Paid,Electronic_EDI,2023-02-10,2023-02-10,2023-02-10,2023-03-07,Auto_Adjudicated,25,1075661656,1034732777,246ZN0300X,Neuropsychology,11,In_Network,N39.0,,92014,,0,Medicaid_MCO,MLTSS,84,F,1.324,,,410.7,321.88,320.88,0.0,1.0,0.0,88.82,0.0,0.0,0,,0.0453,none,0,1,0,0,0,3e-05,0,0,COA_Care_Transitions,FFS
CLM0000002691,MBR00000288,Pharmacy,Paid,Electronic_EDI,2023-03-11,2023-03-11,2023-03-11,2023-04-09,Manual_Review,29,1323379997,1252125670,207RN0300X,Nephrology,23,In_Network,OTHER,,00078043215,,1,Commercial,HMO,36,M,0.8408,,,387.55,251.67,113.04,76.37,34.0,28.26,135.88,0.0,0.0,0,,0.0359,none,0,1,0,0,0,1e-05,0,0,,Bundled_Payment
CLM0000002692,MBR00000299,Dental,Denied,Electronic_EDI,2023-07-09,2023-07-09,2023-07-09,2023-07-11,Auto_Adjudicated,2,1617763056,1013600387,2086S0122X,Orthopedic Surgery,65,In_Network,OTHER,E13.9,D2140,,0,Medicaid_MCO,MCO,74,F,0.8833,50,Medical_Necessity,308.27,260.59,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1151,benford_violation|controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002693,MBR00000250,Medical_Professional,Denied,Electronic_EDI,2023-04-23,2023-04-23,2023-04-23,2023-04-28,Manual_Review,5,1209940651,1887266184,207RE0101X,Endocrinology,21,In_Network,Z00.01,Z00.121,99203,,0,Commercial,PPO,41,M,0.9245,22,Authorization,288.67,229.2,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1365,none,0,1,0,0,0,0.0,0,0,MPT_Annual_Monitoring,P4P
CLM0000002694,MBR00000239,Medical_Professional,Paid,Electronic_EDI,2023-10-18,2023-10-18,2023-10-18,2023-10-30,Clinical_Review,12,1713343912,1623053477,207RN0300X,Nephrology,21,In_Network,Z23,E11.65|OTHER,99383,,0,Commercial,HMO,1,F,1.1193,,,152.38,124.86,0.0,119.21,5.65,0.0,27.52,0.0,0.0,0,,0.0751,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002695,MBR00000115,Pharmacy,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-11-20,Manual_Review,9,1089569577,1288028182,208600000X,Surgery General,81,In_Network,J44.1,M79.3,00006001954,,1,Commercial,PPO,15,F,0.7398,,,330.85,236.69,0.0,236.69,0.0,0.0,94.16,0.0,0.0,0,,0.0578,none,0,1,0,0,0,0.0,0,1,MPT_Annual_Monitoring,P4P
CLM0000002696,MBR00000175,Medical_Professional,Denied,Electronic_EDI,2023-03-09,2023-03-09,2023-03-09,2023-03-12,Manual_Review,3,1101385540,1705448933,207RE0101X,Endocrinology,11,In_Network,Z87.891,J06.9,74177,,0,Commercial,PPO,14,F,1.5785,5,Medical_Necessity,500.1,415.98,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.008,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002697,MBR00000111,Pharmacy,Paid,Provider_Portal,2023-12-22,2023-12-22,2023-12-22,2024-01-07,Manual_Review,16,1141106555,1825450791,207RG0100X,Gastroenterology,32,In_Network,I10,Z12.11|OTHER,00310075090,,1,Medicare_Advantage,MA_PPO,44,M,0.7462,,,79.18,51.48,19.53,11.06,16.0,4.88,27.7,0.0,0.0,0,,0.097,none,0,1,0,0,0,2e-06,0,1,,Shared_Savings
CLM0000002698,MBR00000232,Pharmacy,Paid,Electronic_EDI,2023-08-15,2023-08-15,2023-08-15,2023-08-30,Auto_Adjudicated,15,1451329728,1040061910,225100000X,Physical Therapist,81,In_Network,OTHER,E78.5,50458085930,,3,Medicaid_MCO,MCO,40,M,1.1083,,,90.83,53.08,51.08,0.0,2.0,0.0,37.75,0.0,0.0,0,,0.1102,none,0,1,0,0,0,5e-06,0,0,SPD_Spirometry_Testing,Bundled_Payment
CLM0000002699,MBR00000054,Medical_Professional,Partially_Paid,Electronic_EDI,2023-04-05,2023-04-05,2023-04-05,2023-04-18,Auto_Adjudicated,13,1092800235,1945682535,225100000X,Physical Therapist,24,In_Network,Z79.4,I10|M25.511|K21.0,99205,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,256,Medical_Necessity,934.58,348.5,182.89,6.74,1.0,45.72,698.22,0.0,0.0,0,,0.1011,geographic_mismatch,0,1,0,0,0,1.7e-05,0,0,DAE_Drug_Alcohol_Dependence,FFS
CLM0000002700,MBR00000066,Medical_Institutional,Paid,Electronic_EDI,2023-03-14,2023-03-14,2023-03-17,2023-03-15,Auto_Adjudicated,1,1214787184,1498781755,101YP2500X,Psychologist Clinical,21,In_Network,Z00.00,E11.9,revenue_code:0110,470,0,Medicaid_MCO,MCO,54,M,0.6083,,,9181.36,7445.25,7445.25,0.0,0.0,0.0,1736.11,0.0,0.0,0,,0.1062,provider_specialty_mismatch,0,1,1,1,0,0.000689,0,0,MMA_Medication_Management,Capitation
CLM0000002701,MBR00000012,Pharmacy,Paid,Electronic_EDI,2023-03-01,2023-03-01,2023-03-01,2023-03-14,Auto_Adjudicated,13,1983779639,1774401124,207RP1001X,Pulmonary Disease,23,In_Network,Z00.00,OTHER|I10|L70.0,59148001506,,2,Commercial,HMO,84,M,1.3904,,,241.66,132.29,8.58,93.56,28.0,2.15,109.37,0.0,0.0,0,,0.0044,none,0,1,0,0,0,1e-06,0,0,,Bundled_Payment
CLM0000002702,MBR00000184,Vision,Paid,Electronic_EDI,2023-06-19,2023-06-19,2023-06-19,2023-07-03,Auto_Adjudicated,14,1881358103,1619587398,207RN0300X,Nephrology,11,Out_of_Network,E13.9,J06.9|N40.0,V2320,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,154.05,61.39,59.39,0.0,2.0,0.0,92.66,0.0,0.0,0,,0.1348,duplicate_claim_indicator,0,1,0,0,0,5e-06,0,0,W30_Well_Child_Visit,Capitation
CLM0000002703,MBR00000205,Medical_Professional,Paid,Electronic_EDI,2023-01-26,2023-01-26,2023-01-26,2023-02-02,Auto_Adjudicated,7,1159268684,1297948643,207RE0101X,Endocrinology,11,In_Network,Z00.121,OTHER,97010,,0,Medicaid_MCO,MCO,1,F,0.9425,,,569.42,402.11,401.11,0.0,1.0,0.0,167.31,0.0,0.0,0,,0.0648,none,0,1,0,0,0,3.7e-05,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000002704,MBR00000002,Pharmacy,Paid,Electronic_EDI,2023-02-17,2023-02-17,2023-02-17,2023-03-13,Auto_Adjudicated,24,1484613641,1509799493,207RN0300X,Nephrology,11,In_Network,M54.5,I10,00310075090,,1,Commercial,PPO,42,F,0.9012,,,60.13,31.06,0.0,31.06,0.0,0.0,29.07,0.0,0.0,0,,0.106,none,0,1,0,0,0,0.0,0,1,,Capitation
CLM0000002705,MBR00000157,Medical_Professional,Paid,Provider_Portal,2023-09-28,2023-09-28,2023-09-28,2023-10-25,Auto_Adjudicated,27,1443292773,1291071007,207RC0000X,Cardiovascular Disease,11,In_Network,I10,,99385,,0,Medicare_Advantage,MA_HMO,26,F,0.9164,,,337.21,209.71,149.1,6.33,17.0,37.28,127.5,0.0,0.0,0,,0.0738,controlled_substance_high_volume,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000002706,MBR00000120,Dental,Paid,Electronic_EDI,2023-06-25,2023-06-25,2023-06-25,2023-07-23,Auto_Adjudicated,28,1231231881,1267212691,207R00000X,Internal Medicine,81,Out_of_Network,E11.9,OTHER,D0120,,0,Commercial,PPO,62,F,1.0823,,,202.68,171.92,87.35,45.74,17.0,21.84,30.76,53.64,28.18,0,,0.1288,none,0,1,0,0,0,8e-06,0,0,,Capitation
CLM0000002707,MBR00000235,Pharmacy,Paid,Electronic_EDI,2023-07-09,2023-07-09,2023-07-09,2023-07-30,Manual_Review,21,1641779816,1589482133,246ZN0300X,Neuropsychology,23,In_Network,Z12.11,F33.0,16590051660,,1,Commercial,HDHP_HSA,85,F,1.4308,,,340.86,230.91,170.86,17.33,0.0,42.72,109.95,0.0,0.0,0,,0.1663,high_volume_same_code,0,1,0,0,0,1.6e-05,0,0,,Capitation
CLM0000002708,MBR00000012,Medical_Professional,Paid,Electronic_EDI,2023-04-27,2023-04-27,2023-04-27,2023-05-18,Auto_Adjudicated,21,1453331651,1510751265,208600000X,Surgery General,21,In_Network,Z79.4,OTHER,97110,,0,Commercial,HMO,84,M,1.3904,,,185.71,67.32,0.0,66.7,0.62,0.0,118.39,0.0,0.0,0,,0.126,none,0,1,0,0,0,0.0,0,0,SPD_Spirometry_Testing,Shared_Savings
CLM0000002709,MBR00000014,Pharmacy,Paid,Electronic_EDI,2023-07-19,2023-07-19,2023-07-19,2023-07-24,Auto_Adjudicated,5,1315569619,1013600387,207V00000X,Obstetrics & Gynecology,22,In_Network,I10,,00071012831,,3,Commercial,HMO,77,M,2.8513,,,108.56,41.02,0.0,41.02,0.0,0.0,67.54,0.0,0.0,0,,0.1094,none,0,1,0,0,0,0.0,0,1,,Bundled_Payment
CLM0000002710,MBR00000185,Pharmacy,Denied,Electronic_EDI,2023-05-04,2023-05-04,2023-05-04,2023-05-16,Clinical_Review,12,1495592428,1903401648,207R00000X,Internal Medicine,22,Out_of_Network,OTHER,Z00.00|Z00.121,00003014960,,3,Medicaid_MCO,MCO,73,M,1.5417,50,Coding_Error,461.44,295.25,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.198,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002711,MBR00000178,Pharmacy,Denied,Electronic_EDI,2023-01-17,2023-01-17,2023-01-17,2023-01-18,Manual_Review,1,1145498455,1432077493,207RC0000X,Cardiovascular Disease,11,In_Network,E78.5,,00003014960,,1,Medicaid_MCO,MCO,89,M,0.7057,1,Timely_Filing,613.65,230.36,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1376,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002712,MBR00000248,Medical_Professional,Paid,Electronic_EDI,2023-07-23,2023-07-23,2023-07-23,2023-08-09,Auto_Adjudicated,17,1122148537,1049766043,207R00000X,Internal Medicine,11,In_Network,OTHER,OTHER|Z87.891,90837,,0,Commercial,PPO,40,F,0.6665,,,652.73,230.5,0.0,230.5,0.0,0.0,422.23,0.0,0.0,0,,0.0904,controlled_substance_high_volume,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000002713,MBR00000178,Pharmacy,Denied,Paper,2023-01-30,2023-01-30,2023-01-30,2023-02-22,Manual_Review,23,1262622669,1842149518,2086S0122X,Orthopedic Surgery,22,Out_of_Network,OTHER,OTHER|Z23|Z87.891,00310075090,,4,Medicaid_MCO,MCO,89,M,0.7057,97,Network,131.93,67.37,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0075,none,0,1,0,0,0,0.0,1,0,,Shared_Savings
CLM0000002714,MBR00000288,Pharmacy,Paid,Electronic_EDI,2023-09-05,2023-09-05,2023-09-05,2023-09-26,Manual_Review,21,1454749898,1560230600,207V00000X,Obstetrics & Gynecology,31,In_Network,I10,,00069420020,,2,Commercial,HMO,36,M,0.8408,,,197.58,74.76,5.59,33.77,34.0,1.4,122.82,0.0,0.0,0,,0.085,none,0,1,0,0,0,1e-06,0,1,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000002715,MBR00000100,Medical_Professional,Paid,Electronic_EDI,2023-11-25,2023-11-25,2023-11-25,2023-11-26,Auto_Adjudicated,1,1466478716,1689327034,207R00000X,Internal Medicine,11,In_Network,OTHER,E11.65,97110,,0,ACA_Marketplace,ACA_Gold,87,M,1.435,,,2733.59,2128.09,1595.18,122.11,12.0,398.8,605.5,0.0,0.0,0,,0.0509,none,0,1,0,1,0,0.000148,0,0,,FFS
CLM0000002716,MBR00000126,Medical_Professional,Denied,Electronic_EDI,2023-08-28,2023-08-28,2023-08-28,2023-09-14,Manual_Review,17,1461820376,1148659045,207RG0100X,Gastroenterology,31,Out_of_Network,Z87.891,J06.9,90837,,0,Medicaid_MCO,MLTSS,48,F,0.637,PR-1,Duplicate,538.65,289.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0532,none,0,1,0,0,0,0.0,1,0,,P4P
CLM0000002717,MBR00000294,Dental,Denied,Electronic_EDI,2023-07-27,2023-07-27,2023-07-27,2023-08-23,Auto_Adjudicated,27,1120678352,1662516615,207R00000X,Internal Medicine,22,Emergency,OTHER,F33.0|J06.9|OTHER,D0150,,0,Medicare_Advantage,MA_HMO,8,M,0.6878,18,Authorization,350.73,206.92,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1192,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002718,MBR00000033,Medical_Institutional,Paid,Electronic_EDI,2023-12-13,2023-12-13,2023-12-16,2023-12-17,Auto_Adjudicated,4,1986485249,1188760037,246ZN0300X,Neuropsychology,22,In_Network,J06.9,OTHER|F41.1,revenue_code:0300,,0,Medicare_Advantage,PFFS,31,F,0.821,,,4652.02,3393.26,2670.57,15.05,40.0,667.64,1258.76,0.0,0.0,0,,0.1339,none,0,1,0,0,0,0.000247,0,0,,FFS
CLM0000002719,MBR00000236,Medical_Institutional,Paid,Electronic_EDI,2023-03-20,2023-03-20,2023-03-20,2023-04-05,Auto_Adjudicated,16,1424643153,1704466150,225100000X,Physical Therapist,11,In_Network,OTHER,OTHER,revenue_code:0250,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,6520.8,3361.61,3355.61,0.0,6.0,0.0,3159.19,0.0,0.0,0,,0.149,high_oop_waiver,0,1,0,0,0,0.000311,0,0,,P4P
CLM0000002720,MBR00000004,Dental,Paid,Electronic_EDI,2023-10-05,2023-10-05,2023-10-05,2023-10-13,Auto_Adjudicated,8,1853233709,1300957944,207RP1001X,Pulmonary Disease,22,In_Network,F41.1,J06.9|G47.33|N18.3,D7140,,0,Medicare_Advantage,MA_PPO,68,M,1.23,,,455.91,233.11,139.71,50.47,8.0,34.93,222.8,0.0,0.0,0,,0.076,upcoding_pattern,0,1,0,0,0,1.3e-05,0,0,,Bundled_Payment
CLM0000002721,MBR00000151,Medical_Professional,Paid,Electronic_EDI,2023-03-16,2023-03-16,2023-03-16,2023-04-13,Auto_Adjudicated,28,1269720844,1321680994,207V00000X,Obstetrics & Gynecology,21,In_Network,I10,Z00.00,47562,,0,Medicare_Advantage,MA_HMO,77,M,0.8709,,,1214.58,588.23,464.18,2.0,6.0,116.05,626.35,0.0,0.0,0,,0.0975,none,0,1,0,1,0,4.3e-05,0,0,,Shared_Savings
CLM0000002722,MBR00000049,Pharmacy,Paid,Electronic_EDI,2023-01-01,2023-01-01,2023-01-01,2023-01-18,Auto_Adjudicated,17,1838794554,1579331190,207RG0100X,Gastroenterology,11,In_Network,OTHER,OTHER,59148001506,,2,Medicare_Advantage,PFFS,67,M,0.978,,,229.26,192.16,139.6,13.67,4.0,34.9,37.1,0.0,0.0,0,,0.0875,none,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000002723,MBR00000181,Medical_Institutional,Paid,Electronic_EDI,2023-03-28,2023-03-28,2023-03-31,2023-04-21,Auto_Adjudicated,24,1175448241,1325999602,207RE0101X,Endocrinology,32,In_Network,OTHER,Z23,revenue_code:0360,,0,Commercial,PPO,82,F,1.0432,,,25343.42,11525.81,9150.62,34.54,53.0,2287.65,13817.61,0.0,0.0,0,,0.0813,none,0,1,1,1,0,0.000847,0,0,,Shared_Savings
CLM0000002724,MBR00000236,Medical_Professional,Paid,Provider_Portal,2023-06-30,2023-06-30,2023-06-30,2023-07-16,Auto_Adjudicated,16,1526973051,1942423230,225100000X,Physical Therapist,22,In_Network,I10,OTHER|F32.9,99381,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,169.79,117.51,114.51,0.0,3.0,0.0,52.28,0.0,0.0,0,,0.1597,service_date_weekend,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000002725,MBR00000011,Behavioral_Health,Paid,Electronic_EDI,2023-01-23,2023-01-23,2023-01-23,2023-02-19,Auto_Adjudicated,27,1288855406,1128148362,225100000X,Physical Therapist,11,In_Network,F32.9,,99285,,0,Medicare_Advantage,SNP,35,F,1.0833,,,126.95,85.36,54.17,0.65,17.0,13.54,41.59,0.0,0.0,0,,0.0918,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000002726,MBR00000052,Pharmacy,Paid,Electronic_EDI,2023-04-11,2023-04-11,2023-04-11,2023-04-20,Auto_Adjudicated,9,1133514780,1274911960,207RG0100X,Gastroenterology,11,In_Network,OTHER,E78.5|Z79.4,00078043215,,2,Commercial,PPO,0,F,1.325,,,339.84,197.35,0.0,197.35,0.0,0.0,142.49,0.0,0.0,0,,0.0855,duplicate_claim_indicator,0,1,0,0,0,0.0,0,1,,FFS
CLM0000002727,MBR00000107,Medical_Professional,Paid,Electronic_EDI,2023-01-18,2023-01-18,2023-01-18,2023-02-10,Auto_Adjudicated,23,1889525696,1301833092,101YP2500X,Psychologist Clinical,11,In_Network,J20.9,,90853,,0,Medicare_Advantage,MA_PPO,44,M,1.0439,,,465.76,340.52,252.54,16.84,8.0,63.14,125.24,175.99,67.79,0,,0.0473,none,0,1,0,0,0,2.3e-05,0,0,W30_Well_Child_Visit,P4P
CLM0000002728,MBR00000079,Vision,Paid,Electronic_EDI,2023-03-29,2023-03-29,2023-03-29,2023-04-11,Manual_Review,13,1625939855,1847196500,207RN0300X,Nephrology,71,Emergency,F41.1,,92004,,0,Medicaid_MCO,MLTSS,55,F,0.5016,,,155.64,68.51,64.51,0.0,4.0,0.0,87.13,0.0,0.0,0,,0.0101,none,0,1,0,0,0,6e-06,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000002729,MBR00000121,Vision,Paid,Electronic_EDI,2023-09-16,2023-09-16,2023-09-16,2023-10-04,Auto_Adjudicated,18,1243052462,1579331190,225100000X,Physical Therapist,11,In_Network,E11.9,Z00.121|F32.9|J44.1,V2115,,0,Medicare_Advantage,MA_PPO,58,M,1.226,,,309.89,120.74,65.28,21.14,18.0,16.32,189.15,0.0,0.0,0,,0.1323,none,0,1,0,0,0,6e-06,0,0,,P4P
CLM0000002730,MBR00000288,Pharmacy,Paid,Electronic_EDI,2023-02-24,2023-02-24,2023-02-24,2023-03-17,Auto_Adjudicated,21,1133514780,1898471307,207Q00000X,Family Medicine,22,In_Network,Z23,OTHER|I10,00003014960,,1,Commercial,HMO,36,M,0.8408,,,192.8,129.07,25.47,63.23,34.0,6.37,63.73,0.0,0.0,0,,0.1953,geographic_mismatch,0,1,0,0,0,2e-06,0,0,TRC_Transition_of_Care,FFS
CLM0000002731,MBR00000030,Medical_Professional,Paid,Electronic_EDI,2023-04-05,2023-04-05,2023-04-05,2023-04-11,Auto_Adjudicated,6,1647029816,1607833568,207RN0300X,Nephrology,24,In_Network,F41.1,M17.11,12001,,0,Medicaid_MCO,MCO,67,M,0.4581,,,569.11,273.44,270.44,0.0,3.0,0.0,295.67,223.88,36.38,0,,0.1779,diagnosis_procedure_mismatch,0,1,0,1,0,2.5e-05,0,0,,FFS
CLM0000002732,MBR00000134,Medical_Professional,Paid,Electronic_EDI,2023-02-18,2023-02-18,2023-02-18,2023-03-17,Manual_Review,27,1364214492,1903401648,207RN0300X,Nephrology,11,In_Network,N40.0,OTHER|Z12.11,99284,,0,Medicare_Advantage,MA_PPO,33,M,1.115,,,1727.84,1360.17,1060.04,22.12,13.0,265.01,367.67,0.0,0.0,1,Upcoding,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|benford_violation|duplicate_claim_indicator|upcoding_pattern|phantom_billing_indicator|npi_mismatch|high_oop_waiver,1,5,0,0,0,9.8e-05,0,0,,Bundled_Payment
CLM0000002733,MBR00000142,Pharmacy,Paid,Electronic_EDI,2023-05-19,2023-05-19,2023-05-19,2023-06-10,Manual_Review,22,1097600151,1747935894,101YP2500X,Psychologist Clinical,21,In_Network,K21.0,OTHER,59148001506,,1,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,387.91,246.47,0.0,246.47,0.0,0.0,141.44,0.0,0.0,0,,0.0943,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002734,MBR00000088,Dental,Paid,Electronic_EDI,2023-10-01,2023-10-01,2023-10-01,2023-10-14,Clinical_Review,13,1172766349,1355732274,207V00000X,Obstetrics & Gynecology,23,In_Network,Z79.4,,D1110,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,,,452.88,200.26,4.95,155.19,38.0,2.12,252.62,0.0,0.0,0,,0.0425,none,0,1,0,0,0,0.0,0,0,KED_ESRD_Patients,FFS
CLM0000002735,MBR00000087,Medical_Professional,Paid,Electronic_EDI,2023-07-12,2023-07-12,2023-07-12,2023-07-30,Auto_Adjudicated,18,1710668368,1983760474,207RC0000X,Cardiovascular Disease,32,In_Network,Z00.01,E11.65,12001,,0,Medicaid_MCO,MCO,70,F,0.9232,,,1707.93,841.01,840.01,0.0,1.0,0.0,866.92,0.0,0.0,0,,0.1257,none,0,1,0,0,0,7.8e-05,0,0,,FFS
CLM0000002736,MBR00000211,Medical_Institutional,Paid,Electronic_EDI,2023-03-13,2023-03-13,2023-03-17,2023-04-02,Auto_Adjudicated,20,1080383191,1170002937,207RN0300X,Nephrology,23,In_Network,OTHER,Z23|OTHER|I10,revenue_code:0200,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,,,13831.01,8970.03,7152.19,0.79,29.0,1788.05,4860.98,5757.52,791.81,0,,0.1697,high_volume_same_code,0,1,1,1,0,0.000662,0,0,HBD_Hemoglobin_A1c_Testing,Shared_Savings
CLM0000002737,MBR00000185,Medical_Professional,Paid,Paper,2023-04-25,2023-04-25,2023-04-25,2023-05-09,Manual_Review,14,1592228076,1391074619,225100000X,Physical Therapist,11,In_Network,Z00.00,,97110,,0,Medicaid_MCO,MCO,73,M,1.5417,,,567.56,463.07,460.07,0.0,3.0,0.0,104.49,0.0,0.0,0,,0.1827,phantom_billing_indicator,0,1,0,0,0,4.3e-05,0,0,,FFS
CLM0000002738,MBR00000241,Medical_Institutional,Paid,Electronic_EDI,2023-08-29,2023-08-29,2023-08-30,2023-09-18,Auto_Adjudicated,20,1520692162,1689327034,246ZN0300X,Neuropsychology,21,In_Network,M79.3,,revenue_code:0110,871,0,Medicare_Advantage,MA_HMO,77,M,1.2169,,,7096.86,3838.78,3052.17,1.56,22.0,763.04,3258.08,0.0,0.0,0,,0.1301,none,0,1,0,0,0,0.000283,0,0,,FFS
CLM0000002739,MBR00000129,Medical_Institutional,Denied,Electronic_EDI,2023-06-21,2023-06-21,2023-06-25,2023-07-08,Auto_Adjudicated,17,1211612843,1321680994,2084P0800X,Psychiatry,21,In_Network,OTHER,J06.9|E11.9,revenue_code:0200,193,0,Medicare_Advantage,MA_PPO,9,F,0.8196,5,Duplicate,5935.16,2254.46,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0424,none,0,1,0,0,1,0.0,0,0,,P4P
CLM0000002740,MBR00000183,Medical_Professional,Paid,Electronic_EDI,2023-06-15,2023-06-15,2023-06-15,2023-07-09,Clinical_Review,24,1331264469,1649705287,207RE0101X,Endocrinology,21,In_Network,OTHER,OTHER,71046,,0,Commercial,PPO,51,M,0.8463,,,1244.62,864.83,657.51,3.94,39.0,164.38,379.79,0.0,0.0,0,,0.0507,none,0,1,0,0,0,6.1e-05,0,0,,Shared_Savings
CLM0000002741,MBR00000271,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-11-07,2023-11-07,2023-11-11,2023-11-14,Auto_Adjudicated,7,1172766349,1321680994,207Q00000X,Family Medicine,71,In_Network,I10,I10,revenue_code:0450,,0,Medicaid_MCO,MCO,4,F,0.6696,4,Medical_Necessity,3105.68,1950.96,1229.68,0.0,9.0,0.0,1867.0,0.0,0.0,0,,0.0956,none,0,1,0,0,0,0.000114,0,0,,FFS
CLM0000002742,MBR00000257,Medical_Institutional,Paid,Electronic_EDI,2023-10-22,2023-10-22,2023-10-24,2023-10-23,Auto_Adjudicated,1,1428403730,1689327034,207R00000X,Internal Medicine,11,In_Network,OTHER,Z00.01,revenue_code:0370,,0,Medicaid_MCO,MCO,76,F,0.8322,,,7029.01,5110.59,5102.59,0.0,8.0,0.0,1918.42,0.0,0.0,0,,0.0283,none,0,1,1,0,0,0.000472,0,0,BCS_Breast_Cancer_Screening,Bundled_Payment
CLM0000002743,MBR00000277,Medical_Institutional,Paid,Electronic_EDI,2023-03-29,2023-03-29,2023-04-01,2023-04-11,Auto_Adjudicated,13,1838794554,1574982369,207Q00000X,Family Medicine,11,In_Network,Z00.00,E78.5|N18.3|J06.9,revenue_code:0120,,0,Medicaid_MCO,MCO,30,M,1.8495,,,8728.32,5243.66,5241.66,0.0,2.0,0.0,3484.66,0.0,0.0,0,,0.0635,unusual_service_frequency,0,1,1,0,0,0.000485,0,0,,Shared_Savings
CLM0000002744,MBR00000083,Dental,Paid,Electronic_EDI,2023-09-10,2023-09-10,2023-09-10,2023-10-05,Auto_Adjudicated,25,1594322174,1388050552,207RN0300X,Nephrology,22,In_Network,Z00.00,,D0150,,0,Commercial,PPO,76,M,0.6621,,,150.43,82.64,0.0,82.64,0.0,0.0,67.79,0.0,0.0,0,,0.0591,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000002745,MBR00000296,Medical_Professional,Paid,Electronic_EDI,2023-10-12,2023-10-12,2023-10-12,2023-10-16,Auto_Adjudicated,4,1519595029,1903401648,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,,99385,,0,Commercial,HMO,83,F,1.4969,,,230.23,130.1,72.77,8.14,31.0,18.19,100.13,0.0,0.0,0,,0.0197,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000002746,MBR00000243,Medical_Professional,Paid,Electronic_EDI,2023-11-20,2023-11-20,2023-11-20,2023-12-16,Manual_Review,26,1556072255,1903401648,207Q00000X,Family Medicine,22,In_Network,I10,N39.0,90837,,0,Medicaid_MCO,MCO,21,M,0.4834,,,694.09,524.69,520.69,0.0,4.0,0.0,169.4,0.0,0.0,0,,0.0802,none,0,1,0,0,0,4.8e-05,0,0,,Shared_Savings
CLM0000002747,MBR00000235,Medical_Institutional,Paid,Electronic_EDI,2023-04-05,2023-04-05,2023-04-09,2023-04-18,Auto_Adjudicated,13,1264432433,1396850418,207RN0300X,Nephrology,11,In_Network,K21.0,Z79.4,revenue_code:0370,,0,Commercial,HDHP_HSA,85,F,1.4308,,,30248.46,16482.9,12822.66,454.58,0.0,3205.66,13765.56,0.0,0.0,0,,0.1849,unusual_service_frequency,0,1,1,0,0,0.001187,0,0,,FFS
CLM0000002748,MBR00000198,Medical_Institutional,Paid,Electronic_EDI,2023-09-19,2023-09-19,2023-09-23,2023-09-26,Auto_Adjudicated,7,1232573801,1354959095,225100000X,Physical Therapist,31,In_Network,OTHER,,revenue_code:0370,,0,Medicaid_MCO,MCO,81,F,1.4199,,,7610.16,4429.3,4427.3,0.0,2.0,0.0,3180.86,0.0,0.0,0,,0.0426,none,0,1,0,0,0,0.00041,0,0,,FFS
CLM0000002749,MBR00000296,Medical_Professional,Paid,Electronic_EDI,2023-03-09,2023-03-09,2023-03-09,2023-03-24,Manual_Review,15,1950560596,1287472731,225100000X,Physical Therapist,11,In_Network,E11.9,I25.10,97035,,0,Commercial,HMO,83,F,1.4969,,,1160.92,551.66,402.33,17.75,31.0,100.58,609.26,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|temporal_clustering|high_volume_same_code|benford_violation|duplicate_claim_indicator|unbundling_pattern|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,3.7e-05,0,0,,P4P
CLM0000002750,MBR00000138,Vision,Denied,Electronic_EDI,2023-06-09,2023-06-09,2023-06-09,2023-07-04,Manual_Review,25,1207676414,1827839595,246ZN0300X,Neuropsychology,22,Out_of_Network,OTHER,F33.0,92002,,0,Commercial,HDHP_HSA,47,M,0.996,5,Coding_Error,152.41,54.43,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0627,none,0,1,0,0,0,0.0,1,0,,FFS
CLM0000002751,MBR00000217,Medical_Professional,Paid,Electronic_EDI,2023-01-27,2023-01-27,2023-01-27,2023-02-22,Manual_Review,26,1484438840,1965244699,207R00000X,Internal Medicine,22,Out_of_Network,I25.10,I50.9,99386,,0,ACA_Marketplace,ACA_Bronze,11,F,1.1619,,,108.09,49.27,0.0,49.27,0.0,0.0,58.82,0.0,0.0,0,,0.0801,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002752,MBR00000207,Medical_Professional,Paid,Electronic_EDI,2023-08-05,2023-08-05,2023-08-05,2023-08-24,Manual_Review,19,1881170383,1339359594,207RC0000X,Cardiovascular Disease,11,In_Network,Z23,OTHER,71046,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,1289.73,971.9,971.9,0.0,0.0,0.0,317.83,0.0,0.0,0,,0.0223,none,0,1,0,0,0,9e-05,0,0,,Shared_Savings
CLM0000002753,MBR00000214,Pharmacy,Paid,Electronic_EDI,2023-09-03,2023-09-03,2023-09-03,2023-09-19,Auto_Adjudicated,16,1896279539,1623053477,246ZN0300X,Neuropsychology,21,In_Network,F32.9,,00003014960,,2,Commercial,HDHP_HSA,76,M,1.7526,,,138.47,111.84,0.0,111.84,0.0,0.0,26.63,0.0,0.0,0,,0.061,unusual_service_frequency,0,1,0,0,0,0.0,0,1,,FFS
CLM0000002754,MBR00000221,Vision,Paid,Electronic_EDI,2023-06-10,2023-06-10,2023-06-10,2023-07-05,Auto_Adjudicated,25,1243052462,1510751265,207Q00000X,Family Medicine,22,In_Network,Z23,I50.9,92004,,0,Commercial,HDHP_HSA,28,M,1.6683,,,312.71,225.41,43.0,171.67,0.0,10.75,87.3,0.0,0.0,0,,0.0999,none,0,1,0,0,0,4e-06,0,0,FLU_Flu_Vaccination,FFS
CLM0000002755,MBR00000059,Medical_Institutional,Paid,Electronic_EDI,2023-05-28,2023-05-28,2023-05-29,2023-06-25,Auto_Adjudicated,28,1404237143,1170002937,207RN0300X,Nephrology,24,In_Network,OTHER,F10.10|Z12.11,revenue_code:0110,,0,Medicare_Advantage,SNP,12,F,1.266,,,19221.98,10929.93,8709.79,9.69,33.0,2177.45,8292.05,0.0,0.0,0,,0.123,none,0,1,1,0,0,0.000806,0,0,,FFS
CLM0000002756,MBR00000110,Medical_Professional,Paid,Electronic_EDI,2023-03-28,2023-03-28,2023-03-28,2023-04-21,Auto_Adjudicated,24,1007266616,1123879500,207R00000X,Internal Medicine,22,In_Network,OTHER,OTHER,33510,,0,Medicare_Advantage,MA_HMO,83,F,1.127,,,1144.71,789.86,623.4,1.61,9.0,155.85,354.85,0.0,0.0,0,,0.1012,controlled_substance_high_volume,0,1,0,0,0,5.8e-05,0,0,MPT_Annual_Monitoring,FFS
CLM0000002757,MBR00000125,Medical_Professional,Paid,Electronic_EDI,2023-10-04,2023-10-04,2023-10-04,2023-11-03,Auto_Adjudicated,30,1506426842,1867626800,207Q00000X,Family Medicine,22,Emergency,Z12.11,OTHER,99221,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,763.16,314.35,240.63,2.57,11.0,60.16,448.81,0.0,0.0,0,,0.1099,provider_specialty_mismatch,0,1,0,0,0,2.2e-05,0,0,,Shared_Savings
CLM0000002758,MBR00000219,Medical_Professional,Paid,Electronic_EDI,2023-11-23,2023-11-23,2023-11-23,2023-12-18,Auto_Adjudicated,25,1443292773,1616762819,207RN0300X,Nephrology,22,In_Network,M47.816,I25.10,17000,,0,Medicare_Advantage,MA_HMO,84,M,0.9513,,,631.46,250.07,179.44,25.78,0.0,44.86,381.39,0.0,0.0,0,,0.1092,none,0,1,0,0,0,1.7e-05,0,0,,FFS
CLM0000002759,MBR00000212,Medical_Institutional,Paid,Electronic_EDI,2023-02-17,2023-02-17,2023-02-20,2023-02-19,Auto_Adjudicated,2,1015411732,1767402068,207RG0100X,Gastroenterology,21,In_Network,N39.0,K21.0,revenue_code:0300,291,0,Commercial,HMO,57,F,2.5456,,,6325.07,2807.28,1985.89,256.92,68.0,496.47,3517.79,0.0,0.0,0,,0.1113,temporal_clustering,0,1,0,0,0,0.000184,0,0,TRC_Transition_of_Care,Shared_Savings
CLM0000002760,MBR00000249,Pharmacy,Paid,Electronic_EDI,2023-04-10,2023-04-10,2023-04-10,2023-04-11,Manual_Review,1,1145887050,1297948643,207R00000X,Internal Medicine,23,In_Network,I48.91,Z00.00|OTHER,00071012831,,2,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,314.7,205.19,0.0,205.19,0.0,0.0,109.51,0.0,0.0,0,,0.0042,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002761,MBR00000233,Medical_Professional,Paid,Provider_Portal,2023-08-05,2023-08-05,2023-08-05,2023-08-23,Auto_Adjudicated,18,1739169232,1649705287,207Q00000X,Family Medicine,11,Emergency,Z00.00,I10|M17.11,17000,,0,Medicare_Advantage,MA_PPO,87,M,0.8034,,,3398.19,1903.58,1489.07,39.25,3.0,372.27,1494.61,919.11,477.9,0,,0.0769,none,0,1,0,0,0,0.000138,0,0,,FFS
CLM0000002762,MBR00000180,Medical_Institutional,Paid,Paper,2023-05-12,2023-05-12,2023-05-14,2023-06-10,Auto_Adjudicated,29,1625939855,1938465393,225100000X,Physical Therapist,22,In_Network,J06.9,,revenue_code:0300,,0,Medicare_Advantage,MA_PPO,72,F,1.1909,,,7386.46,3261.0,2567.61,0.49,51.0,641.9,4125.46,0.0,0.0,0,,0.1306,none,0,1,0,1,0,0.000238,0,0,MMA_Medication_Management,FFS
CLM0000002763,MBR00000044,Pharmacy,Paid,Electronic_EDI,2023-01-05,2023-01-05,2023-01-05,2023-01-14,Manual_Review,9,1069440570,1903401648,207RE0101X,Endocrinology,65,In_Network,J06.9,,00085163102,,1,Commercial,PPO,29,M,0.7512,,,95.29,59.35,0.0,59.35,0.0,0.0,35.94,0.0,0.0,0,,0.0438,none,0,1,0,1,0,0.0,0,1,,FFS
CLM0000002764,MBR00000188,Medical_Professional,Denied,Electronic_EDI,2023-01-08,2023-01-08,2023-01-08,2023-02-06,Auto_Adjudicated,29,1324084461,1175334579,101YP2500X,Psychologist Clinical,22,In_Network,J44.1,,99212,,0,Commercial,HMO,8,F,1.5853,170,Duplicate,78.05,62.89,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1288,unbundling_pattern,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002765,MBR00000269,Medical_Professional,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-25,2023-04-20,Auto_Adjudicated,26,1310250833,1140170394,2086S0122X,Orthopedic Surgery,22,In_Network,E11.9,,90847,,0,Commercial,EPO,10,F,0.718,,,152.93,95.68,0.0,68.11,27.57,0.0,57.25,0.0,0.0,0,,0.1035,none,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000002766,MBR00000191,Pharmacy,Paid,Electronic_EDI,2023-12-14,2023-12-14,2023-12-14,2023-12-19,Auto_Adjudicated,5,1012271279,1068662623,101YP2500X,Psychologist Clinical,24,Out_of_Network,N39.0,J06.9,00003014960,,1,Commercial,POS,85,F,0.9729,,,560.29,341.1,112.92,161.95,38.0,28.23,219.19,0.0,0.0,0,,0.0504,none,0,1,0,0,0,1e-05,0,0,SPD_Spirometry_Testing,FFS
CLM0000002767,MBR00000272,Medical_Professional,Paid,Electronic_EDI,2023-08-07,2023-08-07,2023-08-07,2023-08-22,Auto_Adjudicated,15,1688560518,1148659045,225100000X,Physical Therapist,21,In_Network,OTHER,,99386,,0,Medicare_Advantage,MA_HMO,15,M,0.8525,,,256.73,135.42,96.1,0.3,15.0,24.02,121.31,0.0,0.0,0,,0.0733,none,0,1,0,0,0,9e-06,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000002768,MBR00000300,Medical_Professional,Paid,Electronic_EDI,2023-04-02,2023-04-02,2023-04-02,2023-04-09,Manual_Review,7,1478458171,1650774392,207RP1001X,Pulmonary Disease,22,In_Network,Z00.00,M54.5|Z23,99383,,0,Commercial,PPO,64,F,1.0393,,,158.52,56.46,0.0,56.46,0.0,0.0,102.06,0.0,0.0,0,,0.1,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000002769,MBR00000113,Medical_Professional,Paid,Electronic_EDI,2023-01-21,2023-01-21,2023-01-21,2023-01-24,Auto_Adjudicated,3,1905691248,1007652766,207R00000X,Internal Medicine,11,In_Network,M17.11,I25.10,84443,,0,Medicaid_MCO,MLTSS,29,F,1.1621,,,651.38,308.07,307.07,0.0,1.0,0.0,343.31,0.0,0.0,0,,0.1201,none,0,1,0,0,0,2.8e-05,0,0,,Bundled_Payment
CLM0000002770,MBR00000212,Medical_Institutional,Paid,Electronic_EDI,2023-09-29,2023-09-29,2023-10-01,2023-10-20,Auto_Adjudicated,21,1980039511,1825450791,225100000X,Physical Therapist,11,In_Network,I10,,revenue_code:0100,,0,Commercial,HMO,57,F,2.5456,,,124720.41,64241.17,51271.97,83.21,68.0,12817.99,60479.24,0.0,0.0,0,,0.125,outlier_billing_amount,0,1,1,0,0,0.004746,0,0,,Shared_Savings
CLM0000002771,MBR00000164,Medical_Institutional,Paid,Electronic_EDI,2023-05-16,2023-05-16,2023-05-19,2023-05-23,Auto_Adjudicated,7,1648123576,1196833348,2084P0800X,Psychiatry,11,In_Network,I25.10,,revenue_code:0100,,0,ACA_Marketplace,ACA_Silver,3,F,0.7155,,,12045.34,6952.34,4624.18,258.36,88.0,1981.79,5093.0,0.0,0.0,0,,0.0908,none,0,1,0,1,0,0.000428,0,0,,FFS
CLM0000002772,MBR00000141,Medical_Institutional,Denied,Electronic_EDI,2023-05-22,2023-05-22,2023-05-26,2023-06-08,Clinical_Review,17,1201027197,1625992541,207RE0101X,Endocrinology,24,In_Network,E11.9,,revenue_code:0120,,0,Commercial,HMO,47,F,0.6724,16,Medical_Necessity,67230.94,54531.2,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1161,outlier_billing_amount,0,1,0,0,0,0.0,0,0,POD_Persistence_of_Beta_Blocker,P4P
CLM0000002773,MBR00000075,Medical_Institutional,Denied,Electronic_EDI,2023-07-21,2023-07-21,2023-07-21,2023-08-11,Manual_Review,21,1390393668,1132693989,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,Z00.00,revenue_code:0370,,0,Medicaid_MCO,MCO,5,M,1.0573,PR-1,Network,5163.78,2583.37,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0589,none,0,1,0,0,0,0.0,0,0,TRC_Transition_of_Care,Capitation
CLM0000002774,MBR00000076,Medical_Institutional,Paid,Electronic_EDI,2023-03-24,2023-03-24,2023-03-28,2023-04-06,Auto_Adjudicated,13,1534538584,1098360555,2084P0800X,Psychiatry,71,In_Network,M54.5,I10,revenue_code:0360,,0,Commercial,HMO,26,M,2.1785,,,44664.16,22623.3,18035.95,38.37,40.0,4508.99,22040.86,0.0,0.0,0,,0.1317,impossible_service_combo|upcoding_pattern,0,1,1,1,0,0.001669,0,0,,FFS
CLM0000002775,MBR00000058,Medical_Professional,Paid,Electronic_EDI,2023-09-19,2023-09-19,2023-09-19,2023-09-22,Auto_Adjudicated,3,1469009511,1983760474,207RN0300X,Nephrology,11,Out_of_Network,OTHER,N18.3,71046,,0,Commercial,PPO,56,F,1.1626,,,438.88,224.05,116.76,63.11,15.0,29.19,214.83,0.0,0.0,0,,0.0919,diagnosis_procedure_mismatch,0,1,0,0,0,1.1e-05,0,0,MMA_Medication_Management,FFS
CLM0000002776,MBR00000187,Pharmacy,Denied,Electronic_EDI,2023-04-23,2023-04-23,2023-04-23,2023-04-26,Auto_Adjudicated,3,1466478716,1301869102,207RE0101X,Endocrinology,11,In_Network,Z00.00,,00310075090,,5,Medicaid_MCO,MCO,36,F,1.191,1,COB,97.25,44.45,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0337,none,0,1,0,1,0,0.0,0,1,,P4P
CLM0000002777,MBR00000045,Behavioral_Health,Paid,Electronic_EDI,2023-09-11,2023-09-11,2023-09-11,2023-09-23,Auto_Adjudicated,12,1466478716,1220755708,225100000X,Physical Therapist,23,Emergency,OTHER,K29.70|I50.9|OTHER,82947,,0,Commercial,HMO,78,F,1.0658,,,137.53,77.89,25.78,13.66,32.0,6.45,59.64,0.0,0.0,0,,0.1559,duplicate_claim_indicator,0,1,0,0,0,2e-06,0,0,ACR_Urine_Protein,FFS
CLM0000002778,MBR00000135,Medical_Institutional,Paid,Electronic_EDI,2023-07-05,2023-07-05,2023-07-06,2023-07-07,Manual_Review,2,1487261286,1746676564,207R00000X,Internal Medicine,11,In_Network,E78.5,Z00.00,revenue_code:0300,,0,Commercial,PPO,58,F,2.2702,,,8965.3,6489.25,5142.64,1.95,59.0,1285.66,2476.05,0.0,0.0,0,,0.0624,none,0,1,1,0,0,0.000476,0,0,,Bundled_Payment
CLM0000002779,MBR00000160,Medical_Professional,Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-23,2023-03-22,Auto_Adjudicated,27,1083045036,1867389043,2086S0122X,Orthopedic Surgery,22,In_Network,E11.9,M17.11,99285,,0,Commercial,HMO,73,M,1.9608,,,456.11,327.25,107.17,170.28,23.0,26.79,128.86,0.0,0.0,0,,0.0867,high_volume_same_code,0,1,0,0,0,1e-05,0,0,,Bundled_Payment
CLM0000002780,MBR00000137,Pharmacy,Paid,Electronic_EDI,2023-08-12,2023-08-12,2023-08-12,2023-08-17,Auto_Adjudicated,5,1810800968,1447657873,101YP2500X,Psychologist Clinical,11,In_Network,OTHER,Z23,00310075090,,1,Commercial,PPO,87,M,0.5201,,,122.44,43.1,8.7,7.23,25.0,2.17,79.34,0.0,0.0,0,,0.1208,none,0,1,0,0,0,1e-06,0,0,CDC_BP_Control,Capitation
CLM0000002781,MBR00000258,Medical_Professional,Paid,Electronic_EDI,2023-01-27,2023-01-27,2023-01-27,2023-01-28,Auto_Adjudicated,1,1340676357,1978943761,246ZN0300X,Neuropsychology,11,In_Network,M54.5,,99212,,0,Commercial,EPO,9,F,0.5431,,,478.0,350.97,258.28,10.11,18.0,64.57,127.03,0.0,0.0,0,,0.0656,none,0,1,0,0,0,2.4e-05,0,0,,FFS
CLM0000002782,MBR00000139,Medical_Professional,Denied,Provider_Portal,2023-09-14,2023-09-14,2023-09-14,2023-09-19,Auto_Adjudicated,5,1594587354,1209882852,246ZN0300X,Neuropsychology,22,In_Network,I25.10,E11.9|OTHER,71250,,0,Commercial,PPO,74,M,1.7701,CO-45,Timely_Filing,393.4,215.01,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1007,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002783,MBR00000025,Vision,Paid,Electronic_EDI,2023-05-16,2023-05-16,2023-05-16,2023-06-06,Clinical_Review,21,1457568950,1356856197,207RP1001X,Pulmonary Disease,22,In_Network,H52.4,I10|M17.11,92004,,0,Commercial,POS,74,M,1.3309,,,268.74,96.68,0.0,96.68,0.0,0.0,172.06,0.0,0.0,0,,0.118,none,0,1,0,0,0,0.0,0,0,CDC_BP_Control,Bundled_Payment
CLM0000002784,MBR00000298,Medical_Professional,Paid,Electronic_EDI,2023-08-29,2023-08-29,2023-08-29,2023-09-16,Manual_Review,18,1671999102,1643323506,207V00000X,Obstetrics & Gynecology,11,In_Network,Z23,,99214,,0,Medicaid_MCO,MCO,75,M,0.8324,,,214.74,181.56,181.56,0.0,0.0,0.0,33.18,0.0,0.0,0,,0.1174,benford_violation,0,1,0,1,0,1.7e-05,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000002785,MBR00000254,Medical_Professional,Paid,Paper,2023-03-28,2023-03-28,2023-03-28,2023-04-18,Auto_Adjudicated,21,1728728765,1788579687,207RE0101X,Endocrinology,11,In_Network,Z00.01,,99214,,0,Commercial,PPO,22,F,0.9285,,,692.81,545.17,389.46,30.35,28.0,97.36,147.64,0.0,0.0,0,,0.0986,none,0,1,0,0,0,3.6e-05,0,0,,Capitation
CLM0000002786,MBR00000196,Medical_Institutional,Paid,Electronic_EDI,2023-05-27,2023-05-27,2023-05-31,2023-06-07,Manual_Review,11,1588313061,1012893364,207RN0300X,Nephrology,11,In_Network,OTHER,E11.9,revenue_code:0300,,0,Commercial,PPO,16,F,1.6015,,,19118.96,10110.11,7812.29,308.75,36.0,1953.07,9008.85,0.0,0.0,0,,0.0613,npi_mismatch,0,1,1,0,0,0.000723,0,0,,Capitation
CLM0000002787,MBR00000221,Medical_Institutional,Paid,Electronic_EDI,2023-04-20,2023-04-20,2023-04-20,2023-04-30,Auto_Adjudicated,10,1747318937,1898471307,207V00000X,Obstetrics & Gynecology,11,In_Network,R05.9,K21.0,revenue_code:0300,,0,Commercial,HDHP_HSA,28,M,1.6683,,,15497.83,10709.41,8153.43,517.62,0.0,2038.36,4788.42,6884.26,737.27,0,,0.0826,none,0,1,1,0,0,0.000755,0,0,BPD_BP_Declined,Bundled_Payment
CLM0000002788,MBR00000039,Medical_Institutional,Paid,Electronic_EDI,2023-04-01,2023-04-01,2023-04-05,2023-04-22,Auto_Adjudicated,21,1084831484,1588993671,207RN0300X,Nephrology,81,In_Network,OTHER,OTHER|Z87.891|I10,revenue_code:0120,,0,Medicaid_MCO,MCO,20,F,0.5358,,,9336.43,6244.95,6240.95,0.0,4.0,0.0,3091.48,0.0,0.0,0,,0.133,benford_violation|duplicate_claim_indicator,0,1,1,0,0,0.000578,0,0,CBP_Controlling_BP,FFS
CLM0000002789,MBR00000225,Medical_Professional,Paid,Electronic_EDI,2023-05-03,2023-05-03,2023-05-03,2023-05-07,Manual_Review,4,1549436467,1320546364,207RN0300X,Nephrology,23,In_Network,OTHER,Z00.00,99395,,0,Commercial,PPO,27,F,0.5948,,,209.21,176.3,0.0,176.3,0.0,0.0,32.91,0.0,0.0,0,,0.0425,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000002790,MBR00000063,Pharmacy,Paid,Electronic_EDI,2023-01-20,2023-01-20,2023-01-20,2023-02-01,Auto_Adjudicated,12,1901508637,1390802135,207RG0100X,Gastroenterology,11,In_Network,OTHER,F10.10|Z00.01,00069420020,,2,ACA_Marketplace,ACA_Silver,56,M,0.8198,,,80.45,35.46,0.0,35.46,0.0,0.0,44.99,0.0,0.0,0,,0.1383,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000002791,MBR00000152,Medical_Professional,Paid,Electronic_EDI,2023-05-23,2023-05-23,2023-05-23,2023-05-27,Auto_Adjudicated,4,1918359820,1574982369,207RG0100X,Gastroenterology,21,In_Network,J44.1,,99231,,0,Commercial,HMO,82,F,1.2506,,,542.28,247.58,0.0,247.58,0.0,0.0,294.7,0.0,0.0,0,,0.0762,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000002792,MBR00000056,Vision,Paid,Electronic_EDI,2023-02-14,2023-02-14,2023-02-14,2023-02-27,Auto_Adjudicated,13,1402833352,1461075342,2086S0122X,Orthopedic Surgery,11,In_Network,Z00.00,Z12.11,92014,,0,Commercial,EPO,74,F,1.3941,,,124.9,85.56,0.0,85.56,0.0,0.0,39.34,0.0,0.0,0,,0.0485,none,0,1,0,0,0,0.0,0,0,PPC_Prenatal_Care,Shared_Savings
CLM0000002793,MBR00000221,Medical_Professional,Denied,Electronic_EDI,2023-07-06,2023-07-06,2023-07-06,2023-08-05,Manual_Review,30,1426424205,1690197969,207RN0300X,Nephrology,11,In_Network,OTHER,OTHER,99394,,0,Commercial,HDHP_HSA,28,M,1.6683,3,Eligibility,233.6,90.54,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1917,benford_violation,0,1,0,0,0,0.0,0,0,TRC_Transition_of_Care,P4P
CLM0000002794,MBR00000076,Medical_Professional,Paid,Electronic_EDI,2023-02-02,2023-02-02,2023-02-02,2023-02-28,Auto_Adjudicated,26,1210349885,1884259357,207RC0000X,Cardiovascular Disease,71,In_Network,OTHER,Z23|F32.9|OTHER,27447,,0,Commercial,HMO,26,M,2.1785,,,33386.75,25388.98,20255.03,38.19,32.0,5063.76,7997.77,14486.79,4467.67,0,,0.0548,none,0,1,1,0,0,0.001875,0,0,AWV_Annual_Wellness_Visit,FFS
CLM0000002795,MBR00000078,Medical_Institutional,Paid,Electronic_EDI,2023-01-04,2023-01-04,2023-01-06,2023-01-25,Auto_Adjudicated,21,1956107350,1564691686,207RE0101X,Endocrinology,11,Out_of_Network,G43.909,OTHER,revenue_code:0200,,0,Commercial,EPO,65,F,1.3174,,,2656.75,1214.24,670.22,341.47,35.0,167.55,1442.51,0.0,0.0,0,,0.0241,none,0,1,0,0,0,6.2e-05,1,0,MPT_Annual_Monitoring,FFS
CLM0000002796,MBR00000034,Medical_Professional,Partially_Paid,Electronic_EDI,2023-06-07,2023-06-07,2023-06-07,2023-06-27,Auto_Adjudicated,20,1556434733,1965244699,207RN0300X,Nephrology,32,In_Network,OTHER,Z00.01|OTHER,99385,,0,Medicare_Advantage,MA_HMO,35,M,0.7712,16,Medical_Necessity,306.1,224.53,84.82,3.75,7.0,21.2,189.33,0.0,0.0,0,,0.094,none,0,1,0,0,0,8e-06,0,0,POD_Persistence_of_Beta_Blocker,FFS
CLM0000002797,MBR00000212,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-04-17,2023-04-17,2023-04-21,2023-04-29,Manual_Review,12,1091395764,1831337866,101YP2500X,Psychologist Clinical,31,In_Network,I10,,revenue_code:0100,,0,Commercial,HMO,57,F,2.5456,CO-45,Medical_Necessity,5481.41,2339.43,921.78,358.78,68.0,230.44,3902.41,0.0,0.0,0,,0.1324,none,0,1,0,0,0,8.5e-05,0,0,,FFS
CLM0000002798,MBR00000092,Medical_Professional,Partially_Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-12-03,Auto_Adjudicated,22,1654042271,1995553359,207RN0300X,Nephrology,24,In_Network,E78.5,F41.1,90853,,0,Medicaid_MCO,MLTSS,68,F,1.3217,18,Medical_Necessity,662.24,476.91,376.25,0.0,3.0,0.0,282.99,0.0,0.0,0,,0.0822,none,0,1,0,1,0,3.5e-05,0,0,DDE_Diabetes_Short_Term_Complications,Bundled_Payment
CLM0000002799,MBR00000159,Medical_Institutional,Paid,Electronic_EDI,2023-04-05,2023-04-05,2023-04-07,2023-05-01,Clinical_Review,26,1091271799,1774401124,225100000X,Physical Therapist,22,In_Network,I10,OTHER,revenue_code:0450,,0,Commercial,PPO,70,F,1.2009,,,16751.36,6535.51,5152.68,23.66,71.0,1288.17,10215.85,4360.08,406.65,1,Date of Service Falsification,1.0,geographic_mismatch|temporal_clustering|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|controlled_substance_high_volume|high_oop_waiver,1,5,1,0,0,0.000477,0,0,,FFS
CLM0000002800,MBR00000105,Medical_Professional,Paid,Electronic_EDI,2023-05-24,2023-05-24,2023-05-24,2023-06-10,Auto_Adjudicated,17,1972755666,1564691686,207V00000X,Obstetrics & Gynecology,11,In_Network,M79.3,,82947,,0,Commercial,HMO,74,M,1.1834,,,1015.93,408.46,149.14,207.03,15.0,37.29,607.47,0.0,0.0,0,,0.1599,impossible_service_combo|diagnosis_procedure_mismatch,0,1,0,1,0,1.4e-05,0,0,,FFS
CLM0000002801,MBR00000228,Medical_Institutional,Denied,Electronic_EDI,2023-03-26,2023-03-26,2023-03-29,2023-03-30,Auto_Adjudicated,4,1893327624,1930040953,208600000X,Surgery General,31,In_Network,K21.0,J06.9|OTHER,revenue_code:0110,,0,Commercial,PPO,55,F,0.7203,3,Medical_Necessity,4932.65,1846.08,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0269,none,0,1,0,0,0,0.0,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000002802,MBR00000071,Medical_Professional,Paid,Electronic_EDI,2023-11-16,2023-11-16,2023-11-16,2023-12-07,Auto_Adjudicated,21,1482771601,1765164601,207RN0300X,Nephrology,31,Emergency,Z00.01,OTHER,97110,,0,Commercial,EPO,19,F,0.5699,,,442.7,300.94,198.92,30.29,22.0,49.73,141.76,0.0,0.0,0,,0.0636,none,0,1,0,0,0,1.8e-05,0,0,FUH_Follow_Up_Hospitalization,Shared_Savings
CLM0000002803,MBR00000285,Medical_Professional,Paid,Paper,2023-10-11,2023-10-11,2023-10-11,2023-10-15,Auto_Adjudicated,4,1424104563,1579331190,207RN0300X,Nephrology,22,In_Network,I25.10,K21.0,99381,,0,Commercial,HDHP_HSA,56,M,0.9226,,,287.19,124.29,0.0,124.29,0.0,0.0,162.9,0.0,0.0,0,,0.0956,impossible_service_combo,0,1,0,1,0,0.0,0,0,COA_Care_Transitions,Shared_Savings
CLM0000002804,MBR00000102,Medical_Professional,Paid,Electronic_EDI,2023-03-03,2023-03-03,2023-03-03,2023-03-13,Auto_Adjudicated,10,1568777164,1860951128,246ZN0300X,Neuropsychology,11,In_Network,J06.9,J06.9,90837,,0,Commercial,POS,68,M,1.6864,,,845.53,449.6,297.78,45.38,32.0,74.44,395.93,0.0,0.0,0,,0.0964,none,0,1,0,0,0,2.8e-05,0,0,,Shared_Savings
CLM0000002805,MBR00000031,Pharmacy,Paid,Electronic_EDI,2023-04-01,2023-04-01,2023-04-01,2023-04-07,Auto_Adjudicated,6,1451464799,1867389043,101YP2500X,Psychologist Clinical,11,In_Network,F41.1,E11.9|E78.5,00078043215,,5,Commercial,PPO,71,M,0.6746,,,257.46,204.52,125.83,31.23,16.0,31.46,52.94,0.0,0.0,0,,0.029,none,0,1,0,0,0,1.2e-05,0,1,,FFS
CLM0000002806,MBR00000076,Pharmacy,Partially_Paid,Electronic_EDI,2023-03-08,2023-03-08,2023-03-08,2023-03-10,Auto_Adjudicated,2,1733777382,1649705287,246ZN0300X,Neuropsychology,11,In_Network,E78.5,,00310075090,,3,Commercial,HMO,26,M,2.1785,1,Medical_Necessity,338.88,172.37,68.96,12.11,32.0,17.24,208.57,49.84,12.16,0,,0.1091,none,0,1,0,1,0,6e-06,0,1,,FFS
CLM0000002807,MBR00000023,Medical_Professional,Denied,Electronic_EDI,2023-02-24,2023-02-24,2023-02-24,2023-03-19,Manual_Review,23,1593056613,1025886739,207R00000X,Internal Medicine,11,In_Network,I10,K21.0,71046,,0,Medicare_Advantage,MA_PPO,87,M,1.084,256,Network,115.54,49.94,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0783,unbundling_pattern,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002808,MBR00000144,Medical_Professional,Paid,Electronic_EDI,2023-03-28,2023-03-28,2023-03-28,2023-04-17,Clinical_Review,20,1946657989,1196833348,225100000X,Physical Therapist,22,In_Network,K21.0,J06.9|M79.3,99384,,0,Commercial,HDHP_HSA,56,F,2.5926,,,356.44,244.1,0.0,244.1,0.0,0.0,112.34,0.0,0.0,0,,0.11,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002809,MBR00000077,Medical_Professional,Paid,Electronic_EDI,2023-11-02,2023-11-02,2023-11-02,2023-11-15,Auto_Adjudicated,13,1810800968,1825450791,207RP1001X,Pulmonary Disease,31,In_Network,E11.9,,83036,,0,Medicare_Advantage,MA_HMO,27,F,0.9229,,,655.01,281.29,215.13,8.38,4.0,53.78,373.72,0.0,0.0,0,,0.0494,none,0,1,0,0,0,2e-05,0,0,,FFS
CLM0000002810,MBR00000269,Medical_Professional,Paid,Provider_Portal,2023-06-14,2023-06-14,2023-06-14,2023-06-26,Manual_Review,12,1813729693,1577226132,2086S0122X,Orthopedic Surgery,23,In_Network,Z23,Z79.4|E11.9,99212,,0,Commercial,EPO,10,F,0.718,,,212.32,151.7,57.23,49.16,31.0,14.31,60.62,0.0,0.0,0,,0.0673,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000002811,MBR00000158,Medical_Institutional,Denied,Electronic_EDI,2023-05-18,2023-05-18,2023-05-20,2023-06-07,Manual_Review,20,1155203600,1650774392,207RE0101X,Endocrinology,22,In_Network,Z12.11,E78.5|Z00.00,revenue_code:0370,,0,Commercial,HMO,65,M,1.5361,PR-1,Network,15199.13,8703.33,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0725,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002812,MBR00000073,Medical_Professional,Paid,Electronic_EDI,2023-03-10,2023-03-10,2023-03-10,2023-03-26,Auto_Adjudicated,16,1900781649,1319611206,2086S0122X,Orthopedic Surgery,24,In_Network,OTHER,,90837,,0,Commercial,POS,79,M,1.1768,,,1238.13,1011.73,728.51,68.09,33.0,182.13,226.4,0.0,0.0,0,,0.1155,none,0,1,0,0,0,6.7e-05,0,0,,Capitation
CLM0000002813,MBR00000140,Behavioral_Health,Paid,Electronic_EDI,2023-03-08,2023-03-08,2023-03-08,2023-03-15,Auto_Adjudicated,7,1139362508,1061113875,246ZN0300X,Neuropsychology,23,In_Network,I10,,99385,,0,Medicare_Advantage,MA_HMO,7,M,1.3997,,,141.93,66.15,22.61,25.88,12.0,5.65,75.78,0.0,0.0,0,,0.1418,none,0,1,0,0,0,2e-06,0,0,COL_Colorectal_Cancer_Screening,Shared_Savings
CLM0000002814,MBR00000060,Pharmacy,Paid,Electronic_EDI,2023-07-19,2023-07-19,2023-07-19,2023-08-03,Manual_Review,15,1205349488,1355732274,207V00000X,Obstetrics & Gynecology,22,In_Network,E78.5,Z12.11|F32.9,00071015523,,1,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,552.55,327.81,58.91,229.62,0.0,39.28,224.74,0.0,0.0,0,,0.1003,none,0,1,0,0,0,5e-06,0,0,,P4P
CLM0000002815,MBR00000056,Medical_Professional,Paid,Provider_Portal,2023-09-27,2023-09-27,2023-09-27,2023-10-21,Auto_Adjudicated,24,1315569619,1469642907,207R00000X,Internal Medicine,31,In_Network,OTHER,Z00.01|E78.5|N39.0,99396,,0,Commercial,EPO,74,F,1.3941,,,496.68,385.24,124.84,218.19,11.0,31.21,111.44,0.0,0.0,0,,0.0914,billing_spike_recent,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000002816,MBR00000095,Medical_Professional,Denied,Electronic_EDI,2023-07-20,2023-07-20,2023-07-20,2023-08-06,Manual_Review,17,1901508637,1666461892,207RN0300X,Nephrology,11,In_Network,M54.5,,83036,,0,Commercial,HMO,28,M,0.5827,18,Duplicate,842.24,568.07,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0229,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002817,MBR00000033,Medical_Professional,Paid,Electronic_EDI,2023-08-24,2023-08-24,2023-08-24,2023-09-18,Auto_Adjudicated,25,1421421733,1809122260,207RN0300X,Nephrology,65,In_Network,F41.1,OTHER|Z12.11|K21.0,11200,,0,Medicare_Advantage,PFFS,31,F,0.821,,,276.11,124.92,77.51,23.03,5.0,19.38,151.19,0.0,0.0,0,,0.1262,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000002818,MBR00000059,Medical_Professional,Paid,Electronic_EDI,2023-04-04,2023-04-04,2023-04-04,2023-04-20,Auto_Adjudicated,16,1133265917,1321680994,207RG0100X,Gastroenterology,11,In_Network,OTHER,,99285,,0,Medicare_Advantage,SNP,12,F,1.266,,,822.44,316.94,208.74,40.01,16.0,52.19,505.5,0.0,0.0,0,,0.0737,none,0,1,0,1,0,1.9e-05,0,0,,Capitation
CLM0000002819,MBR00000284,Medical_Institutional,Paid,Electronic_EDI,2023-12-06,2023-12-06,2023-12-07,2023-12-19,Auto_Adjudicated,13,1468401280,1809122260,207RE0101X,Endocrinology,23,In_Network,Z00.00,E11.65,revenue_code:0120,,0,Medicaid_MCO,FFS_Medicaid,23,M,0.5234,,,15500.74,9773.62,9769.62,0.0,4.0,0.0,5727.12,0.0,0.0,0,,0.0256,none,0,1,1,0,0,0.000904,0,0,CBP_Controlling_BP,FFS
CLM0000002820,MBR00000198,Medical_Professional,Paid,Electronic_EDI,2023-10-23,2023-10-23,2023-10-23,2023-11-15,Auto_Adjudicated,23,1089569577,1510751265,207RN0300X,Nephrology,22,In_Network,OTHER,J06.9|OTHER,90837,,0,Medicaid_MCO,MCO,81,F,1.4199,,,721.11,457.5,455.5,0.0,2.0,0.0,263.61,399.26,39.75,0,,0.0696,high_volume_same_code,0,1,0,0,0,4.2e-05,0,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000002821,MBR00000277,Medical_Professional,Denied,Electronic_EDI,2023-11-12,2023-11-12,2023-11-12,2023-11-19,Auto_Adjudicated,7,1102590784,1319611206,208600000X,Surgery General,21,In_Network,F32.9,E78.5,99396,,0,Medicaid_MCO,MCO,30,M,1.8495,256,Authorization,296.37,135.54,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.116,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002822,MBR00000080,Medical_Professional,Paid,Electronic_EDI,2023-08-28,2023-08-28,2023-08-28,2023-09-16,Auto_Adjudicated,19,1374847145,1831337866,225100000X,Physical Therapist,21,In_Network,OTHER,Z23|OTHER,99203,,0,Commercial,HDHP_HSA,74,M,0.5935,,,369.1,275.13,201.67,23.04,0.0,50.42,93.97,0.0,0.0,0,,0.0291,none,0,1,0,1,0,1.9e-05,0,0,COL_Colorectal_Cancer_Screening,Shared_Savings
CLM0000002823,MBR00000259,Pharmacy,Paid,Electronic_EDI,2023-09-07,2023-09-07,2023-09-07,2023-09-26,Auto_Adjudicated,19,1102590784,1564691686,246ZN0300X,Neuropsychology,11,In_Network,OTHER,,00078043215,,3,Medicare_Advantage,MA_PPO,5,M,1.6554,,,377.85,176.89,128.68,9.04,7.0,32.17,200.96,0.0,0.0,0,,0.08,none,0,1,0,0,0,1.2e-05,0,1,SPC_Statin_Therapy,Bundled_Payment
CLM0000002824,MBR00000114,Medical_Professional,Paid,Electronic_EDI,2023-01-26,2023-01-26,2023-01-26,2023-02-04,Auto_Adjudicated,9,1736809698,1767402068,207R00000X,Internal Medicine,24,In_Network,OTHER,J06.9,71250,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,638.66,533.94,388.24,29.64,19.0,97.06,104.72,0.0,0.0,0,,0.1225,none,0,1,0,0,0,3.6e-05,0,0,,Bundled_Payment
CLM0000002825,MBR00000045,Vision,Denied,Electronic_EDI,2023-02-27,2023-02-27,2023-02-27,2023-03-07,Auto_Adjudicated,8,1866366547,1319611206,207R00000X,Internal Medicine,21,In_Network,E11.9,M17.11|OTHER|M54.5,92004,,0,Commercial,HMO,78,F,1.0658,256,Timely_Filing,150.42,106.16,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0064,none,0,1,0,0,0,0.0,0,0,CCS_Cervical_Cancer_Screening,Capitation
CLM0000002826,MBR00000238,Medical_Professional,Paid,Electronic_EDI,2023-02-17,2023-02-17,2023-02-17,2023-02-20,Auto_Adjudicated,3,1873731689,1355732274,207Q00000X,Family Medicine,22,Out_of_Network,J20.9,,99214,,0,Commercial,PPO,74,F,0.4382,,,1179.29,769.9,563.22,40.88,25.0,140.8,409.39,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|service_date_weekend|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|npi_mismatch,1,5,0,0,0,5.2e-05,1,0,,FFS
CLM0000002827,MBR00000017,Medical_Professional,Paid,Provider_Portal,2023-06-23,2023-06-23,2023-06-23,2023-06-28,Auto_Adjudicated,5,1076251878,1649705287,225100000X,Physical Therapist,31,In_Network,Z23,OTHER|E11.9,27447,,0,Commercial,PPO,55,F,0.6174,,,8908.75,6036.02,4737.99,74.54,39.0,1184.5,2872.73,0.0,0.0,0,,0.0069,none,0,1,0,1,0,0.000439,0,0,LCS_Lung_Cancer_Screening,Capitation
CLM0000002828,MBR00000129,Medical_Institutional,Paid,Electronic_EDI,2023-07-31,2023-07-31,2023-08-01,2023-08-03,Manual_Review,3,1356562955,1649705287,246ZN0300X,Neuropsychology,22,In_Network,N39.0,E13.9|Z00.00|N39.0,revenue_code:0100,,0,Medicare_Advantage,MA_PPO,9,F,0.8196,,,11331.47,4003.03,3151.38,4.81,59.0,787.84,7328.44,0.0,0.0,0,,0.0023,none,0,1,0,1,0,0.000292,0,0,CDC_BP_Control,Capitation
CLM0000002829,MBR00000244,Medical_Institutional,Paid,Electronic_EDI,2023-02-12,2023-02-12,2023-02-14,2023-03-03,Manual_Review,19,1145860509,1986847322,207RE0101X,Endocrinology,31,In_Network,OTHER,I10|Z79.4,revenue_code:0250,,0,Commercial,PPO,52,M,0.6677,,,7962.04,4223.23,3179.83,190.44,58.0,794.96,3738.81,0.0,0.0,0,,0.0689,high_volume_same_code,0,1,0,0,0,0.000294,0,0,HBD_Hemoglobin_A1c_Testing,Capitation
CLM0000002830,MBR00000184,Medical_Institutional,Paid,Electronic_EDI,2023-09-27,2023-09-27,2023-09-29,2023-10-01,Manual_Review,4,1478458171,1415734567,225100000X,Physical Therapist,11,In_Network,J06.9,F33.0|Z23|OTHER,revenue_code:0210,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,16893.39,13234.26,13234.26,0.0,0.0,0.0,3659.13,0.0,0.0,0,,0.0887,none,0,1,1,0,0,0.001225,0,0,,Capitation
CLM0000002831,MBR00000159,Medical_Institutional,Paid,Electronic_EDI,2023-07-17,2023-07-17,2023-07-20,2023-08-02,Auto_Adjudicated,16,1007266616,1831337866,2086S0122X,Orthopedic Surgery,11,In_Network,F41.1,OTHER|H52.4|F10.10,revenue_code:0450,,0,Commercial,PPO,70,F,1.2009,,,20045.57,16253.12,12917.35,35.43,71.0,3229.34,3792.45,11111.74,1407.25,0,,0.2029,duplicate_claim_indicator,0,2,1,0,0,0.001196,0,0,,FFS
CLM0000002832,MBR00000112,Medical_Professional,Partially_Paid,Electronic_EDI,2023-08-02,2023-08-02,2023-08-02,2023-08-06,Auto_Adjudicated,4,1183801932,1938465393,207RN0300X,Nephrology,11,Out_of_Network,N18.3,,71046,,0,Medicare_Advantage,MA_HMO,18,M,1.01,3,Medical_Necessity,467.75,208.46,81.54,25.86,6.0,20.39,333.96,0.0,0.0,0,,0.0635,none,0,1,0,0,0,8e-06,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000002833,MBR00000023,Medical_Professional,Paid,Electronic_EDI,2023-11-26,2023-11-26,2023-11-26,2023-12-20,Auto_Adjudicated,24,1658382624,1358873132,207RN0300X,Nephrology,32,In_Network,E78.5,Z00.00,90832,,0,Medicare_Advantage,MA_PPO,87,M,1.084,,,707.59,565.51,394.34,57.59,15.0,98.58,142.08,0.0,0.0,0,,0.0205,none,0,1,0,0,0,3.6e-05,0,0,,FFS
CLM0000002834,MBR00000298,Medical_Professional,Paid,Electronic_EDI,2023-07-29,2023-07-29,2023-07-29,2023-08-19,Auto_Adjudicated,21,1713343912,1132693989,207R00000X,Internal Medicine,24,In_Network,N18.3,M54.5,97012,,0,Medicaid_MCO,MCO,75,M,0.8324,,,462.78,248.32,248.32,0.0,0.0,0.0,214.46,0.0,0.0,0,,0.0105,none,0,1,0,0,0,2.3e-05,0,0,,Bundled_Payment
CLM0000002835,MBR00000055,Pharmacy,Paid,Electronic_EDI,2023-01-02,2023-01-02,2023-01-02,2023-01-11,Auto_Adjudicated,9,1821999097,1105733833,207R00000X,Internal Medicine,31,In_Network,I10,E11.9|Z12.11,00078043215,,2,Commercial,PPO,68,F,1.2896,,,332.42,232.02,115.76,77.32,10.0,28.94,100.4,0.0,0.0,0,,0.148,none,0,1,0,1,0,1.1e-05,0,0,,Shared_Savings
CLM0000002836,MBR00000079,Medical_Institutional,Denied,Electronic_EDI,2023-10-03,2023-10-03,2023-10-07,2023-10-26,Manual_Review,23,1627776731,1390802135,207RE0101X,Endocrinology,22,In_Network,F33.0,Z00.01|M54.5,revenue_code:0120,,0,Medicaid_MCO,MLTSS,55,F,0.5016,18,Timely_Filing,18655.38,14693.91,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0151,none,0,1,0,0,0,0.0,0,0,FLU_Flu_Vaccination,FFS
CLM0000002837,MBR00000074,Pharmacy,Denied,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-11-18,Clinical_Review,7,1950560596,1965244699,207RP1001X,Pulmonary Disease,11,In_Network,I10,,00003014960,,2,Medicare_Advantage,MA_PPO,21,F,0.8719,5,COB,319.56,147.37,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1172,none,0,1,0,0,0,0.0,0,0,TRC_Transition_of_Care,Capitation
CLM0000002838,MBR00000274,Vision,Paid,Electronic_EDI,2023-01-30,2023-01-30,2023-01-30,2023-02-19,Auto_Adjudicated,20,1015096289,1607833568,246ZN0300X,Neuropsychology,21,In_Network,OTHER,E11.65|I10,V2103,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,242.91,101.53,77.18,5.05,0.0,19.3,141.38,0.0,0.0,0,,0.1417,provider_specialty_mismatch|impossible_service_combo,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000002839,MBR00000224,Medical_Institutional,Paid,Electronic_EDI,2023-07-13,2023-07-13,2023-07-16,2023-08-02,Clinical_Review,20,1630305772,1527857018,2086S0122X,Orthopedic Surgery,22,Out_of_Network,E11.9,Z00.01,revenue_code:0210,,0,Medicaid_MCO,MCO,86,F,1.3289,,,15140.93,8878.06,8869.06,0.0,9.0,0.0,6262.87,0.0,0.0,0,,0.0421,none,0,1,1,0,0,0.000821,0,0,,FFS
CLM0000002840,MBR00000142,Dental,Denied,Provider_Portal,2023-06-18,2023-06-18,2023-06-18,2023-07-02,Auto_Adjudicated,14,1111846258,1694343357,208600000X,Surgery General,11,In_Network,M79.3,C50.911|E11.9,D0120,,0,ACA_Marketplace,ACA_Silver,48,M,1.3761,96,Duplicate,475.31,314.39,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1443,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000002841,MBR00000289,Medical_Institutional,Denied,Electronic_EDI,2023-02-24,2023-02-24,2023-02-24,2023-03-18,Auto_Adjudicated,22,1313352855,1396850418,207V00000X,Obstetrics & Gynecology,23,In_Network,I25.10,F41.1,revenue_code:0100,,0,Commercial,POS,51,M,1.0534,16,Coding_Error,23544.2,14925.31,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1058,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000002842,MBR00000014,Medical_Institutional,Paid,Electronic_EDI,2023-04-10,2023-04-10,2023-04-12,2023-05-09,Auto_Adjudicated,29,1760186113,1810068286,207Q00000X,Family Medicine,31,In_Network,Z23,OTHER,revenue_code:0360,,0,Commercial,HMO,77,M,2.8513,,,21790.39,15033.6,11626.07,466.02,35.0,2906.52,6756.79,0.0,0.0,0,,0.276,geographic_mismatch|service_date_weekend|duplicate_claim_indicator|unbundling_pattern,0,2,1,0,0,0.001076,0,0,DDE_Diabetes_Short_Term_Complications,Bundled_Payment
CLM0000002843,MBR00000271,Medical_Institutional,Paid,Electronic_EDI,2023-11-04,2023-11-04,2023-11-04,2023-11-17,Auto_Adjudicated,13,1886537420,1898471307,207RP1001X,Pulmonary Disease,21,In_Network,M79.3,Z12.11|Z00.01,revenue_code:0300,683,0,Medicaid_MCO,MCO,4,F,0.6696,,,10744.23,8695.93,8686.93,0.0,9.0,0.0,2048.3,0.0,0.0,0,,0.0187,none,0,1,1,1,1,0.000804,0,0,,FFS
CLM0000002844,MBR00000018,Medical_Professional,Denied,Electronic_EDI,2023-05-21,2023-05-21,2023-05-21,2023-05-30,Manual_Review,9,1233824762,1133410177,246ZN0300X,Neuropsychology,23,In_Network,OTHER,OTHER,99282,,0,Commercial,EPO,5,F,0.5555,18,Eligibility,157.58,64.18,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1439,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002845,MBR00000125,Medical_Professional,Paid,Electronic_EDI,2023-07-12,2023-07-12,2023-07-12,2023-07-26,Manual_Review,14,1269720844,1291071007,208600000X,Surgery General,22,In_Network,Z00.01,K29.70|N18.3,99386,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,359.82,299.29,229.07,1.96,11.0,57.27,60.53,0.0,0.0,0,,0.1686,unusual_service_frequency,0,1,0,0,0,2.1e-05,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000002846,MBR00000014,Medical_Institutional,Paid,Electronic_EDI,2023-10-06,2023-10-06,2023-10-08,2023-10-24,Auto_Adjudicated,18,1399379863,1662516615,207RP1001X,Pulmonary Disease,11,In_Network,K57.30,J20.9|M25.511,revenue_code:0110,,0,Commercial,HMO,77,M,2.8513,,,46628.92,20068.64,15694.85,415.07,35.0,3923.71,26560.28,10881.18,4048.81,1,Date of Service Falsification,1.0,outlier_billing_amount|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|impossible_service_combo|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|npi_mismatch|controlled_substance_high_volume,1,5,1,0,0,0.001453,0,0,,Bundled_Payment
CLM0000002847,MBR00000300,Medical_Professional,Paid,Provider_Portal,2023-06-10,2023-06-10,2023-06-10,2023-06-14,Manual_Review,4,1972755666,1741177636,207RN0300X,Nephrology,11,In_Network,Z23,J06.9|M54.5,71250,,0,Commercial,PPO,64,F,1.0393,,,1175.75,959.79,631.19,141.81,29.0,157.8,215.96,0.0,0.0,0,,0.0989,none,0,1,0,1,0,5.8e-05,0,0,,FFS
CLM0000002848,MBR00000276,Medical_Professional,Paid,Electronic_EDI,2023-11-16,2023-11-16,2023-11-16,2023-12-15,Auto_Adjudicated,29,1051254008,1672803287,101YP2500X,Psychologist Clinical,22,In_Network,I50.9,Z79.4|I10,82947,,0,Commercial,POS,38,M,0.8085,,,725.1,528.8,300.75,117.86,35.0,75.19,196.3,0.0,0.0,0,,0.0692,duplicate_claim_indicator,0,1,0,0,0,2.8e-05,0,0,TRC_Transition_of_Care,FFS
CLM0000002849,MBR00000176,Pharmacy,Paid,Electronic_EDI,2023-06-29,2023-06-29,2023-06-29,2023-07-14,Auto_Adjudicated,15,1135745665,1867626800,207RC0000X,Cardiovascular Disease,23,In_Network,OTHER,Z79.4|OTHER|M17.11,00069420020,,1,Commercial,POS,4,M,0.8792,,,162.36,122.69,0.0,122.69,0.0,0.0,39.67,0.0,0.0,0,,0.2015,duplicate_claim_indicator,0,2,0,0,0,0.0,0,1,MPT_Annual_Monitoring,FFS
CLM0000002850,MBR00000067,Medical_Institutional,Paid,Electronic_EDI,2023-12-20,2023-12-20,2023-12-22,2024-01-18,Auto_Adjudicated,29,1793630905,1938465393,207RC0000X,Cardiovascular Disease,21,In_Network,R05.9,,revenue_code:0200,871,0,Medicaid_MCO,MCO,55,M,0.4175,,,14541.78,11448.39,11440.39,0.0,8.0,0.0,3093.39,0.0,0.0,0,,0.0851,none,0,1,1,0,0,0.001059,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000002851,MBR00000086,Medical_Professional,Paid,Electronic_EDI,2023-02-22,2023-02-22,2023-02-22,2023-03-23,Clinical_Review,29,1393200616,1105871325,101YP2500X,Psychologist Clinical,11,In_Network,I10,Z00.01,99397,,0,Medicare_Advantage,MA_PPO,8,M,0.5427,,,446.0,181.25,137.64,1.2,8.0,34.41,264.75,0.0,0.0,0,,0.0446,none,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000002852,MBR00000140,Medical_Professional,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-11-17,Auto_Adjudicated,2,1556072255,1352413270,2086S0122X,Orthopedic Surgery,11,Out_of_Network,Z23,,99284,,0,Medicare_Advantage,MA_HMO,7,M,1.3997,,,610.36,416.23,315.07,10.39,12.0,78.77,194.13,0.0,0.0,0,,0.1001,none,0,1,0,0,0,2.9e-05,0,0,,FFS
CLM0000002853,MBR00000102,Dental,Denied,Electronic_EDI,2023-02-10,2023-02-10,2023-02-10,2023-02-14,Auto_Adjudicated,4,1035707913,1619587398,208600000X,Surgery General,23,In_Network,J20.9,G47.33,D0150,,0,Commercial,POS,68,M,1.6864,16,Coding_Error,338.92,177.26,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1734,benford_violation,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002854,MBR00000007,Vision,Paid,Paper,2023-10-19,2023-10-19,2023-10-19,2023-10-25,Manual_Review,6,1771383741,1747935894,246ZN0300X,Neuropsychology,21,In_Network,I10,OTHER|E11.9,V2100,,0,Commercial,HDHP_HSA,72,F,0.7578,,,249.53,134.78,0.0,134.78,0.0,0.0,114.75,0.0,0.0,0,,0.1197,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002855,MBR00000196,Medical_Institutional,Paid,Electronic_EDI,2023-08-26,2023-08-26,2023-08-30,2023-09-13,Manual_Review,18,1971354640,1930040953,207RN0300X,Nephrology,23,In_Network,M79.3,N18.3|E11.9,revenue_code:0110,,0,Commercial,PPO,16,F,1.6015,,,20736.85,12712.95,9948.74,241.02,36.0,2487.19,8023.9,0.0,0.0,0,,0.1495,none,0,1,1,0,0,0.000921,0,0,FUH_Follow_Up_Hospitalization,Shared_Savings
CLM0000002856,MBR00000184,Medical_Professional,Paid,Provider_Portal,2023-07-20,2023-07-20,2023-07-20,2023-07-31,Auto_Adjudicated,11,1519595029,1358873132,207RN0300X,Nephrology,11,In_Network,N40.0,OTHER,85025,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,563.92,366.23,364.23,0.0,2.0,0.0,197.69,0.0,0.0,1,Unbundling,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|benford_violation|impossible_service_combo|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,3.4e-05,0,0,,Capitation
CLM0000002857,MBR00000274,Medical_Professional,Partially_Paid,Electronic_EDI,2023-11-13,2023-11-13,2023-11-13,2023-11-14,Manual_Review,1,1393200616,1288028182,207Q00000X,Family Medicine,24,In_Network,OTHER,E78.5|Z79.4,97110,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,PR-1,Medical_Necessity,251.8,176.59,66.96,35.03,0.0,16.74,133.07,0.0,0.0,0,,0.1171,unbundling_pattern,0,1,0,0,0,6e-06,0,0,,Capitation
CLM0000002858,MBR00000146,Medical_Professional,Paid,Electronic_EDI,2023-08-19,2023-08-19,2023-08-19,2023-09-05,Auto_Adjudicated,17,1874109311,1469697158,2086S0122X,Orthopedic Surgery,21,In_Network,Z00.01,,99222,,0,Medicaid_MCO,MCO,24,M,0.6484,,,140.84,92.29,88.29,0.0,4.0,0.0,48.55,0.0,0.0,0,,0.1212,temporal_clustering,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000002859,MBR00000108,Pharmacy,Paid,Electronic_EDI,2023-09-07,2023-09-07,2023-09-07,2023-09-17,Auto_Adjudicated,10,1373899620,1419347445,207RN0300X,Nephrology,11,In_Network,Z87.891,J44.1|Z12.11|OTHER,00169751112,,1,Medicaid_MCO,MCO,25,F,0.2795,,,623.65,289.04,289.04,0.0,0.0,0.0,334.61,0.0,0.0,0,,0.0098,none,0,1,0,0,0,2.7e-05,0,0,SPD_Spirometry_Testing,Shared_Savings
CLM0000002860,MBR00000157,Medical_Institutional,Paid,Electronic_EDI,2023-09-28,2023-09-28,2023-09-29,2023-10-24,Manual_Review,26,1192302048,1809122260,101YP2500X,Psychologist Clinical,22,Out_of_Network,J06.9,,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,26,F,0.9164,,,1841.3,977.84,755.77,5.13,28.0,188.94,863.46,0.0,0.0,0,,0.0693,none,0,1,0,1,0,7e-05,0,0,SPC_Statin_Therapy,P4P
CLM0000002861,MBR00000060,Pharmacy,Paid,Electronic_EDI,2023-10-29,2023-10-29,2023-10-29,2023-11-21,Auto_Adjudicated,23,1421421733,1140170394,2086S0122X,Orthopedic Surgery,24,In_Network,E11.9,,00310075090,,3,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,512.22,399.86,0.0,399.86,0.0,0.0,112.36,0.0,0.0,0,,0.1112,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000002862,MBR00000186,Medical_Professional,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-25,2023-04-20,Manual_Review,26,1390393668,1039962073,207R00000X,Internal Medicine,65,In_Network,N39.0,,97110,,0,Commercial,PPO,65,M,1.6983,,,1936.78,1369.29,954.77,163.83,12.0,238.69,567.49,0.0,0.0,0,,0.0667,none,0,1,0,0,0,8.8e-05,0,0,,FFS
CLM0000002863,MBR00000226,Dental,Paid,Electronic_EDI,2023-10-31,2023-10-31,2023-10-31,2023-11-18,Auto_Adjudicated,18,1969707582,1114756459,207RC0000X,Cardiovascular Disease,81,In_Network,I25.10,OTHER|J06.9|M17.11,D2140,,0,Medicare_Advantage,MA_PPO,84,M,1.0796,,,429.09,248.86,189.34,2.18,10.0,47.34,180.23,0.0,0.0,0,,0.0848,none,0,1,0,0,0,1.8e-05,0,0,,P4P
CLM0000002864,MBR00000049,Medical_Institutional,Paid,Electronic_EDI,2023-07-31,2023-07-31,2023-08-02,2023-08-21,Auto_Adjudicated,21,1932483309,1579331190,207RN0300X,Nephrology,22,In_Network,F32.9,E78.5,revenue_code:0100,,0,Medicare_Advantage,PFFS,67,M,0.978,,,20698.67,9704.45,7703.89,23.58,51.0,1925.97,10994.22,0.0,0.0,0,,0.208,duplicate_claim_indicator|phantom_billing_indicator,0,2,1,0,0,0.000713,0,0,DAE_Drug_Alcohol_Dependence,FFS
CLM0000002865,MBR00000101,Medical_Institutional,Paid,Electronic_EDI,2023-01-12,2023-01-12,2023-01-14,2023-01-15,Auto_Adjudicated,3,1402833352,1098360555,225100000X,Physical Therapist,22,In_Network,OTHER,M54.5,revenue_code:0200,,0,Commercial,PPO,83,M,0.3627,,,2910.19,2229.43,1745.06,0.1,48.0,436.27,680.76,0.0,0.0,0,,0.0424,none,0,1,0,0,0,0.000162,0,0,COA_Care_Transitions,Shared_Savings
CLM0000002866,MBR00000262,Medical_Institutional,Paid,Electronic_EDI,2023-11-26,2023-11-26,2023-11-26,2023-12-19,Auto_Adjudicated,23,1889525696,1994275960,207V00000X,Obstetrics & Gynecology,22,In_Network,I10,Z00.00,revenue_code:0300,,0,Medicare_Advantage,PFFS,77,F,1.7452,,,7703.93,3657.51,2900.72,0.61,31.0,725.18,4046.42,0.0,0.0,0,,0.0888,none,0,1,0,0,0,0.000268,0,0,,FFS
CLM0000002867,MBR00000156,Medical_Institutional,Paid,Paper,2023-10-04,2023-10-04,2023-10-04,2023-10-18,Auto_Adjudicated,14,1006962798,1912895973,101YP2500X,Psychologist Clinical,22,In_Network,Z23,,revenue_code:0100,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,16568.68,13289.13,10583.46,30.8,29.0,2645.87,3279.55,0.0,0.0,0,,0.1489,none,0,1,1,0,0,0.00098,0,0,CCS_Cervical_Cancer_Screening,Shared_Savings
CLM0000002868,MBR00000162,Dental,Denied,Electronic_EDI,2023-11-17,2023-11-17,2023-11-17,2023-11-18,Auto_Adjudicated,1,1192302048,1061113875,246ZN0300X,Neuropsychology,11,In_Network,E78.5,,D2140,,0,Medicaid_MCO,MLTSS,84,F,1.324,22,Timely_Filing,426.46,243.05,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.122,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002869,MBR00000212,Medical_Institutional,Paid,Electronic_EDI,2023-10-05,2023-10-05,2023-10-08,2023-10-08,Auto_Adjudicated,3,1718336220,1898471307,225100000X,Physical Therapist,23,In_Network,Z00.00,,revenue_code:0360,,0,Commercial,HMO,57,F,2.5456,,,17900.39,12194.55,9631.42,87.28,68.0,2407.85,5705.84,7056.47,2132.05,0,,0.0914,benford_violation,0,1,1,0,0,0.000891,0,0,,FFS
CLM0000002870,MBR00000174,Vision,Paid,Electronic_EDI,2023-05-05,2023-05-05,2023-05-05,2023-05-15,Auto_Adjudicated,10,1747318937,1356856197,207RN0300X,Nephrology,81,In_Network,J06.9,Z00.01,V2320,,0,Medicare_Advantage,MA_HMO,85,M,0.3901,,,330.03,152.23,99.79,9.49,18.0,24.95,177.8,0.0,0.0,0,,0.0614,none,0,1,0,1,0,9e-06,0,0,,Shared_Savings
CLM0000002871,MBR00000022,Medical_Professional,Paid,Provider_Portal,2023-05-06,2023-05-06,2023-05-06,2023-05-18,Auto_Adjudicated,12,1377412382,1564636990,207V00000X,Obstetrics & Gynecology,11,In_Network,N40.0,,17000,,0,Medicare_Advantage,MA_HMO,34,M,0.9472,,,659.63,281.43,179.72,40.78,16.0,44.93,378.2,0.0,0.0,0,,0.0501,none,0,1,0,0,0,1.7e-05,0,0,,FFS
CLM0000002872,MBR00000238,Medical_Professional,Partially_Paid,Electronic_EDI,2023-04-10,2023-04-10,2023-04-10,2023-04-17,Auto_Adjudicated,7,1113370285,1577226132,207Q00000X,Family Medicine,11,In_Network,N39.0,G47.33,47562,,0,Commercial,PPO,74,F,0.4382,97,Medical_Necessity,276.36,129.48,0.0,88.0,0.0,0.0,188.36,0.0,0.0,0,,0.1588,billing_spike_recent,0,1,0,0,0,0.0,0,0,,P4P
CLM0000002873,MBR00000279,Medical_Professional,Paid,Electronic_EDI,2023-05-28,2023-05-28,2023-05-28,2023-06-21,Manual_Review,24,1288855406,1301869102,2084P0800X,Psychiatry,11,In_Network,Z23,M54.5,99386,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,,,333.89,209.9,160.36,0.46,9.0,40.09,123.99,0.0,0.0,0,,0.0043,none,0,1,0,0,0,1.5e-05,0,0,,P4P
CLM0000002874,MBR00000014,Medical_Professional,Paid,Electronic_EDI,2023-01-13,2023-01-13,2023-01-13,2023-01-27,Auto_Adjudicated,14,1641660170,1616762819,207RN0300X,Nephrology,21,Out_of_Network,F32.9,Z00.01,90837,,0,Commercial,HMO,77,M,2.8513,,,293.29,203.53,0.0,176.08,27.45,0.0,89.76,0.0,0.0,0,,0.0788,none,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000002875,MBR00000037,Pharmacy,Paid,Electronic_EDI,2023-09-25,2023-09-25,2023-09-25,2023-10-03,Auto_Adjudicated,8,1207676414,1553094822,207RC0000X,Cardiovascular Disease,22,Out_of_Network,M54.5,OTHER|M54.5,59148001506,,2,Medicaid_MCO,MLTSS,11,M,1.043,,,134.44,79.43,78.43,0.0,1.0,0.0,55.01,0.0,0.0,0,,0.1222,geographic_mismatch|upcoding_pattern,0,1,0,0,0,7e-06,1,0,,Capitation
CLM0000002876,MBR00000208,Medical_Professional,Paid,Electronic_EDI,2023-09-28,2023-09-28,2023-09-28,2023-10-19,Auto_Adjudicated,21,1770738194,1402472115,207Q00000X,Family Medicine,21,In_Network,I10,,33510,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,1722.4,1280.85,1019.21,0.84,6.0,254.8,441.55,0.0,0.0,0,,0.2502,provider_specialty_mismatch|high_oop_waiver,0,2,0,1,0,9.4e-05,0,0,,Shared_Savings
CLM0000002877,MBR00000182,Medical_Professional,Paid,Provider_Portal,2023-12-21,2023-12-21,2023-12-21,2024-01-04,Auto_Adjudicated,14,1826567270,1148612764,2084P0800X,Psychiatry,22,In_Network,J44.1,E11.9,17000,,0,Commercial,HMO,82,F,0.8489,,,217.44,92.59,0.0,92.59,0.0,0.0,124.85,0.0,0.0,0,,0.059,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002878,MBR00000121,Medical_Professional,Paid,Paper,2023-07-17,2023-07-17,2023-07-17,2023-08-10,Auto_Adjudicated,24,1243349799,1402472115,207R00000X,Internal Medicine,24,In_Network,OTHER,,33510,,0,Medicare_Advantage,MA_PPO,58,M,1.226,,,595.84,487.74,365.68,12.64,18.0,91.42,108.1,0.0,0.0,0,,0.1161,none,0,1,0,0,0,3.4e-05,0,0,,FFS
CLM0000002879,MBR00000164,Pharmacy,Denied,Electronic_EDI,2023-12-21,2023-12-21,2023-12-21,2024-01-06,Manual_Review,16,1664872214,1829216053,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,N39.0|OTHER|E11.9,00310075090,,1,ACA_Marketplace,ACA_Silver,3,F,0.7155,5,Timely_Filing,360.52,234.32,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1106,none,0,1,0,0,0,0.0,0,1,AWV_Annual_Wellness_Visit,FFS
CLM0000002880,MBR00000208,Vision,Paid,Provider_Portal,2023-03-17,2023-03-17,2023-03-17,2023-04-09,Manual_Review,23,1474985672,1148612764,207RN0300X,Nephrology,24,In_Network,E11.9,J45.20|N39.0|J44.1,92002,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,597.97,308.61,234.59,9.37,6.0,58.65,289.36,0.0,0.0,1,Kickback Arrangement,1.0,outlier_billing_amount|unusual_service_frequency|temporal_clustering|high_volume_same_code|benford_violation|impossible_service_combo|service_date_weekend|billing_spike_recent|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,1,0,2.2e-05,0,0,,Shared_Savings
CLM0000002881,MBR00000156,Pharmacy,Paid,Electronic_EDI,2023-06-20,2023-06-20,2023-06-20,2023-07-16,Auto_Adjudicated,26,1369267360,1774401124,207RE0101X,Endocrinology,24,In_Network,K21.0,,00006001954,,2,Medicare_Advantage,MA_PPO,66,F,1.8933,,,104.7,65.3,31.83,12.51,13.0,7.96,39.4,0.0,0.0,0,,0.0597,none,0,1,0,0,0,3e-06,0,0,FLU_Flu_Vaccination,Shared_Savings
CLM0000002882,MBR00000044,Medical_Professional,Paid,Electronic_EDI,2023-10-08,2023-10-08,2023-10-08,2023-10-11,Auto_Adjudicated,3,1017424540,1020312030,207R00000X,Internal Medicine,22,Out_of_Network,J20.9,,99213,,0,Commercial,PPO,29,M,0.7512,,,539.26,307.93,165.67,62.84,38.0,41.42,231.33,0.0,0.0,0,,0.0365,none,0,1,0,0,0,1.5e-05,0,0,CCS_Cervical_Cancer_Screening,Capitation
CLM0000002883,MBR00000027,Medical_Institutional,Denied,Electronic_EDI,2023-10-11,2023-10-11,2023-10-12,2023-10-15,Auto_Adjudicated,4,1034130209,1977073565,208600000X,Surgery General,21,In_Network,OTHER,,revenue_code:0200,292,0,Medicare_Advantage,MA_HMO,45,M,0.6886,CO-45,Medical_Necessity,3988.13,3007.28,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0786,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002884,MBR00000137,Medical_Professional,Denied,Electronic_EDI,2023-10-05,2023-10-05,2023-10-05,2023-10-27,Auto_Adjudicated,22,1990244466,1575884274,207RC0000X,Cardiovascular Disease,65,In_Network,E11.9,,99204,,0,Commercial,PPO,87,M,0.5201,170,Eligibility,395.94,195.29,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.034,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002885,MBR00000279,Vision,Paid,Electronic_EDI,2023-06-17,2023-06-17,2023-06-17,2023-07-04,Manual_Review,17,1923937825,1827839595,207V00000X,Obstetrics & Gynecology,21,In_Network,I10,,V2115,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,,,302.27,200.11,124.43,35.57,9.0,31.11,102.16,0.0,0.0,0,,0.1431,none,0,1,0,0,0,1.2e-05,0,0,ACR_Urine_Protein,P4P
CLM0000002886,MBR00000168,Medical_Professional,Paid,Electronic_EDI,2023-01-27,2023-01-27,2023-01-27,2023-02-04,Auto_Adjudicated,8,1375098560,1575884274,101YP2500X,Psychologist Clinical,11,In_Network,OTHER,,43239,,0,Commercial,HMO,76,M,1.2791,,,374.76,268.01,0.0,268.01,0.0,0.0,106.75,0.0,0.0,0,,0.0874,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002887,MBR00000113,Vision,Paid,Electronic_EDI,2023-11-07,2023-11-07,2023-11-07,2023-11-08,Auto_Adjudicated,1,1918160357,1623053477,207RG0100X,Gastroenterology,11,In_Network,I10,,92002,,0,Medicaid_MCO,MLTSS,29,F,1.1621,,,230.5,192.73,191.73,0.0,1.0,0.0,37.77,0.0,0.0,0,,0.0767,none,0,1,0,0,0,1.8e-05,0,0,FUH_Follow_Up_Hospitalization,P4P
CLM0000002888,MBR00000274,Pharmacy,Paid,Electronic_EDI,2023-05-17,2023-05-17,2023-05-17,2023-06-15,Auto_Adjudicated,29,1014482814,1114756459,207R00000X,Internal Medicine,32,In_Network,OTHER,,50458085930,,1,Medicare_Advantage,MA_HMO,58,F,2.1025,,,766.52,303.03,211.17,39.06,0.0,52.79,463.49,167.61,30.94,0,,0.1068,benford_violation,0,1,0,0,0,2e-05,0,1,SPD_Spirometry_Testing,Bundled_Payment
CLM0000002889,MBR00000124,Pharmacy,Paid,Electronic_EDI,2023-08-22,2023-08-22,2023-08-22,2023-08-25,Auto_Adjudicated,3,1808451151,1301869102,207R00000X,Internal Medicine,11,In_Network,J44.1,K21.0,00169751112,,1,Commercial,EPO,40,F,0.4583,,,71.04,46.94,16.79,13.95,12.0,4.2,24.1,12.14,3.41,0,,0.0656,none,0,1,0,0,0,2e-06,0,1,AMR_Asthma_Medication_Ratio,P4P
CLM0000002890,MBR00000156,Pharmacy,Paid,Electronic_EDI,2023-02-17,2023-02-17,2023-02-17,2023-03-03,Auto_Adjudicated,14,1907932706,1884259357,225100000X,Physical Therapist,22,In_Network,M17.11,,00069420020,,1,Medicare_Advantage,MA_PPO,66,F,1.8933,,,44.04,23.41,7.88,0.57,13.0,1.97,20.63,0.0,0.0,0,,0.0833,npi_mismatch,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000002891,MBR00000036,Medical_Professional,Paid,Electronic_EDI,2023-12-03,2023-12-03,2023-12-03,2023-12-10,Auto_Adjudicated,7,1462532026,1591405274,225100000X,Physical Therapist,23,In_Network,I10,I10,97110,,0,Commercial,EPO,17,M,2.0136,,,415.88,227.24,78.79,95.75,33.0,19.7,188.64,0.0,0.0,0,,0.1556,duplicate_claim_indicator,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000002892,MBR00000216,Medical_Professional,Paid,Electronic_EDI,2023-04-03,2023-04-03,2023-04-03,2023-04-15,Auto_Adjudicated,12,1167433253,1175334579,2084P0800X,Psychiatry,22,In_Network,OTHER,OTHER|J20.9,99213,,0,Medicare_Advantage,MA_HMO,71,F,0.7117,,,344.22,193.73,131.25,19.67,10.0,32.81,150.49,0.0,0.0,0,,0.0368,none,0,1,0,0,0,1.2e-05,0,0,,Capitation
CLM0000002893,MBR00000208,Medical_Professional,Paid,Electronic_EDI,2023-12-25,2023-12-25,2023-12-25,2024-01-16,Auto_Adjudicated,22,1375098560,1809122260,208600000X,Surgery General,23,In_Network,I10,Z23,80053,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,1761.01,912.66,712.05,16.59,6.0,178.01,848.35,0.0,0.0,0,,0.132,high_oop_waiver,0,1,0,0,0,6.6e-05,0,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000002894,MBR00000235,Medical_Professional,Paid,Electronic_EDI,2023-09-14,2023-09-14,2023-09-14,2023-09-30,Auto_Adjudicated,16,1411619682,1978943761,2084P0800X,Psychiatry,21,In_Network,Z23,,97110,,0,Commercial,HDHP_HSA,85,F,1.4308,,,661.61,406.57,80.29,306.2,0.0,20.07,255.04,0.0,0.0,0,,0.123,none,0,1,0,0,0,7e-06,0,0,,Shared_Savings
CLM0000002895,MBR00000103,Pharmacy,Paid,Electronic_EDI,2023-04-29,2023-04-29,2023-04-29,2023-05-01,Auto_Adjudicated,2,1830816512,1829216053,207V00000X,Obstetrics & Gynecology,23,In_Network,Z00.00,I50.9|Z23|OTHER,00085163102,,1,Medicaid_MCO,MCO,24,M,0.4785,,,48.92,23.09,22.09,0.0,1.0,0.0,25.83,0.0,0.0,0,,0.0856,none,0,1,0,0,0,2e-06,0,1,MMA_Medication_Management,Capitation
CLM0000002896,MBR00000136,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-05-13,2023-05-13,2023-05-14,2023-05-16,Auto_Adjudicated,3,1642333103,1622950074,207RE0101X,Endocrinology,11,In_Network,Z00.00,I10,revenue_code:0200,,0,Commercial,POS,2,F,1.2611,CO-45,Medical_Necessity,13078.02,10134.72,5808.26,408.78,72.0,1452.06,5336.92,0.0,0.0,0,,0.0571,diagnosis_procedure_mismatch,0,1,1,1,0,0.000538,0,0,,FFS
CLM0000002897,MBR00000053,Dental,Paid,Electronic_EDI,2023-12-18,2023-12-18,2023-12-18,2024-01-16,Clinical_Review,29,1746688640,1994275960,101YP2500X,Psychologist Clinical,11,In_Network,L70.0,,D2391,,0,Medicaid_MCO,MLTSS,74,F,0.9277,,,584.93,449.13,449.13,0.0,0.0,0.0,135.8,0.0,0.0,0,,0.0923,none,0,1,0,0,0,4.2e-05,0,0,,FFS
CLM0000002898,MBR00000292,Dental,Paid,Electronic_EDI,2023-08-02,2023-08-02,2023-08-02,2023-08-10,Auto_Adjudicated,8,1369267360,1688513262,208600000X,Surgery General,11,In_Network,E11.9,Z00.00,D0120,,0,Medicare_Advantage,MA_HMO,4,M,1.1779,,,424.22,168.26,109.32,28.61,3.0,27.33,255.96,0.0,0.0,0,,0.0981,none,0,1,0,0,0,1e-05,0,0,,Capitation
CLM0000002899,MBR00000026,Medical_Professional,Paid,Electronic_EDI,2023-09-06,2023-09-06,2023-09-06,2023-09-19,Auto_Adjudicated,13,1196858674,1148612764,207RC0000X,Cardiovascular Disease,22,Out_of_Network,J44.1,,99221,,0,Medicaid_MCO,MCO,17,M,1.0686,,,731.64,283.61,282.61,0.0,1.0,0.0,448.03,0.0,0.0,1,Medically Unnecessary Services,1.0,geographic_mismatch|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|service_date_weekend|billing_spike_recent|upcoding_pattern|phantom_billing_indicator|npi_mismatch|high_oop_waiver,1,5,0,0,0,2.6e-05,1,0,,Shared_Savings
CLM0000002900,MBR00000193,Medical_Professional,Paid,Electronic_EDI,2023-08-08,2023-08-08,2023-08-08,2023-09-01,Auto_Adjudicated,24,1667149552,1591405274,207RN0300X,Nephrology,11,In_Network,G43.909,E11.65,90847,,0,Commercial,PPO,11,M,0.5266,,,254.04,141.96,0.0,141.96,0.0,0.0,112.08,0.0,0.0,0,,0.015,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002901,MBR00000208,Medical_Institutional,Paid,Electronic_EDI,2023-03-27,2023-03-27,2023-03-31,2023-04-22,Auto_Adjudicated,26,1374458552,1318978078,225100000X,Physical Therapist,22,In_Network,F41.1,E78.5|Z00.01,revenue_code:0200,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,10637.33,7279.01,5766.6,16.76,54.0,1441.65,3358.32,0.0,0.0,0,,0.0669,none,0,1,1,0,0,0.000534,0,0,,FFS
CLM0000002902,MBR00000050,Medical_Professional,Denied,Electronic_EDI,2023-02-17,2023-02-17,2023-02-17,2023-02-26,Auto_Adjudicated,9,1853403237,1763260577,207RN0300X,Nephrology,11,In_Network,R05.9,Z00.00,99396,,0,Medicare_Advantage,MA_PPO,12,F,0.8486,1,Medical_Necessity,493.51,321.14,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0889,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000002903,MBR00000115,Pharmacy,Paid,Electronic_EDI,2023-01-02,2023-01-02,2023-01-02,2023-01-09,Auto_Adjudicated,7,1309817189,1288028182,246ZN0300X,Neuropsychology,21,In_Network,E11.9,OTHER|F32.9,16590051660,,4,Commercial,PPO,15,F,0.7398,,,145.16,65.85,0.0,65.85,0.0,0.0,79.31,0.0,0.0,1,DME Fraud,1.0,provider_specialty_mismatch|high_volume_same_code|benford_violation|impossible_service_combo|billing_spike_recent|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|npi_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,0.0,0,0,,FFS
CLM0000002904,MBR00000013,Pharmacy,Paid,Electronic_EDI,2023-05-26,2023-05-26,2023-05-26,2023-06-09,Auto_Adjudicated,14,1017424540,1685903362,207RN0300X,Nephrology,11,In_Network,OTHER,OTHER,00169751112,,2,Commercial,PPO,64,F,1.428,,,205.6,128.58,0.0,128.58,0.0,0.0,77.02,0.0,0.0,0,,0.0528,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000002905,MBR00000168,Pharmacy,Paid,Electronic_EDI,2023-09-03,2023-09-03,2023-09-03,2023-09-14,Manual_Review,11,1557212800,1068662623,101YP2500X,Psychologist Clinical,22,In_Network,E11.9,,16590051660,,1,Commercial,HMO,76,M,1.2791,,,78.16,28.15,0.0,28.15,0.0,0.0,50.01,0.0,0.0,0,,0.0838,none,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,Shared_Savings
CLM0000002906,MBR00000299,Medical_Institutional,Paid,Electronic_EDI,2023-04-19,2023-04-19,2023-04-20,2023-05-11,Auto_Adjudicated,22,1490172833,1498781755,207RC0000X,Cardiovascular Disease,24,Out_of_Network,J44.1,OTHER,revenue_code:0100,,0,Medicaid_MCO,MCO,74,F,0.8833,,,6185.99,2676.51,2674.51,0.0,2.0,0.0,3509.48,0.0,0.0,0,,0.0764,benford_violation,0,1,0,0,0,0.000248,0,0,FLU_Flu_Vaccination,P4P
CLM0000002907,MBR00000135,Pharmacy,Denied,Electronic_EDI,2023-03-21,2023-03-21,2023-03-21,2023-04-12,Auto_Adjudicated,22,1120678352,1694343357,2084P0800X,Psychiatry,21,In_Network,OTHER,OTHER,00003014960,,2,Commercial,PPO,58,F,2.2702,18,Network,176.41,86.39,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.034,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000002908,MBR00000297,Medical_Institutional,Paid,Electronic_EDI,2023-05-20,2023-05-20,2023-05-24,2023-05-28,Auto_Adjudicated,8,1310250833,1538261819,246ZN0300X,Neuropsychology,23,Out_of_Network,OTHER,M54.5|Z00.00,revenue_code:0360,,0,Commercial,HMO,88,M,1.5311,,,8635.24,6177.76,4902.83,10.22,39.0,1225.71,2457.48,0.0,0.0,0,,0.0877,none,0,1,0,0,0,0.000454,1,0,,Shared_Savings
CLM0000002909,MBR00000038,Behavioral_Health,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-25,2023-04-06,Auto_Adjudicated,12,1864546991,1450837722,207R00000X,Internal Medicine,21,In_Network,Z00.00,Z79.4|OTHER,99223,,0,Commercial,EPO,46,M,1.1295,,,331.6,240.81,114.08,60.21,38.0,28.52,90.79,0.0,0.0,0,,0.061,phantom_billing_indicator,0,1,0,0,0,1.1e-05,0,0,,Capitation
CLM0000002910,MBR00000125,Pharmacy,Denied,Electronic_EDI,2023-06-06,2023-06-06,2023-06-06,2023-06-28,Auto_Adjudicated,22,1313352855,1789540567,207Q00000X,Family Medicine,11,In_Network,J06.9,OTHER,16590051660,,2,Medicare_Advantage,MA_HMO,3,F,1.9037,22,Medical_Necessity,128.55,52.89,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0528,none,0,1,0,0,0,0.0,0,0,MMA_Medication_Management,FFS
CLM0000002911,MBR00000273,Pharmacy,Paid,Electronic_EDI,2023-07-18,2023-07-18,2023-07-18,2023-08-03,Auto_Adjudicated,16,1374847145,1390802135,207Q00000X,Family Medicine,11,In_Network,OTHER,Z00.00|OTHER|K21.0,16590051660,,2,ACA_Marketplace,ACA_Bronze,4,M,1.3569,,,366.0,158.92,0.0,158.92,0.0,0.0,207.08,0.0,0.0,0,,0.1899,duplicate_claim_indicator,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000002912,MBR00000264,Medical_Professional,Paid,Electronic_EDI,2023-04-08,2023-04-08,2023-04-08,2023-04-25,Clinical_Review,17,1736809698,1004714954,207R00000X,Internal Medicine,11,Out_of_Network,OTHER,,99204,,0,ACA_Marketplace,ACA_Bronze,12,F,0.5826,,,233.67,104.7,0.0,104.7,0.0,0.0,128.97,0.0,0.0,0,,0.1159,unusual_service_frequency|geographic_mismatch,0,1,0,0,0,0.0,1,0,,Shared_Savings
CLM0000002913,MBR00000102,Pharmacy,Paid,Electronic_EDI,2023-01-12,2023-01-12,2023-01-12,2023-02-06,Auto_Adjudicated,25,1963647323,1450837722,207RN0300X,Nephrology,24,In_Network,Z79.4,OTHER|Z23|E13.9,00006001954,,2,Commercial,POS,68,M,1.6864,,,183.48,116.58,0.0,116.58,0.0,0.0,66.9,0.0,0.0,0,,0.1916,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002914,MBR00000201,Medical_Professional,Paid,Provider_Portal,2023-02-06,2023-02-06,2023-02-06,2023-02-26,Auto_Adjudicated,20,1014995735,1827839595,2084P0800X,Psychiatry,11,In_Network,Z00.01,,33510,,0,Medicare_Advantage,MA_PPO,74,M,1.1575,,,1137.86,446.78,343.43,11.49,6.0,85.86,691.08,0.0,0.0,0,,0.1048,none,0,1,0,0,0,3.2e-05,0,0,,P4P
CLM0000002915,MBR00000269,Medical_Institutional,Paid,Electronic_EDI,2023-05-30,2023-05-30,2023-06-02,2023-06-19,Auto_Adjudicated,20,1419204214,1912895973,207RC0000X,Cardiovascular Disease,81,In_Network,Z23,E11.9|OTHER,revenue_code:0370,,0,Commercial,EPO,10,F,0.718,,,10896.37,8104.64,6415.63,15.11,70.0,1603.91,2791.73,0.0,0.0,0,,0.0728,billing_spike_recent,0,1,1,0,0,0.000594,0,0,,FFS
CLM0000002916,MBR00000226,Medical_Institutional,Paid,Paper,2023-03-05,2023-03-05,2023-03-06,2023-03-20,Auto_Adjudicated,15,1658094898,1289435414,207RG0100X,Gastroenterology,23,In_Network,OTHER,Z00.00,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,84,M,1.0796,,,8177.66,5629.42,4472.88,2.32,36.0,1118.22,2548.24,0.0,0.0,0,,0.1103,none,0,1,0,0,0,0.000414,0,0,,FFS
CLM0000002917,MBR00000187,Medical_Professional,Paid,Electronic_EDI,2023-10-14,2023-10-14,2023-10-14,2023-11-09,Auto_Adjudicated,26,1482771601,1300957944,207RN0300X,Nephrology,21,In_Network,Z00.01,Z79.4,99394,,0,Medicaid_MCO,MCO,36,F,1.191,,,270.48,190.87,187.87,0.0,3.0,0.0,79.61,0.0,0.0,0,,0.0657,none,0,1,0,0,0,1.7e-05,0,0,,FFS
CLM0000002918,MBR00000049,Medical_Professional,Paid,Electronic_EDI,2023-03-01,2023-03-01,2023-03-01,2023-03-02,Manual_Review,1,1555292468,1878017518,207RC0000X,Cardiovascular Disease,81,In_Network,OTHER,Z00.00|M54.5,99203,,0,Medicare_Advantage,PFFS,67,M,0.978,,,437.65,217.64,157.26,17.07,4.0,39.31,220.01,0.0,0.0,0,,0.0917,npi_mismatch,0,1,0,0,0,1.5e-05,0,0,FUM_Follow_Up_ED_Mental_Health,P4P
CLM0000002919,MBR00000023,Medical_Professional,Paid,Electronic_EDI,2023-01-10,2023-01-10,2023-01-10,2023-01-13,Auto_Adjudicated,3,1887698203,1068662623,101YP2500X,Psychologist Clinical,11,In_Network,Z23,Z00.00,84443,,0,Medicare_Advantage,MA_PPO,87,M,1.084,,,819.86,512.77,397.78,0.55,15.0,99.44,307.09,0.0,0.0,0,,0.1917,temporal_clustering,0,1,0,0,0,3.7e-05,0,0,,FFS
CLM0000002920,MBR00000184,Pharmacy,Paid,Electronic_EDI,2023-08-11,2023-08-11,2023-08-11,2023-09-01,Auto_Adjudicated,21,1769163673,1170002937,207V00000X,Obstetrics & Gynecology,24,Out_of_Network,J45.20,E11.9,50458085930,,2,Medicaid_MCO,MLTSS,30,M,2.8302,,,32.37,16.27,14.27,0.0,2.0,0.0,16.1,0.0,0.0,0,,0.1443,none,0,1,0,0,0,1e-06,1,1,,FFS
CLM0000002921,MBR00000154,Pharmacy,Paid,Provider_Portal,2023-08-12,2023-08-12,2023-08-12,2023-08-31,Auto_Adjudicated,19,1379875145,1930040953,208600000X,Surgery General,11,In_Network,Z00.00,I10|OTHER,50458085930,,3,Medicare_Advantage,MA_HMO,54,F,1.9463,,,101.02,57.14,37.66,10.06,0.0,9.42,43.88,0.0,0.0,0,,0.1708,high_volume_same_code,0,1,0,0,0,3e-06,0,0,MPT_Annual_Monitoring,Capitation
CLM0000002922,MBR00000075,Vision,Denied,Electronic_EDI,2023-08-30,2023-08-30,2023-08-30,2023-09-08,Manual_Review,9,1213747973,1408846353,225100000X,Physical Therapist,22,In_Network,Z00.00,,92012,,0,Medicaid_MCO,MCO,5,M,1.0573,256,Authorization,195.99,77.33,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1465,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002923,MBR00000092,Pharmacy,Paid,Electronic_EDI,2023-02-26,2023-02-26,2023-02-26,2023-03-17,Manual_Review,19,1549436467,1972530373,207RE0101X,Endocrinology,11,In_Network,M54.5,Z00.00,16590051660,,2,Medicaid_MCO,MLTSS,68,F,1.3217,,,287.08,128.61,125.61,0.0,3.0,0.0,158.47,0.0,0.0,0,,0.0834,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000002924,MBR00000125,Medical_Institutional,Denied,Electronic_EDI,2023-09-02,2023-09-02,2023-09-06,2023-09-06,Manual_Review,4,1869706360,1252125670,207V00000X,Obstetrics & Gynecology,31,In_Network,OTHER,N18.3|I50.9,revenue_code:0210,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,1,Timely_Filing,2138.86,836.7,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0476,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002925,MBR00000154,Pharmacy,Paid,Electronic_EDI,2023-11-06,2023-11-06,2023-11-06,2023-11-25,Auto_Adjudicated,19,1196858674,1461075342,207RN0300X,Nephrology,21,In_Network,K57.30,OTHER,00006001954,,2,Medicare_Advantage,MA_HMO,54,F,1.9463,,,225.15,148.52,112.81,7.51,0.0,28.2,76.63,0.0,0.0,0,,0.045,none,0,1,0,0,0,1e-05,0,0,PPC_Prenatal_Care,Capitation
CLM0000002926,MBR00000125,Medical_Institutional,Paid,Electronic_EDI,2023-08-06,2023-08-06,2023-08-09,2023-08-17,Auto_Adjudicated,11,1388662212,1650774392,207Q00000X,Family Medicine,22,In_Network,N18.3,,revenue_code:0300,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,21270.58,15996.0,12754.52,7.85,45.0,3188.63,5274.58,0.0,0.0,0,,0.0458,none,0,1,1,1,0,0.001181,0,0,W30_Well_Child_Visit,FFS
CLM0000002927,MBR00000123,Medical_Professional,Paid,Electronic_EDI,2023-05-21,2023-05-21,2023-05-21,2023-06-08,Auto_Adjudicated,18,1210349885,1354959095,207RN0300X,Nephrology,65,In_Network,OTHER,,99203,,0,ACA_Marketplace,ACA_Bronze,7,M,0.2444,,,384.86,323.17,0.0,323.17,0.0,0.0,61.69,0.0,0.0,0,,0.0881,none,0,1,0,0,0,0.0,0,0,PPC_Prenatal_Care,FFS
CLM0000002928,MBR00000036,Behavioral_Health,Paid,Provider_Portal,2023-06-22,2023-06-22,2023-06-22,2023-07-03,Manual_Review,11,1549436467,1354265777,207R00000X,Internal Medicine,11,In_Network,J06.9,,99215,,0,Commercial,EPO,17,M,2.0136,,,210.88,146.09,0.0,146.09,0.0,0.0,64.79,0.0,0.0,0,,0.1077,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002929,MBR00000262,Vision,Paid,Paper,2023-10-19,2023-10-19,2023-10-19,2023-11-10,Manual_Review,22,1981623199,1738617370,2086S0122X,Orthopedic Surgery,81,In_Network,OTHER,J06.9|I10,92014,,0,Medicare_Advantage,PFFS,77,F,1.7452,,,124.82,97.29,74.07,0.71,4.0,18.52,27.53,0.0,0.0,0,,0.0397,none,0,1,0,0,0,7e-06,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000002930,MBR00000184,Medical_Professional,Denied,Electronic_EDI,2023-02-21,2023-02-21,2023-02-21,2023-02-25,Auto_Adjudicated,4,1625939855,1694343357,207RG0100X,Gastroenterology,22,In_Network,Z00.01,I10,99213,,0,Medicaid_MCO,MLTSS,30,M,2.8302,96,Medical_Necessity,246.21,128.7,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0661,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000002931,MBR00000046,Pharmacy,Paid,Electronic_EDI,2023-09-17,2023-09-17,2023-09-17,2023-10-13,Auto_Adjudicated,26,1874914200,1691162131,207RC0000X,Cardiovascular Disease,24,In_Network,I10,,00006001954,,1,Commercial,HMO,76,F,0.9613,,,585.23,439.59,265.45,72.78,35.0,66.36,145.64,0.0,0.0,0,,0.1959,temporal_clustering,0,1,0,0,0,2.5e-05,0,1,PPC_Prenatal_Care,Shared_Savings
CLM0000002932,MBR00000134,Medical_Professional,Paid,Electronic_EDI,2023-04-07,2023-04-07,2023-04-07,2023-04-22,Auto_Adjudicated,15,1007414142,1061149198,207RC0000X,Cardiovascular Disease,22,In_Network,F41.1,I10,10060,,0,Medicare_Advantage,MA_PPO,33,M,1.115,,,428.32,198.37,116.94,39.2,13.0,29.23,229.95,0.0,0.0,0,,0.123,none,0,1,0,1,0,1.1e-05,0,0,,FFS
CLM0000002933,MBR00000132,Vision,Denied,Electronic_EDI,2023-11-12,2023-11-12,2023-11-12,2023-11-19,Auto_Adjudicated,7,1869706360,1705448933,208600000X,Surgery General,31,In_Network,OTHER,,92012,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,3,Eligibility,833.14,522.5,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0465,none,0,1,0,0,0,0.0,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000002934,MBR00000181,Medical_Institutional,Paid,Electronic_EDI,2023-02-20,2023-02-20,2023-02-21,2023-03-21,Manual_Review,29,1295273693,1986847322,2084P0800X,Psychiatry,32,In_Network,Z87.891,N39.0|J44.1|OTHER,revenue_code:0450,,0,Commercial,PPO,82,F,1.0432,,,24901.89,13414.29,10640.88,60.2,53.0,2660.22,11487.6,0.0,0.0,0,,0.0376,none,0,1,1,0,0,0.000985,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000002935,MBR00000184,Medical_Professional,Paid,Electronic_EDI,2023-07-05,2023-07-05,2023-07-05,2023-07-09,Auto_Adjudicated,4,1797494973,1356856197,207R00000X,Internal Medicine,21,Out_of_Network,Z00.01,OTHER|Z00.01,85025,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,588.08,407.98,405.98,0.0,2.0,0.0,180.1,0.0,0.0,0,,0.1171,none,0,1,0,0,0,3.8e-05,0,0,,Capitation
CLM0000002936,MBR00000192,Pharmacy,Denied,Electronic_EDI,2023-05-24,2023-05-24,2023-05-24,2023-06-10,Auto_Adjudicated,17,1821999097,1591405274,207RG0100X,Gastroenterology,23,In_Network,OTHER,,00169751112,,1,Medicaid_MCO,MCO,22,F,1.1739,CO-45,Timely_Filing,215.63,138.68,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1903,provider_specialty_mismatch,0,1,0,1,0,0.0,0,0,,FFS
CLM0000002937,MBR00000207,Medical_Institutional,Paid,Electronic_EDI,2023-06-24,2023-06-24,2023-06-26,2023-06-27,Auto_Adjudicated,3,1120678352,1330485436,207RN0300X,Nephrology,81,In_Network,OTHER,,revenue_code:0250,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,16807.93,12419.97,12413.97,0.0,6.0,0.0,4387.96,8567.53,3182.01,0,,0.0637,none,0,1,1,0,0,0.001149,0,0,,Bundled_Payment
CLM0000002938,MBR00000031,Medical_Professional,Denied,Electronic_EDI,2023-05-18,2023-05-18,2023-05-18,2023-06-14,Auto_Adjudicated,27,1732726112,1005335812,208600000X,Surgery General,24,In_Network,H52.4,J45.20|Z00.00,99284,,0,Commercial,PPO,71,M,0.6746,5,Timely_Filing,536.64,249.86,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Unbundling,1.0,outlier_billing_amount|geographic_mismatch|temporal_clustering|high_volume_same_code|impossible_service_combo|service_date_weekend|upcoding_pattern|phantom_billing_indicator|npi_mismatch,1,5,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002939,MBR00000097,Pharmacy,Paid,Electronic_EDI,2023-01-14,2023-01-14,2023-01-14,2023-01-19,Auto_Adjudicated,5,1232573801,1068662623,2084P0800X,Psychiatry,71,In_Network,J20.9,OTHER,00071012831,,1,Commercial,EPO,34,M,1.3765,,,887.73,707.19,144.47,502.6,24.0,36.12,180.54,0.0,0.0,0,,0.0288,none,0,1,0,1,0,1.3e-05,0,0,,FFS
CLM0000002940,MBR00000006,Pharmacy,Paid,Provider_Portal,2023-11-04,2023-11-04,2023-11-04,2023-11-12,Auto_Adjudicated,8,1865750966,1447186817,207RC0000X,Cardiovascular Disease,24,In_Network,Z12.11,N39.0,00069420020,,3,Commercial,EPO,88,M,1.4365,,,593.67,301.03,188.71,32.14,33.0,47.18,292.64,0.0,0.0,0,,0.1729,high_oop_waiver,0,1,0,0,0,1.7e-05,0,1,DDE_Diabetes_Short_Term_Complications,P4P
CLM0000002941,MBR00000141,Medical_Institutional,Paid,Provider_Portal,2023-07-11,2023-07-11,2023-07-12,2023-07-31,Auto_Adjudicated,20,1119160702,1607833568,207RN0300X,Nephrology,21,In_Network,Z00.01,M79.3,revenue_code:0110,683,0,Commercial,HMO,47,F,0.6724,,,8541.28,3280.79,2560.01,42.77,38.0,640.0,5260.49,0.0,0.0,0,,0.0965,none,0,1,0,0,0,0.000237,0,0,COA_Care_Transitions,FFS
CLM0000002942,MBR00000135,Pharmacy,Paid,Electronic_EDI,2023-08-04,2023-08-04,2023-08-04,2023-08-31,Manual_Review,27,1388662212,1704466150,2086S0122X,Orthopedic Surgery,31,In_Network,F33.0,F33.0,00071012831,,4,Commercial,PPO,58,F,2.2702,,,96.53,52.85,12.17,0.63,37.0,3.04,43.68,0.0,0.0,0,,0.056,none,0,1,0,0,0,1e-06,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000002943,MBR00000214,Medical_Professional,Paid,Electronic_EDI,2023-07-07,2023-07-07,2023-07-07,2023-07-20,Manual_Review,13,1034130209,1694343357,101YP2500X,Psychologist Clinical,23,In_Network,I10,E11.65|N39.0|OTHER,99396,,0,Commercial,HDHP_HSA,76,M,1.7526,,,126.24,46.28,0.0,46.28,0.0,0.0,79.96,0.0,0.0,0,,0.0622,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,,P4P
CLM0000002944,MBR00000053,Medical_Professional,Denied,Electronic_EDI,2023-07-09,2023-07-09,2023-07-09,2023-07-17,Auto_Adjudicated,8,1091271799,1767402068,207RC0000X,Cardiovascular Disease,11,In_Network,J44.1,J06.9|OTHER,99212,,0,Medicaid_MCO,MLTSS,74,F,0.9277,CO-45,COB,823.1,558.38,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.115,provider_specialty_mismatch|phantom_billing_indicator,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000002945,MBR00000187,Pharmacy,Denied,Electronic_EDI,2023-08-06,2023-08-06,2023-08-06,2023-08-17,Auto_Adjudicated,11,1618564043,1354265777,246ZN0300X,Neuropsychology,11,In_Network,J20.9,,00069420020,,1,Medicaid_MCO,MCO,36,F,1.191,256,Authorization,408.46,181.45,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0273,none,0,1,0,1,0,0.0,0,1,,Shared_Savings
CLM0000002946,MBR00000097,Medical_Professional,Paid,Electronic_EDI,2023-05-31,2023-05-31,2023-05-31,2023-06-28,Auto_Adjudicated,28,1051254008,1061149198,2086S0122X,Orthopedic Surgery,11,In_Network,J44.1,J06.9|Z00.00,12001,,0,Commercial,EPO,34,M,1.3765,,,1555.38,1119.76,872.56,5.06,24.0,218.14,435.62,0.0,0.0,0,,0.0624,none,0,1,0,1,0,8.1e-05,0,0,,FFS
CLM0000002947,MBR00000121,Medical_Institutional,Paid,Electronic_EDI,2023-02-17,2023-02-17,2023-02-21,2023-03-17,Auto_Adjudicated,28,1269185915,1747596016,207V00000X,Obstetrics & Gynecology,24,In_Network,OTHER,Z12.11|I10,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,58,M,1.226,,,7358.54,5919.29,4689.22,1.77,56.0,1172.3,1439.25,0.0,0.0,0,,0.145,none,0,1,0,0,0,0.000434,0,0,W30_Well_Child_Visit,Capitation
CLM0000002948,MBR00000212,Vision,Paid,Electronic_EDI,2023-01-11,2023-01-11,2023-01-11,2023-01-15,Manual_Review,4,1713343912,1829216053,207RN0300X,Nephrology,24,In_Network,Z23,,92004,,0,Commercial,HMO,57,F,2.5456,,,206.47,133.14,24.63,84.36,18.0,6.16,73.33,0.0,0.0,0,,0.1762,unbundling_pattern,0,1,0,0,0,2e-06,0,0,,FFS
CLM0000002949,MBR00000022,Pharmacy,Denied,Paper,2023-07-13,2023-07-13,2023-07-13,2023-08-10,Manual_Review,28,1558692441,1289435414,101YP2500X,Psychologist Clinical,31,In_Network,K21.0,K21.0|Z00.01,00078043215,,2,Medicare_Advantage,MA_HMO,34,M,0.9472,CO-45,Duplicate,86.12,58.75,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2759,geographic_mismatch|duplicate_claim_indicator|unbundling_pattern,0,2,0,0,0,0.0,0,1,,FFS
CLM0000002950,MBR00000107,Medical_Institutional,Paid,Electronic_EDI,2023-03-08,2023-03-08,2023-03-10,2023-04-03,Auto_Adjudicated,26,1874914200,1912895973,207Q00000X,Family Medicine,11,In_Network,Z00.00,OTHER,revenue_code:0300,,0,Medicare_Advantage,MA_PPO,44,M,1.0439,,,698.32,393.72,268.83,26.68,31.0,67.21,304.6,0.0,0.0,0,,0.1063,none,0,1,0,0,0,2.5e-05,0,0,,Shared_Savings
CLM0000002951,MBR00000125,Medical_Institutional,Paid,Paper,2023-06-12,2023-06-12,2023-06-12,2023-06-29,Manual_Review,17,1233824762,1995553359,207RE0101X,Endocrinology,11,Out_of_Network,E78.5,J44.1,revenue_code:0370,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,5461.93,2153.32,1678.78,9.84,45.0,419.7,3308.61,0.0,0.0,0,,0.0844,npi_mismatch,0,1,0,0,0,0.000155,0,0,,P4P
CLM0000002952,MBR00000212,Dental,Denied,Electronic_EDI,2023-08-06,2023-08-06,2023-08-06,2023-08-14,Auto_Adjudicated,8,1046207613,1804282800,207RN0300X,Nephrology,11,In_Network,Z00.01,Z00.00|M79.3|OTHER,D0150,,0,Commercial,HMO,57,F,2.5456,22,Coding_Error,423.98,239.65,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1294,unusual_service_frequency|upcoding_pattern,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002953,MBR00000061,Dental,Paid,Electronic_EDI,2023-08-02,2023-08-02,2023-08-02,2023-08-16,Auto_Adjudicated,14,1501282310,1320546364,207V00000X,Obstetrics & Gynecology,23,In_Network,I10,Z00.00|J06.9,D3310,,0,Commercial,PPO,66,M,2.3575,,,406.25,225.5,150.54,24.32,13.0,37.64,180.75,0.0,0.0,0,,0.0488,none,0,1,0,0,0,1.4e-05,0,0,MMA_Medication_Management,Shared_Savings
CLM0000002954,MBR00000287,Medical_Professional,Paid,Electronic_EDI,2023-03-02,2023-03-02,2023-03-02,2023-03-26,Auto_Adjudicated,24,1923937825,1705448933,208600000X,Surgery General,31,In_Network,Z23,,81001,,0,Commercial,PPO,4,M,0.7685,,,422.28,229.31,148.29,17.94,26.0,37.07,192.97,0.0,0.0,0,,0.138,service_date_weekend|duplicate_claim_indicator,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000002955,MBR00000300,Medical_Institutional,Paid,Paper,2023-08-26,2023-08-26,2023-08-29,2023-09-04,Auto_Adjudicated,9,1252009836,1930040953,225100000X,Physical Therapist,32,Out_of_Network,Z23,OTHER,revenue_code:0450,,0,Commercial,PPO,64,F,1.0393,,,21630.29,14327.05,11323.61,124.54,48.0,2830.9,7303.24,0.0,0.0,0,,0.1475,none,0,1,1,0,0,0.001048,1,0,BPD_BP_Declined,Bundled_Payment
CLM0000002956,MBR00000244,Medical_Professional,Paid,Provider_Portal,2023-12-04,2023-12-04,2023-12-04,2023-12-15,Auto_Adjudicated,11,1008470017,1151295616,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,Z00.00,71046,,0,Commercial,PPO,52,M,0.6677,,,405.48,245.81,93.97,117.34,11.0,23.49,159.67,0.0,0.0,0,,0.1624,upcoding_pattern,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000002957,MBR00000094,Medical_Professional,Paid,Electronic_EDI,2023-05-10,2023-05-10,2023-05-10,2023-05-24,Auto_Adjudicated,14,1699074676,1942423230,207V00000X,Obstetrics & Gynecology,24,In_Network,Z00.01,OTHER|M54.5,99204,,0,Commercial,POS,36,F,0.3997,,,411.02,330.75,0.0,308.45,22.3,0.0,80.27,0.0,0.0,0,,0.1654,unusual_service_frequency|billing_spike_recent,0,1,0,0,0,0.0,0,0,POD_Persistence_of_Beta_Blocker,Capitation
CLM0000002958,MBR00000197,Medical_Professional,Paid,Provider_Portal,2023-02-12,2023-02-12,2023-02-12,2023-02-15,Auto_Adjudicated,3,1364746046,1355732274,2086S0122X,Orthopedic Surgery,23,In_Network,I10,,70553,,0,Medicare_Advantage,MA_HMO,59,M,1.1414,,,1102.53,803.3,627.31,6.17,13.0,156.83,299.23,0.0,0.0,0,,0.1275,temporal_clustering,0,1,0,0,0,5.8e-05,0,0,FLU_Flu_Vaccination,Shared_Savings
CLM0000002959,MBR00000025,Medical_Institutional,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-07-03,2023-07-13,Auto_Adjudicated,13,1019263018,1282319940,207RN0300X,Nephrology,65,Emergency,M25.511,F32.9,revenue_code:0450,,0,Commercial,POS,74,M,1.3309,,,25082.07,17717.78,13798.92,400.13,69.0,3449.73,7364.29,11993.31,1007.91,0,,0.0032,none,0,1,1,0,0,0.001277,0,0,,P4P
CLM0000002960,MBR00000263,Pharmacy,Paid,Paper,2023-08-10,2023-08-10,2023-08-10,2023-08-15,Auto_Adjudicated,5,1555292468,1291071007,207Q00000X,Family Medicine,24,In_Network,Z00.00,OTHER|Z00.00,00003014960,,2,Medicare_Advantage,MA_HMO,29,F,1.5001,,,190.96,153.23,90.11,21.59,19.0,22.53,37.73,0.0,0.0,0,,0.1861,geographic_mismatch,0,1,0,0,0,8e-06,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000002961,MBR00000158,Dental,Paid,Electronic_EDI,2023-05-22,2023-05-22,2023-05-22,2023-05-23,Auto_Adjudicated,1,1641660170,1039962073,246ZN0300X,Neuropsychology,22,In_Network,R05.9,M54.5|Z00.00,D0120,,0,Commercial,HMO,65,M,1.5361,,,214.48,126.49,0.0,126.49,0.0,0.0,87.99,0.0,0.0,0,,0.0617,none,0,1,0,1,0,0.0,0,0,MMA_Medication_Management,Capitation
CLM0000002962,MBR00000055,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-08-04,2023-08-04,2023-08-05,2023-08-16,Auto_Adjudicated,12,1739169232,1151295616,207RE0101X,Endocrinology,24,In_Network,I48.91,,revenue_code:0360,,0,Commercial,PPO,68,F,1.2896,97,Medical_Necessity,4103.44,3321.79,1305.45,39.92,74.0,326.36,2357.71,0.0,0.0,0,,0.131,none,0,1,0,0,0,0.000121,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000002963,MBR00000104,Medical_Institutional,Paid,Provider_Portal,2023-10-02,2023-10-02,2023-10-06,2023-10-25,Manual_Review,23,1315569619,1829216053,207RC0000X,Cardiovascular Disease,11,Out_of_Network,Z79.4,I48.91|R05.9|OTHER,revenue_code:0100,,0,Medicaid_MCO,MCO,87,F,1.2297,,,1704.26,949.72,948.72,0.0,1.0,0.0,754.54,0.0,0.0,0,,0.0343,none,0,1,0,0,0,8.8e-05,1,0,,FFS
CLM0000002964,MBR00000236,Medical_Professional,Paid,Electronic_EDI,2023-07-27,2023-07-27,2023-07-27,2023-08-26,Auto_Adjudicated,30,1871417879,1391074619,207V00000X,Obstetrics & Gynecology,24,In_Network,E78.5,,90832,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,1104.33,545.68,542.68,0.0,3.0,0.0,558.65,0.0,0.0,0,,0.1653,benford_violation,0,1,0,0,0,5e-05,0,0,SPC_Statin_Therapy,Capitation
CLM0000002965,MBR00000263,Medical_Professional,Paid,Electronic_EDI,2023-10-13,2023-10-13,2023-10-13,2023-10-27,Auto_Adjudicated,14,1508520529,1622950074,207RC0000X,Cardiovascular Disease,24,In_Network,Z00.01,I10|J20.9,90853,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,,,199.71,148.89,85.84,22.59,19.0,21.46,50.82,0.0,0.0,0,,0.1723,geographic_mismatch,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000002966,MBR00000159,Medical_Professional,Partially_Paid,Electronic_EDI,2023-02-22,2023-02-22,2023-02-22,2023-03-17,Auto_Adjudicated,23,1532359759,1930040953,207RP1001X,Pulmonary Disease,31,In_Network,OTHER,N40.0,71250,,0,Commercial,PPO,70,F,1.2009,96,Medical_Necessity,591.36,443.77,196.35,43.07,14.0,49.09,288.85,0.0,0.0,0,,0.1491,phantom_billing_indicator,0,1,0,0,0,1.8e-05,0,0,COL_Colorectal_Cancer_Screening,Shared_Savings
CLM0000002967,MBR00000148,Behavioral_Health,Paid,Electronic_EDI,2023-04-16,2023-04-16,2023-04-16,2023-04-23,Auto_Adjudicated,7,1995916350,1738617370,207RG0100X,Gastroenterology,11,In_Network,OTHER,E78.5|OTHER|E11.9,99383,,0,Commercial,EPO,51,F,0.6534,,,245.34,136.28,0.0,136.28,0.0,0.0,109.06,0.0,0.0,0,,0.0962,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002968,MBR00000220,Medical_Professional,Paid,Electronic_EDI,2023-07-19,2023-07-19,2023-07-19,2023-08-08,Manual_Review,20,1875632885,1804282800,207RE0101X,Endocrinology,31,In_Network,L70.0,Z00.01|E78.5,12001,,0,Commercial,HMO,38,M,0.7736,,,307.54,205.15,58.29,97.29,35.0,14.57,102.39,0.0,0.0,0,,0.0293,none,0,1,0,0,0,5e-06,0,0,PPC_Prenatal_Care,Capitation
CLM0000002969,MBR00000247,Pharmacy,Paid,Electronic_EDI,2023-04-04,2023-04-04,2023-04-04,2023-04-24,Auto_Adjudicated,20,1119083414,1477113725,207R00000X,Internal Medicine,11,In_Network,I10,OTHER|N40.0,59148001506,,2,Medicare_Advantage,MA_PPO,60,F,1.0618,,,163.1,127.77,89.4,11.02,5.0,22.35,35.33,0.0,0.0,0,,0.0445,none,0,1,0,0,0,8e-06,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000002970,MBR00000225,Medical_Professional,Paid,Electronic_EDI,2023-12-23,2023-12-23,2023-12-23,2024-01-02,Manual_Review,10,1943769986,1643673796,207R00000X,Internal Medicine,24,In_Network,K21.0,,73721,,0,Commercial,PPO,27,F,0.5948,,,812.62,296.07,10.01,250.56,33.0,2.5,516.55,0.0,0.0,0,,0.0366,none,0,1,0,0,0,1e-06,0,0,,Bundled_Payment
CLM0000002971,MBR00000122,Medical_Institutional,Denied,Electronic_EDI,2023-09-01,2023-09-01,2023-09-03,2023-09-15,Auto_Adjudicated,14,1906448800,1039962073,207Q00000X,Family Medicine,65,In_Network,C50.911,OTHER|F33.0,revenue_code:0360,,0,Commercial,EPO,64,F,0.8625,4,Medical_Necessity,9382.93,6869.8,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1103,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002972,MBR00000191,Dental,Paid,Provider_Portal,2023-05-28,2023-05-28,2023-05-28,2023-06-18,Auto_Adjudicated,21,1972755666,1986847322,2086S0122X,Orthopedic Surgery,11,In_Network,Z00.01,OTHER,D2391,,0,Commercial,POS,85,F,0.9729,,,461.36,241.91,0.0,223.76,18.15,0.0,219.45,0.0,0.0,0,,0.177,service_date_weekend,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002973,MBR00000259,Vision,Paid,Electronic_EDI,2023-10-05,2023-10-05,2023-10-05,2023-10-15,Auto_Adjudicated,10,1356562955,1880530717,2084P0800X,Psychiatry,23,In_Network,OTHER,J20.9,92004,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,224.19,182.77,131.65,11.2,7.0,32.91,41.42,0.0,0.0,0,,0.1283,provider_specialty_mismatch,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000002974,MBR00000048,Medical_Professional,Paid,Electronic_EDI,2023-12-19,2023-12-19,2023-12-19,2024-01-07,Auto_Adjudicated,19,1451329728,1690197969,207RN0300X,Nephrology,23,In_Network,OTHER,OTHER|F32.9|Z00.00,70553,,0,Commercial,POS,27,F,0.639,,,535.13,224.48,92.96,83.28,25.0,23.24,310.65,0.0,0.0,0,,0.0157,none,0,1,0,0,0,9e-06,0,0,,Bundled_Payment
CLM0000002975,MBR00000124,Dental,Paid,Electronic_EDI,2023-01-04,2023-01-04,2023-01-04,2023-01-11,Auto_Adjudicated,7,1317654726,1842149518,2084P0800X,Psychiatry,31,Out_of_Network,I10,OTHER|F41.1,D0150,,0,Commercial,EPO,40,F,0.4583,,,205.34,137.98,0.0,137.98,0.0,0.0,67.36,0.0,0.0,0,,0.1336,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002976,MBR00000016,Medical_Professional,Paid,Electronic_EDI,2023-07-19,2023-07-19,2023-07-19,2023-08-05,Auto_Adjudicated,17,1110312325,1553094822,207RP1001X,Pulmonary Disease,11,In_Network,E11.9,K29.70,17000,,0,Commercial,HDHP_HSA,20,F,0.5843,,,591.14,431.25,279.95,81.31,0.0,69.99,159.89,0.0,0.0,0,,0.0837,none,0,1,0,0,0,2.6e-05,0,0,,FFS
CLM0000002977,MBR00000130,Pharmacy,Denied,Electronic_EDI,2023-06-03,2023-06-03,2023-06-03,2023-06-05,Auto_Adjudicated,2,1393200616,1951488764,2086S0122X,Orthopedic Surgery,65,In_Network,J06.9,,00069420020,,1,Medicare_Advantage,MA_PPO,58,M,1.3394,16,Duplicate,180.88,76.42,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1721,billing_spike_recent,0,1,0,0,0,0.0,0,1,,FFS
CLM0000002978,MBR00000227,Medical_Professional,Paid,Electronic_EDI,2023-09-29,2023-09-29,2023-09-29,2023-10-13,Auto_Adjudicated,14,1636337876,1288028182,208600000X,Surgery General,81,In_Network,K21.0,K21.0,99396,,0,Medicare_Advantage,MA_PPO,2,F,0.7835,,,176.42,138.95,99.72,0.3,14.0,24.93,37.47,0.0,0.0,0,,0.1213,none,0,1,0,0,0,9e-06,0,0,,Shared_Savings
CLM0000002979,MBR00000061,Medical_Institutional,Paid,Electronic_EDI,2023-04-21,2023-04-21,2023-04-22,2023-05-07,Auto_Adjudicated,16,1639236553,1827839595,207RN0300X,Nephrology,23,In_Network,K21.0,,revenue_code:0110,,0,Commercial,PPO,66,M,2.3575,,,17653.96,9753.56,7657.33,147.9,34.0,1914.33,7900.4,0.0,0.0,0,,0.0333,none,0,1,1,0,0,0.000709,0,0,,Shared_Savings
CLM0000002980,MBR00000165,Pharmacy,Paid,Electronic_EDI,2023-04-27,2023-04-27,2023-04-27,2023-05-22,Manual_Review,25,1664872214,1365397818,2086S0122X,Orthopedic Surgery,21,In_Network,E13.9,,00169751112,,1,ACA_Marketplace,ACA_Bronze,55,M,0.9775,,,25.04,9.15,0.0,9.15,0.0,0.0,15.89,0.0,0.0,0,,0.1594,service_date_weekend,0,1,0,0,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000002981,MBR00000012,Pharmacy,Paid,Electronic_EDI,2023-10-03,2023-10-03,2023-10-03,2023-10-15,Manual_Review,12,1055717021,1296566243,207V00000X,Obstetrics & Gynecology,23,In_Network,F32.9,J06.9|J44.1|OTHER,16590051660,,2,Commercial,HMO,84,M,1.3904,,,427.76,290.19,140.97,85.98,28.0,35.24,137.57,0.0,0.0,0,,0.0939,phantom_billing_indicator,0,1,0,0,0,1.3e-05,0,0,,Shared_Savings
CLM0000002982,MBR00000272,Pharmacy,Paid,Electronic_EDI,2023-11-16,2023-11-16,2023-11-16,2023-11-17,Auto_Adjudicated,1,1211372728,1809122260,208600000X,Surgery General,11,In_Network,I10,E11.65,00078043215,,2,Medicare_Advantage,MA_HMO,15,M,0.8525,,,57.91,20.4,0.0,20.4,0.0,0.0,37.51,0.0,0.0,0,,0.0708,none,0,1,0,0,0,0.0,0,1,,Capitation
CLM0000002983,MBR00000244,Medical_Professional,Paid,Electronic_EDI,2023-02-21,2023-02-21,2023-02-21,2023-02-23,Manual_Review,2,1274357072,1978943761,207RG0100X,Gastroenterology,24,In_Network,E78.5,,97035,,0,Commercial,PPO,52,M,0.6677,,,1346.51,1102.54,766.5,133.42,11.0,191.62,243.97,0.0,0.0,0,,0.1229,none,0,1,0,0,0,7.1e-05,0,0,,FFS
CLM0000002984,MBR00000160,Dental,Paid,Electronic_EDI,2023-08-09,2023-08-09,2023-08-09,2023-08-26,Auto_Adjudicated,17,1404237143,1622950074,207RN0300X,Nephrology,11,In_Network,Z23,N39.0,D3310,,0,Commercial,HMO,73,M,1.9608,,,507.87,307.96,0.0,307.96,0.0,0.0,199.91,0.0,0.0,0,,0.1272,benford_violation,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000002985,MBR00000208,Medical_Professional,Denied,Electronic_EDI,2023-10-07,2023-10-07,2023-10-07,2023-11-01,Auto_Adjudicated,25,1560886857,1187669363,207Q00000X,Family Medicine,21,In_Network,N39.0,,97110,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,4,Medical_Necessity,1320.53,1041.59,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1425,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,SPD_Spirometry_Testing,Shared_Savings
CLM0000002986,MBR00000031,Medical_Professional,Paid,Electronic_EDI,2023-03-01,2023-03-01,2023-03-01,2023-03-28,Auto_Adjudicated,27,1112402001,1432077493,208600000X,Surgery General,11,Emergency,OTHER,,27130,,0,Commercial,PPO,71,M,0.6746,,,8182.89,5596.12,4443.66,25.54,16.0,1110.92,2586.77,0.0,0.0,0,,0.0281,none,0,1,0,0,0,0.000411,0,0,,FFS
CLM0000002987,MBR00000254,Medical_Professional,Paid,Paper,2023-08-26,2023-08-26,2023-08-26,2023-09-20,Auto_Adjudicated,25,1804302686,1995553359,207RN0300X,Nephrology,23,In_Network,Z00.01,M54.5|F32.9,99223,,0,Commercial,PPO,22,F,0.9285,,,252.9,207.16,140.24,3.87,28.0,35.06,45.74,0.0,0.0,0,,0.039,none,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000002988,MBR00000212,Medical_Professional,Denied,Paper,2023-12-18,2023-12-18,2023-12-18,2023-12-29,Auto_Adjudicated,11,1331264469,1040061910,225100000X,Physical Therapist,22,In_Network,OTHER,,47562,,0,Commercial,HMO,57,F,2.5456,5,Coding_Error,798.43,495.75,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1019,none,0,1,0,0,0,0.0,0,0,AMR_Asthma_Medication_Ratio,Bundled_Payment
CLM0000002989,MBR00000037,Medical_Professional,Paid,Provider_Portal,2023-10-30,2023-10-30,2023-10-30,2023-11-14,Manual_Review,15,1976304517,1034732777,101YP2500X,Psychologist Clinical,23,Out_of_Network,M54.5,,84443,,0,Medicaid_MCO,MLTSS,11,M,1.043,,,877.03,449.68,448.68,0.0,1.0,0.0,427.35,0.0,0.0,0,,0.1824,unusual_service_frequency,0,1,0,0,0,4.2e-05,1,0,,FFS
CLM0000002990,MBR00000295,Pharmacy,Paid,Electronic_EDI,2023-03-11,2023-03-11,2023-03-11,2023-04-07,Manual_Review,27,1214787184,1148659045,207RE0101X,Endocrinology,11,In_Network,G43.909,,16590051660,,2,Commercial,HDHP_HSA,78,F,0.8618,,,352.51,137.54,0.0,137.54,0.0,0.0,214.97,0.0,0.0,0,,0.0212,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000002991,MBR00000007,Medical_Professional,Paid,Electronic_EDI,2023-12-22,2023-12-22,2023-12-22,2024-01-17,Auto_Adjudicated,26,1120678352,1319611206,208600000X,Surgery General,21,In_Network,E78.5,I10|J45.20,99282,,0,Commercial,HDHP_HSA,72,F,0.7578,,,387.79,184.91,0.0,184.91,0.0,0.0,202.88,0.0,0.0,0,,0.1298,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002992,MBR00000187,Medical_Institutional,Paid,Electronic_EDI,2023-05-09,2023-05-09,2023-05-12,2023-05-23,Auto_Adjudicated,14,1001149267,1995553359,208600000X,Surgery General,21,In_Network,Z12.11,,revenue_code:0300,248,0,Medicaid_MCO,MCO,36,F,1.191,,,18413.68,14781.95,14774.95,0.0,7.0,0.0,3631.73,0.0,0.0,0,,0.0635,none,0,1,1,0,0,0.001368,0,0,,Capitation
CLM0000002993,MBR00000054,Medical_Professional,Denied,Electronic_EDI,2023-06-21,2023-06-21,2023-06-21,2023-07-06,Manual_Review,15,1882720848,1767402068,207RE0101X,Endocrinology,22,In_Network,K21.0,OTHER,97035,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,3,Eligibility,916.83,771.68,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0563,none,0,1,0,0,0,0.0,0,0,AMR_Asthma_Medication_Ratio,Shared_Savings
CLM0000002994,MBR00000212,Pharmacy,Paid,Electronic_EDI,2023-04-15,2023-04-15,2023-04-15,2023-04-18,Auto_Adjudicated,3,1667149552,1020312030,207Q00000X,Family Medicine,11,In_Network,M25.511,E11.9|E11.65|E78.5,00310075090,,1,Commercial,HMO,57,F,2.5456,,,311.05,114.61,0.0,97.53,17.08,0.0,196.44,0.0,0.0,0,,0.0669,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000002995,MBR00000022,Medical_Professional,Paid,Electronic_EDI,2023-09-09,2023-09-09,2023-09-09,2023-09-15,Auto_Adjudicated,6,1965812565,1049766043,101YP2500X,Psychologist Clinical,23,In_Network,I10,OTHER,81001,,0,Medicare_Advantage,MA_HMO,34,M,0.9472,,,659.09,315.29,206.24,41.49,16.0,51.56,343.8,0.0,0.0,0,,0.0183,none,0,1,0,0,0,1.9e-05,0,0,,FFS
CLM0000002996,MBR00000025,Medical_Professional,Denied,Electronic_EDI,2023-02-15,2023-02-15,2023-02-15,2023-03-03,Auto_Adjudicated,16,1647029816,1339359594,207RP1001X,Pulmonary Disease,21,In_Network,J06.9,,99394,,0,Commercial,POS,74,M,1.3309,170,Eligibility,496.57,224.22,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1176,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000002997,MBR00000144,Medical_Institutional,Paid,Electronic_EDI,2023-09-12,2023-09-12,2023-09-12,2023-09-28,Auto_Adjudicated,16,1961590405,1666461892,208600000X,Surgery General,65,In_Network,N39.0,M54.5|OTHER,revenue_code:0100,,0,Commercial,HDHP_HSA,56,F,2.5926,,,11196.92,6804.41,5334.56,136.21,0.0,1333.64,4392.51,0.0,0.0,0,,0.0811,none,0,1,1,0,0,0.000494,0,0,,Capitation
CLM0000002998,MBR00000299,Vision,Paid,Electronic_EDI,2023-01-20,2023-01-20,2023-01-20,2023-02-07,Auto_Adjudicated,18,1097702209,1013600387,207RC0000X,Cardiovascular Disease,22,In_Network,G47.33,Z87.891,V2115,,0,Medicaid_MCO,MCO,74,F,0.8833,,,120.2,69.64,67.64,0.0,2.0,0.0,50.56,0.0,0.0,0,,0.1469,upcoding_pattern,0,1,0,0,0,6e-06,0,0,AWV_Annual_Wellness_Visit,Capitation
CLM0000002999,MBR00000086,Behavioral_Health,Paid,Electronic_EDI,2023-10-31,2023-10-31,2023-10-31,2023-11-10,Auto_Adjudicated,10,1390393668,1034732777,2086S0122X,Orthopedic Surgery,11,In_Network,Z00.00,OTHER|F10.10,99215,,0,Medicare_Advantage,MA_PPO,8,M,0.5427,,,410.07,344.76,269.14,0.34,8.0,67.28,65.31,0.0,0.0,0,,0.2128,geographic_mismatch|temporal_clustering,0,2,0,1,0,2.5e-05,0,0,,Shared_Savings
CLM0000003000,MBR00000184,Medical_Professional,Paid,Electronic_EDI,2023-04-28,2023-04-28,2023-04-28,2023-05-05,Auto_Adjudicated,7,1380824221,1433350836,207RN0300X,Nephrology,11,In_Network,Z00.01,,99205,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,353.82,186.45,184.45,0.0,2.0,0.0,167.37,0.0,0.0,0,,0.0728,none,0,1,0,1,0,1.7e-05,0,0,,FFS
CLM0000003001,MBR00000159,Vision,Denied,Electronic_EDI,2023-07-06,2023-07-06,2023-07-06,2023-07-20,Manual_Review,14,1505049857,1179350099,207RE0101X,Endocrinology,11,In_Network,F10.10,,V2320,,0,Commercial,PPO,70,F,1.2009,97,COB,259.9,168.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0693,upcoding_pattern,0,1,0,1,0,0.0,0,0,BPD_BP_Declined,P4P
CLM0000003002,MBR00000252,Medical_Institutional,Paid,Electronic_EDI,2023-03-23,2023-03-23,2023-03-27,2023-04-19,Manual_Review,27,1865750966,1368666316,101YP2500X,Psychologist Clinical,11,Out_of_Network,J06.9,,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,80,M,0.7173,,,13297.34,9943.77,7930.96,3.07,27.0,1982.74,3353.57,0.0,0.0,0,,0.1447,none,0,1,1,0,0,0.000734,1,0,FLU_Flu_Vaccination,Capitation
CLM0000003003,MBR00000091,Dental,Paid,Electronic_EDI,2023-02-08,2023-02-08,2023-02-08,2023-03-10,Auto_Adjudicated,30,1618546650,1274911960,207RP1001X,Pulmonary Disease,24,Out_of_Network,I10,N18.3,D1110,,0,Commercial,PPO,13,F,1.2451,,,864.5,309.09,94.56,166.89,24.0,23.64,555.41,0.0,0.0,0,,0.0735,none,0,1,0,1,0,9e-06,1,0,,FFS
CLM0000003004,MBR00000167,Medical_Professional,Denied,Electronic_EDI,2023-01-09,2023-01-09,2023-01-09,2023-01-11,Manual_Review,2,1727787144,1878017518,207RN0300X,Nephrology,23,In_Network,E78.5,F32.9,71250,,0,Commercial,PPO,77,F,0.9377,256,Medical_Necessity,697.16,519.54,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0107,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003005,MBR00000288,Medical_Professional,Paid,Electronic_EDI,2023-12-18,2023-12-18,2023-12-18,2023-12-29,Auto_Adjudicated,11,1098094939,1175334579,207RE0101X,Endocrinology,11,In_Network,J44.1,F32.9,99397,,0,Commercial,HMO,36,M,0.8408,,,598.43,416.75,147.56,198.3,34.0,36.89,181.68,0.0,0.0,0,,0.0643,none,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000003006,MBR00000105,Medical_Professional,Paid,Paper,2023-02-18,2023-02-18,2023-02-18,2023-03-06,Auto_Adjudicated,16,1175448241,1388050552,207RN0300X,Nephrology,31,In_Network,OTHER,Z00.00,99283,,0,Commercial,HMO,74,M,1.1834,,,354.47,285.16,170.38,57.19,15.0,42.59,69.31,0.0,0.0,0,,0.1141,none,0,1,0,0,0,1.6e-05,0,0,KED_ESRD_Patients,FFS
CLM0000003007,MBR00000138,Pharmacy,Paid,Provider_Portal,2023-01-21,2023-01-21,2023-01-21,2023-01-28,Manual_Review,7,1344162462,1402472115,207RP1001X,Pulmonary Disease,11,Emergency,L70.0,OTHER,00069420020,,2,Commercial,HDHP_HSA,47,M,0.996,,,134.65,112.03,0.0,112.03,0.0,0.0,22.62,0.0,0.0,0,,0.1014,none,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000003008,MBR00000270,Medical_Professional,Paid,Electronic_EDI,2023-07-04,2023-07-04,2023-07-04,2023-07-15,Auto_Adjudicated,11,1550698436,1581533104,246ZN0300X,Neuropsychology,24,In_Network,OTHER,E11.65,33510,,0,Commercial,POS,1,F,1.6363,,,259.86,164.56,0.0,164.56,0.0,0.0,95.3,0.0,0.0,0,,0.1048,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003009,MBR00000105,Medical_Professional,Paid,Electronic_EDI,2023-12-12,2023-12-12,2023-12-12,2023-12-16,Auto_Adjudicated,4,1035707913,1144950506,207RN0300X,Nephrology,11,In_Network,N18.3,,99385,,0,Commercial,HMO,74,M,1.1834,,,293.09,210.15,0.0,210.15,0.0,0.0,82.94,0.0,0.0,0,,0.0883,unusual_service_frequency,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003010,MBR00000121,Medical_Institutional,Paid,Electronic_EDI,2023-01-30,2023-01-30,2023-02-02,2023-02-13,Auto_Adjudicated,14,1376791933,1068662623,208600000X,Surgery General,21,In_Network,Z12.11,J44.1,revenue_code:0210,470,0,Medicare_Advantage,MA_PPO,58,M,1.226,,,53453.96,45081.02,36008.98,13.8,56.0,9002.24,8372.94,0.0,0.0,1,Prescription Drug Diversion,1.0,outlier_billing_amount|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|benford_violation|impossible_service_combo|billing_spike_recent|duplicate_claim_indicator|phantom_billing_indicator|diagnosis_procedure_mismatch|high_oop_waiver,1,5,1,0,0,0.003333,0,0,,FFS
CLM0000003011,MBR00000096,Vision,Paid,Electronic_EDI,2023-04-02,2023-04-02,2023-04-02,2023-04-29,Manual_Review,27,1855186422,1938465393,207RP1001X,Pulmonary Disease,24,In_Network,OTHER,I10|K21.0,92004,,0,Medicaid_MCO,MCO,62,M,0.7948,,,336.33,259.54,257.54,0.0,2.0,0.0,76.79,0.0,0.0,0,,0.1099,none,0,1,0,0,0,2.4e-05,0,0,,FFS
CLM0000003012,MBR00000240,Medical_Institutional,Paid,Paper,2023-07-19,2023-07-19,2023-07-20,2023-08-16,Auto_Adjudicated,28,1130461876,1538261819,2084P0800X,Psychiatry,11,In_Network,Z00.01,E11.9|J20.9|E78.5,revenue_code:0200,,0,Medicaid_MCO,MCO,9,F,0.386,,,47772.84,30616.27,30610.27,0.0,6.0,0.0,17156.57,0.0,0.0,0,,0.0846,outlier_billing_amount,0,1,1,0,0,0.002833,0,0,,FFS
CLM0000003013,MBR00000280,Pharmacy,Paid,Electronic_EDI,2023-06-26,2023-06-26,2023-06-26,2023-06-27,Manual_Review,1,1564110057,1406199453,207R00000X,Internal Medicine,11,Out_of_Network,OTHER,,00071012831,,1,Commercial,PPO,79,F,0.6697,,,43.58,18.45,0.0,18.45,0.0,0.0,25.13,0.0,0.0,0,,0.0803,phantom_billing_indicator,0,1,0,0,0,0.0,1,0,,FFS
CLM0000003014,MBR00000187,Medical_Professional,Paid,Electronic_EDI,2023-02-22,2023-02-22,2023-02-22,2023-03-14,Auto_Adjudicated,20,1019263018,1365397818,207Q00000X,Family Medicine,24,In_Network,E78.5,G47.33,10060,,0,Medicaid_MCO,MCO,36,F,1.191,,,858.56,459.88,456.88,0.0,3.0,0.0,398.68,0.0,0.0,0,,0.062,none,0,1,0,0,0,4.2e-05,0,0,AWV_Annual_Wellness_Visit,FFS
CLM0000003015,MBR00000186,Dental,Paid,Electronic_EDI,2023-12-08,2023-12-08,2023-12-08,2024-01-05,Auto_Adjudicated,28,1133514780,1662516615,207R00000X,Internal Medicine,23,In_Network,N18.3,,D1110,,0,Commercial,PPO,65,M,1.6983,,,488.02,384.74,257.99,50.25,12.0,64.5,103.28,0.0,0.0,0,,0.1349,none,0,1,0,0,0,2.4e-05,0,0,ACR_Urine_Protein,Capitation
CLM0000003016,MBR00000125,Medical_Professional,Paid,Electronic_EDI,2023-05-09,2023-05-09,2023-05-09,2023-06-02,Auto_Adjudicated,24,1114266188,1175334579,225100000X,Physical Therapist,32,In_Network,OTHER,Z12.11,97140,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,834.0,326.64,246.86,7.06,11.0,61.72,507.36,0.0,0.0,0,,0.0826,none,0,1,0,0,0,2.3e-05,0,0,,FFS
CLM0000003017,MBR00000004,Medical_Professional,Denied,Electronic_EDI,2023-08-31,2023-08-31,2023-08-31,2023-09-02,Auto_Adjudicated,2,1706018784,1187669363,246ZN0300X,Neuropsychology,23,In_Network,OTHER,Z12.11,82947,,0,Medicare_Advantage,MA_PPO,68,M,1.23,2,Eligibility,197.2,156.47,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0789,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003018,MBR00000055,Medical_Institutional,Denied,Electronic_EDI,2023-06-14,2023-06-14,2023-06-14,2023-06-26,Manual_Review,12,1313587359,1356856197,2084P0800X,Psychiatry,11,In_Network,OTHER,Z87.891|I50.9,revenue_code:0250,,0,Commercial,PPO,68,F,1.2896,50,Timely_Filing,6059.16,4031.96,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0943,none,0,1,0,1,0,0.0,0,0,IET_Initiation_Substance_Use,FFS
CLM0000003019,MBR00000046,Medical_Professional,Paid,Electronic_EDI,2023-07-30,2023-07-30,2023-07-30,2023-08-22,Manual_Review,23,1171387771,1619587398,225100000X,Physical Therapist,23,In_Network,OTHER,Z23|OTHER|M54.5,90847,,0,Commercial,HMO,76,F,0.9613,,,150.94,113.94,0.0,113.94,0.0,0.0,37.0,0.0,0.0,0,,0.0619,impossible_service_combo,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003020,MBR00000036,Pharmacy,Paid,Electronic_EDI,2023-11-21,2023-11-21,2023-11-21,2023-12-21,Auto_Adjudicated,30,1209940651,1339359594,207RN0300X,Nephrology,31,In_Network,F32.9,F10.10,00310075090,,2,Commercial,EPO,17,M,2.0136,,,62.73,34.57,0.0,34.57,0.0,0.0,28.16,0.0,0.0,0,,0.0294,none,0,1,0,1,0,0.0,0,1,KED_ESRD_Patients,FFS
CLM0000003021,MBR00000195,Pharmacy,Paid,Electronic_EDI,2023-04-27,2023-04-27,2023-04-27,2023-05-06,Manual_Review,9,1380824221,1433350836,207RC0000X,Cardiovascular Disease,11,In_Network,Z12.11,OTHER,00003014960,,4,Commercial,PPO,13,F,0.5967,,,353.51,177.94,106.95,31.25,13.0,26.74,175.57,0.0,0.0,0,,0.0296,none,0,1,0,0,0,1e-05,0,0,,Shared_Savings
CLM0000003022,MBR00000042,Medical_Professional,Paid,Electronic_EDI,2023-10-20,2023-10-20,2023-10-20,2023-10-29,Auto_Adjudicated,9,1309817189,1688513262,207RE0101X,Endocrinology,11,In_Network,M17.11,E11.9,99203,,0,Commercial,HMO,78,F,1.1448,,,237.41,198.19,134.61,9.93,20.0,33.65,39.22,0.0,0.0,0,,0.135,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000003023,MBR00000026,Medical_Professional,Paid,Electronic_EDI,2023-04-15,2023-04-15,2023-04-15,2023-04-23,Auto_Adjudicated,8,1313352855,1252125670,2084P0800X,Psychiatry,23,In_Network,E78.5,F32.9,99284,,0,Medicaid_MCO,MCO,17,M,1.0686,,,421.75,271.95,270.95,0.0,1.0,0.0,149.8,0.0,0.0,0,,0.1488,none,0,1,0,0,0,2.5e-05,0,0,,FFS
CLM0000003024,MBR00000121,Medical_Professional,Paid,Paper,2023-04-24,2023-04-24,2023-04-24,2023-05-21,Auto_Adjudicated,27,1300740186,1577226132,246ZN0300X,Neuropsychology,24,In_Network,F41.1,Z00.00|M54.5,99204,,0,Medicare_Advantage,MA_PPO,58,M,1.226,,,410.37,284.26,194.13,23.59,18.0,48.53,126.11,0.0,0.0,0,,0.1302,none,0,1,0,0,0,1.8e-05,0,0,,Bundled_Payment
CLM0000003025,MBR00000077,Medical_Professional,Paid,Electronic_EDI,2023-01-12,2023-01-12,2023-01-12,2023-01-18,Clinical_Review,6,1900781649,1672803287,207RP1001X,Pulmonary Disease,21,In_Network,I10,,83036,,0,Medicare_Advantage,MA_HMO,27,F,0.9229,,,296.02,240.84,189.44,0.04,4.0,47.36,55.18,0.0,0.0,0,,0.0942,billing_spike_recent,0,1,0,0,0,1.8e-05,0,0,,FFS
CLM0000003026,MBR00000046,Dental,Paid,Electronic_EDI,2023-05-05,2023-05-05,2023-05-05,2023-05-16,Auto_Adjudicated,11,1641779816,1148659045,2084P0800X,Psychiatry,24,In_Network,OTHER,,D1110,,0,Commercial,HMO,76,F,0.9613,,,387.42,227.56,124.6,36.81,35.0,31.15,159.86,0.0,0.0,0,,0.0084,none,0,1,0,1,0,1.2e-05,0,0,,FFS
CLM0000003027,MBR00000046,Medical_Institutional,Paid,Electronic_EDI,2023-07-30,2023-07-30,2023-08-01,2023-08-04,Auto_Adjudicated,5,1243349799,1282319940,246ZN0300X,Neuropsychology,11,In_Network,H52.4,E78.5|OTHER,revenue_code:0110,,0,Commercial,HMO,76,F,0.9613,,,2878.5,1125.72,785.87,102.38,41.0,196.47,1752.78,633.8,93.72,0,,0.1408,none,0,1,0,0,0,7.3e-05,0,0,,Bundled_Payment
CLM0000003028,MBR00000079,Medical_Professional,Paid,Electronic_EDI,2023-08-18,2023-08-18,2023-08-18,2023-09-16,Auto_Adjudicated,29,1944105498,1489434038,207RN0300X,Nephrology,22,In_Network,Z00.00,E11.9,99213,,0,Medicaid_MCO,MLTSS,55,F,0.5016,,,321.23,152.32,148.32,0.0,4.0,0.0,168.91,0.0,0.0,0,,0.1115,none,0,1,0,0,0,1.4e-05,0,0,,Capitation
CLM0000003029,MBR00000163,Medical_Professional,Partially_Paid,Electronic_EDI,2023-06-04,2023-06-04,2023-06-04,2023-06-06,Manual_Review,2,1836409547,1034732777,225100000X,Physical Therapist,24,In_Network,G47.33,Z00.00|OTHER,99283,,0,Medicaid_MCO,MCO,21,F,0.9607,CO-45,Medical_Necessity,346.07,228.99,162.71,0.0,4.0,0.0,179.36,0.0,0.0,0,,0.1088,none,0,1,0,0,0,1.5e-05,0,0,CDC_BP_Control,FFS
CLM0000003030,MBR00000222,Pharmacy,Paid,Paper,2023-05-08,2023-05-08,2023-05-08,2023-05-24,Auto_Adjudicated,16,1461820376,1123879500,207RG0100X,Gastroenterology,11,In_Network,OTHER,I10,00003014960,,4,Commercial,PPO,48,F,0.6945,,,150.06,109.77,0.0,106.31,3.46,0.0,40.29,0.0,0.0,0,,0.0279,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000003031,MBR00000257,Pharmacy,Denied,Paper,2023-03-22,2023-03-22,2023-03-22,2023-03-27,Auto_Adjudicated,5,1506426842,1747935894,207RG0100X,Gastroenterology,21,In_Network,OTHER,,00069420020,,1,Medicaid_MCO,MCO,76,F,0.8322,1,Duplicate,46.87,28.26,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.044,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003032,MBR00000221,Vision,Paid,Electronic_EDI,2023-11-21,2023-11-21,2023-11-21,2023-12-04,Auto_Adjudicated,13,1518661623,1625992541,207R00000X,Internal Medicine,23,In_Network,M54.5,,V2320,,0,Commercial,HDHP_HSA,28,M,1.6683,,,133.08,89.26,35.27,45.18,0.0,8.82,43.82,0.0,0.0,0,,0.1855,high_oop_waiver,0,1,0,0,0,3e-06,0,0,,FFS
CLM0000003033,MBR00000187,Medical_Professional,Paid,Electronic_EDI,2023-05-18,2023-05-18,2023-05-18,2023-06-05,Auto_Adjudicated,18,1135745665,1554490060,207RC0000X,Cardiovascular Disease,21,In_Network,Z79.4,M79.3|E11.9,97110,,0,Medicaid_MCO,MCO,36,F,1.191,,,3853.78,2662.09,2659.09,0.0,3.0,0.0,1191.69,0.0,0.0,0,,0.1005,none,0,1,0,0,0,0.000246,0,0,,FFS
CLM0000003034,MBR00000274,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-04-20,2023-04-20,2023-04-22,2023-05-11,Auto_Adjudicated,21,1972755666,1560230600,101YP2500X,Psychologist Clinical,32,In_Network,E78.5,E11.9,revenue_code:0370,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,16,Medical_Necessity,20992.42,7785.73,4779.38,29.55,46.0,1194.84,14942.65,0.0,0.0,0,,0.0984,billing_spike_recent,0,1,0,0,0,0.000442,0,0,,FFS
CLM0000003035,MBR00000159,Medical_Professional,Paid,Electronic_EDI,2023-12-04,2023-12-04,2023-12-04,2023-12-22,Auto_Adjudicated,18,1324272690,1983760474,207RN0300X,Nephrology,71,In_Network,OTHER,,80053,,0,Commercial,PPO,70,F,1.2009,,,534.74,314.29,228.4,14.78,14.0,57.1,220.45,0.0,0.0,0,,0.0234,none,0,1,0,0,0,2.1e-05,0,0,CDC_HbA1c_Poor_Control,Bundled_Payment
CLM0000003036,MBR00000188,Pharmacy,Denied,Electronic_EDI,2023-08-17,2023-08-17,2023-08-17,2023-08-30,Auto_Adjudicated,13,1699014308,1810068286,207RE0101X,Endocrinology,23,In_Network,OTHER,,00310075090,,1,Commercial,HMO,8,F,1.5853,50,COB,387.95,305.92,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0576,none,0,1,0,1,0,0.0,0,1,,Shared_Savings
CLM0000003037,MBR00000131,Medical_Institutional,Paid,Electronic_EDI,2023-11-01,2023-11-01,2023-11-04,2023-11-10,Clinical_Review,9,1710668368,1390802135,246ZN0300X,Neuropsychology,24,In_Network,Z00.00,OTHER|K57.30,revenue_code:0450,,0,Commercial,EPO,15,F,0.9228,,,45122.6,17139.39,13576.03,131.36,38.0,3394.01,27983.21,0.0,0.0,0,,0.1485,controlled_substance_high_volume,0,1,1,0,0,0.001257,0,0,,Shared_Savings
CLM0000003038,MBR00000104,Pharmacy,Paid,Electronic_EDI,2023-05-20,2023-05-20,2023-05-20,2023-06-14,Auto_Adjudicated,25,1113370285,1163639177,207RN0300X,Nephrology,65,In_Network,E78.5,R05.9,00071015523,,4,Medicaid_MCO,MCO,87,F,1.2297,,,474.08,325.86,325.86,0.0,0.0,0.0,148.22,0.0,0.0,0,,0.1179,none,0,1,0,0,0,3e-05,0,0,,Shared_Savings
CLM0000003039,MBR00000105,Medical_Professional,Paid,Electronic_EDI,2023-06-04,2023-06-04,2023-06-04,2023-06-25,Auto_Adjudicated,21,1461820376,1061149198,2084P0800X,Psychiatry,23,In_Network,Z00.01,OTHER|M79.3,97110,,0,Commercial,HMO,74,M,1.1834,,,567.66,355.21,0.0,355.21,0.0,0.0,212.45,0.0,0.0,0,,0.0691,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003040,MBR00000046,Pharmacy,Paid,Electronic_EDI,2023-09-19,2023-09-19,2023-09-19,2023-10-10,Auto_Adjudicated,21,1207676414,1867626800,207RN0300X,Nephrology,24,In_Network,Z12.11,I10|OTHER|F32.9,00169751112,,4,Commercial,HMO,76,F,0.9613,,,137.81,97.79,0.0,85.89,11.9,0.0,40.02,0.0,0.0,0,,0.1189,none,0,1,0,0,0,0.0,0,1,KED_ESRD_Patients,Bundled_Payment
CLM0000003041,MBR00000236,Medical_Professional,Paid,Electronic_EDI,2023-12-18,2023-12-18,2023-12-18,2024-01-11,Auto_Adjudicated,24,1177281088,1896197144,2086S0122X,Orthopedic Surgery,11,In_Network,Z00.00,,99232,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,416.85,331.67,328.67,0.0,3.0,0.0,85.18,0.0,0.0,0,,0.0281,none,0,1,0,0,0,3e-05,0,0,,P4P
CLM0000003042,MBR00000015,Pharmacy,Paid,Electronic_EDI,2023-10-11,2023-10-11,2023-10-11,2023-10-18,Auto_Adjudicated,7,1590338573,1884259357,207RN0300X,Nephrology,31,In_Network,OTHER,J20.9|M17.11|H52.4,00078043215,,3,Medicaid_MCO,MCO,43,F,0.3775,,,149.1,118.41,114.41,0.0,4.0,0.0,30.69,0.0,0.0,0,,0.0606,none,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000003043,MBR00000200,Medical_Professional,Denied,Electronic_EDI,2023-06-15,2023-06-15,2023-06-15,2023-07-15,Auto_Adjudicated,30,1171387771,1039962073,207RC0000X,Cardiovascular Disease,11,In_Network,K21.0,J44.1,71250,,0,Commercial,HDHP_HSA,29,M,0.8011,3,Coding_Error,1504.22,1145.23,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1452,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003044,MBR00000262,Pharmacy,Paid,Electronic_EDI,2023-08-03,2023-08-03,2023-08-03,2023-08-31,Auto_Adjudicated,28,1376791933,1151295616,101YP2500X,Psychologist Clinical,11,In_Network,N39.0,I10|Z00.01,00078043215,,2,Medicare_Advantage,PFFS,77,F,1.7452,,,196.89,111.51,85.35,0.82,4.0,21.34,85.38,0.0,0.0,0,,0.0574,none,0,1,0,0,0,8e-06,0,0,,Shared_Savings
CLM0000003045,MBR00000154,Medical_Professional,Paid,Electronic_EDI,2023-05-06,2023-05-06,2023-05-06,2023-05-20,Auto_Adjudicated,14,1513407277,1619587398,207RN0300X,Nephrology,22,In_Network,J45.20,M54.5,99397,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,416.35,182.79,140.75,6.85,0.0,35.19,233.56,0.0,0.0,0,,0.0259,none,0,1,0,0,0,1.3e-05,0,0,FUM_Follow_Up_ED_Mental_Health,Capitation
CLM0000003046,MBR00000022,Pharmacy,Paid,Electronic_EDI,2023-06-13,2023-06-13,2023-06-13,2023-06-20,Manual_Review,7,1344162462,1452088018,101YP2500X,Psychologist Clinical,11,In_Network,N40.0,OTHER,00310075090,,2,Medicare_Advantage,MA_HMO,34,M,0.9472,,,413.48,293.28,210.52,14.14,16.0,52.63,120.2,0.0,0.0,0,,0.1069,none,0,1,0,0,0,1.9e-05,0,0,,Capitation
CLM0000003047,MBR00000135,Pharmacy,Paid,Electronic_EDI,2023-05-20,2023-05-20,2023-05-20,2023-06-01,Auto_Adjudicated,12,1929402739,1847196500,225100000X,Physical Therapist,11,In_Network,M54.5,Z23|OTHER,00169751112,,2,Commercial,PPO,58,F,2.2702,,,63.68,46.28,7.12,0.37,37.0,1.78,17.4,0.0,0.0,0,,0.1256,none,0,1,0,1,0,1e-06,0,0,,Shared_Savings
CLM0000003048,MBR00000107,Medical_Professional,Paid,Provider_Portal,2023-02-05,2023-02-05,2023-02-05,2023-02-17,Auto_Adjudicated,12,1528602428,1054984734,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,,99396,,0,Medicare_Advantage,MA_PPO,44,M,1.0439,,,301.16,127.8,78.96,21.1,8.0,19.74,173.36,0.0,0.0,0,,0.0562,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000003049,MBR00000296,Medical_Professional,Paid,Electronic_EDI,2023-11-10,2023-11-10,2023-11-10,2023-12-10,Auto_Adjudicated,30,1705084901,1527857018,207R00000X,Internal Medicine,11,In_Network,M79.3,I25.10,99384,,0,Commercial,HMO,83,F,1.4969,,,497.17,358.17,63.07,248.33,31.0,15.77,139.0,0.0,0.0,0,,0.088,none,0,1,0,0,0,6e-06,0,0,,Capitation
CLM0000003050,MBR00000206,Medical_Professional,Paid,Electronic_EDI,2023-02-19,2023-02-19,2023-02-19,2023-02-28,Manual_Review,9,1435110996,1938465393,207V00000X,Obstetrics & Gynecology,32,Out_of_Network,E11.9,,90837,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,369.55,266.27,265.27,0.0,1.0,0.0,103.28,0.0,0.0,0,,0.1053,none,0,1,0,0,0,2.5e-05,1,0,,Shared_Savings
CLM0000003051,MBR00000212,Medical_Professional,Denied,Electronic_EDI,2023-04-07,2023-04-07,2023-04-07,2023-05-06,Auto_Adjudicated,29,1360102160,1884259357,207RN0300X,Nephrology,81,In_Network,Z00.00,,99395,,0,Commercial,HMO,57,F,2.5456,3,Duplicate,212.9,132.23,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1487,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003052,MBR00000158,Medical_Institutional,Paid,Electronic_EDI,2023-04-01,2023-04-01,2023-04-02,2023-04-08,Manual_Review,7,1334227781,1054984734,101YP2500X,Psychologist Clinical,24,In_Network,Z00.121,OTHER,revenue_code:0200,,0,Commercial,HMO,65,M,1.5361,,,35381.2,27530.31,21960.08,30.21,50.0,5490.02,7850.89,0.0,0.0,0,,0.1458,unbundling_pattern,0,1,1,1,0,0.002033,0,0,,FFS
CLM0000003053,MBR00000210,Medical_Professional,Paid,Electronic_EDI,2023-03-21,2023-03-21,2023-03-21,2023-04-18,Auto_Adjudicated,28,1393200616,1995553359,207R00000X,Internal Medicine,11,In_Network,I10,OTHER|Z12.11,11200,,0,Medicare_Advantage,SNP,49,M,0.6952,,,1894.11,1517.4,1196.98,3.17,18.0,299.25,376.71,0.0,0.0,0,,0.0375,none,0,1,0,1,0,0.000111,0,0,CCS_Cervical_Cancer_Screening,Bundled_Payment
CLM0000003054,MBR00000212,Medical_Professional,Denied,Electronic_EDI,2023-06-28,2023-06-28,2023-06-28,2023-07-26,Auto_Adjudicated,28,1699014308,1406199453,207RN0300X,Nephrology,22,In_Network,Z00.01,,90837,,0,Commercial,HMO,57,F,2.5456,256,Authorization,55.25,24.27,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1247,none,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000003055,MBR00000020,Medical_Professional,Paid,Electronic_EDI,2023-12-11,2023-12-11,2023-12-11,2023-12-30,Auto_Adjudicated,19,1006962798,1588993671,207RN0300X,Nephrology,11,In_Network,Z23,,99283,,0,Medicare_Advantage,MA_PPO,63,F,0.7119,,,509.86,223.27,166.11,9.63,6.0,41.53,286.59,0.0,0.0,0,,0.0679,none,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000003056,MBR00000069,Medical_Professional,Denied,Electronic_EDI,2023-04-28,2023-04-28,2023-04-28,2023-05-02,Manual_Review,4,1853233709,1765164601,207RN0300X,Nephrology,22,In_Network,OTHER,J20.9|C50.911|Z00.00,99214,,0,Medicare_Advantage,MA_PPO,2,M,0.5765,3,Medical_Necessity,87.56,34.7,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1126,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003057,MBR00000004,Medical_Professional,Paid,Electronic_EDI,2023-09-21,2023-09-21,2023-09-21,2023-10-10,Auto_Adjudicated,19,1167433253,1983760474,207V00000X,Obstetrics & Gynecology,11,In_Network,N40.0,I10,99213,,0,Medicare_Advantage,MA_PPO,68,M,1.23,,,271.3,219.77,144.67,30.93,8.0,36.17,51.53,0.0,0.0,0,,0.0897,none,0,1,0,0,0,1.3e-05,0,0,MPT_Annual_Monitoring,Capitation
CLM0000003058,MBR00000157,Pharmacy,Paid,Electronic_EDI,2023-09-21,2023-09-21,2023-09-21,2023-10-19,Auto_Adjudicated,28,1119160702,1356856197,246ZN0300X,Neuropsychology,22,In_Network,OTHER,L70.0|OTHER,59148001506,,1,Medicare_Advantage,MA_HMO,26,F,0.9164,,,59.4,25.68,2.15,5.99,17.0,0.54,33.72,0.0,0.0,0,,0.1298,none,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000003059,MBR00000264,Medical_Professional,Paid,Electronic_EDI,2023-10-02,2023-10-02,2023-10-02,2023-10-30,Auto_Adjudicated,28,1078527460,1049766043,207Q00000X,Family Medicine,11,In_Network,E78.5,,90837,,0,ACA_Marketplace,ACA_Bronze,12,F,0.5826,,,443.05,273.58,141.74,37.35,0.0,94.49,169.47,0.0,0.0,0,,0.1015,none,0,1,0,0,0,1.3e-05,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000003060,MBR00000184,Vision,Paid,Electronic_EDI,2023-08-12,2023-08-12,2023-08-12,2023-08-26,Auto_Adjudicated,14,1728728765,1140170394,2086S0122X,Orthopedic Surgery,81,Emergency,OTHER,M54.5,92002,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,295.09,116.98,114.98,0.0,2.0,0.0,178.11,0.0,0.0,0,,0.0942,none,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000003061,MBR00000154,Pharmacy,Paid,Electronic_EDI,2023-09-23,2023-09-23,2023-09-23,2023-10-08,Auto_Adjudicated,15,1873731689,1581533104,207RG0100X,Gastroenterology,11,In_Network,Z23,Z12.11|OTHER,00078043215,,1,Medicare_Advantage,MA_HMO,54,F,1.9463,,,275.22,177.73,135.1,8.86,0.0,33.77,97.49,0.0,0.0,0,,0.1271,none,0,1,0,0,0,1.3e-05,0,1,,FFS
CLM0000003062,MBR00000279,Medical_Institutional,Paid,Electronic_EDI,2023-10-01,2023-10-01,2023-10-02,2023-10-13,Auto_Adjudicated,12,1731980913,1287935251,2084P0800X,Psychiatry,21,In_Network,OTHER,,revenue_code:0210,871,0,Medicare_Advantage,MA_PPO,81,M,1.6817,,,43439.62,24393.99,19490.32,1.09,30.0,4872.58,19045.63,0.0,0.0,0,,0.1634,benford_violation|impossible_service_combo,0,1,1,0,0,0.001804,0,0,BPD_BP_Declined,Bundled_Payment
CLM0000003063,MBR00000054,Dental,Paid,Electronic_EDI,2023-09-03,2023-09-03,2023-09-03,2023-09-10,Auto_Adjudicated,7,1966338974,1188760037,207RN0300X,Nephrology,11,In_Network,E11.65,E78.5,D1110,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,,,156.14,72.84,53.62,4.81,1.0,13.41,83.3,41.47,6.64,0,,0.0146,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000003064,MBR00000023,Medical_Institutional,Partially_Paid,Paper,2023-07-20,2023-07-20,2023-07-22,2023-08-09,Auto_Adjudicated,20,1390393668,1179350099,207RN0300X,Nephrology,22,Out_of_Network,N18.3,,revenue_code:0200,,0,Medicare_Advantage,MA_PPO,87,M,1.084,18,Medical_Necessity,33971.45,23449.83,10249.65,9.08,29.0,2562.41,21121.31,0.0,0.0,0,,0.0569,none,0,1,1,1,0,0.000949,1,0,,Capitation
CLM0000003065,MBR00000277,Medical_Institutional,Denied,Provider_Portal,2023-02-02,2023-02-02,2023-02-06,2023-03-04,Auto_Adjudicated,30,1878057972,1040061910,207RN0300X,Nephrology,65,In_Network,OTHER,,revenue_code:0110,,0,Medicaid_MCO,MCO,30,M,1.8495,CO-45,Eligibility,9345.83,5465.38,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.135,duplicate_claim_indicator|phantom_billing_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003066,MBR00000274,Medical_Professional,Paid,Electronic_EDI,2023-07-02,2023-07-02,2023-07-02,2023-07-11,Auto_Adjudicated,9,1866366547,1774401124,207RE0101X,Endocrinology,11,In_Network,OTHER,OTHER,74177,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,543.18,322.95,254.79,4.47,0.0,63.7,220.23,0.0,0.0,0,,0.0452,none,0,1,0,0,0,2.4e-05,0,0,TRC_Transition_of_Care,P4P
CLM0000003067,MBR00000203,Pharmacy,Paid,Paper,2023-09-28,2023-09-28,2023-09-28,2023-10-24,Auto_Adjudicated,26,1901547390,1419347445,101YP2500X,Psychologist Clinical,11,In_Network,Z00.00,I10,00078043215,,1,Commercial,PPO,49,F,0.3046,,,701.56,584.94,407.36,55.74,20.0,101.84,116.62,0.0,0.0,0,,0.1297,none,0,1,0,0,0,3.8e-05,0,1,MMA_Medication_Management,FFS
CLM0000003068,MBR00000076,Medical_Professional,Paid,Electronic_EDI,2023-05-03,2023-05-03,2023-05-03,2023-05-06,Auto_Adjudicated,3,1256824549,1004714954,207RE0101X,Endocrinology,11,In_Network,E11.9,E78.5,99284,,0,Commercial,HMO,26,M,2.1785,,,426.67,216.49,125.58,27.52,32.0,31.39,210.18,0.0,0.0,0,,0.0852,none,0,1,0,0,0,1.2e-05,0,0,,Bundled_Payment
CLM0000003069,MBR00000293,Medical_Institutional,Paid,Electronic_EDI,2023-03-31,2023-03-31,2023-04-04,2023-04-02,Auto_Adjudicated,2,1453331651,1930040953,208600000X,Surgery General,22,Out_of_Network,F33.0,Z00.00,revenue_code:0210,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,2640.1,2234.43,1743.13,23.52,32.0,435.78,405.67,0.0,0.0,0,,0.2164,high_volume_same_code|unbundling_pattern,0,2,0,0,0,0.000161,0,0,,P4P
CLM0000003070,MBR00000225,Medical_Professional,Paid,Electronic_EDI,2023-08-02,2023-08-02,2023-08-02,2023-08-30,Auto_Adjudicated,28,1976304517,1320546364,101YP2500X,Psychologist Clinical,22,In_Network,Z00.00,Z00.01,83036,,0,Commercial,PPO,27,F,0.5948,,,1651.67,1270.69,798.68,239.34,33.0,199.67,380.98,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|unusual_service_frequency|temporal_clustering|impossible_service_combo|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,7.4e-05,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000003071,MBR00000200,Medical_Institutional,Paid,Electronic_EDI,2023-02-17,2023-02-17,2023-02-18,2023-02-21,Auto_Adjudicated,4,1190787795,1607833568,207Q00000X,Family Medicine,31,In_Network,M54.5,E78.5,revenue_code:0120,,0,Commercial,HDHP_HSA,29,M,0.8011,,,8115.18,3492.64,2743.48,63.3,0.0,685.87,4622.54,0.0,0.0,0,,0.1162,none,0,1,0,0,0,0.000254,0,0,MPT_Annual_Monitoring,Capitation
CLM0000003072,MBR00000069,Medical_Institutional,Paid,Electronic_EDI,2023-09-16,2023-09-16,2023-09-16,2023-09-29,Auto_Adjudicated,13,1747318937,1282319940,2084P0800X,Psychiatry,31,In_Network,E11.9,R05.9,revenue_code:0200,,0,Medicare_Advantage,MA_PPO,2,M,0.5765,,,10661.32,5607.63,4415.97,50.67,37.0,1103.99,5053.69,0.0,0.0,0,,0.0216,none,0,1,0,1,0,0.000409,0,0,IET_Initiation_Substance_Use,FFS
CLM0000003073,MBR00000158,Medical_Professional,Paid,Electronic_EDI,2023-12-19,2023-12-19,2023-12-19,2024-01-15,Auto_Adjudicated,27,1411619682,1623053477,246ZN0300X,Neuropsychology,11,In_Network,N39.0,,99204,,0,Commercial,HMO,65,M,1.5361,,,352.98,179.03,0.0,179.03,0.0,0.0,173.95,0.0,0.0,0,,0.0878,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003074,MBR00000245,Medical_Professional,Paid,Electronic_EDI,2023-06-23,2023-06-23,2023-06-23,2023-07-04,Auto_Adjudicated,11,1159268684,1049766043,207RN0300X,Nephrology,65,In_Network,J44.1,,99214,,0,Medicaid_MCO,MCO,60,F,0.7502,,,149.47,106.94,104.94,0.0,2.0,0.0,42.53,0.0,0.0,0,,0.0667,none,0,1,0,1,0,1e-05,0,0,,Shared_Savings
CLM0000003075,MBR00000259,Pharmacy,Paid,Electronic_EDI,2023-01-11,2023-01-11,2023-01-11,2023-01-21,Auto_Adjudicated,10,1207676414,1588993671,207RN0300X,Nephrology,31,In_Network,I10,E11.9|OTHER|J06.9,00078043215,,2,Medicare_Advantage,MA_PPO,5,M,1.6554,,,150.74,72.79,49.49,3.93,7.0,12.37,77.95,0.0,0.0,0,,0.1036,none,0,1,0,0,0,5e-06,0,1,,Shared_Savings
CLM0000003076,MBR00000169,Medical_Professional,Paid,Electronic_EDI,2023-04-08,2023-04-08,2023-04-08,2023-04-10,Manual_Review,2,1728728765,1542515060,207Q00000X,Family Medicine,23,In_Network,N39.0,,99231,,0,Commercial,EPO,30,M,1.4348,,,229.85,112.58,0.0,112.58,0.0,0.0,117.27,0.0,0.0,0,,0.1608,upcoding_pattern,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003077,MBR00000160,Medical_Professional,Paid,Electronic_EDI,2023-01-12,2023-01-12,2023-01-12,2023-02-02,Manual_Review,21,1451329728,1477113725,207RC0000X,Cardiovascular Disease,21,In_Network,Z12.11,M17.11,20610,,0,Commercial,HMO,73,M,1.9608,,,850.55,610.77,416.98,66.54,23.0,104.25,239.78,0.0,0.0,0,,0.0191,none,0,1,0,0,0,3.9e-05,0,0,COA_Care_Transitions,Bundled_Payment
CLM0000003078,MBR00000207,Medical_Professional,Denied,Electronic_EDI,2023-06-14,2023-06-14,2023-06-14,2023-06-24,Manual_Review,10,1484613641,1643323506,207RC0000X,Cardiovascular Disease,24,In_Network,OTHER,G47.33,71250,,0,Medicaid_MCO,MLTSS,11,F,1.6522,2,Medical_Necessity,626.34,462.1,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1081,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003079,MBR00000160,Vision,Paid,Electronic_EDI,2023-04-22,2023-04-22,2023-04-22,2023-04-26,Auto_Adjudicated,4,1567711165,1330485436,225100000X,Physical Therapist,22,In_Network,Z00.00,I10|E13.9,92004,,0,Commercial,HMO,73,M,1.9608,,,447.5,321.04,54.46,229.97,23.0,13.61,126.46,0.0,0.0,0,,0.0797,diagnosis_procedure_mismatch,0,1,0,1,0,5e-06,0,0,CBP_Controlling_BP,FFS
CLM0000003080,MBR00000132,Pharmacy,Paid,Electronic_EDI,2023-10-05,2023-10-05,2023-10-05,2023-10-20,Auto_Adjudicated,15,1637260822,1553094822,207V00000X,Obstetrics & Gynecology,21,In_Network,OTHER,Z00.01|OTHER,16590051660,,1,Medicare_Advantage,MA_PPO,84,F,1.3018,,,221.37,132.39,100.19,1.16,6.0,25.05,88.98,0.0,0.0,0,,0.0188,none,0,1,0,0,0,9e-06,0,1,BCS_Breast_Cancer_Screening,Capitation
CLM0000003081,MBR00000026,Medical_Institutional,Paid,Electronic_EDI,2023-10-31,2023-10-31,2023-10-31,2023-11-06,Manual_Review,6,1943769986,1469642907,207RE0101X,Endocrinology,11,In_Network,OTHER,F41.1|Z00.01,revenue_code:0200,,0,Medicaid_MCO,MCO,17,M,1.0686,,,20652.93,14909.02,14902.02,0.0,7.0,0.0,5743.91,0.0,0.0,0,,0.1448,none,0,1,1,0,0,0.001379,0,0,,FFS
CLM0000003082,MBR00000038,Pharmacy,Paid,Electronic_EDI,2023-06-06,2023-06-06,2023-06-06,2023-07-02,Manual_Review,26,1534538584,1390802135,246ZN0300X,Neuropsychology,22,In_Network,J20.9,C50.911,00069420020,,1,Commercial,EPO,46,M,1.1295,,,216.87,140.0,0.0,140.0,0.0,0.0,76.87,0.0,0.0,0,,0.0238,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000003083,MBR00000224,Pharmacy,Paid,Electronic_EDI,2023-12-18,2023-12-18,2023-12-18,2024-01-10,Auto_Adjudicated,23,1054449469,1098360555,207RP1001X,Pulmonary Disease,22,In_Network,K57.30,,00169751112,,5,Medicaid_MCO,MCO,86,F,1.3289,,,71.76,55.88,52.88,0.0,3.0,0.0,15.88,0.0,0.0,0,,0.1098,none,0,1,0,0,0,5e-06,0,0,CBP_Controlling_BP,Bundled_Payment
CLM0000003084,MBR00000008,Pharmacy,Paid,Electronic_EDI,2023-06-11,2023-06-11,2023-06-11,2023-07-11,Manual_Review,30,1518661623,1415734567,207RN0300X,Nephrology,11,In_Network,I10,Z00.00|OTHER,00085163102,,1,Medicaid_MCO,MCO,74,M,0.8375,,,133.38,93.85,92.85,0.0,1.0,0.0,39.53,0.0,0.0,0,,0.0334,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000003085,MBR00000014,Pharmacy,Paid,Electronic_EDI,2023-02-12,2023-02-12,2023-02-12,2023-03-14,Auto_Adjudicated,30,1124477249,1764064254,207RE0101X,Endocrinology,65,In_Network,J06.9,F32.9|Z12.11,00310075090,,1,Commercial,HMO,77,M,2.8513,,,105.42,69.21,0.0,69.21,0.0,0.0,36.21,0.0,0.0,0,,0.0744,none,0,1,0,0,0,0.0,0,1,FLU_Flu_Vaccination,FFS
CLM0000003086,MBR00000274,Dental,Paid,Provider_Portal,2023-11-23,2023-11-23,2023-11-23,2023-12-19,Auto_Adjudicated,26,1928139578,1447186817,207RE0101X,Endocrinology,11,In_Network,I10,M54.5|K21.0|OTHER,D3310,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,551.85,363.92,260.68,38.07,0.0,65.17,187.93,0.0,0.0,0,,0.0655,none,0,1,0,0,0,2.4e-05,0,0,,Shared_Savings
CLM0000003087,MBR00000208,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-05-22,2023-05-22,2023-05-24,2023-06-07,Clinical_Review,16,1007266616,1643673796,207RG0100X,Gastroenterology,11,In_Network,I25.10,N39.0|M79.3,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,16,Medical_Necessity,25822.46,12820.19,7453.41,1.42,54.0,1863.35,16450.28,0.0,0.0,0,,0.1273,none,0,1,1,0,0,0.00069,0,0,W30_Well_Child_Visit,Bundled_Payment
CLM0000003088,MBR00000002,Medical_Professional,Paid,Electronic_EDI,2023-11-14,2023-11-14,2023-11-14,2023-11-20,Auto_Adjudicated,6,1905691248,1004714954,207RG0100X,Gastroenterology,21,In_Network,OTHER,Z00.00,99222,,0,Commercial,PPO,42,F,0.9012,,,268.77,173.58,92.57,39.87,18.0,23.14,95.19,0.0,0.0,0,,0.0547,none,0,1,0,0,0,9e-06,0,0,COA_Care_Transitions,Capitation
CLM0000003089,MBR00000099,Medical_Professional,Paid,Electronic_EDI,2023-09-21,2023-09-21,2023-09-21,2023-09-23,Auto_Adjudicated,2,1555292468,1623053477,207RP1001X,Pulmonary Disease,23,In_Network,Z00.00,,90837,,0,Commercial,HMO,10,F,0.7843,,,719.57,602.67,360.75,136.73,15.0,90.19,116.9,0.0,0.0,0,,0.0227,none,0,1,0,0,0,3.3e-05,0,0,,Bundled_Payment
CLM0000003090,MBR00000224,Medical_Professional,Denied,Provider_Portal,2023-12-04,2023-12-04,2023-12-04,2023-12-07,Manual_Review,3,1175252466,1318978078,208600000X,Surgery General,11,Out_of_Network,F41.1,OTHER|N39.0,99212,,0,Medicaid_MCO,MCO,86,F,1.3289,1,Network,127.11,104.63,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1409,none,0,1,0,0,0,0.0,1,0,,FFS
CLM0000003091,MBR00000132,Medical_Institutional,Paid,Electronic_EDI,2023-08-20,2023-08-20,2023-08-20,2023-08-28,Auto_Adjudicated,8,1505049857,1318978078,2086S0122X,Orthopedic Surgery,23,In_Network,G43.909,N39.0,revenue_code:0100,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,,,8449.58,3467.5,2754.26,0.67,24.0,688.57,4982.08,0.0,0.0,0,,0.072,unusual_service_frequency,0,1,0,1,0,0.000255,0,0,,Shared_Savings
CLM0000003092,MBR00000144,Behavioral_Health,Denied,Electronic_EDI,2023-08-01,2023-08-01,2023-08-01,2023-08-28,Auto_Adjudicated,27,1231231881,1151295616,225100000X,Physical Therapist,21,In_Network,K21.0,,82947,,0,Commercial,HDHP_HSA,56,F,2.5926,18,COB,62.97,34.44,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0314,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003093,MBR00000142,Pharmacy,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-25,2023-04-01,Manual_Review,7,1229304423,1358873132,207V00000X,Obstetrics & Gynecology,11,In_Network,J20.9,E78.5,59148001506,,3,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,343.87,159.43,0.0,159.43,0.0,0.0,184.44,0.0,0.0,0,,0.1751,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003094,MBR00000061,Pharmacy,Denied,Electronic_EDI,2023-04-11,2023-04-11,2023-04-11,2023-04-14,Auto_Adjudicated,3,1064567615,1540743888,207RP1001X,Pulmonary Disease,11,In_Network,F32.9,Z00.00|J06.9|OTHER,00085163102,,1,Commercial,PPO,66,M,2.3575,18,Medical_Necessity,1070.74,788.21,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0805,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003095,MBR00000212,Pharmacy,Denied,Electronic_EDI,2023-04-29,2023-04-29,2023-04-29,2023-05-28,Auto_Adjudicated,29,1399379863,1498781755,207RE0101X,Endocrinology,21,In_Network,J44.1,,00071015523,,3,Commercial,HMO,57,F,2.5456,4,Duplicate,117.5,74.03,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0002,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003096,MBR00000031,Dental,Paid,Electronic_EDI,2023-04-22,2023-04-22,2023-04-22,2023-05-06,Auto_Adjudicated,14,1026612378,1576271272,208600000X,Surgery General,22,Out_of_Network,Z00.00,J20.9,D1110,,0,Commercial,PPO,71,M,0.6746,,,401.51,318.63,212.68,36.78,16.0,53.17,82.88,0.0,0.0,0,,0.0387,none,0,1,0,0,0,2e-05,0,0,COA_Care_Transitions,P4P
CLM0000003097,MBR00000156,Pharmacy,Paid,Electronic_EDI,2023-08-02,2023-08-02,2023-08-02,2023-08-15,Auto_Adjudicated,13,1181941909,1419347445,207Q00000X,Family Medicine,11,In_Network,J20.9,E78.5,16590051660,,1,Medicare_Advantage,MA_PPO,66,F,1.8933,,,345.23,143.0,97.93,7.59,13.0,24.48,202.23,71.1,16.03,1,Provider Impersonation,1.0,outlier_billing_amount|geographic_mismatch|temporal_clustering|high_volume_same_code|benford_violation|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|phantom_billing_indicator|npi_mismatch,1,5,0,0,0,9e-06,0,0,,FFS
CLM0000003098,MBR00000054,Medical_Professional,Denied,Electronic_EDI,2023-11-09,2023-11-09,2023-11-09,2023-11-19,Auto_Adjudicated,10,1098094939,1133410177,208600000X,Surgery General,22,In_Network,M17.11,,74178,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,4,Duplicate,592.85,391.6,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1195,unbundling_pattern,0,1,0,0,0,0.0,0,0,BPD_BP_Declined,FFS
CLM0000003099,MBR00000014,Medical_Institutional,Paid,Electronic_EDI,2023-01-13,2023-01-13,2023-01-16,2023-02-11,Auto_Adjudicated,29,1026612378,1616762819,246ZN0300X,Neuropsychology,22,Out_of_Network,I10,J44.1|J06.9,revenue_code:0110,,0,Commercial,HMO,77,M,2.8513,,,18281.01,10827.96,8605.17,36.49,35.0,2151.29,7453.05,0.0,0.0,0,,0.0954,none,0,1,1,0,0,0.000796,0,0,,Capitation
CLM0000003100,MBR00000045,Medical_Institutional,Paid,Electronic_EDI,2023-08-11,2023-08-11,2023-08-11,2023-08-22,Auto_Adjudicated,11,1263063839,1049766043,207RG0100X,Gastroenterology,81,Out_of_Network,N39.0,E11.9|K29.70,revenue_code:0450,,0,Commercial,HMO,78,F,1.0658,,,13971.29,8983.17,7123.86,22.35,56.0,1780.96,4988.12,0.0,0.0,0,,0.0585,none,0,1,1,1,0,0.000659,0,0,FUM_Follow_Up_ED_Mental_Health,Capitation
CLM0000003101,MBR00000262,Medical_Professional,Denied,Provider_Portal,2023-09-30,2023-09-30,2023-09-30,2023-10-26,Auto_Adjudicated,26,1356562955,1164525386,225100000X,Physical Therapist,23,In_Network,F32.9,,99222,,0,Medicare_Advantage,PFFS,77,F,1.7452,3,Duplicate,657.16,498.24,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,DME Fraud,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|temporal_clustering|high_volume_same_code|benford_violation|impossible_service_combo|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|npi_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.0,0,0,,FFS
CLM0000003102,MBR00000055,Medical_Professional,Denied,Electronic_EDI,2023-06-09,2023-06-09,2023-06-09,2023-07-09,Auto_Adjudicated,30,1597245892,1985590322,2084P0800X,Psychiatry,11,In_Network,J44.1,I10|I25.10,43239,,0,Commercial,PPO,68,F,1.2896,50,Coding_Error,367.12,283.59,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0814,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003103,MBR00000087,Medical_Professional,Paid,Electronic_EDI,2023-04-09,2023-04-09,2023-04-09,2023-04-23,Auto_Adjudicated,14,1097702209,1662516615,207RN0300X,Nephrology,22,In_Network,E11.65,H52.4,99397,,0,Medicaid_MCO,MCO,70,F,0.9232,,,392.6,137.44,136.44,0.0,1.0,0.0,255.16,0.0,0.0,0,,0.1664,diagnosis_procedure_mismatch,0,1,0,0,0,1.3e-05,0,0,POD_Persistence_of_Beta_Blocker,Capitation
CLM0000003104,MBR00000043,Medical_Professional,Paid,Electronic_EDI,2023-06-05,2023-06-05,2023-06-05,2023-06-27,Clinical_Review,22,1732726112,1133410177,207RG0100X,Gastroenterology,11,In_Network,Z23,Z00.00,99212,,0,Commercial,PPO,68,F,0.4593,,,675.18,524.81,176.47,294.22,10.0,44.12,150.37,0.0,0.0,0,,0.1739,temporal_clustering,0,1,0,1,0,1.6e-05,0,0,,FFS
CLM0000003105,MBR00000215,Medical_Professional,Paid,Electronic_EDI,2023-10-25,2023-10-25,2023-10-25,2023-10-26,Auto_Adjudicated,1,1636337876,1025886739,207RG0100X,Gastroenterology,22,In_Network,OTHER,M47.816|Z00.00,74177,,0,ACA_Marketplace,ACA_Silver,69,M,0.8895,,,159.68,134.16,0.0,134.16,0.0,0.0,25.52,0.0,0.0,0,,0.0809,upcoding_pattern,0,1,0,0,0,0.0,0,0,TRC_Transition_of_Care,P4P
CLM0000003106,MBR00000139,Dental,Paid,Electronic_EDI,2023-11-25,2023-11-25,2023-11-25,2023-12-19,Manual_Review,24,1526973051,1419347445,207RN0300X,Nephrology,21,In_Network,J06.9,OTHER|E78.5,D0120,,0,Commercial,PPO,74,M,1.7701,,,96.16,70.5,0.0,70.5,0.0,0.0,25.66,0.0,0.0,0,,0.1203,service_date_weekend,0,1,0,0,0,0.0,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000003107,MBR00000286,Medical_Professional,Paid,Electronic_EDI,2023-09-03,2023-09-03,2023-09-03,2023-10-03,Auto_Adjudicated,30,1699074676,1368666316,2086S0122X,Orthopedic Surgery,65,In_Network,F32.9,,74177,,0,Medicare_Advantage,PFFS,40,F,1.2751,,,277.77,124.49,86.03,13.95,3.0,21.51,153.28,0.0,0.0,0,,0.1217,none,0,1,0,1,0,8e-06,0,0,AWV_Annual_Wellness_Visit,Shared_Savings
CLM0000003108,MBR00000197,Pharmacy,Paid,Electronic_EDI,2023-06-24,2023-06-24,2023-06-24,2023-06-30,Clinical_Review,6,1117755591,1983760474,2084P0800X,Psychiatry,22,In_Network,Z23,I10,59148001506,,1,Medicare_Advantage,MA_HMO,59,M,1.1414,,,126.47,63.03,38.57,1.81,13.0,9.64,63.44,0.0,0.0,0,,0.1019,none,0,1,0,0,0,4e-06,0,1,,FFS
CLM0000003109,MBR00000162,Medical_Professional,Paid,Provider_Portal,2023-08-20,2023-08-20,2023-08-20,2023-08-21,Manual_Review,1,1475070784,1391074619,207V00000X,Obstetrics & Gynecology,31,In_Network,F41.1,I10|K21.0,97110,,0,Medicaid_MCO,MLTSS,84,F,1.324,,,540.98,216.02,215.02,0.0,1.0,0.0,324.96,0.0,0.0,0,,0.0055,none,0,1,0,0,0,2e-05,0,0,,FFS
CLM0000003110,MBR00000196,Behavioral_Health,Paid,Electronic_EDI,2023-09-01,2023-09-01,2023-09-01,2023-09-03,Auto_Adjudicated,2,1360102160,1318978078,2084P0800X,Psychiatry,22,In_Network,OTHER,E78.5|F32.9,99213,,0,Commercial,PPO,16,F,1.6015,,,394.51,333.18,212.62,44.41,23.0,53.15,61.33,0.0,0.0,1,Duplicate Billing,1.0,outlier_billing_amount|geographic_mismatch|provider_specialty_mismatch|benford_violation|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,2e-05,0,0,,FFS
CLM0000003111,MBR00000012,Pharmacy,Paid,Electronic_EDI,2023-10-03,2023-10-03,2023-10-03,2023-10-29,Manual_Review,26,1677021292,1662516615,207RG0100X,Gastroenterology,21,In_Network,C50.911,OTHER|Z00.01,00003014960,,3,Commercial,HMO,84,M,1.3904,,,161.1,89.77,31.66,22.19,28.0,7.92,71.33,0.0,0.0,0,,0.1208,none,0,1,0,0,0,3e-06,0,1,COL_Colorectal_Cancer_Screening,P4P
CLM0000003112,MBR00000288,Dental,Paid,Paper,2023-02-21,2023-02-21,2023-02-21,2023-03-01,Auto_Adjudicated,8,1950560596,1489434038,246ZN0300X,Neuropsychology,11,Out_of_Network,Z00.00,E78.5|Z00.01|Z79.4,D2140,,0,Commercial,HMO,36,M,0.8408,,,750.87,601.65,347.99,132.67,34.0,87.0,149.22,0.0,0.0,0,,0.0799,none,0,1,0,0,0,3.2e-05,1,0,,FFS
CLM0000003113,MBR00000290,Medical_Institutional,Paid,Electronic_EDI,2023-01-27,2023-01-27,2023-01-29,2023-02-09,Auto_Adjudicated,13,1243052462,1151295616,207Q00000X,Family Medicine,11,In_Network,F41.1,,revenue_code:0360,,0,Commercial,PPO,9,M,0.5261,,,5215.63,3833.04,2796.4,279.53,58.0,699.1,1382.59,0.0,0.0,0,,0.1229,none,0,1,0,0,0,0.000259,0,0,,Bundled_Payment
CLM0000003114,MBR00000086,Medical_Institutional,Paid,Electronic_EDI,2023-05-05,2023-05-05,2023-05-08,2023-05-16,Auto_Adjudicated,11,1825861601,1867389043,207RP1001X,Pulmonary Disease,24,In_Network,I10,F33.0,revenue_code:0120,,0,Medicare_Advantage,MA_PPO,8,M,0.5427,,,70855.03,37359.07,29866.71,2.69,23.0,7466.68,33495.96,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|benford_violation|impossible_service_combo|billing_spike_recent|upcoding_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,1,0,0,0.002764,0,0,,P4P
CLM0000003115,MBR00000187,Medical_Professional,Paid,Electronic_EDI,2023-04-04,2023-04-04,2023-04-04,2023-04-14,Auto_Adjudicated,10,1477762002,1319611206,208600000X,Surgery General,32,In_Network,L70.0,OTHER,99285,,0,Medicaid_MCO,MCO,36,F,1.191,,,134.22,64.37,61.37,0.0,3.0,0.0,69.85,0.0,0.0,0,,0.089,controlled_substance_high_volume,0,1,0,0,0,6e-06,0,0,IET_Initiation_Substance_Use,Capitation
CLM0000003116,MBR00000061,Medical_Institutional,Paid,Electronic_EDI,2023-08-09,2023-08-09,2023-08-11,2023-08-14,Auto_Adjudicated,5,1269720844,1187669363,207R00000X,Internal Medicine,21,In_Network,OTHER,L70.0,revenue_code:0210,683,0,Commercial,PPO,66,M,2.3575,,,2075.33,1198.91,886.67,56.57,34.0,221.67,876.42,0.0,0.0,0,,0.0643,none,0,1,0,1,0,8.2e-05,0,0,,FFS
CLM0000003117,MBR00000166,Pharmacy,Paid,Paper,2023-07-07,2023-07-07,2023-07-07,2023-07-20,Manual_Review,13,1736809698,1296566243,207RE0101X,Endocrinology,22,In_Network,F33.0,Z87.891|I10,00069420020,,3,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,208.82,108.02,0.0,85.69,22.33,0.0,100.8,0.0,0.0,0,,0.0519,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000003118,MBR00000227,Medical_Professional,Denied,Electronic_EDI,2023-11-26,2023-11-26,2023-11-26,2023-12-24,Auto_Adjudicated,28,1419204214,1978943761,246ZN0300X,Neuropsychology,11,In_Network,Z12.11,OTHER,99397,,0,Medicare_Advantage,MA_PPO,2,F,0.7835,1,COB,386.91,243.11,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0128,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003119,MBR00000285,Medical_Professional,Paid,Provider_Portal,2023-10-06,2023-10-06,2023-10-06,2023-10-17,Auto_Adjudicated,11,1950560596,1789540567,2084P0800X,Psychiatry,22,In_Network,Z00.00,,99283,,0,Commercial,HDHP_HSA,56,M,0.9226,,,285.12,104.01,0.0,104.01,0.0,0.0,181.11,0.0,0.0,0,,0.1622,upcoding_pattern,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003120,MBR00000106,Dental,Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-23,2023-03-20,Auto_Adjudicated,25,1898865801,1896197144,207R00000X,Internal Medicine,32,In_Network,M54.5,Z00.00|N40.0,D2140,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,97.75,64.67,35.17,14.7,6.0,8.79,33.08,0.0,0.0,0,,0.1044,none,0,1,0,0,0,3e-06,0,0,,FFS
CLM0000003121,MBR00000206,Medical_Professional,Paid,Electronic_EDI,2023-11-01,2023-11-01,2023-11-01,2023-11-22,Auto_Adjudicated,21,1324272690,1402472115,207RN0300X,Nephrology,11,Out_of_Network,N39.0,,99202,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,120.47,95.62,94.62,0.0,1.0,0.0,24.85,0.0,0.0,0,,0.1014,duplicate_claim_indicator,0,1,0,0,0,9e-06,1,0,,Capitation
CLM0000003122,MBR00000212,Pharmacy,Paid,Electronic_EDI,2023-10-04,2023-10-04,2023-10-04,2023-10-28,Auto_Adjudicated,24,1397401856,1148612764,207RE0101X,Endocrinology,11,In_Network,OTHER,,50458085930,,1,Commercial,HMO,57,F,2.5456,,,119.88,55.44,0.0,55.44,0.0,0.0,64.44,0.0,0.0,0,,0.0648,none,0,1,0,1,0,0.0,0,1,,FFS
CLM0000003123,MBR00000068,Medical_Professional,Partially_Paid,Provider_Portal,2023-05-18,2023-05-18,2023-05-18,2023-06-05,Clinical_Review,18,1399379863,1408846353,2084P0800X,Psychiatry,23,In_Network,M17.11,OTHER|E11.9,43239,,0,Medicare_Advantage,MA_HMO,28,F,0.8494,18,Medical_Necessity,869.57,453.86,214.49,17.52,8.0,53.62,575.94,0.0,0.0,0,,0.1396,none,0,1,0,0,0,2e-05,0,0,,Bundled_Payment
CLM0000003124,MBR00000187,Medical_Professional,Paid,Provider_Portal,2023-01-21,2023-01-21,2023-01-21,2023-02-02,Auto_Adjudicated,12,1426424205,1607833568,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,M54.5|E11.9,99214,,0,Medicaid_MCO,MCO,36,F,1.191,,,234.52,189.04,186.04,0.0,3.0,0.0,45.48,0.0,0.0,0,,0.0765,upcoding_pattern,0,1,0,0,0,1.7e-05,0,0,,Bundled_Payment
CLM0000003125,MBR00000195,Medical_Professional,Paid,Electronic_EDI,2023-10-12,2023-10-12,2023-10-12,2023-10-20,Auto_Adjudicated,8,1871348663,1694343357,207RN0300X,Nephrology,11,In_Network,Z12.11,OTHER,33510,,0,Commercial,PPO,13,F,0.5967,,,1704.73,1190.5,880.36,77.05,13.0,220.09,514.23,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|impossible_service_combo|service_date_weekend|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,8.1e-05,0,0,,Shared_Savings
CLM0000003126,MBR00000224,Medical_Institutional,Paid,Paper,2023-03-11,2023-03-11,2023-03-14,2023-03-20,Auto_Adjudicated,9,1068197532,1164525386,225100000X,Physical Therapist,21,In_Network,Z00.00,Z23,revenue_code:0370,682,0,Medicaid_MCO,MCO,86,F,1.3289,,,27741.73,9897.93,9888.93,0.0,9.0,0.0,17843.8,6843.86,2234.16,0,,0.1344,npi_mismatch,0,1,1,0,0,0.000915,0,0,,Bundled_Payment
CLM0000003127,MBR00000300,Pharmacy,Partially_Paid,Electronic_EDI,2023-03-21,2023-03-21,2023-03-21,2023-04-06,Auto_Adjudicated,16,1602370875,1588993671,101YP2500X,Psychologist Clinical,23,In_Network,Z79.4,J06.9,59148001506,,2,Commercial,PPO,64,F,1.0393,97,Medical_Necessity,71.11,39.49,0.0,28.58,0.0,0.0,42.53,0.0,0.0,0,,0.0784,service_date_weekend,0,1,0,0,0,0.0,0,1,,FFS
CLM0000003128,MBR00000012,Dental,Paid,Electronic_EDI,2023-06-18,2023-06-18,2023-06-18,2023-07-01,Auto_Adjudicated,13,1850379080,1330485436,207R00000X,Internal Medicine,81,In_Network,E11.9,,D1110,,0,Commercial,HMO,84,M,1.3904,,,369.01,151.54,69.76,36.35,28.0,17.44,217.47,47.65,12.45,0,,0.0641,duplicate_claim_indicator,0,1,0,0,0,6e-06,0,0,,Capitation
CLM0000003129,MBR00000061,Medical_Professional,Paid,Electronic_EDI,2023-01-30,2023-01-30,2023-01-30,2023-02-12,Auto_Adjudicated,13,1468401280,1179350099,225100000X,Physical Therapist,32,In_Network,E11.9,M17.11,27447,,0,Commercial,PPO,66,M,2.3575,,,49277.83,23053.29,18391.45,50.97,13.0,4597.86,26224.54,0.0,0.0,0,,0.1794,outlier_billing_amount|upcoding_pattern,0,1,1,0,0,0.001702,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000003130,MBR00000045,Medical_Professional,Paid,Provider_Portal,2023-05-24,2023-05-24,2023-05-24,2023-06-05,Clinical_Review,12,1664872214,1128148362,207RP1001X,Pulmonary Disease,22,In_Network,Z00.00,,97035,,0,Commercial,HMO,78,F,1.0658,,,734.44,538.93,402.9,3.3,32.0,100.73,195.51,0.0,0.0,1,DME Fraud,1.0,outlier_billing_amount|high_volume_same_code|benford_violation|impossible_service_combo|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|npi_mismatch|high_oop_waiver,1,5,0,0,0,3.7e-05,0,0,KED_ESRD_Patients,Capitation
CLM0000003131,MBR00000049,Pharmacy,Paid,Provider_Portal,2023-03-30,2023-03-30,2023-03-30,2023-04-27,Auto_Adjudicated,28,1147452455,1554490060,246ZN0300X,Neuropsychology,24,In_Network,N39.0,L70.0|G47.33,50458085930,,1,Medicare_Advantage,PFFS,67,M,0.978,,,192.86,75.94,35.49,27.58,4.0,8.87,116.92,0.0,0.0,0,,0.0465,none,0,1,0,0,0,3e-06,0,1,,Shared_Savings
CLM0000003132,MBR00000141,Medical_Professional,Paid,Electronic_EDI,2023-01-20,2023-01-20,2023-01-20,2023-02-09,Auto_Adjudicated,20,1597649716,1354265777,207R00000X,Internal Medicine,22,In_Network,E78.5,C50.911|OTHER,99385,,0,Commercial,HMO,47,F,0.6724,,,165.04,85.17,8.06,49.1,26.0,2.01,79.87,0.0,0.0,0,,0.1303,none,0,1,0,0,0,1e-06,0,0,,Capitation
CLM0000003133,MBR00000265,Medical_Professional,Paid,Electronic_EDI,2023-11-21,2023-11-21,2023-11-21,2023-12-18,Clinical_Review,27,1679629515,1358873132,246ZN0300X,Neuropsychology,22,In_Network,OTHER,,27447,,0,Commercial,PPO,84,F,0.7969,,,7967.39,3421.62,2541.79,219.38,25.0,635.45,4545.77,0.0,0.0,0,,0.1577,billing_spike_recent,0,1,0,0,0,0.000235,0,0,,Bundled_Payment
CLM0000003134,MBR00000140,Medical_Institutional,Denied,Electronic_EDI,2023-04-04,2023-04-04,2023-04-05,2023-05-02,Auto_Adjudicated,28,1119160702,1352413270,207RN0300X,Nephrology,11,In_Network,OTHER,,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,7,M,1.3997,1,Timely_Filing,8780.02,6447.61,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0205,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003135,MBR00000198,Pharmacy,Denied,Electronic_EDI,2023-07-15,2023-07-15,2023-07-15,2023-08-03,Clinical_Review,19,1952322604,1287472731,2084P0800X,Psychiatry,11,In_Network,F10.10,,00169751112,,1,Medicaid_MCO,MCO,81,F,1.4199,CO-45,COB,148.07,80.57,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1436,high_volume_same_code,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003136,MBR00000119,Medical_Professional,Paid,Electronic_EDI,2023-10-21,2023-10-21,2023-10-21,2023-10-24,Manual_Review,3,1484613641,1287472731,225100000X,Physical Therapist,22,In_Network,J06.9,E78.5|E11.9|R05.9,99233,,0,Commercial,POS,42,M,0.4987,,,407.7,240.97,0.0,240.97,0.0,0.0,166.73,0.0,0.0,0,,0.0782,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003137,MBR00000102,Medical_Professional,Paid,Electronic_EDI,2023-06-22,2023-06-22,2023-06-22,2023-07-21,Auto_Adjudicated,29,1706476585,1510751265,207RG0100X,Gastroenterology,81,In_Network,Z00.00,I10|M79.3,12001,,0,Commercial,POS,68,M,1.6864,,,346.98,144.99,31.7,73.36,32.0,7.93,201.99,0.0,0.0,0,,0.0102,none,0,1,0,0,0,3e-06,0,0,,FFS
CLM0000003138,MBR00000249,Vision,Paid,Electronic_EDI,2023-04-16,2023-04-16,2023-04-16,2023-05-01,Auto_Adjudicated,15,1506426842,1694343357,2086S0122X,Orthopedic Surgery,22,In_Network,I50.9,OTHER|F32.9,V2103,,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,284.3,228.53,0.0,228.53,0.0,0.0,55.77,0.0,0.0,0,,0.1315,none,0,1,0,0,0,0.0,0,0,IET_Initiation_Substance_Use,P4P
CLM0000003139,MBR00000195,Vision,Denied,Electronic_EDI,2023-09-24,2023-09-24,2023-09-24,2023-10-06,Auto_Adjudicated,12,1881358103,1867389043,207RG0100X,Gastroenterology,71,In_Network,Z00.00,E11.9,V2103,,0,Commercial,PPO,13,F,0.5967,50,Timely_Filing,519.02,406.99,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1214,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003140,MBR00000111,Pharmacy,Partially_Paid,Electronic_EDI,2023-09-06,2023-09-06,2023-09-06,2023-09-19,Manual_Review,13,1207676414,1320546364,2084P0800X,Psychiatry,11,In_Network,K21.0,OTHER|Z12.11,59148001506,,3,Medicare_Advantage,MA_PPO,44,M,0.7462,96,Medical_Necessity,460.73,343.01,162.65,11.55,16.0,40.66,229.87,0.0,0.0,0,,0.0226,none,0,1,0,0,0,1.5e-05,0,0,SPC_Statin_Therapy,FFS
CLM0000003141,MBR00000276,Pharmacy,Denied,Provider_Portal,2023-01-04,2023-01-04,2023-01-04,2023-01-07,Auto_Adjudicated,3,1091271799,1209882852,101YP2500X,Psychologist Clinical,11,In_Network,Z00.00,Z00.01,00078043215,,3,Commercial,POS,38,M,0.8085,16,Timely_Filing,164.81,126.21,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0672,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003142,MBR00000154,Vision,Paid,Electronic_EDI,2023-10-22,2023-10-22,2023-10-22,2023-11-11,Auto_Adjudicated,20,1252009836,1187669363,207R00000X,Internal Medicine,81,In_Network,E11.65,,V2115,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,307.74,260.9,208.16,0.7,0.0,52.04,46.84,0.0,0.0,0,,0.2053,diagnosis_procedure_mismatch,0,2,0,0,0,1.9e-05,0,0,,Capitation
CLM0000003143,MBR00000059,Medical_Institutional,Paid,Electronic_EDI,2023-02-12,2023-02-12,2023-02-15,2023-02-14,Auto_Adjudicated,2,1658094898,1986847322,207V00000X,Obstetrics & Gynecology,21,In_Network,E11.65,Z23,revenue_code:0250,439,0,Medicare_Advantage,SNP,12,F,1.266,,,5313.19,3291.76,2583.75,29.07,33.0,645.94,2021.43,0.0,0.0,0,,0.1027,none,0,1,0,0,0,0.000239,0,0,,Shared_Savings
CLM0000003144,MBR00000149,Pharmacy,Paid,Paper,2023-09-22,2023-09-22,2023-09-22,2023-10-14,Manual_Review,22,1331903993,1738617370,207Q00000X,Family Medicine,22,In_Network,N39.0,Z00.01,00071012831,,2,Commercial,PPO,42,F,0.5458,,,226.79,177.8,76.18,50.58,32.0,19.04,48.99,0.0,0.0,0,,0.1146,none,0,1,0,0,0,7e-06,0,1,LCS_Lung_Cancer_Screening,P4P
CLM0000003145,MBR00000200,Medical_Institutional,Paid,Electronic_EDI,2023-02-05,2023-02-05,2023-02-07,2023-03-03,Auto_Adjudicated,26,1210349885,1391074619,208600000X,Surgery General,11,In_Network,N40.0,Z00.01,revenue_code:0200,,0,Commercial,HDHP_HSA,29,M,0.8011,,,47570.62,37501.46,29559.13,552.55,0.0,7389.78,10069.16,0.0,0.0,0,,0.1893,outlier_billing_amount|billing_spike_recent,0,1,1,1,0,0.002736,0,0,FUM_Follow_Up_ED_Mental_Health,Shared_Savings
CLM0000003146,MBR00000116,Medical_Professional,Paid,Electronic_EDI,2023-01-24,2023-01-24,2023-01-24,2023-02-06,Auto_Adjudicated,13,1231954359,1894215172,2086S0122X,Orthopedic Surgery,31,In_Network,E11.9,,99204,,0,Medicaid_MCO,MLTSS,79,F,0.4614,,,536.17,316.33,313.33,0.0,3.0,0.0,219.84,0.0,0.0,0,,0.0058,none,0,1,0,0,0,2.9e-05,0,0,,Shared_Savings
CLM0000003147,MBR00000253,Pharmacy,Paid,Electronic_EDI,2023-02-13,2023-02-13,2023-02-13,2023-02-25,Manual_Review,12,1903785749,1061149198,246ZN0300X,Neuropsychology,11,In_Network,E11.9,Z00.00,00006001954,,1,Commercial,EPO,44,M,0.3882,,,176.83,77.51,0.0,77.51,0.0,0.0,99.32,0.0,0.0,0,,0.0761,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003148,MBR00000162,Pharmacy,Denied,Electronic_EDI,2023-09-23,2023-09-23,2023-09-23,2023-10-14,Manual_Review,21,1741980770,1690197969,101YP2500X,Psychologist Clinical,65,In_Network,Z23,F32.9,00169751112,,5,Medicaid_MCO,MLTSS,84,F,1.324,22,Duplicate,237.38,150.48,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0892,none,0,1,0,0,0,0.0,0,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000003149,MBR00000144,Medical_Professional,Paid,Electronic_EDI,2023-06-12,2023-06-12,2023-06-12,2023-07-08,Auto_Adjudicated,26,1133514780,1388050552,207RN0300X,Nephrology,11,In_Network,Z87.891,,82947,,0,Commercial,HDHP_HSA,56,F,2.5926,,,388.43,288.4,0.0,288.4,0.0,0.0,100.03,0.0,0.0,0,,0.1163,billing_spike_recent,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003150,MBR00000259,Medical_Institutional,Paid,Electronic_EDI,2023-08-04,2023-08-04,2023-08-07,2023-08-07,Auto_Adjudicated,3,1495592428,1894215172,101YP2500X,Psychologist Clinical,11,In_Network,Z00.01,,revenue_code:0300,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,5197.32,3563.34,2813.59,10.36,36.0,703.4,1633.98,0.0,0.0,0,,0.0556,none,0,1,0,0,0,0.00026,0,0,,FFS
CLM0000003151,MBR00000143,Pharmacy,Paid,Electronic_EDI,2023-04-11,2023-04-11,2023-04-11,2023-04-25,Auto_Adjudicated,14,1451329728,1469697158,207R00000X,Internal Medicine,31,Out_of_Network,OTHER,F32.9|H52.4,59148001506,,2,Commercial,POS,85,M,1.6078,,,256.53,181.76,0.0,181.76,0.0,0.0,74.77,0.0,0.0,1,Kickback Arrangement,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|benford_violation|impossible_service_combo|service_date_weekend|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch,1,5,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003152,MBR00000132,Medical_Professional,Paid,Electronic_EDI,2023-02-13,2023-02-13,2023-02-13,2023-02-23,Auto_Adjudicated,10,1739169232,1157814306,2086S0122X,Orthopedic Surgery,21,In_Network,E78.5,J20.9,99284,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,,,401.72,178.39,137.16,0.93,6.0,34.29,223.33,0.0,0.0,0,,0.0151,none,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000003153,MBR00000031,Pharmacy,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-10,2023-10-11,Auto_Adjudicated,1,1496340237,1898471307,207V00000X,Obstetrics & Gynecology,11,In_Network,I10,OTHER,00169751112,,4,Commercial,PPO,71,M,0.6746,,,168.94,67.95,20.63,26.17,16.0,5.16,100.99,16.46,3.21,0,,0.1425,none,0,1,0,0,0,2e-06,0,0,,FFS
CLM0000003154,MBR00000114,Medical_Professional,Paid,Electronic_EDI,2023-10-26,2023-10-26,2023-10-26,2023-10-27,Auto_Adjudicated,1,1218947226,1282319940,207R00000X,Internal Medicine,22,In_Network,J44.1,OTHER|I10|Z00.00,47562,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,884.55,445.51,334.49,8.4,19.0,83.62,439.04,0.0,0.0,0,,0.1027,none,0,1,0,0,0,3.1e-05,0,0,,Shared_Savings
CLM0000003155,MBR00000126,Medical_Institutional,Paid,Electronic_EDI,2023-10-29,2023-10-29,2023-11-02,2023-11-14,Auto_Adjudicated,16,1145887050,1912895973,207V00000X,Obstetrics & Gynecology,11,In_Network,E78.5,C50.911,revenue_code:0360,,0,Medicaid_MCO,MLTSS,48,F,0.637,,,1207.17,749.68,743.68,0.0,6.0,0.0,457.49,0.0,0.0,0,,0.0049,none,0,1,0,1,0,6.9e-05,0,0,,Shared_Savings
CLM0000003156,MBR00000056,Behavioral_Health,Paid,Electronic_EDI,2023-01-24,2023-01-24,2023-01-24,2023-02-16,Manual_Review,23,1076251878,1741177636,207Q00000X,Family Medicine,11,In_Network,Z23,Z00.00,99205,,0,Commercial,EPO,74,F,1.3941,,,239.57,109.56,0.0,109.56,0.0,0.0,130.01,0.0,0.0,0,,0.0895,none,0,1,0,0,0,0.0,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000003157,MBR00000177,Dental,Paid,Electronic_EDI,2023-11-29,2023-11-29,2023-11-29,2023-12-17,Auto_Adjudicated,18,1232573801,1296566243,207RP1001X,Pulmonary Disease,11,In_Network,Z00.00,,D2140,,0,Commercial,HMO,42,F,1.2774,,,241.24,107.65,0.0,107.65,0.0,0.0,133.59,0.0,0.0,0,,0.1612,upcoding_pattern,0,1,0,1,0,0.0,0,0,MPT_Annual_Monitoring,Capitation
CLM0000003158,MBR00000045,Dental,Paid,Electronic_EDI,2023-07-14,2023-07-14,2023-07-14,2023-07-22,Auto_Adjudicated,8,1731980913,1489434038,207RE0101X,Endocrinology,22,In_Network,F32.9,Z12.11,D0120,,0,Commercial,HMO,78,F,1.0658,,,165.25,139.25,74.74,13.82,32.0,18.69,26.0,0.0,0.0,0,,0.1412,geographic_mismatch,0,1,0,1,0,7e-06,0,0,,FFS
CLM0000003159,MBR00000070,Pharmacy,Paid,Electronic_EDI,2023-03-12,2023-03-12,2023-03-12,2023-03-26,Auto_Adjudicated,14,1374458552,1477113725,101YP2500X,Psychologist Clinical,11,In_Network,M54.5,,00078043215,,5,Commercial,POS,42,F,0.8468,,,258.82,188.36,65.58,91.38,15.0,16.4,70.46,0.0,0.0,0,,0.1381,none,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000003160,MBR00000169,Medical_Institutional,Paid,Electronic_EDI,2023-03-13,2023-03-13,2023-03-14,2023-04-11,Manual_Review,29,1945264928,1510751265,207RN0300X,Nephrology,31,In_Network,I10,Z00.00|F32.9,revenue_code:0120,,0,Commercial,EPO,30,M,1.4348,,,44139.32,23391.54,18375.59,361.06,61.0,4593.9,20747.78,0.0,0.0,0,,0.0987,impossible_service_combo,0,1,1,0,0,0.001701,0,0,,P4P
CLM0000003161,MBR00000083,Pharmacy,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-26,Auto_Adjudicated,26,1542851144,1688513262,207RP1001X,Pulmonary Disease,24,In_Network,Z12.11,K21.0|OTHER,00006001954,,5,Commercial,PPO,76,M,0.6621,,,178.04,73.25,0.0,73.25,0.0,0.0,104.79,0.0,0.0,0,,0.1134,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000003162,MBR00000189,Medical_Professional,Paid,Provider_Portal,2023-08-05,2023-08-05,2023-08-05,2023-08-09,Auto_Adjudicated,4,1211612843,1576271272,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,M79.3,43239,,0,Medicaid_MCO,MCO,71,F,0.9722,,,1203.31,511.74,507.74,0.0,4.0,0.0,691.57,0.0,0.0,0,,0.0512,none,0,1,0,0,0,4.7e-05,0,0,,FFS
CLM0000003163,MBR00000206,Medical_Institutional,Paid,Electronic_EDI,2023-01-18,2023-01-18,2023-01-19,2023-02-07,Auto_Adjudicated,20,1076251878,1666461892,225100000X,Physical Therapist,22,In_Network,OTHER,,revenue_code:0100,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,8239.74,4518.65,4513.65,0.0,5.0,0.0,3721.09,0.0,0.0,0,,0.0411,none,0,1,0,0,0,0.000418,0,0,,Shared_Savings
CLM0000003164,MBR00000095,Medical_Institutional,Paid,Provider_Portal,2023-06-28,2023-06-28,2023-07-02,2023-07-17,Auto_Adjudicated,19,1333969109,1197700958,2084P0800X,Psychiatry,22,In_Network,J06.9,,revenue_code:0120,,0,Commercial,HMO,28,M,0.5827,,,76133.11,34675.78,27641.54,68.86,55.0,6910.38,41457.33,0.0,0.0,0,,0.2142,outlier_billing_amount|service_date_weekend,0,2,1,0,0,0.002558,0,0,,FFS
CLM0000003165,MBR00000026,Medical_Institutional,Paid,Electronic_EDI,2023-03-28,2023-03-28,2023-03-31,2023-04-08,Auto_Adjudicated,11,1256824549,1415734567,2084P0800X,Psychiatry,23,In_Network,OTHER,Z23|M17.11,revenue_code:0360,,0,Medicaid_MCO,MCO,17,M,1.0686,,,5470.98,1980.13,1973.13,0.0,7.0,0.0,3490.85,0.0,0.0,1,Code Substitution,1.0,outlier_billing_amount|unusual_service_frequency|temporal_clustering|high_volume_same_code|service_date_weekend|duplicate_claim_indicator|upcoding_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,0.000183,0,0,,Shared_Savings
CLM0000003166,MBR00000152,Medical_Institutional,Paid,Electronic_EDI,2023-11-26,2023-11-26,2023-11-30,2023-12-07,Auto_Adjudicated,11,1727787144,1321680994,207RG0100X,Gastroenterology,21,Out_of_Network,I10,J20.9|E11.9,revenue_code:0120,193,0,Commercial,HMO,82,F,1.2506,,,23598.94,17786.96,14006.69,218.59,60.0,3501.67,5811.98,0.0,0.0,0,,0.0736,billing_spike_recent,0,1,1,0,0,0.001296,1,0,BPD_BP_Declined,FFS
CLM0000003167,MBR00000028,Medical_Professional,Paid,Electronic_EDI,2023-08-09,2023-08-09,2023-08-09,2023-08-31,Auto_Adjudicated,22,1988579666,1691162131,207Q00000X,Family Medicine,23,In_Network,OTHER,OTHER,90847,,0,Commercial,HMO,3,F,2.116,,,636.11,305.47,63.52,212.07,14.0,15.88,330.64,0.0,0.0,0,,0.1287,none,0,1,0,1,0,6e-06,0,0,,P4P
CLM0000003168,MBR00000158,Medical_Professional,Paid,Electronic_EDI,2023-05-14,2023-05-14,2023-05-14,2023-06-12,Manual_Review,29,1918160357,1884259357,207V00000X,Obstetrics & Gynecology,11,In_Network,OTHER,F32.9|M79.3,99397,,0,Commercial,HMO,65,M,1.5361,,,557.24,434.83,269.5,83.96,14.0,67.37,122.41,0.0,0.0,0,,0.0865,none,0,1,0,0,0,2.5e-05,0,0,,Shared_Savings
CLM0000003169,MBR00000213,Medical_Professional,Paid,Electronic_EDI,2023-06-01,2023-06-01,2023-06-01,2023-06-11,Auto_Adjudicated,10,1557212800,1995553359,2084P0800X,Psychiatry,22,In_Network,I25.10,,47562,,0,Commercial,PPO,17,M,1.5857,,,152.29,124.95,43.07,43.12,28.0,10.77,27.34,0.0,0.0,0,,0.0733,none,0,1,0,1,0,4e-06,0,0,,Shared_Savings
CLM0000003170,MBR00000185,Medical_Institutional,Paid,Provider_Portal,2023-10-28,2023-10-28,2023-10-29,2023-11-25,Auto_Adjudicated,28,1205349488,1887266184,101YP2500X,Psychologist Clinical,11,In_Network,Z00.00,Z00.00,revenue_code:0370,,0,Medicaid_MCO,MCO,73,M,1.5417,,,10857.26,6426.75,6418.75,0.0,8.0,0.0,4430.51,0.0,0.0,0,,0.0171,none,0,1,1,0,0,0.000594,0,0,AWV_Annual_Wellness_Visit,Shared_Savings
CLM0000003171,MBR00000140,Medical_Professional,Paid,Electronic_EDI,2023-09-05,2023-09-05,2023-09-05,2023-10-01,Auto_Adjudicated,26,1054449469,1170002937,2086S0122X,Orthopedic Surgery,71,In_Network,OTHER,,99214,,0,Medicare_Advantage,MA_HMO,7,M,1.3997,,,247.18,117.72,74.88,12.12,12.0,18.72,129.46,0.0,0.0,0,,0.1103,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000003172,MBR00000286,Dental,Paid,Electronic_EDI,2023-05-20,2023-05-20,2023-05-20,2023-05-22,Auto_Adjudicated,2,1901508637,1356856197,207RN0300X,Nephrology,21,In_Network,K21.0,Z00.01,D7140,,0,Medicare_Advantage,PFFS,40,F,1.2751,,,327.58,219.71,155.95,21.77,3.0,38.99,107.87,0.0,0.0,0,,0.084,none,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000003173,MBR00000030,Medical_Professional,Paid,Electronic_EDI,2023-10-29,2023-10-29,2023-10-29,2023-11-07,Clinical_Review,9,1086690796,1408846353,246ZN0300X,Neuropsychology,22,In_Network,I10,J44.1,97110,,0,Medicaid_MCO,MCO,67,M,0.4581,,,214.63,176.95,173.95,0.0,3.0,0.0,37.68,0.0,0.0,0,,0.0001,none,0,1,0,1,0,1.6e-05,0,0,TRC_Transition_of_Care,Bundled_Payment
CLM0000003174,MBR00000266,Pharmacy,Denied,Electronic_EDI,2023-08-12,2023-08-12,2023-08-12,2023-08-26,Auto_Adjudicated,14,1971354640,1296566243,207RC0000X,Cardiovascular Disease,22,In_Network,OTHER,J45.20,00071015523,,2,Commercial,EPO,14,M,1.075,5,COB,142.58,103.56,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0674,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003175,MBR00000236,Medical_Professional,Paid,Electronic_EDI,2023-01-22,2023-01-22,2023-01-22,2023-02-11,Auto_Adjudicated,20,1650193199,1040061910,207RP1001X,Pulmonary Disease,11,Out_of_Network,Z23,M54.5|OTHER,27130,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,33386.93,14251.87,14248.87,0.0,3.0,0.0,19135.06,0.0,0.0,1,Provider Impersonation,1.0,geographic_mismatch|provider_specialty_mismatch|temporal_clustering|impossible_service_combo|service_date_weekend|billing_spike_recent|unbundling_pattern|phantom_billing_indicator|npi_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,1,0,0,0.001319,1,0,,Shared_Savings
CLM0000003176,MBR00000133,Dental,Paid,Electronic_EDI,2023-08-15,2023-08-15,2023-08-15,2023-08-22,Auto_Adjudicated,7,1091271799,1312595355,207RG0100X,Gastroenterology,11,In_Network,M17.11,,D4341,,0,Medicaid_MCO,MCO,57,M,0.9592,,,676.47,515.32,514.32,0.0,1.0,0.0,161.15,0.0,0.0,0,,0.1761,geographic_mismatch,0,1,0,0,0,4.8e-05,0,0,,Bundled_Payment
CLM0000003177,MBR00000049,Pharmacy,Paid,Electronic_EDI,2023-12-03,2023-12-03,2023-12-03,2023-12-16,Auto_Adjudicated,13,1797494973,1140170394,208600000X,Surgery General,11,In_Network,E11.65,,00069420020,,1,Medicare_Advantage,PFFS,67,M,0.978,,,196.79,124.29,92.43,4.75,4.0,23.11,72.5,0.0,0.0,0,,0.0543,none,0,1,0,0,0,9e-06,0,0,MMA_Medication_Management,P4P
CLM0000003178,MBR00000050,Vision,Paid,Electronic_EDI,2023-11-06,2023-11-06,2023-11-06,2023-11-09,Auto_Adjudicated,3,1403662694,1163639177,207RC0000X,Cardiovascular Disease,23,In_Network,OTHER,OTHER|N39.0,92014,,0,Medicare_Advantage,MA_PPO,12,F,0.8486,,,345.04,199.7,152.25,9.39,0.0,38.06,145.34,0.0,0.0,0,,0.0983,npi_mismatch,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000003179,MBR00000278,Dental,Paid,Electronic_EDI,2023-01-16,2023-01-16,2023-01-16,2023-01-20,Auto_Adjudicated,4,1873731689,1177602659,208600000X,Surgery General,23,In_Network,M17.11,M79.3,D2140,,0,Commercial,HMO,49,M,0.4107,,,744.3,328.28,45.6,236.28,35.0,11.4,416.02,0.0,0.0,0,,0.0821,none,0,1,0,0,0,4e-06,0,0,,Capitation
CLM0000003180,MBR00000073,Pharmacy,Denied,Provider_Portal,2023-11-13,2023-11-13,2023-11-13,2023-11-27,Auto_Adjudicated,14,1944105498,1004714954,207Q00000X,Family Medicine,11,In_Network,OTHER,J44.1|M54.5|Z00.00,00071012831,,2,Commercial,POS,79,M,1.1768,PR-1,Eligibility,1105.57,685.3,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Phantom Billing,1.0,outlier_billing_amount|geographic_mismatch|high_volume_same_code|benford_violation|impossible_service_combo|billing_spike_recent|phantom_billing_indicator|npi_mismatch|high_oop_waiver,1,5,0,0,0,0.0,0,0,,FFS
CLM0000003181,MBR00000263,Medical_Professional,Paid,Paper,2023-12-19,2023-12-19,2023-12-19,2024-01-07,Auto_Adjudicated,19,1159268684,1581533104,101YP2500X,Psychologist Clinical,22,In_Network,I10,OTHER|F32.9,99395,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,,,417.17,300.11,213.04,14.81,19.0,53.26,117.06,0.0,0.0,0,,0.042,none,0,1,0,0,0,2e-05,0,0,,FFS
CLM0000003182,MBR00000155,Medical_Institutional,Paid,Electronic_EDI,2023-02-28,2023-02-28,2023-03-01,2023-03-14,Auto_Adjudicated,14,1889525696,1527857018,207R00000X,Internal Medicine,21,In_Network,F33.0,OTHER,revenue_code:0210,683,0,ACA_Marketplace,ACA_Bronze,9,F,0.8196,,,24456.95,13184.92,7883.26,46.15,0.0,5255.51,11272.03,0.0,0.0,0,,0.1511,controlled_substance_high_volume,0,1,1,0,0,0.00073,0,0,,FFS
CLM0000003183,MBR00000143,Medical_Professional,Paid,Electronic_EDI,2023-08-17,2023-08-17,2023-08-17,2023-08-29,Auto_Adjudicated,12,1091395764,1587454801,207RC0000X,Cardiovascular Disease,22,In_Network,N39.0,Z12.11,99284,,0,Commercial,POS,85,M,1.6078,,,245.6,202.99,18.12,144.34,36.0,4.53,42.61,0.0,0.0,0,,0.0779,none,0,1,0,0,0,2e-06,0,0,LCS_Lung_Cancer_Screening,Shared_Savings
CLM0000003184,MBR00000185,Dental,Paid,Electronic_EDI,2023-09-29,2023-09-29,2023-09-29,2023-10-14,Clinical_Review,15,1713343912,1489993356,207RC0000X,Cardiovascular Disease,21,In_Network,M54.5,Z00.00|I10,D2140,,0,Medicaid_MCO,MCO,73,M,1.5417,,,265.82,115.56,112.56,0.0,3.0,0.0,150.26,84.13,16.49,0,,0.1834,geographic_mismatch,0,1,0,0,0,1e-05,0,0,KED_ESRD_Patients,FFS
CLM0000003185,MBR00000065,Dental,Paid,Electronic_EDI,2023-01-16,2023-01-16,2023-01-16,2023-02-05,Auto_Adjudicated,20,1699074676,1587454801,207RE0101X,Endocrinology,65,In_Network,E11.9,,D3310,,0,Commercial,HDHP_HSA,63,M,0.7795,,,177.76,64.13,0.0,64.13,0.0,0.0,113.63,0.0,0.0,0,,0.0328,none,0,1,0,0,0,0.0,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000003186,MBR00000135,Medical_Professional,Denied,Electronic_EDI,2023-10-25,2023-10-25,2023-10-25,2023-11-16,Auto_Adjudicated,22,1871348663,1764064254,207RC0000X,Cardiovascular Disease,22,Out_of_Network,Z00.00,I10,27130,,0,Commercial,PPO,58,F,2.2702,CO-45,Authorization,4625.23,2791.72,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1296,none,0,1,0,1,0,0.0,0,0,CDC_HbA1c_Poor_Control,P4P
CLM0000003187,MBR00000284,Pharmacy,Paid,Electronic_EDI,2023-05-22,2023-05-22,2023-05-22,2023-06-08,Auto_Adjudicated,17,1167433253,1355732274,207RP1001X,Pulmonary Disease,21,In_Network,E78.5,,00169751112,,2,Medicaid_MCO,FFS_Medicaid,23,M,0.5234,,,355.24,154.69,152.69,0.0,2.0,0.0,200.55,0.0,0.0,0,,0.045,none,0,1,0,0,0,1.4e-05,0,0,,Capitation
CLM0000003188,MBR00000075,Medical_Professional,Denied,Electronic_EDI,2023-04-18,2023-04-18,2023-04-18,2023-04-21,Auto_Adjudicated,3,1414670047,1013600387,207R00000X,Internal Medicine,23,In_Network,K57.30,,33510,,0,Medicaid_MCO,MCO,5,M,1.0573,1,Coding_Error,1110.49,745.15,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1239,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003189,MBR00000278,Pharmacy,Paid,Electronic_EDI,2023-04-03,2023-04-03,2023-04-03,2023-04-05,Manual_Review,2,1288855406,1912895973,207RG0100X,Gastroenterology,24,In_Network,E78.5,L70.0|Z00.00,00169751112,,2,Commercial,HMO,49,M,0.4107,,,166.17,94.17,0.0,94.17,0.0,0.0,72.0,0.0,0.0,0,,0.2553,benford_violation|diagnosis_procedure_mismatch,0,2,0,0,0,0.0,0,1,CDC_HbA1c_Poor_Control,FFS
CLM0000003190,MBR00000299,Medical_Institutional,Paid,Paper,2023-07-01,2023-07-01,2023-07-01,2023-07-12,Clinical_Review,11,1611521069,1811797489,208600000X,Surgery General,22,Out_of_Network,G43.909,OTHER,revenue_code:0360,,0,Medicaid_MCO,MCO,74,F,0.8833,,,22732.1,12628.3,12626.3,0.0,2.0,0.0,10103.8,0.0,0.0,0,,0.0682,none,0,1,1,0,0,0.001169,1,0,CBP_Controlling_BP,Capitation
CLM0000003191,MBR00000014,Medical_Institutional,Paid,Electronic_EDI,2023-10-14,2023-10-14,2023-10-17,2023-10-21,Auto_Adjudicated,7,1682685390,1114756459,2084P0800X,Psychiatry,11,In_Network,OTHER,E13.9|M54.5,revenue_code:0120,,0,Commercial,HMO,77,M,2.8513,,,30148.14,17408.13,13589.3,386.5,35.0,3397.33,12740.01,0.0,0.0,0,,0.087,none,0,1,1,0,0,0.001258,0,0,,Capitation
CLM0000003192,MBR00000162,Dental,Paid,Electronic_EDI,2023-10-22,2023-10-22,2023-10-22,2023-11-08,Auto_Adjudicated,17,1900781649,1951488764,2086S0122X,Orthopedic Surgery,11,In_Network,M47.816,N39.0|OTHER,D2140,,0,Medicaid_MCO,MLTSS,84,F,1.324,,,119.16,48.92,47.92,0.0,1.0,0.0,70.24,0.0,0.0,0,,0.1597,high_oop_waiver,0,1,0,0,0,4e-06,0,0,,Shared_Savings
CLM0000003193,MBR00000054,Medical_Professional,Paid,Electronic_EDI,2023-03-22,2023-03-22,2023-03-22,2023-04-13,Clinical_Review,22,1882720848,1049766043,207Q00000X,Family Medicine,21,In_Network,OTHER,Z00.00|J06.9,99204,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,,,317.17,154.57,122.39,0.58,1.0,30.6,162.6,0.0,0.0,0,,0.0361,none,0,1,0,1,0,1.1e-05,0,0,PCR_Plan_All_Cause_Readmission,Bundled_Payment
CLM0000003194,MBR00000185,Pharmacy,Paid,Provider_Portal,2023-10-24,2023-10-24,2023-10-24,2023-11-01,Auto_Adjudicated,8,1887322427,1553094822,2086S0122X,Orthopedic Surgery,24,In_Network,I25.10,Z12.11|OTHER,00071012831,,3,Medicaid_MCO,MCO,73,M,1.5417,,,148.23,85.06,82.06,0.0,3.0,0.0,63.17,0.0,0.0,0,,0.1189,none,0,1,0,1,0,8e-06,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000003195,MBR00000297,Pharmacy,Paid,Electronic_EDI,2023-10-24,2023-10-24,2023-10-24,2023-11-08,Auto_Adjudicated,15,1918160357,1282319940,2086S0122X,Orthopedic Surgery,23,Emergency,OTHER,,00071012831,,3,Commercial,HMO,88,M,1.5311,,,254.36,186.22,121.75,7.04,27.0,30.44,68.14,80.75,25.75,0,,0.1441,none,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000003196,MBR00000272,Medical_Professional,Paid,Electronic_EDI,2023-01-23,2023-01-23,2023-01-23,2023-01-30,Manual_Review,7,1647029816,1945682535,207RN0300X,Nephrology,11,Emergency,OTHER,,27130,,0,Medicare_Advantage,MA_HMO,15,M,0.8525,,,20508.0,16249.02,12941.48,57.17,15.0,3235.37,4258.98,0.0,0.0,0,,0.1252,none,0,1,1,0,0,0.001198,0,0,,FFS
CLM0000003197,MBR00000279,Medical_Institutional,Denied,Electronic_EDI,2023-04-23,2023-04-23,2023-04-27,2023-05-07,Auto_Adjudicated,14,1943769986,1179350099,207RC0000X,Cardiovascular Disease,11,In_Network,M54.5,OTHER|E78.5,revenue_code:0200,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,18,Timely_Filing,23994.07,11653.02,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0793,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003198,MBR00000065,Medical_Professional,Denied,Electronic_EDI,2023-01-06,2023-01-06,2023-01-06,2023-01-18,Auto_Adjudicated,12,1793630905,1352413270,207Q00000X,Family Medicine,23,Out_of_Network,G43.909,OTHER,99203,,0,Commercial,HDHP_HSA,63,M,0.7795,18,Coding_Error,304.94,130.7,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Medically Unnecessary Services,0.8334,geographic_mismatch|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|unbundling_pattern|npi_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.0,0,0,,FFS
CLM0000003199,MBR00000165,Medical_Institutional,Denied,Electronic_EDI,2023-12-22,2023-12-22,2023-12-26,2023-12-23,Manual_Review,1,1399379863,1965244699,207Q00000X,Family Medicine,22,In_Network,I50.9,F41.1,revenue_code:0300,,0,ACA_Marketplace,ACA_Bronze,55,M,0.9775,18,Eligibility,7490.32,3990.48,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1134,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000003200,MBR00000074,Dental,Paid,Electronic_EDI,2023-06-19,2023-06-19,2023-06-19,2023-07-09,Auto_Adjudicated,20,1257723293,1148659045,101YP2500X,Psychologist Clinical,24,In_Network,M25.511,M79.3|OTHER|E78.5,D2391,,0,Medicare_Advantage,MA_PPO,21,F,0.8719,,,322.91,172.51,99.38,29.28,19.0,24.85,150.4,0.0,0.0,0,,0.1946,impossible_service_combo|duplicate_claim_indicator,0,1,0,0,0,9e-06,0,0,,Bundled_Payment
CLM0000003201,MBR00000273,Medical_Professional,Paid,Paper,2023-04-08,2023-04-08,2023-04-08,2023-04-18,Auto_Adjudicated,10,1677021292,1252125670,2084P0800X,Psychiatry,23,In_Network,M54.5,OTHER|Z23,99386,,0,ACA_Marketplace,ACA_Bronze,4,M,1.3569,,,116.17,66.99,0.0,66.99,0.0,0.0,49.18,0.0,0.0,0,,0.0754,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003202,MBR00000059,Medical_Professional,Paid,Electronic_EDI,2023-11-18,2023-11-18,2023-11-18,2023-12-11,Clinical_Review,23,1719850506,1560230600,207RE0101X,Endocrinology,11,In_Network,M17.11,,71046,,0,Medicare_Advantage,SNP,12,F,1.266,,,604.55,396.62,286.49,22.51,16.0,71.62,207.93,0.0,0.0,0,,0.0184,none,0,1,0,1,0,2.7e-05,0,0,PPC_Prenatal_Care,FFS
CLM0000003203,MBR00000049,Medical_Institutional,Paid,Electronic_EDI,2023-09-03,2023-09-03,2023-09-04,2023-09-24,Auto_Adjudicated,21,1267286378,1133410177,207RC0000X,Cardiovascular Disease,24,In_Network,OTHER,OTHER|J20.9,revenue_code:0250,,0,Medicare_Advantage,PFFS,67,M,0.978,,,11805.31,6628.23,5249.01,15.97,51.0,1312.25,5177.08,0.0,0.0,0,,0.0124,none,0,1,1,1,0,0.000486,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000003204,MBR00000004,Medical_Professional,Paid,Electronic_EDI,2023-12-04,2023-12-04,2023-12-04,2023-12-10,Auto_Adjudicated,6,1421421733,1685903362,207RE0101X,Endocrinology,22,In_Network,OTHER,E11.9|OTHER,99381,,0,Medicare_Advantage,MA_PPO,68,M,1.23,,,269.05,128.34,80.04,20.29,8.0,20.01,140.71,66.85,8.59,0,,0.0155,none,0,1,0,1,0,7e-06,0,0,,FFS
CLM0000003205,MBR00000057,Medical_Professional,Partially_Paid,Electronic_EDI,2023-10-15,2023-10-15,2023-10-15,2023-11-11,Auto_Adjudicated,27,1733777382,1164525386,208600000X,Surgery General,22,Out_of_Network,J06.9,Z00.01|I10|OTHER,74177,,0,Medicare_Advantage,MA_PPO,45,M,0.6701,CO-45,Medical_Necessity,388.32,151.66,65.28,21.22,2.0,16.32,283.5,0.0,0.0,0,,0.1534,diagnosis_procedure_mismatch,0,1,0,0,0,6e-06,0,0,FUM_Follow_Up_ED_Mental_Health,Capitation
CLM0000003206,MBR00000059,Medical_Institutional,Paid,Electronic_EDI,2023-12-09,2023-12-09,2023-12-11,2023-12-10,Manual_Review,1,1907932706,1157814306,101YP2500X,Psychologist Clinical,21,In_Network,F41.1,OTHER|I25.10,revenue_code:0370,682,0,Medicare_Advantage,SNP,12,F,1.266,,,4003.83,3010.04,2364.26,21.72,33.0,591.06,993.79,0.0,0.0,0,,0.1032,none,0,1,0,1,0,0.000219,0,0,,FFS
CLM0000003207,MBR00000024,Medical_Institutional,Paid,Electronic_EDI,2023-03-19,2023-03-19,2023-03-21,2023-04-06,Clinical_Review,18,1098094939,1179350099,207RN0300X,Nephrology,24,Out_of_Network,M54.5,,revenue_code:0450,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,21372.09,15376.4,15374.4,0.0,2.0,0.0,5995.69,0.0,0.0,0,,0.0862,none,0,1,1,0,0,0.001423,1,0,,Shared_Savings
CLM0000003208,MBR00000262,Pharmacy,Paid,Electronic_EDI,2023-03-15,2023-03-15,2023-03-15,2023-04-09,Auto_Adjudicated,25,1513278494,1986847322,246ZN0300X,Neuropsychology,11,In_Network,N40.0,E78.5|Z12.11,00078043215,,1,Medicare_Advantage,PFFS,77,F,1.7452,,,44.85,34.88,24.46,0.31,4.0,6.11,9.97,0.0,0.0,0,,0.0726,none,0,1,0,1,0,2e-06,0,0,,Bundled_Payment
CLM0000003209,MBR00000230,Medical_Institutional,Paid,Electronic_EDI,2023-01-28,2023-01-28,2023-01-28,2023-02-14,Auto_Adjudicated,17,1002224900,1318978078,207Q00000X,Family Medicine,11,In_Network,Z00.00,I10|Z00.00,revenue_code:0100,,0,Commercial,HMO,9,M,0.4087,,,24755.3,11006.27,8767.82,3.49,43.0,2191.96,13749.03,0.0,0.0,0,,0.0097,none,0,1,1,0,0,0.000812,0,0,,Capitation
CLM0000003210,MBR00000078,Medical_Institutional,Paid,Paper,2023-05-04,2023-05-04,2023-05-04,2023-05-21,Auto_Adjudicated,17,1625939855,1396850418,207V00000X,Obstetrics & Gynecology,11,In_Network,OTHER,OTHER,revenue_code:0360,,0,Commercial,EPO,65,F,1.3174,,,55145.51,42739.38,34012.85,188.32,35.0,8503.21,12406.13,0.0,0.0,0,,0.1406,outlier_billing_amount,0,1,1,0,0,0.003148,0,0,SPC_Statin_Therapy,Capitation
CLM0000003211,MBR00000232,Medical_Professional,Paid,Electronic_EDI,2023-07-17,2023-07-17,2023-07-17,2023-08-01,Auto_Adjudicated,15,1871417879,1694343357,2086S0122X,Orthopedic Surgery,24,Out_of_Network,J20.9,E11.9|Z00.00,99396,,0,Medicaid_MCO,MCO,40,M,1.1083,,,848.25,680.07,678.07,0.0,2.0,0.0,168.18,0.0,0.0,0,,0.0121,none,0,1,0,1,0,6.3e-05,0,0,,FFS
CLM0000003212,MBR00000134,Medical_Professional,Paid,Electronic_EDI,2023-07-22,2023-07-22,2023-07-22,2023-07-24,Auto_Adjudicated,2,1177281088,1522426351,207RC0000X,Cardiovascular Disease,23,In_Network,E78.5,I10,85025,,0,Medicare_Advantage,MA_PPO,33,M,1.115,,,304.44,235.24,164.75,16.3,13.0,41.19,69.2,0.0,0.0,0,,0.1094,none,0,1,0,0,0,1.5e-05,0,0,,Shared_Savings
CLM0000003213,MBR00000229,Medical_Institutional,Paid,Electronic_EDI,2023-09-01,2023-09-01,2023-09-02,2023-09-22,Manual_Review,21,1679629515,1575884274,2086S0122X,Orthopedic Surgery,11,Out_of_Network,Z00.00,OTHER|J06.9|R05.9,revenue_code:0210,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,20422.98,7539.38,5947.48,51.03,54.0,1486.87,12883.6,0.0,0.0,0,,0.0182,none,0,1,1,0,0,0.00055,0,0,,Capitation
CLM0000003214,MBR00000102,Pharmacy,Paid,Electronic_EDI,2023-09-21,2023-09-21,2023-09-21,2023-10-20,Auto_Adjudicated,29,1086690796,1788579687,207V00000X,Obstetrics & Gynecology,11,In_Network,E11.65,Z00.00|N39.0|I48.91,00071015523,,1,Commercial,POS,68,M,1.6864,,,114.77,60.04,0.0,60.04,0.0,0.0,54.73,0.0,0.0,0,,0.0374,none,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000003215,MBR00000170,Vision,Paid,Electronic_EDI,2023-10-21,2023-10-21,2023-10-21,2023-11-14,Auto_Adjudicated,24,1881358103,1574982369,207Q00000X,Family Medicine,11,Out_of_Network,I25.10,,V2100,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,516.49,430.64,336.43,7.1,3.0,84.11,85.85,0.0,0.0,0,,0.1075,npi_mismatch,0,1,0,0,0,3.1e-05,0,0,,FFS
CLM0000003216,MBR00000121,Medical_Professional,Paid,Electronic_EDI,2023-07-06,2023-07-06,2023-07-06,2023-07-08,Clinical_Review,2,1404237143,1013600387,101YP2500X,Psychologist Clinical,23,In_Network,M47.816,Z00.00,27130,,0,Medicare_Advantage,MA_PPO,58,M,1.226,,,23700.59,14678.62,11711.78,20.9,18.0,2927.94,9021.97,0.0,0.0,0,,0.0176,none,0,1,1,0,0,0.001084,0,0,PPC_Prenatal_Care,P4P
CLM0000003217,MBR00000059,Medical_Institutional,Denied,Electronic_EDI,2023-04-08,2023-04-08,2023-04-10,2023-04-15,Auto_Adjudicated,7,1874109311,1867389043,207RN0300X,Nephrology,22,In_Network,N39.0,,revenue_code:0370,,0,Medicare_Advantage,SNP,12,F,1.266,18,COB,9224.56,6777.95,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1277,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003218,MBR00000176,Medical_Institutional,Paid,Paper,2023-06-07,2023-06-07,2023-06-11,2023-07-02,Auto_Adjudicated,25,1205744244,1747596016,225100000X,Physical Therapist,23,In_Network,M17.11,M54.5,revenue_code:0250,,0,Commercial,POS,4,M,0.8792,,,5288.6,2668.07,1853.2,311.58,40.0,463.3,2620.53,0.0,0.0,0,,0.0858,benford_violation,0,1,0,0,0,0.000172,0,0,,Bundled_Payment
CLM0000003219,MBR00000220,Medical_Professional,Paid,Electronic_EDI,2023-11-10,2023-11-10,2023-11-10,2023-12-02,Auto_Adjudicated,22,1421421733,1365397818,207R00000X,Internal Medicine,23,In_Network,M54.5,,99285,,0,Commercial,HMO,38,M,0.7736,,,232.76,133.51,0.0,133.51,0.0,0.0,99.25,0.0,0.0,0,,0.0494,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000003220,MBR00000221,Pharmacy,Paid,Electronic_EDI,2023-10-20,2023-10-20,2023-10-20,2023-10-31,Auto_Adjudicated,11,1550698436,1300957944,207Q00000X,Family Medicine,31,In_Network,E11.9,M54.5,00071015523,,5,Commercial,HDHP_HSA,28,M,1.6683,,,104.95,56.85,0.0,56.85,0.0,0.0,48.1,0.0,0.0,0,,0.0445,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003221,MBR00000112,Medical_Professional,Paid,Electronic_EDI,2023-11-25,2023-11-25,2023-11-25,2023-12-03,Auto_Adjudicated,8,1788188920,1884259357,225100000X,Physical Therapist,21,Out_of_Network,E78.5,,99213,,0,Medicare_Advantage,MA_HMO,18,M,1.01,,,276.62,206.96,149.26,14.39,6.0,37.31,69.66,0.0,0.0,0,,0.0974,service_date_weekend,0,1,0,0,0,1.4e-05,1,0,,FFS
CLM0000003222,MBR00000159,Dental,Paid,Provider_Portal,2023-07-13,2023-07-13,2023-07-13,2023-07-27,Auto_Adjudicated,14,1813729693,1312595355,225100000X,Physical Therapist,31,Out_of_Network,Z12.11,OTHER|G47.33,D1110,,0,Commercial,PPO,70,F,1.2009,,,355.76,151.08,76.92,40.92,14.0,19.23,204.68,0.0,0.0,0,,0.0686,billing_spike_recent,0,1,0,0,0,7e-06,1,0,,Capitation
CLM0000003223,MBR00000224,Medical_Institutional,Paid,Electronic_EDI,2023-10-07,2023-10-07,2023-10-11,2023-10-08,Auto_Adjudicated,1,1666911728,1157814306,207RP1001X,Pulmonary Disease,21,In_Network,OTHER,,revenue_code:0360,291,0,Medicaid_MCO,MCO,86,F,1.3289,,,7285.02,4225.48,4216.48,0.0,9.0,0.0,3059.54,0.0,0.0,0,,0.1315,none,0,1,0,0,0,0.00039,0,0,CCS_Cervical_Cancer_Screening,Bundled_Payment
CLM0000003224,MBR00000014,Medical_Professional,Denied,Electronic_EDI,2023-05-29,2023-05-29,2023-05-29,2023-06-01,Auto_Adjudicated,3,1907932706,1560230600,207RE0101X,Endocrinology,23,In_Network,Z00.01,,99212,,0,Commercial,HMO,77,M,2.8513,2,COB,432.52,343.23,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,DME Fraud,1.0,unusual_service_frequency|provider_specialty_mismatch|benford_violation|impossible_service_combo|duplicate_claim_indicator|upcoding_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003225,MBR00000022,Pharmacy,Paid,Electronic_EDI,2023-01-03,2023-01-03,2023-01-03,2023-01-06,Manual_Review,3,1252009836,1330485436,207RN0300X,Nephrology,22,In_Network,M79.3,,50458085930,,1,Medicare_Advantage,MA_HMO,34,M,0.9472,,,315.25,246.57,148.9,44.44,16.0,37.23,68.68,0.0,0.0,0,,0.023,none,0,1,0,0,0,1.4e-05,0,0,,Capitation
CLM0000003226,MBR00000119,Medical_Professional,Paid,Paper,2023-09-25,2023-09-25,2023-09-25,2023-10-20,Auto_Adjudicated,25,1853403237,1874728994,207RN0300X,Nephrology,65,In_Network,Z00.00,OTHER,99282,,0,Commercial,POS,42,M,0.4987,,,186.5,141.24,54.1,57.62,16.0,13.52,45.26,0.0,0.0,0,,0.0058,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000003227,MBR00000070,Pharmacy,Denied,Paper,2023-02-01,2023-02-01,2023-02-01,2023-02-03,Clinical_Review,2,1918160357,1887266184,225100000X,Physical Therapist,21,Out_of_Network,Z00.00,,16590051660,,2,Commercial,POS,42,F,0.8468,50,COB,247.47,99.7,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Code Substitution,1.0,outlier_billing_amount|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|impossible_service_combo|service_date_weekend|billing_spike_recent|unbundling_pattern|npi_mismatch|high_oop_waiver,1,5,0,0,0,0.0,1,1,,Capitation
CLM0000003228,MBR00000118,Pharmacy,Denied,Electronic_EDI,2023-08-17,2023-08-17,2023-08-17,2023-09-03,Manual_Review,17,1490172833,1390802135,207RG0100X,Gastroenterology,23,In_Network,E78.5,Z12.11|J44.1,00169751112,,4,Medicaid_MCO,MCO,69,M,1.2773,97,Network,1449.93,928.18,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0251,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003229,MBR00000028,Medical_Institutional,Paid,Electronic_EDI,2023-12-25,2023-12-25,2023-12-28,2024-01-03,Auto_Adjudicated,9,1462532026,1878017518,208600000X,Surgery General,22,In_Network,J06.9,M17.11,revenue_code:0210,,0,Commercial,HMO,3,F,2.116,,,5146.66,2631.1,1884.77,196.14,79.0,471.19,2515.56,0.0,0.0,0,,0.1613,phantom_billing_indicator|high_oop_waiver,0,1,0,0,0,0.000174,0,0,,FFS
CLM0000003230,MBR00000178,Medical_Professional,Paid,Electronic_EDI,2023-01-10,2023-01-10,2023-01-10,2023-02-02,Manual_Review,23,1243052462,1607833568,246ZN0300X,Neuropsychology,81,Out_of_Network,I10,E78.5|Z23|E11.9,99231,,0,Medicaid_MCO,MCO,89,M,0.7057,,,317.81,265.56,262.56,0.0,3.0,0.0,52.25,0.0,0.0,0,,0.007,none,0,1,0,0,0,2.4e-05,1,0,POD_Persistence_of_Beta_Blocker,Shared_Savings
CLM0000003231,MBR00000199,Medical_Institutional,Paid,Electronic_EDI,2023-09-21,2023-09-21,2023-09-25,2023-09-25,Auto_Adjudicated,4,1323379997,1123879500,207RE0101X,Endocrinology,11,In_Network,OTHER,,revenue_code:0250,,0,Medicaid_MCO,MLTSS,17,F,1.0776,,,17912.18,11442.4,11442.4,0.0,0.0,0.0,6469.78,0.0,0.0,0,,0.0339,none,0,1,1,0,0,0.001059,0,0,,Shared_Savings
CLM0000003232,MBR00000235,Medical_Institutional,Paid,Electronic_EDI,2023-11-08,2023-11-08,2023-11-11,2023-12-06,Auto_Adjudicated,28,1207523397,1553094822,207R00000X,Internal Medicine,22,In_Network,M54.5,,revenue_code:0110,,0,Commercial,HDHP_HSA,85,F,1.4308,,,6593.61,5278.78,3862.42,450.76,0.0,965.6,1314.83,2587.34,836.14,0,,0.0338,none,0,1,0,1,0,0.000358,0,0,,FFS
CLM0000003233,MBR00000193,Pharmacy,Paid,Electronic_EDI,2023-08-14,2023-08-14,2023-08-14,2023-08-17,Auto_Adjudicated,3,1667149552,1368666316,2084P0800X,Psychiatry,11,Out_of_Network,F32.9,Z00.00|OTHER,00003014960,,4,Commercial,PPO,11,M,0.5266,,,90.44,39.8,0.0,39.8,0.0,0.0,50.64,0.0,0.0,0,,0.0059,none,0,1,0,0,0,0.0,1,1,,Capitation
CLM0000003234,MBR00000126,Medical_Institutional,Paid,Electronic_EDI,2023-09-05,2023-09-05,2023-09-07,2023-10-01,Manual_Review,26,1220710861,1177602659,2086S0122X,Orthopedic Surgery,32,In_Network,OTHER,OTHER,revenue_code:0370,,0,Medicaid_MCO,MLTSS,48,F,0.637,,,9331.46,7124.18,7118.18,0.0,6.0,0.0,2207.28,0.0,0.0,0,,0.0479,none,0,1,1,0,0,0.000659,0,0,FUM_Follow_Up_ED_Mental_Health,Shared_Savings
CLM0000003235,MBR00000282,Medical_Institutional,Paid,Electronic_EDI,2023-11-20,2023-11-20,2023-11-24,2023-11-25,Auto_Adjudicated,5,1170257806,1625992541,207RP1001X,Pulmonary Disease,24,In_Network,E78.5,,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,16,M,0.7304,,,5508.91,3070.35,2420.5,7.72,37.0,605.13,2438.56,0.0,0.0,0,,0.0994,none,0,1,0,1,0,0.000224,0,0,,Shared_Savings
CLM0000003236,MBR00000213,Pharmacy,Paid,Electronic_EDI,2023-10-07,2023-10-07,2023-10-07,2023-10-08,Auto_Adjudicated,1,1901547390,1396850418,207RG0100X,Gastroenterology,23,In_Network,F33.0,,16590051660,,3,Commercial,PPO,17,M,1.5857,,,209.28,124.04,0.0,124.04,0.0,0.0,85.24,0.0,0.0,0,,0.0068,none,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000003237,MBR00000160,Pharmacy,Paid,Electronic_EDI,2023-01-15,2023-01-15,2023-01-15,2023-01-17,Manual_Review,2,1424416273,1144950506,207RG0100X,Gastroenterology,22,In_Network,I48.91,OTHER|I10,00071012831,,1,Commercial,HMO,73,M,1.9608,,,91.21,69.44,0.0,69.44,0.0,0.0,21.77,0.0,0.0,0,,0.0787,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003238,MBR00000063,Pharmacy,Denied,Electronic_EDI,2023-10-05,2023-10-05,2023-10-05,2023-10-29,Clinical_Review,24,1175252466,1304018750,207RE0101X,Endocrinology,23,In_Network,E78.5,,00006001954,,1,ACA_Marketplace,ACA_Silver,56,M,0.8198,22,Network,202.4,91.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1772,upcoding_pattern,0,1,0,0,0,0.0,0,0,,P4P
CLM0000003239,MBR00000193,Medical_Professional,Paid,Electronic_EDI,2023-09-29,2023-09-29,2023-09-29,2023-10-10,Manual_Review,11,1175252466,1282319940,207RP1001X,Pulmonary Disease,22,In_Network,Z00.00,Z00.00,99211,,0,Commercial,PPO,11,M,0.5266,,,99.74,43.03,0.0,43.03,0.0,0.0,56.71,0.0,0.0,0,,0.1425,impossible_service_combo,0,1,0,0,0,0.0,0,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000003240,MBR00000178,Medical_Institutional,Paid,Provider_Portal,2023-03-23,2023-03-23,2023-03-27,2023-04-05,Clinical_Review,13,1424416273,1012893364,207Q00000X,Family Medicine,11,Out_of_Network,OTHER,E11.9|OTHER,revenue_code:0210,,0,Medicaid_MCO,MCO,89,M,0.7057,,,5804.62,2181.7,2181.7,0.0,0.0,0.0,3622.92,0.0,0.0,0,,0.135,none,0,1,0,0,0,0.000202,0,0,DDE_Diabetes_Short_Term_Complications,P4P
CLM0000003241,MBR00000204,Medical_Institutional,Denied,Electronic_EDI,2023-08-24,2023-08-24,2023-08-25,2023-09-18,Auto_Adjudicated,25,1181941909,1039962073,225100000X,Physical Therapist,31,In_Network,E78.5,I10|E11.9,revenue_code:0200,,0,Commercial,HMO,12,M,0.8716,1,Authorization,8222.51,5097.29,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0834,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003242,MBR00000231,Pharmacy,Paid,Electronic_EDI,2023-10-30,2023-10-30,2023-10-30,2023-11-07,Auto_Adjudicated,8,1741980770,1318978078,208600000X,Surgery General,22,In_Network,M54.5,E13.9|F41.1,00071015523,,3,ACA_Marketplace,ACA_Silver,12,M,0.6456,,,400.81,280.26,21.4,208.69,41.0,9.17,120.55,0.0,0.0,0,,0.1585,geographic_mismatch|controlled_substance_high_volume,0,1,0,1,0,2e-06,0,1,COL_Colorectal_Cancer_Screening,FFS
CLM0000003243,MBR00000276,Pharmacy,Denied,Electronic_EDI,2023-11-01,2023-11-01,2023-11-01,2023-11-18,Auto_Adjudicated,17,1864546991,1884259357,101YP2500X,Psychologist Clinical,11,In_Network,Z23,R05.9,00078043215,,4,Commercial,POS,38,M,0.8085,97,Network,112.76,91.81,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Code Substitution,1.0,outlier_billing_amount|geographic_mismatch|temporal_clustering|high_volume_same_code|benford_violation|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,0.0,0,1,,Shared_Savings
CLM0000003244,MBR00000287,Dental,Paid,Electronic_EDI,2023-11-09,2023-11-09,2023-11-09,2023-11-18,Auto_Adjudicated,9,1015411732,1068662623,225100000X,Physical Therapist,23,In_Network,Z00.00,E11.65|I25.10,D2391,,0,Commercial,PPO,4,M,0.7685,,,519.97,381.78,207.52,96.38,26.0,51.88,138.19,0.0,0.0,0,,0.0601,none,0,1,0,0,0,1.9e-05,0,0,SPC_Statin_Therapy,Shared_Savings
CLM0000003245,MBR00000187,Medical_Professional,Paid,Electronic_EDI,2023-10-07,2023-10-07,2023-10-07,2023-10-09,Clinical_Review,2,1924450526,1188760037,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,OTHER,97010,,0,Medicaid_MCO,MCO,36,F,1.191,,,186.25,122.78,119.78,0.0,3.0,0.0,63.47,0.0,0.0,0,,0.1207,service_date_weekend,0,1,0,0,0,1.1e-05,0,0,W30_Well_Child_Visit,FFS
CLM0000003246,MBR00000292,Pharmacy,Paid,Electronic_EDI,2023-02-13,2023-02-13,2023-02-13,2023-03-15,Clinical_Review,30,1889525696,1878874025,207R00000X,Internal Medicine,23,In_Network,OTHER,,00069420020,,4,Medicare_Advantage,MA_HMO,4,M,1.1779,,,276.83,167.26,107.85,29.44,3.0,26.96,109.57,0.0,0.0,0,,0.0007,none,0,1,0,0,0,1e-05,0,1,,Bundled_Payment
CLM0000003247,MBR00000275,Dental,Paid,Electronic_EDI,2023-06-24,2023-06-24,2023-06-24,2023-07-06,Auto_Adjudicated,12,1952322604,1274911960,225100000X,Physical Therapist,22,In_Network,OTHER,E11.9,D1110,,0,Medicare_Advantage,MA_PPO,67,M,0.8169,,,200.32,115.85,48.99,39.61,15.0,12.25,84.47,0.0,0.0,0,,0.008,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000003248,MBR00000002,Medical_Professional,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-25,2023-04-20,Manual_Review,26,1899326088,1764064254,2086S0122X,Orthopedic Surgery,23,Out_of_Network,I10,I10|Z23|N39.0,99204,,0,Commercial,PPO,42,F,0.9012,,,372.56,211.83,99.91,68.94,18.0,24.98,160.73,72.15,20.0,0,,0.1208,none,0,1,0,1,0,9e-06,1,0,AWV_Annual_Wellness_Visit,Capitation
CLM0000003249,MBR00000189,Medical_Professional,Paid,Electronic_EDI,2023-01-26,2023-01-26,2023-01-26,2023-02-08,Manual_Review,13,1518661623,1358873132,207R00000X,Internal Medicine,11,In_Network,OTHER,F41.1,97110,,0,Medicaid_MCO,MCO,71,F,0.9722,,,1010.67,760.95,756.95,0.0,4.0,0.0,249.72,0.0,0.0,0,,0.0916,none,0,1,0,0,0,7e-05,0,0,,FFS
CLM0000003250,MBR00000056,Medical_Professional,Paid,Electronic_EDI,2023-04-05,2023-04-05,2023-04-05,2023-05-02,Auto_Adjudicated,27,1084831484,1509799493,207RP1001X,Pulmonary Disease,23,In_Network,G47.33,J20.9,99385,,0,Commercial,EPO,74,F,1.3941,,,416.28,219.89,0.0,219.89,0.0,0.0,196.39,0.0,0.0,0,,0.1078,none,0,1,0,0,0,0.0,0,0,ACR_Urine_Protein,Shared_Savings
CLM0000003251,MBR00000092,Medical_Institutional,Paid,Electronic_EDI,2023-11-23,2023-11-23,2023-11-24,2023-11-29,Auto_Adjudicated,6,1374458552,1358873132,101YP2500X,Psychologist Clinical,23,In_Network,J44.1,F41.1,revenue_code:0100,,0,Medicaid_MCO,MLTSS,68,F,1.3217,,,7174.87,3638.97,3629.97,0.0,9.0,0.0,3535.9,0.0,0.0,0,,0.0031,none,0,1,0,0,0,0.000336,0,0,BPD_BP_Declined,FFS
CLM0000003252,MBR00000093,Medical_Institutional,Paid,Electronic_EDI,2023-08-03,2023-08-03,2023-08-07,2023-08-20,Manual_Review,17,1793630905,1576271272,207RP1001X,Pulmonary Disease,24,In_Network,F10.10,M17.11|OTHER,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,43,F,0.6162,,,22171.37,17655.95,14057.39,43.22,41.0,3514.35,4515.42,0.0,0.0,0,,0.0826,none,0,1,1,0,0,0.001301,0,0,,FFS
CLM0000003253,MBR00000149,Medical_Professional,Paid,Electronic_EDI,2023-10-02,2023-10-02,2023-10-02,2023-10-14,Auto_Adjudicated,12,1797494973,1291071007,207RE0101X,Endocrinology,22,In_Network,Z00.121,Z00.00,90837,,0,Commercial,PPO,42,F,0.5458,,,1910.16,1500.94,845.29,412.33,32.0,211.32,409.22,0.0,0.0,0,,0.0454,none,0,1,0,0,0,7.8e-05,0,0,,Shared_Savings
CLM0000003254,MBR00000004,Medical_Institutional,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-30,Auto_Adjudicated,30,1340676357,1560230600,2084P0800X,Psychiatry,23,In_Network,Z23,OTHER,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,68,M,1.23,,,19312.78,13872.23,11039.7,19.6,53.0,2759.93,5440.55,0.0,0.0,1,Kickback Arrangement,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|impossible_service_combo|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,1,0,0,0.001022,0,0,CDC_BP_Control,FFS
CLM0000003255,MBR00000074,Pharmacy,Denied,Provider_Portal,2023-05-08,2023-05-08,2023-05-08,2023-05-19,Manual_Review,11,1618546650,1098360555,207RE0101X,Endocrinology,22,In_Network,I25.10,,00071012831,,3,Medicare_Advantage,MA_PPO,21,F,0.8719,3,Duplicate,317.75,215.22,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0932,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003256,MBR00000010,Dental,Paid,Electronic_EDI,2023-06-23,2023-06-23,2023-06-23,2023-07-17,Manual_Review,24,1826919173,1473869105,207V00000X,Obstetrics & Gynecology,11,In_Network,I25.10,,D2140,,0,Medicare_Advantage,MA_HMO,44,F,1.4631,,,63.43,33.74,0.0,33.74,0.0,0.0,29.69,0.0,0.0,0,,0.1303,provider_specialty_mismatch,0,1,0,1,0,0.0,0,0,MPT_Annual_Monitoring,Bundled_Payment
CLM0000003257,MBR00000193,Pharmacy,Paid,Electronic_EDI,2023-12-20,2023-12-20,2023-12-20,2024-01-04,Manual_Review,15,1377412382,1175334579,208600000X,Surgery General,11,In_Network,Z00.00,J44.1,00078043215,,1,Commercial,PPO,11,M,0.5266,,,82.08,60.18,0.0,39.08,21.1,0.0,21.9,0.0,0.0,0,,0.0772,none,0,1,0,1,0,0.0,0,0,SPD_Spirometry_Testing,Shared_Savings
CLM0000003258,MBR00000270,Dental,Paid,Electronic_EDI,2023-04-14,2023-04-14,2023-04-14,2023-04-27,Auto_Adjudicated,13,1421421733,1114756459,2084P0800X,Psychiatry,21,In_Network,Z00.00,Z00.00|N18.3,D3310,,0,Commercial,POS,1,F,1.6363,,,1330.45,988.18,588.39,240.69,12.0,147.1,342.27,0.0,0.0,1,Unbundling,1.0,outlier_billing_amount|geographic_mismatch|high_volume_same_code|benford_violation|upcoding_pattern|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,1,0,5.4e-05,0,0,,FFS
CLM0000003259,MBR00000300,Medical_Institutional,Paid,Paper,2023-04-22,2023-04-22,2023-04-24,2023-05-13,Auto_Adjudicated,21,1915327071,1061149198,207RC0000X,Cardiovascular Disease,31,In_Network,F32.9,E13.9,revenue_code:0200,,0,Commercial,PPO,64,F,1.0393,,,9884.53,5956.25,4725.46,1.42,48.0,1181.37,3928.28,0.0,0.0,0,,0.0242,none,0,1,0,0,0,0.000437,0,0,,FFS
CLM0000003260,MBR00000140,Pharmacy,Paid,Electronic_EDI,2023-11-01,2023-11-01,2023-11-01,2023-11-21,Auto_Adjudicated,20,1739169232,1148612764,207Q00000X,Family Medicine,21,In_Network,E11.65,N39.0,00078043215,,2,Medicare_Advantage,MA_HMO,7,M,1.3997,,,84.75,46.1,21.64,7.04,12.0,5.41,38.65,0.0,0.0,0,,0.0131,none,0,1,0,0,0,2e-06,0,0,,Capitation
CLM0000003261,MBR00000081,Medical_Institutional,Paid,Electronic_EDI,2023-05-14,2023-05-14,2023-05-15,2023-05-29,Auto_Adjudicated,15,1679629515,1177602659,246ZN0300X,Neuropsychology,24,In_Network,C50.911,K21.0,revenue_code:0200,,0,Medicare_Advantage,SNP,66,F,2.159,,,12290.7,5030.03,3982.89,7.41,44.0,995.72,7260.67,0.0,0.0,0,,0.1414,none,0,1,0,0,0,0.000369,0,0,,Capitation
CLM0000003262,MBR00000257,Dental,Paid,Paper,2023-11-21,2023-11-21,2023-11-21,2023-11-23,Auto_Adjudicated,2,1733777382,1538261819,246ZN0300X,Neuropsychology,23,In_Network,M25.511,E78.5,D0150,,0,Medicaid_MCO,MCO,76,F,0.8322,,,254.52,162.75,161.75,0.0,1.0,0.0,91.77,0.0,0.0,0,,0.0489,none,0,1,0,1,0,1.5e-05,0,0,,FFS
CLM0000003263,MBR00000035,Dental,Paid,Electronic_EDI,2023-12-16,2023-12-16,2023-12-16,2023-12-19,Auto_Adjudicated,3,1588313061,1391074619,207R00000X,Internal Medicine,21,In_Network,I25.10,N18.3|OTHER,D4341,,0,ACA_Marketplace,ACA_Platinum,46,M,0.6598,,,122.71,74.91,0.0,74.91,0.0,0.0,47.8,0.0,0.0,0,,0.057,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003264,MBR00000293,Pharmacy,Paid,Electronic_EDI,2023-01-24,2023-01-24,2023-01-24,2023-02-11,Manual_Review,18,1981853293,1297948643,207RE0101X,Endocrinology,11,Out_of_Network,E78.5,Z23|M47.816,59148001506,,2,Medicare_Advantage,MA_HMO,84,F,2.8513,,,510.33,341.21,245.21,23.7,11.0,61.3,169.12,0.0,0.0,0,,0.1396,duplicate_claim_indicator,0,1,0,0,0,2.3e-05,1,1,,Bundled_Payment
CLM0000003265,MBR00000212,Medical_Institutional,Paid,Electronic_EDI,2023-08-28,2023-08-28,2023-08-31,2023-08-30,Auto_Adjudicated,2,1205744244,1005335812,208600000X,Surgery General,21,Out_of_Network,F33.0,Z00.00|K21.0,revenue_code:0210,682,0,Commercial,HMO,57,F,2.5456,,,6420.65,2290.36,1510.1,334.73,68.0,377.53,4130.29,0.0,0.0,0,,0.0112,none,0,1,0,1,0,0.00014,0,0,,Bundled_Payment
CLM0000003266,MBR00000156,Medical_Professional,Paid,Paper,2023-02-03,2023-02-03,2023-02-03,2023-02-22,Auto_Adjudicated,19,1988579666,1112696614,207V00000X,Obstetrics & Gynecology,21,In_Network,E78.5,,99204,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,244.42,161.87,101.63,21.83,13.0,25.41,82.55,0.0,0.0,0,,0.0247,none,0,1,0,0,0,9e-06,0,0,PCR_Plan_All_Cause_Readmission,Capitation
CLM0000003267,MBR00000028,Medical_Professional,Paid,Electronic_EDI,2023-11-12,2023-11-12,2023-11-12,2023-12-09,Auto_Adjudicated,27,1903785749,1588993671,225100000X,Physical Therapist,11,In_Network,OTHER,OTHER|Z23,99285,,0,Commercial,HMO,3,F,2.116,,,114.8,87.39,44.16,18.19,14.0,11.04,27.41,0.0,0.0,0,,0.0221,none,0,1,0,0,0,4e-06,0,0,,Capitation
CLM0000003268,MBR00000006,Medical_Professional,Denied,Electronic_EDI,2023-02-11,2023-02-11,2023-02-11,2023-03-07,Auto_Adjudicated,24,1120678352,1912895973,207RG0100X,Gastroenterology,31,In_Network,Z23,,99212,,0,Commercial,EPO,88,M,1.4365,2,Duplicate,214.27,138.09,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0134,none,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000003269,MBR00000166,Medical_Professional,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-12-06,Auto_Adjudicated,21,1918359820,1513198866,207RP1001X,Pulmonary Disease,71,In_Network,OTHER,,99396,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,463.02,266.68,0.0,266.68,0.0,0.0,196.34,0.0,0.0,0,,0.1549,unbundling_pattern,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003270,MBR00000131,Medical_Institutional,Paid,Electronic_EDI,2023-10-04,2023-10-04,2023-10-08,2023-10-13,Manual_Review,9,1193571728,1287472731,207RN0300X,Nephrology,11,In_Network,I10,E11.65,revenue_code:0100,,0,Commercial,EPO,15,F,0.9228,,,27736.72,23516.91,18451.34,414.73,38.0,4612.84,4219.81,0.0,0.0,0,,0.0833,none,0,1,1,0,0,0.001708,0,0,,FFS
CLM0000003271,MBR00000252,Medical_Professional,Paid,Electronic_EDI,2023-07-12,2023-07-12,2023-07-12,2023-08-01,Auto_Adjudicated,20,1205349488,1148659045,207RP1001X,Pulmonary Disease,11,In_Network,Z87.891,,99385,,0,Medicare_Advantage,MA_HMO,80,M,0.7173,,,283.56,186.29,102.6,43.04,15.0,25.65,97.27,0.0,0.0,0,,0.0718,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000003272,MBR00000191,Dental,Paid,Electronic_EDI,2023-03-16,2023-03-16,2023-03-16,2023-03-22,Auto_Adjudicated,6,1618564043,1012893364,225100000X,Physical Therapist,23,In_Network,K21.0,,D2140,,0,Commercial,POS,85,F,0.9729,,,240.58,180.19,77.49,45.33,38.0,19.37,60.39,0.0,0.0,0,,0.1172,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000003273,MBR00000135,Medical_Institutional,Denied,Electronic_EDI,2023-04-06,2023-04-06,2023-04-07,2023-05-04,Manual_Review,28,1484613641,1144950506,101YP2500X,Psychologist Clinical,71,In_Network,I10,,revenue_code:0450,,0,Commercial,PPO,58,F,2.2702,PR-1,COB,12282.16,5662.57,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0942,none,0,1,0,0,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,P4P
CLM0000003274,MBR00000070,Pharmacy,Paid,Electronic_EDI,2023-06-04,2023-06-04,2023-06-04,2023-06-07,Auto_Adjudicated,3,1735391772,1972530373,208600000X,Surgery General,65,In_Network,E11.65,I10,00085163102,,1,Commercial,POS,42,F,0.8468,,,269.75,120.58,33.1,64.2,15.0,8.28,149.17,0.0,0.0,0,,0.0218,none,0,1,0,0,0,3e-06,0,0,FLU_Flu_Vaccination,P4P
CLM0000003275,MBR00000148,Medical_Institutional,Paid,Electronic_EDI,2023-11-01,2023-11-01,2023-11-02,2023-11-18,Auto_Adjudicated,17,1482771601,1012893364,207Q00000X,Family Medicine,65,In_Network,E11.9,,revenue_code:0210,,0,Commercial,EPO,51,F,0.6534,,,3119.38,2532.27,1977.9,12.89,47.0,494.48,587.11,0.0,0.0,0,,0.0932,none,0,1,0,0,0,0.000183,0,0,,Capitation
CLM0000003276,MBR00000052,Medical_Professional,Paid,Electronic_EDI,2023-11-19,2023-11-19,2023-11-19,2023-12-04,Auto_Adjudicated,15,1181941909,1513198866,101YP2500X,Psychologist Clinical,22,In_Network,E78.5,M54.5|I50.9,81001,,0,Commercial,PPO,0,F,1.325,,,774.64,630.31,308.85,212.25,32.0,77.21,144.33,0.0,0.0,0,,0.1271,none,0,1,0,1,0,2.9e-05,0,0,,FFS
CLM0000003277,MBR00000198,Medical_Professional,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-03,Clinical_Review,3,1394029346,1209882852,207RN0300X,Nephrology,81,In_Network,F32.9,OTHER,99284,,0,Medicaid_MCO,MCO,81,F,1.4199,,,410.77,170.12,168.12,0.0,2.0,0.0,240.65,0.0,0.0,0,,0.0145,none,0,1,0,0,0,1.6e-05,0,0,,FFS
CLM0000003278,MBR00000183,Dental,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-25,2023-03-31,Manual_Review,6,1924450526,1040061910,207RN0300X,Nephrology,21,In_Network,J06.9,Z00.01,D4341,,0,Commercial,PPO,51,M,0.8463,,,337.57,280.79,2.4,238.79,39.0,0.6,56.78,0.0,0.0,0,,0.0949,none,0,1,0,0,0,0.0,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000003279,MBR00000241,Medical_Professional,Paid,Electronic_EDI,2023-07-22,2023-07-22,2023-07-22,2023-08-13,Auto_Adjudicated,22,1906448800,1542515060,207R00000X,Internal Medicine,11,In_Network,Z12.11,OTHER,99283,,0,Medicare_Advantage,MA_HMO,77,M,1.2169,,,277.29,198.14,128.38,20.67,17.0,32.09,79.15,0.0,0.0,0,,0.0058,none,0,1,0,0,0,1.2e-05,0,0,CDC_HbA1c_Poor_Control,Shared_Savings
CLM0000003280,MBR00000140,Pharmacy,Paid,Electronic_EDI,2023-10-26,2023-10-26,2023-10-26,2023-11-13,Auto_Adjudicated,18,1617763056,1591405274,207RN0300X,Nephrology,23,In_Network,Z12.11,OTHER|I10,00085163102,,2,Medicare_Advantage,MA_HMO,7,M,1.3997,,,100.67,50.29,13.67,21.2,12.0,3.42,50.38,0.0,0.0,0,,0.0884,none,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000003281,MBR00000087,Medical_Professional,Denied,Electronic_EDI,2023-07-14,2023-07-14,2023-07-14,2023-07-19,Auto_Adjudicated,5,1214787184,1473869105,207RC0000X,Cardiovascular Disease,22,Out_of_Network,Z00.00,Z00.00|J06.9,85025,,0,Medicaid_MCO,MCO,70,F,0.9232,4,Timely_Filing,800.31,367.32,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.009,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003282,MBR00000250,Medical_Professional,Paid,Electronic_EDI,2023-11-16,2023-11-16,2023-11-16,2023-11-21,Auto_Adjudicated,5,1889525696,1767402068,101YP2500X,Psychologist Clinical,24,In_Network,J06.9,,99393,,0,Commercial,PPO,41,M,0.9245,,,1395.65,943.09,440.33,368.68,24.0,110.08,452.56,0.0,0.0,1,Unbundling,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|impossible_service_combo|duplicate_claim_indicator|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,4.1e-05,0,0,SPC_Statin_Therapy,Capitation
CLM0000003283,MBR00000206,Medical_Professional,Paid,Electronic_EDI,2023-01-04,2023-01-04,2023-01-04,2023-01-24,Manual_Review,20,1274357072,1554490060,207RE0101X,Endocrinology,22,In_Network,Z12.11,OTHER|K21.0,27447,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,12030.5,4796.78,4795.78,0.0,1.0,0.0,7233.72,0.0,0.0,0,,0.0311,none,0,1,0,0,0,0.000444,0,0,PPC_Prenatal_Care,Shared_Savings
CLM0000003284,MBR00000209,Medical_Institutional,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-07-01,2023-07-20,Manual_Review,20,1508520529,1415734567,207R00000X,Internal Medicine,31,In_Network,J44.1,M54.5,revenue_code:0370,,0,Medicare_Advantage,MA_HMO,10,F,0.5199,,,8566.11,6041.75,4802.66,15.42,23.0,1200.67,2524.36,0.0,0.0,0,,0.0082,none,0,1,0,1,0,0.000445,0,0,,Bundled_Payment
CLM0000003285,MBR00000160,Medical_Professional,Paid,Electronic_EDI,2023-01-17,2023-01-17,2023-01-17,2023-01-30,Clinical_Review,13,1424104563,1789540567,207RP1001X,Pulmonary Disease,21,In_Network,F41.1,OTHER|I10|Z79.4,99232,,0,Commercial,HMO,73,M,1.9608,,,554.22,421.81,134.86,230.23,23.0,33.72,132.41,0.0,0.0,0,,0.1173,none,0,1,0,0,0,1.2e-05,0,0,,Shared_Savings
CLM0000003286,MBR00000264,Dental,Paid,Electronic_EDI,2023-08-08,2023-08-08,2023-08-08,2023-08-09,Auto_Adjudicated,1,1141106555,1027261156,207RE0101X,Endocrinology,11,In_Network,I10,Z12.11,D2140,,0,ACA_Marketplace,ACA_Bronze,12,F,0.5826,,,500.16,302.34,0.0,302.34,0.0,0.0,197.82,0.0,0.0,0,,0.0512,none,0,1,0,1,0,0.0,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000003287,MBR00000071,Medical_Professional,Paid,Paper,2023-08-10,2023-08-10,2023-08-10,2023-08-11,Auto_Adjudicated,1,1061181028,1325999602,207RN0300X,Nephrology,24,In_Network,J44.1,,99214,,0,Commercial,EPO,19,F,0.5699,,,373.24,284.71,189.5,25.83,22.0,47.38,88.53,0.0,0.0,0,,0.0167,none,0,1,0,0,0,1.8e-05,0,0,,FFS
CLM0000003288,MBR00000128,Medical_Professional,Paid,Provider_Portal,2023-04-23,2023-04-23,2023-04-23,2023-04-28,Auto_Adjudicated,5,1474985672,1220755708,207R00000X,Internal Medicine,22,In_Network,Z00.00,OTHER|Z00.121,99393,,0,Commercial,PPO,13,F,1.4203,,,113.37,77.92,0.0,77.92,0.0,0.0,35.45,0.0,0.0,0,,0.0333,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000003289,MBR00000236,Medical_Professional,Denied,Electronic_EDI,2023-10-13,2023-10-13,2023-10-13,2023-10-15,Auto_Adjudicated,2,1887363539,1867389043,207RP1001X,Pulmonary Disease,11,In_Network,M54.5,,97140,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,3,COB,1233.17,788.35,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1257,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003290,MBR00000041,Behavioral_Health,Paid,Electronic_EDI,2023-12-08,2023-12-08,2023-12-08,2023-12-25,Auto_Adjudicated,17,1983779639,1132693989,207RE0101X,Endocrinology,21,In_Network,F33.0,I25.10|OTHER,73721,,0,Commercial,PPO,42,F,0.8283,,,191.21,107.72,0.0,107.72,0.0,0.0,83.49,0.0,0.0,0,,0.1217,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003291,MBR00000239,Medical_Institutional,Paid,Paper,2023-06-14,2023-06-14,2023-06-17,2023-06-26,Auto_Adjudicated,12,1496340237,1489434038,207RN0300X,Nephrology,24,In_Network,F33.0,M17.11,revenue_code:0360,,0,Commercial,HMO,1,F,1.1193,,,14806.13,10011.8,7842.2,144.05,65.0,1960.55,4794.33,0.0,0.0,0,,0.1226,none,0,1,1,0,0,0.000726,0,0,,P4P
CLM0000003292,MBR00000111,Medical_Institutional,Paid,Electronic_EDI,2023-06-06,2023-06-06,2023-06-07,2023-06-13,Manual_Review,7,1688560518,1288028182,207RE0101X,Endocrinology,65,In_Network,I10,,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,44,M,0.7462,,,6359.88,5324.3,4223.47,16.97,28.0,1055.87,1035.58,0.0,0.0,0,,0.0122,none,0,1,0,0,0,0.000391,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000003293,MBR00000038,Medical_Institutional,Paid,Electronic_EDI,2023-03-10,2023-03-10,2023-03-13,2023-03-28,Auto_Adjudicated,18,1893886964,1616762819,208600000X,Surgery General,24,In_Network,J06.9,,revenue_code:0450,,0,Commercial,EPO,46,M,1.1295,,,52960.37,21656.02,17246.23,27.24,71.0,4311.56,31304.35,0.0,0.0,0,,0.1842,outlier_billing_amount,0,1,1,0,0,0.001596,0,0,,FFS
CLM0000003294,MBR00000024,Dental,Paid,Electronic_EDI,2023-01-11,2023-01-11,2023-01-11,2023-02-02,Auto_Adjudicated,22,1177281088,1151295616,2086S0122X,Orthopedic Surgery,23,In_Network,F32.9,,D7140,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,194.99,84.7,81.7,0.0,3.0,0.0,110.29,0.0,0.0,0,,0.0669,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000003295,MBR00000252,Medical_Professional,Paid,Electronic_EDI,2023-05-26,2023-05-26,2023-05-26,2023-06-01,Auto_Adjudicated,6,1721465780,1034732777,207V00000X,Obstetrics & Gynecology,24,In_Network,Z23,,27447,,0,Medicare_Advantage,MA_HMO,80,M,0.7173,,,70607.46,48119.56,38479.74,4.89,15.0,9619.93,22487.9,0.0,0.0,0,,0.0692,outlier_billing_amount,0,1,1,1,0,0.003562,0,0,,FFS
CLM0000003296,MBR00000229,Pharmacy,Denied,Electronic_EDI,2023-06-08,2023-06-08,2023-06-08,2023-06-27,Clinical_Review,19,1404237143,1148612764,246ZN0300X,Neuropsychology,11,In_Network,E13.9,OTHER,00085163102,,1,Medicare_Advantage,PFFS,63,M,1.1626,96,Authorization,184.18,155.13,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1325,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003297,MBR00000091,Pharmacy,Denied,Electronic_EDI,2023-10-03,2023-10-03,2023-10-03,2023-10-07,Auto_Adjudicated,4,1736809698,1625992541,207R00000X,Internal Medicine,22,In_Network,K29.70,OTHER|N18.3,00071012831,,2,Commercial,PPO,13,F,1.2451,170,Duplicate,157.44,94.43,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0842,none,0,1,0,0,0,0.0,0,1,AMR_Asthma_Medication_Ratio,FFS
CLM0000003298,MBR00000036,Medical_Professional,Paid,Electronic_EDI,2023-11-06,2023-11-06,2023-11-06,2023-11-24,Auto_Adjudicated,18,1083045036,1575884274,207RE0101X,Endocrinology,22,Out_of_Network,Z00.00,,90847,,0,Commercial,EPO,17,M,2.0136,,,350.31,191.98,51.48,94.63,33.0,12.87,158.33,0.0,0.0,0,,0.018,none,0,1,0,0,0,5e-06,1,0,,P4P
CLM0000003299,MBR00000076,Medical_Professional,Denied,Electronic_EDI,2023-02-08,2023-02-08,2023-02-08,2023-02-20,Auto_Adjudicated,12,1231231881,1704466150,207RN0300X,Nephrology,71,In_Network,J45.20,,74178,,0,Commercial,HMO,26,M,2.1785,4,Duplicate,450.82,374.27,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1249,service_date_weekend,0,1,0,0,0,0.0,0,0,,P4P
CLM0000003300,MBR00000065,Medical_Institutional,Paid,Electronic_EDI,2023-02-24,2023-02-24,2023-02-25,2023-02-28,Auto_Adjudicated,4,1141106555,1625992541,246ZN0300X,Neuropsychology,11,In_Network,OTHER,OTHER|I10,revenue_code:0210,,0,Commercial,HDHP_HSA,63,M,0.7795,,,9993.43,4890.97,3601.36,389.27,0.0,900.34,5102.46,0.0,0.0,0,,0.0097,none,0,1,0,0,0,0.000333,0,0,,Shared_Savings
CLM0000003301,MBR00000214,Medical_Professional,Paid,Provider_Portal,2023-07-21,2023-07-21,2023-07-21,2023-08-15,Auto_Adjudicated,25,1034130209,1469881892,208600000X,Surgery General,81,In_Network,OTHER,,27130,,0,Commercial,HDHP_HSA,76,M,1.7526,,,19780.89,10175.83,7638.16,628.14,0.0,1909.54,9605.06,0.0,0.0,0,,0.1409,none,0,1,1,0,0,0.000707,0,0,,FFS
CLM0000003302,MBR00000066,Medical_Professional,Paid,Electronic_EDI,2023-05-15,2023-05-15,2023-05-15,2023-05-21,Auto_Adjudicated,6,1176378924,1039962073,207Q00000X,Family Medicine,23,In_Network,Z00.00,E78.5|K21.0,99282,,0,Medicaid_MCO,MCO,54,M,0.6083,,,366.69,205.71,202.71,0.0,3.0,0.0,160.98,0.0,0.0,0,,0.1492,phantom_billing_indicator,0,1,0,0,0,1.9e-05,0,0,ACR_Urine_Protein,Bundled_Payment
CLM0000003303,MBR00000066,Medical_Institutional,Paid,Electronic_EDI,2023-09-10,2023-09-10,2023-09-13,2023-10-04,Auto_Adjudicated,24,1882720848,1055872102,246ZN0300X,Neuropsychology,11,Out_of_Network,OTHER,,revenue_code:0360,,0,Medicaid_MCO,MCO,54,M,0.6083,,,9946.01,6063.72,6063.72,0.0,0.0,0.0,3882.29,5383.96,432.27,0,,0.2453,impossible_service_combo|upcoding_pattern,0,2,1,0,0,0.000561,1,0,LCS_Lung_Cancer_Screening,FFS
CLM0000003304,MBR00000010,Medical_Professional,Denied,Paper,2023-04-26,2023-04-26,2023-04-26,2023-05-07,Auto_Adjudicated,11,1889525696,1527857018,207RP1001X,Pulmonary Disease,22,In_Network,I10,E11.9|OTHER,99205,,0,Medicare_Advantage,MA_HMO,44,F,1.4631,50,COB,366.55,138.2,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.182,benford_violation,0,1,0,0,0,0.0,0,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000003305,MBR00000180,Pharmacy,Paid,Electronic_EDI,2023-05-30,2023-05-30,2023-05-30,2023-06-20,Manual_Review,21,1513407277,1148659045,2086S0122X,Orthopedic Surgery,11,In_Network,J06.9,I10|F32.9,00071015523,,4,Medicare_Advantage,MA_PPO,72,F,1.1909,,,463.67,255.62,179.55,14.19,17.0,44.89,208.05,0.0,0.0,0,,0.0868,impossible_service_combo,0,1,0,0,0,1.7e-05,0,1,,FFS
CLM0000003306,MBR00000205,Medical_Institutional,Paid,Electronic_EDI,2023-06-09,2023-06-09,2023-06-09,2023-07-01,Manual_Review,22,1403662694,1789540567,2084P0800X,Psychiatry,22,In_Network,Z12.11,,revenue_code:0360,,0,Medicaid_MCO,MCO,1,F,0.9425,,,31117.07,19956.67,19948.67,0.0,8.0,0.0,11160.4,0.0,0.0,0,,0.0649,none,0,1,1,0,0,0.001846,0,0,,Shared_Savings
CLM0000003307,MBR00000194,Medical_Institutional,Denied,Electronic_EDI,2023-08-04,2023-08-04,2023-08-05,2023-08-17,Clinical_Review,13,1181941909,1291071007,207RG0100X,Gastroenterology,22,Out_of_Network,M54.5,N39.0,revenue_code:0450,,0,Commercial,PPO,77,M,0.9783,PR-1,Authorization,21092.88,8686.8,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0656,none,0,1,0,0,0,0.0,1,0,,FFS
CLM0000003308,MBR00000170,Medical_Institutional,Paid,Electronic_EDI,2023-01-26,2023-01-26,2023-01-27,2023-02-16,Auto_Adjudicated,21,1313587359,1132693989,207RN0300X,Nephrology,24,In_Network,M54.5,OTHER,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,18825.02,10929.14,8683.9,28.27,46.0,2170.97,7895.88,0.0,0.0,0,,0.019,none,0,1,1,0,0,0.000804,0,0,,Bundled_Payment
CLM0000003309,MBR00000293,Medical_Institutional,Paid,Electronic_EDI,2023-11-14,2023-11-14,2023-11-16,2023-11-28,Auto_Adjudicated,14,1091395764,1878874025,2084P0800X,Psychiatry,22,In_Network,I10,,revenue_code:0360,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,4621.24,2327.46,1800.14,45.28,32.0,450.04,2293.78,0.0,0.0,0,,0.1177,none,0,1,0,0,0,0.000167,0,0,,Capitation
CLM0000003310,MBR00000144,Medical_Institutional,Paid,Electronic_EDI,2023-05-02,2023-05-02,2023-05-05,2023-05-21,Manual_Review,19,1780111559,1589482133,207RN0300X,Nephrology,24,In_Network,G47.33,E78.5,revenue_code:0210,,0,Commercial,HDHP_HSA,56,F,2.5926,,,14482.58,5876.47,4289.16,515.02,0.0,1072.29,8606.11,0.0,0.0,0,,0.1154,npi_mismatch,0,1,0,1,0,0.000397,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000003311,MBR00000259,Dental,Paid,Electronic_EDI,2023-03-18,2023-03-18,2023-03-18,2023-03-25,Manual_Review,7,1470105939,1774401124,2084P0800X,Psychiatry,21,In_Network,I25.10,OTHER|E78.5,D1110,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,182.56,147.51,106.43,7.47,7.0,26.61,35.05,0.0,0.0,0,,0.0603,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000003312,MBR00000192,Medical_Professional,Denied,Provider_Portal,2023-08-18,2023-08-18,2023-08-18,2023-08-31,Auto_Adjudicated,13,1771383741,1388050552,101YP2500X,Psychologist Clinical,31,In_Network,N18.3,I10|E78.5,99381,,0,Medicaid_MCO,MCO,22,F,1.1739,2,Duplicate,465.58,246.28,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0428,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000003313,MBR00000025,Medical_Institutional,Paid,Electronic_EDI,2023-02-18,2023-02-18,2023-02-21,2023-02-23,Auto_Adjudicated,5,1216417633,1319611206,208600000X,Surgery General,32,In_Network,N39.0,,revenue_code:0370,,0,Commercial,POS,74,M,1.3309,,,15558.86,9280.08,7196.73,215.17,69.0,1799.18,6278.78,0.0,0.0,0,,0.1059,none,0,1,1,0,0,0.000666,0,0,SPC_Statin_Therapy,FFS
CLM0000003314,MBR00000241,Pharmacy,Denied,Electronic_EDI,2023-07-31,2023-07-31,2023-07-31,2023-08-13,Auto_Adjudicated,13,1213747973,1354959095,207V00000X,Obstetrics & Gynecology,23,In_Network,E11.9,OTHER|I10,00085163102,,2,Medicare_Advantage,MA_HMO,77,M,1.2169,CO-45,Eligibility,444.4,272.14,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0644,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003315,MBR00000176,Medical_Institutional,Paid,Electronic_EDI,2023-01-22,2023-01-22,2023-01-26,2023-01-23,Auto_Adjudicated,1,1356562955,1829216053,207RP1001X,Pulmonary Disease,11,In_Network,I25.10,,revenue_code:0360,,0,Commercial,POS,4,M,0.8792,,,34559.02,14962.79,11919.46,23.47,40.0,2979.86,19596.23,0.0,0.0,0,,0.1179,none,0,1,1,0,0,0.001103,0,0,,Bundled_Payment
CLM0000003316,MBR00000194,Medical_Professional,Paid,Electronic_EDI,2023-04-05,2023-04-05,2023-04-05,2023-04-18,Auto_Adjudicated,13,1564110057,1133410177,207RG0100X,Gastroenterology,81,Emergency,R05.9,,27130,,0,Commercial,PPO,77,M,0.9783,,,47480.06,30066.5,23947.76,113.8,18.0,5986.94,17413.56,0.0,0.0,1,Code Substitution,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|benford_violation|impossible_service_combo|billing_spike_recent|duplicate_claim_indicator|unbundling_pattern|phantom_billing_indicator|npi_mismatch,1,5,1,1,0,0.002217,0,0,,FFS
CLM0000003317,MBR00000056,Medical_Professional,Denied,Electronic_EDI,2023-09-18,2023-09-18,2023-09-18,2023-10-14,Manual_Review,26,1543927384,1177602659,2086S0122X,Orthopedic Surgery,31,In_Network,Z00.00,,99395,,0,Commercial,EPO,74,F,1.3941,5,COB,91.24,43.15,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0365,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003318,MBR00000137,Medical_Institutional,Paid,Electronic_EDI,2023-05-14,2023-05-14,2023-05-17,2023-05-25,Manual_Review,11,1267286378,1352413270,2084P0800X,Psychiatry,31,In_Network,OTHER,Z00.00,revenue_code:0370,,0,Commercial,PPO,87,M,0.5201,,,19559.27,12763.03,10137.45,31.22,60.0,2534.36,6796.24,0.0,0.0,0,,0.0927,none,0,1,1,0,0,0.000938,0,0,,Capitation
CLM0000003319,MBR00000266,Pharmacy,Paid,Electronic_EDI,2023-11-20,2023-11-20,2023-11-20,2023-12-05,Auto_Adjudicated,15,1298243993,1390802135,246ZN0300X,Neuropsychology,11,In_Network,I25.10,,00085163102,,2,Commercial,EPO,14,M,1.075,,,157.35,64.3,0.0,64.3,0.0,0.0,93.05,0.0,0.0,0,,0.0725,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003320,MBR00000066,Pharmacy,Paid,Electronic_EDI,2023-05-08,2023-05-08,2023-05-08,2023-06-03,Auto_Adjudicated,26,1110312325,1489993356,207RG0100X,Gastroenterology,31,In_Network,M79.3,,59148001506,,2,Medicaid_MCO,MCO,54,M,0.6083,,,341.46,254.73,251.73,0.0,3.0,0.0,86.73,0.0,0.0,0,,0.1434,none,0,1,0,1,0,2.3e-05,0,0,,FFS
CLM0000003321,MBR00000001,Pharmacy,Paid,Paper,2023-09-05,2023-09-05,2023-09-05,2023-09-06,Auto_Adjudicated,1,1641779816,1995553359,207Q00000X,Family Medicine,11,In_Network,E11.65,E78.5,50458085930,,2,Commercial,EPO,73,M,0.6527,,,314.69,246.0,0.0,246.0,0.0,0.0,68.69,0.0,0.0,0,,0.1216,none,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000003322,MBR00000080,Medical_Professional,Paid,Paper,2023-01-11,2023-01-11,2023-01-11,2023-02-01,Auto_Adjudicated,21,1274357072,1894215172,207RP1001X,Pulmonary Disease,22,Out_of_Network,E13.9,J20.9|J06.9|I10,99231,,0,Commercial,HDHP_HSA,74,M,0.5935,,,377.66,317.31,0.0,317.31,0.0,0.0,60.35,0.0,0.0,0,,0.1278,none,0,1,0,0,0,0.0,1,0,,Shared_Savings
CLM0000003323,MBR00000151,Pharmacy,Paid,Paper,2023-12-17,2023-12-17,2023-12-17,2024-01-02,Auto_Adjudicated,16,1633089013,1498781755,225100000X,Physical Therapist,23,Out_of_Network,R05.9,J06.9,16590051660,,2,Medicare_Advantage,MA_HMO,77,M,0.8709,,,219.34,174.98,129.63,6.94,6.0,32.41,44.36,84.77,39.62,0,,0.0222,none,0,1,0,0,0,1.2e-05,1,1,DAE_Drug_Alcohol_Dependence,FFS
CLM0000003324,MBR00000245,Medical_Institutional,Denied,Electronic_EDI,2023-08-10,2023-08-10,2023-08-10,2023-08-21,Manual_Review,11,1838794554,1564636990,207V00000X,Obstetrics & Gynecology,21,Out_of_Network,OTHER,M47.816|K21.0|I25.10,revenue_code:0300,872,0,Medicaid_MCO,MCO,60,F,0.7502,96,Medical_Necessity,2696.82,1839.47,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0451,none,0,1,0,0,0,0.0,1,0,,Bundled_Payment
CLM0000003325,MBR00000191,Behavioral_Health,Paid,Electronic_EDI,2023-09-12,2023-09-12,2023-09-12,2023-09-20,Auto_Adjudicated,8,1780111559,1469642907,225100000X,Physical Therapist,11,In_Network,I10,,97010,,0,Commercial,POS,85,F,0.9729,,,413.86,174.78,0.0,174.78,0.0,0.0,239.08,0.0,0.0,0,,0.0929,impossible_service_combo,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003326,MBR00000277,Pharmacy,Partially_Paid,Electronic_EDI,2023-04-27,2023-04-27,2023-04-27,2023-05-15,Auto_Adjudicated,18,1111846258,1579331190,2084P0800X,Psychiatry,22,In_Network,I10,OTHER|I48.91,50458085930,,1,Medicaid_MCO,MCO,30,M,1.8495,256,Medical_Necessity,65.85,25.92,13.0,0.0,3.0,0.0,49.85,0.0,0.0,0,,0.0672,none,0,1,0,0,0,1e-06,0,1,,Shared_Savings
CLM0000003327,MBR00000142,Medical_Institutional,Paid,Electronic_EDI,2023-04-14,2023-04-14,2023-04-17,2023-04-27,Auto_Adjudicated,13,1528834564,1930040953,207RE0101X,Endocrinology,11,In_Network,E11.9,,revenue_code:0200,,0,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,6701.76,2610.55,1749.41,30.39,81.0,749.75,4091.21,0.0,0.0,0,,0.0003,none,0,1,0,0,0,0.000162,0,0,,Capitation
CLM0000003328,MBR00000125,Pharmacy,Denied,Electronic_EDI,2023-06-06,2023-06-06,2023-06-06,2023-06-18,Auto_Adjudicated,12,1404237143,1319611206,2086S0122X,Orthopedic Surgery,22,In_Network,OTHER,,00006001954,,2,Medicare_Advantage,MA_HMO,3,F,1.9037,PR-1,Network,138.18,106.4,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0481,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003329,MBR00000073,Medical_Institutional,Denied,Paper,2023-04-02,2023-04-02,2023-04-02,2023-04-23,Auto_Adjudicated,21,1368580443,1938465393,207R00000X,Internal Medicine,11,In_Network,J06.9,,revenue_code:0370,,0,Commercial,POS,79,M,1.1768,2,Authorization,12199.89,8935.57,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0144,none,0,1,0,0,0,0.0,0,0,ACR_Urine_Protein,FFS
CLM0000003330,MBR00000067,Medical_Professional,Paid,Electronic_EDI,2023-01-08,2023-01-08,2023-01-08,2023-01-20,Auto_Adjudicated,12,1042080259,1365397818,207Q00000X,Family Medicine,21,In_Network,M54.5,OTHER,27447,,0,Medicaid_MCO,MCO,55,M,0.4175,,,14396.57,6640.71,6638.71,0.0,2.0,0.0,7755.86,0.0,0.0,0,,0.0577,none,0,1,1,0,0,0.000614,0,0,,Shared_Savings
CLM0000003331,MBR00000215,Medical_Institutional,Paid,Provider_Portal,2023-08-28,2023-08-28,2023-08-30,2023-09-22,Auto_Adjudicated,25,1346717076,1151295616,207V00000X,Obstetrics & Gynecology,22,In_Network,E11.9,,revenue_code:0370,,0,ACA_Marketplace,ACA_Silver,69,M,0.8895,,,7276.93,3407.43,2147.73,265.24,74.0,920.46,3869.5,0.0,0.0,0,,0.0227,none,0,1,0,0,0,0.000199,0,0,LCS_Lung_Cancer_Screening,Shared_Savings
CLM0000003332,MBR00000025,Medical_Professional,Paid,Electronic_EDI,2023-09-15,2023-09-15,2023-09-15,2023-09-24,Auto_Adjudicated,9,1519595029,1986847322,207Q00000X,Family Medicine,81,In_Network,F41.1,E78.5|M17.11,99223,,0,Commercial,POS,74,M,1.3309,,,418.25,166.59,17.52,119.7,25.0,4.38,251.66,0.0,0.0,0,,0.0197,none,0,1,0,0,0,2e-06,0,0,,FFS
CLM0000003333,MBR00000076,Medical_Professional,Paid,Electronic_EDI,2023-08-31,2023-08-31,2023-08-31,2023-09-22,Auto_Adjudicated,22,1909649019,1415734567,207Q00000X,Family Medicine,22,Out_of_Network,OTHER,J06.9|F41.1,99397,,0,Commercial,HMO,26,M,2.1785,,,143.88,120.27,37.77,41.06,32.0,9.44,23.61,0.0,0.0,0,,0.0285,none,0,1,0,0,0,3e-06,1,0,,FFS
CLM0000003334,MBR00000269,Pharmacy,Paid,Paper,2023-07-18,2023-07-18,2023-07-18,2023-08-04,Auto_Adjudicated,17,1963647323,1175334579,208600000X,Surgery General,21,In_Network,I50.9,,59148001506,,1,Commercial,EPO,10,F,0.718,,,129.21,61.45,0.0,61.45,0.0,0.0,67.76,0.0,0.0,0,,0.1935,controlled_substance_high_volume,0,1,0,1,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,Capitation
CLM0000003335,MBR00000173,Medical_Professional,Paid,Electronic_EDI,2023-07-08,2023-07-08,2023-07-08,2023-08-04,Auto_Adjudicated,27,1963647323,1288028182,207RE0101X,Endocrinology,81,In_Network,I10,Z00.01|M17.11,74177,,0,Medicare_Advantage,PFFS,23,F,1.0279,,,149.8,115.92,58.64,28.62,14.0,14.66,33.88,0.0,0.0,0,,0.069,phantom_billing_indicator,0,1,0,1,0,5e-06,0,0,,Capitation
CLM0000003336,MBR00000014,Pharmacy,Paid,Electronic_EDI,2023-12-20,2023-12-20,2023-12-20,2024-01-02,Manual_Review,13,1145498455,1622950074,207RC0000X,Cardiovascular Disease,65,In_Network,OTHER,,00071012831,,4,Commercial,HMO,77,M,2.8513,,,78.9,57.8,0.0,57.8,0.0,0.0,21.1,0.0,0.0,0,,0.0353,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003337,MBR00000208,Medical_Institutional,Denied,Electronic_EDI,2023-07-09,2023-07-09,2023-07-11,2023-07-17,Auto_Adjudicated,8,1889525696,1179350099,2086S0122X,Orthopedic Surgery,23,In_Network,OTHER,,revenue_code:0370,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,50,Medical_Necessity,2939.12,2207.48,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0759,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000003338,MBR00000156,Pharmacy,Denied,Electronic_EDI,2023-09-11,2023-09-11,2023-09-11,2023-09-23,Manual_Review,12,1952322604,1055872102,207RN0300X,Nephrology,22,In_Network,N40.0,,16590051660,,1,Medicare_Advantage,MA_PPO,66,F,1.8933,CO-45,Coding_Error,323.81,215.11,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1391,unbundling_pattern,0,1,0,0,0,0.0,0,1,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000003339,MBR00000258,Pharmacy,Paid,Electronic_EDI,2023-05-30,2023-05-30,2023-05-30,2023-06-19,Auto_Adjudicated,20,1061181028,1577226132,207RP1001X,Pulmonary Disease,11,In_Network,J44.1,,00169751112,,1,Commercial,EPO,9,F,0.5431,,,209.01,95.43,53.23,10.89,18.0,13.31,113.58,0.0,0.0,0,,0.0641,none,0,1,0,1,0,5e-06,0,0,,FFS
CLM0000003340,MBR00000203,Pharmacy,Partially_Paid,Provider_Portal,2023-01-12,2023-01-12,2023-01-12,2023-01-25,Auto_Adjudicated,13,1641779816,1706603847,208600000X,Surgery General,22,In_Network,I50.9,,00078043215,,1,Commercial,PPO,49,F,0.3046,97,Medical_Necessity,94.24,43.36,0.0,22.26,0.0,0.0,71.98,0.0,0.0,0,,0.0399,none,0,1,0,0,0,0.0,0,0,ACR_Urine_Protein,Capitation
CLM0000003341,MBR00000002,Medical_Institutional,Denied,Electronic_EDI,2023-05-06,2023-05-06,2023-05-07,2023-06-02,Auto_Adjudicated,27,1956215244,1666461892,207RC0000X,Cardiovascular Disease,31,In_Network,H52.4,,revenue_code:0360,,0,Commercial,PPO,42,F,0.9012,1,Network,674.36,550.82,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1916,benford_violation,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003342,MBR00000062,Vision,Paid,Electronic_EDI,2023-09-16,2023-09-16,2023-09-16,2023-09-21,Auto_Adjudicated,5,1879212418,1005335812,207RG0100X,Gastroenterology,81,In_Network,OTHER,N39.0,92014,,0,Commercial,HMO,46,F,0.5516,,,130.57,81.83,0.0,69.04,12.79,0.0,48.74,0.0,0.0,0,,0.0143,none,0,1,0,0,0,0.0,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000003343,MBR00000080,Medical_Institutional,Paid,Electronic_EDI,2023-08-16,2023-08-16,2023-08-19,2023-08-26,Auto_Adjudicated,10,1122148537,1616762819,225100000X,Physical Therapist,11,In_Network,G47.33,I25.10|E11.9,revenue_code:0300,,0,Commercial,HDHP_HSA,74,M,0.5935,,,4462.89,3058.62,2157.85,361.31,0.0,539.46,1404.27,0.0,0.0,0,,0.2307,duplicate_claim_indicator|controlled_substance_high_volume,0,2,0,0,0,0.0002,0,0,COL_Colorectal_Cancer_Screening,Capitation
CLM0000003344,MBR00000208,Pharmacy,Paid,Provider_Portal,2023-09-07,2023-09-07,2023-09-07,2023-10-07,Auto_Adjudicated,30,1981623199,1197700958,207RG0100X,Gastroenterology,11,In_Network,N39.0,E11.9|J06.9,00071015523,,2,Medicare_Advantage,MA_HMO,66,M,2.1466,,,134.9,82.99,50.92,13.35,6.0,12.73,51.91,0.0,0.0,0,,0.0207,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000003345,MBR00000156,Medical_Institutional,Paid,Electronic_EDI,2023-09-26,2023-09-26,2023-09-29,2023-10-20,Auto_Adjudicated,24,1323379997,1144950506,207RC0000X,Cardiovascular Disease,32,In_Network,I10,J20.9|J06.9|C50.911,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,23735.08,12371.57,9847.18,33.59,29.0,2461.8,11363.51,0.0,0.0,0,,0.0039,none,0,1,1,0,0,0.000911,0,0,,FFS
CLM0000003346,MBR00000219,Medical_Professional,Paid,Electronic_EDI,2023-03-20,2023-03-20,2023-03-20,2023-03-23,Auto_Adjudicated,3,1324272690,1339359594,207V00000X,Obstetrics & Gynecology,31,In_Network,Z12.11,,99231,,0,Medicare_Advantage,MA_HMO,84,M,0.9513,,,136.38,95.77,35.36,51.57,0.0,8.84,40.61,0.0,0.0,0,,0.0182,none,0,1,0,0,0,3e-06,0,0,COA_Care_Transitions,P4P
CLM0000003347,MBR00000158,Medical_Institutional,Paid,Electronic_EDI,2023-10-20,2023-10-20,2023-10-23,2023-11-18,Auto_Adjudicated,29,1313587359,1977073565,207RC0000X,Cardiovascular Disease,23,In_Network,Z00.01,,revenue_code:0100,,0,Commercial,HMO,65,M,1.5361,,,3558.07,2774.41,2081.88,122.06,50.0,520.47,783.66,0.0,0.0,0,,0.0257,none,0,1,0,1,0,0.000193,0,0,,Shared_Savings
CLM0000003348,MBR00000104,Medical_Institutional,Paid,Electronic_EDI,2023-09-14,2023-09-14,2023-09-16,2023-09-27,Auto_Adjudicated,13,1956215244,1643673796,207Q00000X,Family Medicine,11,In_Network,L70.0,I25.10,revenue_code:0210,,0,Medicaid_MCO,MCO,87,F,1.2297,,,6440.99,3007.21,3006.21,0.0,1.0,0.0,3433.78,2167.71,533.37,1,Provider Impersonation,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|high_volume_same_code|benford_violation|impossible_service_combo|duplicate_claim_indicator|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.000278,0,0,,Capitation
CLM0000003349,MBR00000031,Medical_Professional,Paid,Electronic_EDI,2023-04-21,2023-04-21,2023-04-21,2023-05-11,Auto_Adjudicated,20,1068197532,1012893364,207RC0000X,Cardiovascular Disease,23,In_Network,OTHER,Z00.01,99385,,0,Commercial,PPO,71,M,0.6746,,,94.65,40.82,9.97,12.35,16.0,2.49,53.83,0.0,0.0,0,,0.1358,none,0,1,0,1,0,1e-06,0,0,SPD_Spirometry_Testing,P4P
CLM0000003350,MBR00000061,Medical_Professional,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-01,Clinical_Review,1,1061181028,1179350099,246ZN0300X,Neuropsychology,22,In_Network,Z00.01,,99396,,0,Commercial,PPO,66,M,2.3575,,,115.84,44.36,0.0,42.11,2.25,0.0,71.48,0.0,0.0,0,,0.1742,impossible_service_combo|upcoding_pattern,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003351,MBR00000128,Medical_Professional,Paid,Electronic_EDI,2023-11-04,2023-11-04,2023-11-04,2023-11-09,Auto_Adjudicated,5,1980039511,1625992541,225100000X,Physical Therapist,21,Out_of_Network,K21.0,E11.9|N18.3,90847,,0,Commercial,PPO,13,F,1.4203,,,904.1,724.71,493.66,94.63,13.0,123.42,179.39,0.0,0.0,0,,0.0892,none,0,1,0,0,0,4.6e-05,0,0,MPT_Annual_Monitoring,FFS
CLM0000003352,MBR00000166,Behavioral_Health,Denied,Provider_Portal,2023-03-02,2023-03-02,2023-03-02,2023-03-23,Manual_Review,21,1083045036,1252125670,207V00000X,Obstetrics & Gynecology,11,In_Network,Z87.891,N39.0|J06.9|I10,99203,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,5,Timely_Filing,471.37,326.96,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0054,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003353,MBR00000284,Medical_Institutional,Paid,Electronic_EDI,2023-04-19,2023-04-19,2023-04-23,2023-04-27,Manual_Review,8,1373899620,1390802135,225100000X,Physical Therapist,21,Out_of_Network,Z00.00,OTHER,revenue_code:0360,470,0,Medicaid_MCO,FFS_Medicaid,23,M,0.5234,,,12708.13,8963.32,8959.32,0.0,4.0,0.0,3744.81,0.0,0.0,0,,0.0869,none,0,1,1,0,0,0.000829,1,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000003354,MBR00000075,Medical_Professional,Paid,Paper,2023-03-10,2023-03-10,2023-03-10,2023-03-14,Manual_Review,4,1721465780,1027261156,208600000X,Surgery General,22,In_Network,K21.0,K21.0|E11.9|F10.10,83036,,0,Medicaid_MCO,MCO,5,M,1.0573,,,521.74,196.79,192.79,0.0,4.0,0.0,324.95,0.0,0.0,0,,0.0414,none,0,1,0,0,0,1.8e-05,0,0,,FFS
CLM0000003355,MBR00000198,Pharmacy,Denied,Electronic_EDI,2023-04-20,2023-04-20,2023-04-20,2023-05-11,Auto_Adjudicated,21,1793630905,1705448933,207Q00000X,Family Medicine,11,In_Network,OTHER,,00078043215,,3,Medicaid_MCO,MCO,81,F,1.4199,5,Authorization,1028.01,564.69,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1256,high_volume_same_code,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003356,MBR00000048,Medical_Institutional,Paid,Paper,2023-03-15,2023-03-15,2023-03-18,2023-03-22,Auto_Adjudicated,7,1435110996,1894215172,225100000X,Physical Therapist,22,Emergency,M54.5,E78.5,revenue_code:0110,,0,Commercial,POS,27,F,0.639,,,7504.27,2841.51,2185.32,59.86,50.0,546.33,4662.76,0.0,0.0,0,,0.0026,none,0,1,0,1,0,0.000202,0,0,,Bundled_Payment
CLM0000003357,MBR00000211,Pharmacy,Denied,Electronic_EDI,2023-10-17,2023-10-17,2023-10-17,2023-11-12,Manual_Review,26,1865750966,1513198866,207RG0100X,Gastroenterology,11,In_Network,G47.33,,00003014960,,2,Medicare_Advantage,MA_PPO,68,M,1.3146,97,Authorization,118.91,82.58,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1409,benford_violation,0,1,0,0,0,0.0,0,0,ACR_Urine_Protein,FFS
CLM0000003358,MBR00000004,Medical_Institutional,Paid,Electronic_EDI,2023-12-22,2023-12-22,2023-12-23,2023-12-28,Auto_Adjudicated,6,1216417633,1196833348,207RP1001X,Pulmonary Disease,21,In_Network,N18.3,E78.5,revenue_code:0210,248,0,Medicare_Advantage,MA_PPO,68,M,1.23,,,7404.82,3859.43,3029.54,19.51,53.0,757.38,3545.39,0.0,0.0,0,,0.0821,none,0,1,0,0,0,0.00028,0,0,,FFS
CLM0000003359,MBR00000196,Medical_Professional,Paid,Provider_Portal,2023-12-15,2023-12-15,2023-12-15,2023-12-16,Auto_Adjudicated,1,1588313061,1860951128,207R00000X,Internal Medicine,81,In_Network,Z87.891,,85025,,0,Commercial,PPO,16,F,1.6015,,,1858.32,1561.65,1177.84,66.35,23.0,294.46,296.67,0.0,0.0,0,,0.1133,none,0,1,0,0,0,0.000109,0,0,,Shared_Savings
CLM0000003360,MBR00000052,Medical_Professional,Paid,Electronic_EDI,2023-05-09,2023-05-09,2023-05-09,2023-05-21,Auto_Adjudicated,12,1264953395,1880530717,101YP2500X,Psychologist Clinical,24,In_Network,E11.9,OTHER,99215,,0,Commercial,PPO,0,F,1.325,,,366.6,260.44,13.38,211.72,32.0,3.34,106.16,0.0,0.0,0,,0.0754,none,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000003361,MBR00000056,Pharmacy,Paid,Electronic_EDI,2023-12-01,2023-12-01,2023-12-01,2023-12-11,Auto_Adjudicated,10,1313352855,1320546364,207R00000X,Internal Medicine,11,In_Network,I10,,00069420020,,2,Commercial,EPO,74,F,1.3941,,,274.69,115.74,0.0,115.74,0.0,0.0,158.95,0.0,0.0,0,,0.1474,none,0,1,0,0,0,0.0,0,1,,Bundled_Payment
CLM0000003362,MBR00000168,Pharmacy,Paid,Provider_Portal,2023-01-30,2023-01-30,2023-01-30,2023-02-19,Auto_Adjudicated,20,1898865801,1643323506,207Q00000X,Family Medicine,23,In_Network,Z00.00,OTHER,00071012831,,4,Commercial,HMO,76,M,1.2791,,,233.74,103.09,0.0,103.09,0.0,0.0,130.65,0.0,0.0,0,,0.0116,none,0,1,0,0,0,0.0,0,0,AWV_Annual_Wellness_Visit,P4P
CLM0000003363,MBR00000119,Pharmacy,Partially_Paid,Electronic_EDI,2023-02-09,2023-02-09,2023-02-09,2023-02-17,Manual_Review,8,1008470017,1774401124,207R00000X,Internal Medicine,11,In_Network,F41.1,F32.9|Z79.4,00006001954,,1,Commercial,POS,42,M,0.4987,97,Medical_Necessity,124.91,51.33,0.0,33.28,0.0,0.0,91.63,0.0,0.0,0,,0.0625,geographic_mismatch,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003364,MBR00000144,Medical_Professional,Paid,Electronic_EDI,2023-04-27,2023-04-27,2023-04-27,2023-05-27,Auto_Adjudicated,30,1654042271,1527857018,101YP2500X,Psychologist Clinical,22,Out_of_Network,I10,J06.9,99231,,0,Commercial,HDHP_HSA,56,F,2.5926,,,238.22,113.1,0.0,113.1,0.0,0.0,125.12,0.0,0.0,0,,0.0893,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003365,MBR00000097,Pharmacy,Paid,Electronic_EDI,2023-04-14,2023-04-14,2023-04-14,2023-04-27,Auto_Adjudicated,13,1826043246,1469642907,246ZN0300X,Neuropsychology,11,In_Network,R05.9,Z79.4,00006001954,,2,Commercial,EPO,34,M,1.3765,,,83.2,69.52,0.0,54.78,14.74,0.0,13.68,0.0,0.0,0,,0.0435,none,0,1,0,0,0,0.0,0,1,BCS_Breast_Cancer_Screening,P4P
CLM0000003366,MBR00000289,Medical_Institutional,Denied,Electronic_EDI,2023-11-26,2023-11-26,2023-11-29,2023-12-18,Auto_Adjudicated,22,1388566092,1188760037,207R00000X,Internal Medicine,65,In_Network,J20.9,G43.909|F10.10|Z00.00,revenue_code:0250,,0,Commercial,POS,51,M,1.0534,18,Eligibility,8401.32,7079.66,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1106,impossible_service_combo,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003367,MBR00000091,Pharmacy,Paid,Provider_Portal,2023-09-30,2023-09-30,2023-09-30,2023-10-24,Auto_Adjudicated,24,1154652946,1738617370,208600000X,Surgery General,11,In_Network,OTHER,Z00.01|C50.911,00085163102,,4,Commercial,PPO,13,F,1.2451,,,225.66,111.35,0.0,111.35,0.0,0.0,114.31,0.0,0.0,0,,0.029,none,0,1,0,0,0,0.0,0,0,KED_ESRD_Patients,Shared_Savings
CLM0000003368,MBR00000165,Medical_Professional,Paid,Paper,2023-09-28,2023-09-28,2023-09-28,2023-10-25,Auto_Adjudicated,27,1059948944,1498781755,2086S0122X,Orthopedic Surgery,32,In_Network,OTHER,N39.0|OTHER|Z00.01,80053,,0,ACA_Marketplace,ACA_Bronze,55,M,0.9775,,,566.88,267.63,0.0,267.63,0.0,0.0,299.25,0.0,0.0,0,,0.2874,high_volume_same_code|benford_violation|unbundling_pattern,0,2,0,0,0,0.0,0,0,CBP_Controlling_BP,FFS
CLM0000003369,MBR00000258,Pharmacy,Paid,Electronic_EDI,2023-10-17,2023-10-17,2023-10-17,2023-11-02,Auto_Adjudicated,16,1923937825,1055872102,207V00000X,Obstetrics & Gynecology,23,In_Network,J06.9,,59148001506,,2,Commercial,EPO,9,F,0.5431,,,343.9,164.49,109.47,9.66,18.0,27.37,179.41,0.0,0.0,0,,0.143,none,0,1,0,0,0,1e-05,0,0,,Capitation
CLM0000003370,MBR00000197,Behavioral_Health,Denied,Electronic_EDI,2023-09-18,2023-09-18,2023-09-18,2023-09-25,Auto_Adjudicated,7,1403662694,1564691686,207RE0101X,Endocrinology,21,In_Network,M54.5,OTHER,97010,,0,Medicare_Advantage,MA_HMO,59,M,1.1414,3,Eligibility,250.86,151.25,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0591,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003371,MBR00000102,Medical_Professional,Paid,Provider_Portal,2023-07-01,2023-07-01,2023-07-01,2023-07-17,Auto_Adjudicated,16,1375680589,1288028182,207Q00000X,Family Medicine,32,In_Network,Z00.01,I10|Z00.00,27447,,0,Commercial,POS,68,M,1.6864,,,20557.94,12146.72,9507.83,229.93,32.0,2376.96,8411.22,0.0,0.0,0,,0.014,none,0,1,1,0,0,0.00088,0,0,AWV_Annual_Wellness_Visit,Bundled_Payment
CLM0000003372,MBR00000167,Pharmacy,Paid,Electronic_EDI,2023-01-22,2023-01-22,2023-01-22,2023-02-04,Auto_Adjudicated,13,1007414142,1978943761,207Q00000X,Family Medicine,21,In_Network,Z00.121,OTHER|M17.11|E78.5,59148001506,,2,Commercial,PPO,77,F,0.9377,,,89.9,51.62,0.0,51.62,0.0,0.0,38.28,0.0,0.0,0,,0.2037,controlled_substance_high_volume,0,2,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003373,MBR00000025,Medical_Institutional,Denied,Electronic_EDI,2023-01-06,2023-01-06,2023-01-08,2023-01-25,Auto_Adjudicated,19,1046058495,1282319940,225100000X,Physical Therapist,23,In_Network,F41.1,,revenue_code:0110,,0,Commercial,POS,74,M,1.3309,1,Authorization,3979.12,1551.06,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1083,none,0,1,0,0,0,0.0,0,0,COA_Care_Transitions,P4P
CLM0000003374,MBR00000166,Medical_Professional,Paid,Electronic_EDI,2023-12-17,2023-12-17,2023-12-17,2023-12-25,Auto_Adjudicated,8,1793406356,1878874025,207RP1001X,Pulmonary Disease,24,In_Network,J06.9,I25.10|Z12.11|OTHER,99205,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,159.44,76.4,0.0,76.4,0.0,0.0,83.04,0.0,0.0,0,,0.072,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003375,MBR00000135,Medical_Professional,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-16,Auto_Adjudicated,16,1464997678,1339359594,101YP2500X,Psychologist Clinical,11,In_Network,Z87.891,OTHER,99384,,0,Commercial,PPO,58,F,2.2702,,,482.37,278.37,191.86,1.54,37.0,47.97,204.0,0.0,0.0,0,,0.1458,none,0,1,0,1,0,1.8e-05,0,0,TRC_Transition_of_Care,Capitation
CLM0000003376,MBR00000222,Pharmacy,Denied,Provider_Portal,2023-12-09,2023-12-09,2023-12-09,2024-01-07,Auto_Adjudicated,29,1170319307,1574982369,246ZN0300X,Neuropsychology,11,Out_of_Network,E78.5,R05.9|M54.5,00071015523,,2,Commercial,PPO,48,F,0.6945,96,Timely_Filing,45.21,20.7,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1034,service_date_weekend,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003377,MBR00000255,Medical_Professional,Paid,Electronic_EDI,2023-01-12,2023-01-12,2023-01-12,2023-02-02,Auto_Adjudicated,21,1832660692,1356856197,207RE0101X,Endocrinology,32,In_Network,F41.1,Z00.00,74177,,0,Medicare_Advantage,MA_HMO,21,M,0.6945,,,742.4,491.67,376.86,2.59,18.0,94.22,250.73,0.0,0.0,0,,0.1359,none,0,1,0,0,0,3.5e-05,0,0,,Shared_Savings
CLM0000003378,MBR00000061,Medical_Professional,Paid,Electronic_EDI,2023-08-17,2023-08-17,2023-08-17,2023-09-15,Auto_Adjudicated,29,1364746046,1589482133,207R00000X,Internal Medicine,11,In_Network,K21.0,,83036,,0,Commercial,PPO,66,M,2.3575,,,742.69,317.12,157.61,107.1,13.0,39.4,425.57,0.0,0.0,0,,0.1455,upcoding_pattern,0,1,0,1,0,1.5e-05,0,0,,Bundled_Payment
CLM0000003379,MBR00000025,Dental,Paid,Electronic_EDI,2023-04-12,2023-04-12,2023-04-12,2023-04-16,Auto_Adjudicated,4,1555292468,1020312030,207RP1001X,Pulmonary Disease,65,Out_of_Network,E78.5,,D0150,,0,Commercial,POS,74,M,1.3309,,,232.15,122.94,0.0,122.94,0.0,0.0,109.21,0.0,0.0,0,,0.0709,none,0,1,0,1,0,0.0,1,0,,FFS
CLM0000003380,MBR00000125,Medical_Institutional,Paid,Electronic_EDI,2023-05-11,2023-05-11,2023-05-11,2023-05-31,Auto_Adjudicated,20,1193571728,1039962073,207RE0101X,Endocrinology,21,In_Network,OTHER,,revenue_code:0300,470,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,11618.43,8475.43,6742.94,1.75,45.0,1685.74,3143.0,5565.1,1053.82,0,,0.1722,unusual_service_frequency,0,1,1,1,0,0.000624,0,0,,Shared_Savings
CLM0000003381,MBR00000162,Pharmacy,Denied,Paper,2023-08-24,2023-08-24,2023-08-24,2023-08-25,Auto_Adjudicated,1,1112402001,1942423230,207RG0100X,Gastroenterology,21,In_Network,C50.911,OTHER,50458085930,,3,Medicaid_MCO,MLTSS,84,F,1.324,5,Timely_Filing,206.43,133.32,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1969,impossible_service_combo,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003382,MBR00000120,Medical_Institutional,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-07-01,2023-07-04,Manual_Review,7,1874109311,1040061910,101YP2500X,Psychologist Clinical,21,In_Network,N39.0,Z00.00,revenue_code:0200,871,0,Commercial,PPO,62,F,1.0823,,,4243.02,3420.69,2665.28,10.09,79.0,666.32,822.33,0.0,0.0,0,,0.1531,diagnosis_procedure_mismatch,0,1,0,1,0,0.000247,0,0,,Shared_Savings
CLM0000003383,MBR00000187,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-02-18,2023-02-18,2023-02-21,2023-03-15,Manual_Review,25,1313587359,1061149198,101YP2500X,Psychologist Clinical,22,In_Network,E13.9,Z00.01,revenue_code:0300,,0,Medicaid_MCO,MCO,36,F,1.191,16,Medical_Necessity,5896.82,2914.13,2088.24,0.0,7.0,0.0,3801.58,0.0,0.0,0,,0.1738,unbundling_pattern,0,1,0,1,0,0.000193,0,0,MMA_Medication_Management,FFS
CLM0000003384,MBR00000156,Pharmacy,Denied,Electronic_EDI,2023-12-25,2023-12-25,2023-12-25,2023-12-29,Auto_Adjudicated,4,1059948944,1274911960,207RE0101X,Endocrinology,81,In_Network,Z00.01,J44.1,00003014960,,5,Medicare_Advantage,MA_PPO,66,F,1.8933,5,Duplicate,161.69,57.42,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0723,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000003385,MBR00000283,Medical_Professional,Denied,Provider_Portal,2023-09-13,2023-09-13,2023-09-13,2023-09-28,Auto_Adjudicated,15,1110312325,1995553359,2086S0122X,Orthopedic Surgery,11,Out_of_Network,K21.0,Z00.121,99384,,0,Medicare_Advantage,MA_HMO,21,M,0.5294,2,Medical_Necessity,265.91,160.38,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0088,none,0,1,0,0,0,0.0,1,0,,FFS
CLM0000003386,MBR00000130,Medical_Professional,Paid,Electronic_EDI,2023-05-10,2023-05-10,2023-05-10,2023-05-13,Auto_Adjudicated,3,1543927384,1287472731,207RG0100X,Gastroenterology,22,In_Network,J44.1,,43239,,0,Medicare_Advantage,MA_PPO,58,M,1.3394,,,240.24,110.66,73.48,14.81,4.0,18.37,129.58,0.0,0.0,0,,0.085,none,0,1,0,0,0,7e-06,0,0,,Capitation
CLM0000003387,MBR00000025,Medical_Institutional,Paid,Electronic_EDI,2023-08-12,2023-08-12,2023-08-15,2023-08-21,Auto_Adjudicated,9,1972755666,1296566243,207RE0101X,Endocrinology,11,In_Network,Z12.11,,revenue_code:0250,,0,Commercial,POS,74,M,1.3309,,,12035.64,4954.1,3599.51,385.72,69.0,899.88,7081.54,0.0,0.0,0,,0.0985,diagnosis_procedure_mismatch,0,1,0,0,0,0.000333,0,0,,Capitation
CLM0000003388,MBR00000096,Vision,Paid,Electronic_EDI,2023-02-24,2023-02-24,2023-02-24,2023-02-28,Auto_Adjudicated,4,1871348663,1522426351,207V00000X,Obstetrics & Gynecology,11,In_Network,N40.0,Z23,92014,,0,Medicaid_MCO,MCO,62,M,0.7948,,,285.82,102.58,100.58,0.0,2.0,0.0,183.24,80.27,16.79,0,,0.0212,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000003389,MBR00000183,Medical_Professional,Paid,Electronic_EDI,2023-06-04,2023-06-04,2023-06-04,2023-06-18,Clinical_Review,14,1918359820,1358873132,2084P0800X,Psychiatry,11,In_Network,N39.0,J44.1,99211,,0,Commercial,PPO,51,M,0.8463,,,579.11,372.53,145.6,151.53,39.0,36.4,206.58,0.0,0.0,1,Provider Impersonation,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|benford_violation|billing_spike_recent|duplicate_claim_indicator|unbundling_pattern|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,1.3e-05,0,0,IET_Initiation_Substance_Use,FFS
CLM0000003390,MBR00000079,Behavioral_Health,Denied,Electronic_EDI,2023-06-02,2023-06-02,2023-06-02,2023-06-22,Manual_Review,20,1821999097,1619587398,207V00000X,Obstetrics & Gynecology,22,In_Network,Z12.11,OTHER|E78.5|Z00.00,99233,,0,Medicaid_MCO,MLTSS,55,F,0.5016,256,Coding_Error,172.46,93.67,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0932,upcoding_pattern,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003391,MBR00000083,Pharmacy,Paid,Electronic_EDI,2023-05-14,2023-05-14,2023-05-14,2023-06-03,Auto_Adjudicated,20,1213747973,1282319940,207RP1001X,Pulmonary Disease,22,In_Network,Z23,E11.9|K21.0|OTHER,00069420020,,1,Commercial,PPO,76,M,0.6621,,,311.04,159.14,0.0,159.14,0.0,0.0,151.9,0.0,0.0,0,,0.0625,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003392,MBR00000106,Medical_Institutional,Denied,Electronic_EDI,2023-06-23,2023-06-23,2023-06-26,2023-07-21,Auto_Adjudicated,28,1321381114,1951488764,225100000X,Physical Therapist,11,In_Network,N40.0,Z23,revenue_code:0100,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,50,Duplicate,30324.44,16396.89,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1796,temporal_clustering,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003393,MBR00000219,Medical_Institutional,Paid,Electronic_EDI,2023-11-25,2023-11-25,2023-11-27,2023-11-29,Auto_Adjudicated,4,1310400164,1831337866,2086S0122X,Orthopedic Surgery,81,In_Network,Z00.00,,revenue_code:0200,,0,Medicare_Advantage,MA_HMO,84,M,0.9513,,,3199.78,2340.9,1830.38,29.92,23.0,457.6,858.88,0.0,0.0,0,,0.0799,none,0,1,0,0,0,0.000169,0,0,,FFS
CLM0000003394,MBR00000285,Medical_Professional,Paid,Electronic_EDI,2023-01-03,2023-01-03,2023-01-03,2023-01-16,Auto_Adjudicated,13,1670125610,1287472731,207RN0300X,Nephrology,21,In_Network,OTHER,J44.1|E11.65,97110,,0,Commercial,HDHP_HSA,56,M,0.9226,,,424.35,197.78,0.0,197.78,0.0,0.0,226.57,0.0,0.0,0,,0.1963,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003395,MBR00000110,Medical_Institutional,Paid,Paper,2023-07-18,2023-07-18,2023-07-19,2023-08-03,Auto_Adjudicated,16,1577859682,1187669363,207R00000X,Internal Medicine,31,In_Network,Z00.00,,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,83,F,1.127,,,1656.13,1001.69,752.48,8.09,53.0,188.12,654.44,0.0,0.0,0,,0.177,billing_spike_recent,0,1,0,0,0,7e-05,0,0,,FFS
CLM0000003396,MBR00000060,Medical_Professional,Paid,Electronic_EDI,2023-12-04,2023-12-04,2023-12-04,2023-12-07,Manual_Review,3,1843445592,1810068286,207RG0100X,Gastroenterology,11,In_Network,I10,F41.1,47562,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,312.01,264.27,0.0,264.27,0.0,0.0,47.74,0.0,0.0,0,,0.0574,high_volume_same_code,0,1,0,0,0,0.0,0,0,KED_ESRD_Patients,Capitation
CLM0000003397,MBR00000133,Medical_Institutional,Denied,Electronic_EDI,2023-11-16,2023-11-16,2023-11-20,2023-11-20,Auto_Adjudicated,4,1119160702,1625992541,246ZN0300X,Neuropsychology,23,In_Network,OTHER,I10|Z00.00|E11.9,revenue_code:0210,,0,Medicaid_MCO,MCO,57,M,0.9592,96,Medical_Necessity,42187.37,15818.67,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1387,none,0,1,0,0,0,0.0,0,0,FLU_Flu_Vaccination,Bundled_Payment
CLM0000003398,MBR00000111,Medical_Professional,Denied,Electronic_EDI,2023-11-19,2023-11-19,2023-11-19,2023-11-29,Auto_Adjudicated,10,1988579666,1034732777,208600000X,Surgery General,11,In_Network,Z12.11,E78.5|I10,90834,,0,Medicare_Advantage,MA_PPO,44,M,0.7462,16,Medical_Necessity,288.03,195.52,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1038,unbundling_pattern,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003399,MBR00000297,Vision,Paid,Provider_Portal,2023-05-29,2023-05-29,2023-05-29,2023-06-24,Auto_Adjudicated,26,1788188920,1114756459,246ZN0300X,Neuropsychology,22,In_Network,F32.9,E11.9|N18.3|F32.9,V2100,,0,Commercial,HMO,88,M,1.5311,,,337.88,233.61,151.44,17.31,27.0,37.86,104.27,0.0,0.0,0,,0.102,none,0,1,0,0,0,1.4e-05,0,0,,Bundled_Payment
CLM0000003400,MBR00000143,Medical_Professional,Paid,Electronic_EDI,2023-07-23,2023-07-23,2023-07-23,2023-08-10,Auto_Adjudicated,18,1175978429,1763260577,2086S0122X,Orthopedic Surgery,31,In_Network,Z12.11,,99395,,0,Commercial,POS,85,M,1.6078,,,328.54,184.43,54.8,79.93,36.0,13.7,144.11,0.0,0.0,0,,0.0361,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000003401,MBR00000201,Medical_Institutional,Paid,Electronic_EDI,2023-08-02,2023-08-02,2023-08-04,2023-08-19,Auto_Adjudicated,17,1950560596,1396850418,2086S0122X,Orthopedic Surgery,23,Out_of_Network,Z00.01,E78.5,revenue_code:0360,,0,Medicare_Advantage,MA_PPO,74,M,1.1575,,,6539.27,4928.01,3903.57,2.55,46.0,975.89,1611.26,0.0,0.0,0,,0.0291,none,0,1,0,0,0,0.000361,1,0,,FFS
CLM0000003402,MBR00000276,Medical_Professional,Paid,Electronic_EDI,2023-10-28,2023-10-28,2023-10-28,2023-11-14,Manual_Review,17,1821999097,1616762819,207Q00000X,Family Medicine,21,In_Network,N18.3,E11.9|I10,90837,,0,Commercial,POS,38,M,0.8085,,,443.78,304.3,20.6,243.55,35.0,5.15,139.48,0.0,0.0,0,,0.0373,none,0,1,0,1,0,2e-06,0,0,,FFS
CLM0000003403,MBR00000187,Medical_Professional,Partially_Paid,Electronic_EDI,2023-12-09,2023-12-09,2023-12-09,2024-01-03,Auto_Adjudicated,25,1113370285,1461075342,2086S0122X,Orthopedic Surgery,24,In_Network,E13.9,,90837,,0,Medicaid_MCO,MCO,36,F,1.191,2,Medical_Necessity,1616.33,1141.35,631.89,0.0,3.0,0.0,981.44,0.0,0.0,0,,0.0639,none,0,1,0,1,0,5.8e-05,0,0,,FFS
CLM0000003404,MBR00000077,Medical_Professional,Paid,Electronic_EDI,2023-04-02,2023-04-02,2023-04-02,2023-04-19,Auto_Adjudicated,17,1539066691,1157814306,207V00000X,Obstetrics & Gynecology,21,Emergency,I10,E13.9|F32.9,90837,,0,Medicare_Advantage,MA_HMO,27,F,0.9229,,,1180.43,489.53,383.07,6.69,4.0,95.77,690.9,0.0,0.0,0,,0.1197,none,0,1,0,1,0,3.5e-05,0,0,,Shared_Savings
CLM0000003405,MBR00000183,Pharmacy,Paid,Electronic_EDI,2023-02-14,2023-02-14,2023-02-14,2023-03-08,Auto_Adjudicated,22,1732726112,1763260577,2086S0122X,Orthopedic Surgery,11,In_Network,M25.511,G47.33,00006001954,,1,Commercial,PPO,51,M,0.8463,,,1002.13,625.01,202.69,332.65,39.0,50.67,377.12,125.4,44.81,0,,0.1315,none,0,1,0,0,0,1.9e-05,0,1,,FFS
CLM0000003406,MBR00000128,Medical_Institutional,Paid,Paper,2023-04-06,2023-04-06,2023-04-07,2023-04-16,Auto_Adjudicated,10,1069440570,1619587398,207V00000X,Obstetrics & Gynecology,23,In_Network,Z00.01,Z12.11|Z00.01,revenue_code:0450,,0,Commercial,PPO,13,F,1.4203,,,1109.01,480.94,273.32,88.3,51.0,68.33,628.07,0.0,0.0,0,,0.0702,high_oop_waiver,0,1,0,0,0,2.5e-05,0,0,,Bundled_Payment
CLM0000003407,MBR00000134,Medical_Institutional,Paid,Electronic_EDI,2023-04-05,2023-04-05,2023-04-08,2023-04-30,Manual_Review,25,1568777164,1560230600,2086S0122X,Orthopedic Surgery,65,In_Network,OTHER,OTHER,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,33,M,1.115,,,17876.65,6969.03,5515.39,52.79,22.0,1378.85,10907.62,0.0,0.0,0,,0.0686,impossible_service_combo,0,1,1,0,0,0.000511,0,0,,FFS
CLM0000003408,MBR00000295,Pharmacy,Paid,Electronic_EDI,2023-04-18,2023-04-18,2023-04-18,2023-04-19,Auto_Adjudicated,1,1300740186,1747596016,207RG0100X,Gastroenterology,11,In_Network,Z87.891,,50458085930,,2,Commercial,HDHP_HSA,78,F,0.8618,,,60.75,34.16,0.0,34.16,0.0,0.0,26.59,0.0,0.0,1,Unbundling,1.0,outlier_billing_amount|geographic_mismatch|provider_specialty_mismatch|high_volume_same_code|duplicate_claim_indicator|unbundling_pattern|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,0.0,0,0,,FFS
CLM0000003409,MBR00000087,Medical_Professional,Paid,Electronic_EDI,2023-11-26,2023-11-26,2023-11-26,2023-12-07,Auto_Adjudicated,11,1899326088,1509799493,207R00000X,Internal Medicine,23,In_Network,OTHER,Z00.00|J06.9|I25.10,71250,,0,Medicaid_MCO,MCO,70,F,0.9232,,,520.72,207.95,206.95,0.0,1.0,0.0,312.77,0.0,0.0,0,,0.1053,none,0,1,0,0,0,1.9e-05,0,0,,FFS
CLM0000003410,MBR00000144,Pharmacy,Paid,Electronic_EDI,2023-03-19,2023-03-19,2023-03-19,2023-03-27,Clinical_Review,8,1137079475,1132693989,2086S0122X,Orthopedic Surgery,31,In_Network,OTHER,G47.33|F41.1,00069420020,,2,Commercial,HDHP_HSA,56,F,2.5926,,,66.63,23.33,0.0,23.33,0.0,0.0,43.3,0.0,0.0,0,,0.1415,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003411,MBR00000051,Medical_Professional,Paid,Electronic_EDI,2023-06-01,2023-06-01,2023-06-01,2023-06-06,Auto_Adjudicated,5,1199465234,1027261156,208600000X,Surgery General,22,In_Network,OTHER,OTHER,99384,,0,Medicare_Advantage,MA_PPO,17,F,1.0695,,,197.15,164.73,112.75,9.79,14.0,28.19,32.42,0.0,0.0,0,,0.1289,diagnosis_procedure_mismatch,0,1,0,1,0,1e-05,0,0,,Capitation
CLM0000003412,MBR00000056,Dental,Denied,Provider_Portal,2023-05-09,2023-05-09,2023-05-09,2023-05-26,Auto_Adjudicated,17,1721465780,1694343357,2084P0800X,Psychiatry,22,In_Network,OTHER,F41.1|OTHER|E11.9,D0120,,0,Commercial,EPO,74,F,1.3941,97,Medical_Necessity,275.89,217.53,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.129,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003413,MBR00000182,Vision,Denied,Electronic_EDI,2023-04-08,2023-04-08,2023-04-08,2023-05-05,Manual_Review,27,1658094898,1842149518,208600000X,Surgery General,11,In_Network,OTHER,F32.9,92014,,0,Commercial,HMO,82,F,0.8489,3,Timely_Filing,331.85,146.99,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1196,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003414,MBR00000220,Pharmacy,Paid,Electronic_EDI,2023-03-12,2023-03-12,2023-03-12,2023-03-17,Auto_Adjudicated,5,1325430913,1965244699,207RG0100X,Gastroenterology,11,Out_of_Network,OTHER,Z00.00,00006001954,,3,Commercial,HMO,38,M,0.7736,,,66.53,28.27,0.0,28.27,0.0,0.0,38.26,0.0,0.0,0,,0.105,none,0,1,0,0,0,0.0,1,1,,FFS
CLM0000003415,MBR00000188,Medical_Professional,Paid,Electronic_EDI,2023-12-25,2023-12-25,2023-12-25,2024-01-21,Auto_Adjudicated,27,1243349799,1061113875,101YP2500X,Psychologist Clinical,21,In_Network,E11.9,I25.10,99203,,0,Commercial,HMO,8,F,1.5853,,,184.4,96.17,55.24,2.13,25.0,13.81,88.23,0.0,0.0,0,,0.135,none,0,1,0,0,0,5e-06,0,0,FUM_Follow_Up_ED_Mental_Health,Bundled_Payment
CLM0000003416,MBR00000104,Medical_Institutional,Paid,Electronic_EDI,2023-08-13,2023-08-13,2023-08-13,2023-09-08,Auto_Adjudicated,26,1097600151,1994275960,207RE0101X,Endocrinology,23,In_Network,Z00.121,Z23|K57.30,revenue_code:0100,,0,Medicaid_MCO,MCO,87,F,1.2297,,,17538.58,7126.18,7125.18,0.0,1.0,0.0,10412.4,0.0,0.0,0,,0.1938,upcoding_pattern,0,1,1,0,0,0.00066,0,0,DAE_Drug_Alcohol_Dependence,P4P
CLM0000003417,MBR00000017,Pharmacy,Paid,Electronic_EDI,2023-02-06,2023-02-06,2023-02-06,2023-03-05,Auto_Adjudicated,27,1539066691,1179350099,207Q00000X,Family Medicine,21,Out_of_Network,Z79.4,J45.20,59148001506,,5,Commercial,PPO,55,F,0.6174,,,295.85,153.68,31.14,75.76,39.0,7.78,142.17,0.0,0.0,0,,0.1496,none,0,1,0,0,0,3e-06,1,1,,P4P
CLM0000003418,MBR00000144,Medical_Institutional,Paid,Electronic_EDI,2023-08-24,2023-08-24,2023-08-25,2023-08-25,Manual_Review,1,1145860509,1282319940,2084P0800X,Psychiatry,22,In_Network,OTHER,K21.0,revenue_code:0200,,0,Commercial,HDHP_HSA,56,F,2.5926,,,117138.68,82310.77,65732.59,145.03,0.0,16433.15,34827.91,0.0,0.0,0,,0.2257,outlier_billing_amount|impossible_service_combo,0,2,1,0,0,0.006084,0,0,,Capitation
CLM0000003419,MBR00000156,Medical_Professional,Denied,Electronic_EDI,2023-08-08,2023-08-08,2023-08-08,2023-09-07,Manual_Review,30,1843445592,1880530717,207RN0300X,Nephrology,22,In_Network,F10.10,N18.3|L70.0|OTHER,99221,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,18,Coding_Error,289.86,136.15,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.07,npi_mismatch,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003420,MBR00000227,Medical_Institutional,Paid,Electronic_EDI,2023-05-09,2023-05-09,2023-05-09,2023-05-22,Manual_Review,13,1853403237,1012893364,207R00000X,Internal Medicine,11,In_Network,E78.5,,revenue_code:0300,,0,Medicare_Advantage,MA_PPO,2,F,0.7835,,,19409.36,14349.44,11447.53,0.03,40.0,2861.88,5059.92,0.0,0.0,0,,0.0598,none,0,1,1,0,0,0.00106,0,0,,Capitation
CLM0000003421,MBR00000189,Medical_Professional,Denied,Electronic_EDI,2023-10-10,2023-10-10,2023-10-10,2023-10-28,Auto_Adjudicated,18,1952322604,1339359594,2086S0122X,Orthopedic Surgery,24,In_Network,I10,Z00.01|J20.9,99204,,0,Medicaid_MCO,MCO,71,F,0.9722,5,Medical_Necessity,238.19,193.28,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0838,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003422,MBR00000263,Medical_Institutional,Denied,Electronic_EDI,2023-10-16,2023-10-16,2023-10-16,2023-10-26,Manual_Review,10,1097600151,1965244699,2086S0122X,Orthopedic Surgery,23,Out_of_Network,E78.5,OTHER|E78.5,revenue_code:0200,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,22,Authorization,38780.3,14310.5,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0751,none,0,1,0,0,0,0.0,1,0,,FFS
CLM0000003423,MBR00000232,Medical_Professional,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-10,2023-10-26,Auto_Adjudicated,16,1159640414,1368666316,246ZN0300X,Neuropsychology,22,In_Network,F41.1,,33510,,0,Medicaid_MCO,MCO,40,M,1.1083,,,315.66,195.8,193.8,0.0,2.0,0.0,119.86,0.0,0.0,0,,0.0108,none,0,1,0,0,0,1.8e-05,0,0,,FFS
CLM0000003424,MBR00000115,Medical_Institutional,Paid,Electronic_EDI,2023-08-18,2023-08-18,2023-08-22,2023-09-04,Auto_Adjudicated,17,1099247356,1312595355,207RG0100X,Gastroenterology,22,In_Network,R05.9,Z79.4|E78.5,revenue_code:0100,,0,Commercial,PPO,15,F,0.7398,,,10331.65,4011.13,3140.62,38.35,47.0,785.16,6320.52,0.0,0.0,0,,0.1529,controlled_substance_high_volume,0,1,0,0,0,0.000291,0,0,,Shared_Savings
CLM0000003425,MBR00000188,Medical_Professional,Denied,Electronic_EDI,2023-06-08,2023-06-08,2023-06-08,2023-07-02,Auto_Adjudicated,24,1257723293,1694343357,208600000X,Surgery General,21,In_Network,E11.9,OTHER|J45.20,84443,,0,Commercial,HMO,8,F,1.5853,4,COB,722.82,452.17,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2338,impossible_service_combo|phantom_billing_indicator,0,2,0,0,0,0.0,0,0,,FFS
CLM0000003426,MBR00000219,Medical_Professional,Paid,Electronic_EDI,2023-03-16,2023-03-16,2023-03-16,2023-03-27,Manual_Review,11,1889525696,1616762819,207RP1001X,Pulmonary Disease,22,In_Network,E11.9,OTHER,90837,,0,Medicare_Advantage,MA_HMO,84,M,0.9513,,,853.49,314.6,206.95,55.92,0.0,51.74,538.89,0.0,0.0,0,,0.1016,none,0,1,0,0,0,1.9e-05,0,0,,Capitation
CLM0000003427,MBR00000290,Medical_Professional,Paid,Electronic_EDI,2023-01-16,2023-01-16,2023-01-16,2023-01-20,Manual_Review,4,1253087808,1564691686,207RN0300X,Nephrology,24,In_Network,M54.5,,97110,,0,Commercial,PPO,9,M,0.5261,,,1167.54,698.93,384.97,178.71,39.0,96.24,468.61,0.0,0.0,0,,0.0805,unbundling_pattern,0,1,0,0,0,3.6e-05,0,0,,FFS
CLM0000003428,MBR00000134,Vision,Paid,Electronic_EDI,2023-11-26,2023-11-26,2023-11-26,2023-12-14,Auto_Adjudicated,18,1172766349,1728466420,207RC0000X,Cardiovascular Disease,23,In_Network,OTHER,,92004,,0,Medicare_Advantage,MA_PPO,33,M,1.115,,,240.64,135.6,61.31,45.96,13.0,15.33,105.04,0.0,0.0,0,,0.0045,none,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000003429,MBR00000192,Medical_Institutional,Paid,Electronic_EDI,2023-10-29,2023-10-29,2023-10-31,2023-11-22,Auto_Adjudicated,24,1474985672,1643673796,207V00000X,Obstetrics & Gynecology,24,In_Network,J06.9,,revenue_code:0300,,0,Medicaid_MCO,MCO,22,F,1.1739,,,24500.98,20306.95,20305.95,0.0,1.0,0.0,4194.03,0.0,0.0,0,,0.0252,none,0,1,1,0,0,0.00188,0,0,,FFS
CLM0000003430,MBR00000125,Medical_Institutional,Paid,Electronic_EDI,2023-03-14,2023-03-14,2023-03-18,2023-03-15,Manual_Review,1,1364214492,1068662623,2086S0122X,Orthopedic Surgery,11,In_Network,Z00.00,M47.816,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,3071.58,1354.13,1044.79,3.15,45.0,261.2,1717.45,0.0,0.0,0,,0.074,none,0,1,0,0,0,9.7e-05,0,0,SPC_Statin_Therapy,Capitation
CLM0000003431,MBR00000216,Pharmacy,Paid,Electronic_EDI,2023-10-16,2023-10-16,2023-10-16,2023-11-10,Manual_Review,25,1923332120,1575884274,207RN0300X,Nephrology,24,Out_of_Network,J20.9,F41.1,00006001954,,4,Medicare_Advantage,MA_HMO,71,F,0.7117,,,203.33,82.19,44.72,16.3,10.0,11.18,121.14,0.0,0.0,0,,0.0077,none,0,1,0,1,0,4e-06,1,0,CDC_BP_Control,FFS
CLM0000003432,MBR00000275,Medical_Institutional,Paid,Electronic_EDI,2023-01-18,2023-01-18,2023-01-21,2023-02-12,Auto_Adjudicated,25,1478783612,1581533104,225100000X,Physical Therapist,21,In_Network,Z00.00,J20.9,revenue_code:0200,248,0,Medicare_Advantage,MA_PPO,67,M,0.8169,,,2006.4,775.52,576.85,2.46,52.0,144.21,1230.88,492.03,56.23,0,,0.0356,none,0,1,0,0,0,5.3e-05,0,0,,Shared_Savings
CLM0000003433,MBR00000277,Medical_Institutional,Paid,Paper,2023-03-27,2023-03-27,2023-03-28,2023-04-14,Manual_Review,18,1394029346,1538261819,207V00000X,Obstetrics & Gynecology,11,In_Network,I50.9,OTHER,revenue_code:0300,,0,Medicaid_MCO,MCO,30,M,1.8495,,,8950.43,3757.61,3755.61,0.0,2.0,0.0,5192.82,0.0,0.0,0,,0.0014,none,0,1,0,0,0,0.000348,0,0,DAE_Drug_Alcohol_Dependence,P4P
CLM0000003434,MBR00000050,Medical_Institutional,Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-24,2023-03-24,Auto_Adjudicated,29,1156265220,1560230600,207V00000X,Obstetrics & Gynecology,11,In_Network,OTHER,K29.70,revenue_code:0300,,0,Medicare_Advantage,MA_PPO,12,F,0.8486,,,104129.89,66969.72,53548.18,1.49,33.0,13387.05,37160.17,0.0,0.0,0,,0.1818,outlier_billing_amount|controlled_substance_high_volume,0,1,1,1,0,0.004956,0,0,DAE_Drug_Alcohol_Dependence,FFS
CLM0000003435,MBR00000061,Medical_Professional,Paid,Electronic_EDI,2023-05-03,2023-05-03,2023-05-03,2023-05-15,Manual_Review,12,1321381114,1406199453,207RG0100X,Gastroenterology,31,Out_of_Network,I10,Z00.01|M54.5,80053,,0,Commercial,PPO,66,M,2.3575,,,730.28,611.01,360.99,146.78,13.0,90.25,119.27,0.0,0.0,0,,0.0685,none,0,1,0,0,0,3.3e-05,0,0,,P4P
CLM0000003436,MBR00000221,Medical_Institutional,Paid,Electronic_EDI,2023-04-25,2023-04-25,2023-04-27,2023-04-30,Manual_Review,5,1469009511,1187669363,207RN0300X,Nephrology,22,In_Network,OTHER,K57.30|Z00.01,revenue_code:0120,,0,Commercial,HDHP_HSA,28,M,1.6683,,,7140.18,4625.95,3684.47,20.36,0.0,921.12,2514.23,2761.47,616.81,0,,0.1253,none,0,1,0,0,0,0.000341,0,0,COL_Colorectal_Cancer_Screening,Shared_Savings
CLM0000003437,MBR00000187,Medical_Professional,Paid,Electronic_EDI,2023-07-04,2023-07-04,2023-07-04,2023-07-24,Auto_Adjudicated,20,1981623199,1554490060,2086S0122X,Orthopedic Surgery,31,In_Network,K57.30,G47.33|OTHER,99214,,0,Medicaid_MCO,MCO,36,F,1.191,,,344.54,232.9,229.9,0.0,3.0,0.0,111.64,0.0,0.0,0,,0.0173,none,0,1,0,0,0,2.1e-05,0,0,,Capitation
CLM0000003438,MBR00000274,Dental,Paid,Electronic_EDI,2023-06-14,2023-06-14,2023-06-14,2023-07-03,Manual_Review,19,1419204214,1930040953,225100000X,Physical Therapist,22,In_Network,Z00.01,J06.9|E11.9,D0120,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,320.4,210.73,159.14,11.81,0.0,39.78,109.67,0.0,0.0,0,,0.1461,temporal_clustering,0,1,0,1,0,1.5e-05,0,0,BCS_Breast_Cancer_Screening,Capitation
CLM0000003439,MBR00000100,Medical_Institutional,Paid,Electronic_EDI,2023-02-10,2023-02-10,2023-02-10,2023-03-10,Auto_Adjudicated,28,1177281088,1765164601,207RP1001X,Pulmonary Disease,31,In_Network,E11.9,,revenue_code:0100,,0,ACA_Marketplace,ACA_Gold,87,M,1.435,,,3985.24,1744.26,1314.89,41.65,59.0,328.72,2240.98,0.0,0.0,0,,0.1437,none,0,1,0,0,0,0.000122,0,0,,FFS
CLM0000003440,MBR00000255,Medical_Professional,Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-23,2023-03-02,Auto_Adjudicated,7,1211372728,1619587398,246ZN0300X,Neuropsychology,22,In_Network,E11.9,OTHER|F41.1|Z00.00,99221,,0,Medicare_Advantage,MA_HMO,21,M,0.6945,,,105.9,87.08,49.36,7.38,18.0,12.34,18.82,0.0,0.0,0,,0.0906,none,0,1,0,1,0,5e-06,0,0,,FFS
CLM0000003441,MBR00000204,Medical_Institutional,Paid,Electronic_EDI,2023-10-22,2023-10-22,2023-10-24,2023-10-27,Clinical_Review,5,1324142620,1791502603,207Q00000X,Family Medicine,23,In_Network,E11.9,E11.9|Z00.00,revenue_code:0250,,0,Commercial,HMO,12,M,0.8716,,,10845.43,9174.31,7273.14,12.89,70.0,1818.28,1671.12,0.0,0.0,0,,0.1159,duplicate_claim_indicator,0,1,1,0,0,0.000673,0,0,,Shared_Savings
CLM0000003442,MBR00000060,Medical_Professional,Paid,Electronic_EDI,2023-07-16,2023-07-16,2023-07-16,2023-08-06,Manual_Review,21,1995916350,1763260577,207RG0100X,Gastroenterology,11,In_Network,J06.9,K21.0|OTHER|M79.3,97110,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,528.9,226.41,0.0,226.41,0.0,0.0,302.49,0.0,0.0,0,,0.1287,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003443,MBR00000038,Medical_Institutional,Paid,Electronic_EDI,2023-11-28,2023-11-28,2023-11-30,2023-12-08,Auto_Adjudicated,10,1114266188,1564636990,207RP1001X,Pulmonary Disease,23,In_Network,OTHER,Z00.00,revenue_code:0370,,0,Commercial,EPO,46,M,1.1295,,,8727.59,4140.55,3162.18,116.82,71.0,790.55,4587.04,0.0,0.0,0,,0.1393,none,0,1,0,0,0,0.000293,0,0,,FFS
CLM0000003444,MBR00000208,Dental,Paid,Provider_Portal,2023-02-16,2023-02-16,2023-02-16,2023-02-22,Manual_Review,6,1897701389,1489993356,225100000X,Physical Therapist,22,In_Network,E11.9,Z00.00,D4341,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,546.9,347.36,254.67,23.02,6.0,63.67,199.54,0.0,0.0,0,,0.0766,none,0,1,0,1,0,2.4e-05,0,0,,Capitation
CLM0000003445,MBR00000050,Pharmacy,Denied,Electronic_EDI,2023-04-21,2023-04-21,2023-04-21,2023-05-12,Auto_Adjudicated,21,1199465234,1187669363,101YP2500X,Psychologist Clinical,11,In_Network,OTHER,F10.10,00003014960,,1,Medicare_Advantage,MA_PPO,12,F,0.8486,CO-45,Medical_Necessity,506.06,409.67,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0705,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,FFS
CLM0000003446,MBR00000235,Pharmacy,Paid,Electronic_EDI,2023-02-26,2023-02-26,2023-02-26,2023-03-04,Auto_Adjudicated,6,1853403237,1493836023,207RC0000X,Cardiovascular Disease,11,In_Network,J20.9,Z00.01,00078043215,,1,Commercial,HDHP_HSA,85,F,1.4308,,,301.5,193.11,51.73,128.44,0.0,12.93,108.39,0.0,0.0,0,,0.1904,temporal_clustering|controlled_substance_high_volume,0,1,0,0,0,5e-06,0,1,,FFS
CLM0000003447,MBR00000168,Medical_Institutional,Paid,Electronic_EDI,2023-11-28,2023-11-28,2023-11-28,2023-12-23,Auto_Adjudicated,25,1832660692,1288028182,2086S0122X,Orthopedic Surgery,21,In_Network,M17.11,E11.9,revenue_code:0370,291,0,Commercial,HMO,76,M,1.2791,,,8255.39,4446.48,3374.55,152.29,76.0,843.64,3808.91,0.0,0.0,0,,0.1469,high_volume_same_code|high_oop_waiver,0,1,0,0,0,0.000312,0,0,,Shared_Savings
CLM0000003448,MBR00000146,Medical_Institutional,Paid,Electronic_EDI,2023-02-27,2023-02-27,2023-03-01,2023-03-09,Manual_Review,10,1900781649,1874728994,225100000X,Physical Therapist,11,Out_of_Network,I50.9,M47.816,revenue_code:0100,,0,Medicaid_MCO,MCO,24,M,0.6484,,,12600.09,6803.68,6794.68,0.0,9.0,0.0,5796.41,0.0,0.0,0,,0.1684,duplicate_claim_indicator,0,1,1,0,0,0.000629,0,0,,FFS
CLM0000003449,MBR00000086,Medical_Professional,Paid,Paper,2023-10-15,2023-10-15,2023-10-15,2023-11-04,Clinical_Review,20,1469822310,1061113875,246ZN0300X,Neuropsychology,22,In_Network,OTHER,E78.5|F41.1|Z12.11,99215,,0,Medicare_Advantage,MA_PPO,8,M,0.5427,,,469.32,258.15,198.69,1.78,8.0,49.67,211.17,0.0,0.0,0,,0.0061,none,0,1,0,0,0,1.8e-05,0,0,,FFS
CLM0000003450,MBR00000296,Medical_Institutional,Paid,Electronic_EDI,2023-03-11,2023-03-11,2023-03-15,2023-03-29,Auto_Adjudicated,18,1097563011,1746676564,207R00000X,Internal Medicine,22,In_Network,OTHER,J06.9,revenue_code:0300,,0,Commercial,HMO,83,F,1.4969,,,24908.3,20309.0,16108.05,130.94,43.0,4027.01,4599.3,0.0,0.0,0,,0.0911,none,0,1,1,1,0,0.001491,0,0,,Shared_Savings
CLM0000003451,MBR00000212,Medical_Institutional,Paid,Electronic_EDI,2023-09-19,2023-09-19,2023-09-23,2023-10-07,Manual_Review,18,1899326088,1579331190,207V00000X,Obstetrics & Gynecology,65,In_Network,Z00.00,E78.5,revenue_code:0450,,0,Commercial,HMO,57,F,2.5456,,,18978.15,13959.03,10880.41,290.52,68.0,2720.1,5019.12,0.0,0.0,0,,0.1148,none,0,1,1,0,0,0.001007,0,0,,Bundled_Payment
CLM0000003452,MBR00000229,Medical_Professional,Paid,Electronic_EDI,2023-06-13,2023-06-13,2023-06-13,2023-06-23,Auto_Adjudicated,10,1346717076,1105871325,2084P0800X,Psychiatry,22,In_Network,Z12.11,Z23,20610,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,441.91,331.56,222.15,39.87,14.0,55.54,110.35,170.88,32.35,0,,0.0279,none,0,1,0,0,0,2.1e-05,0,0,,FFS
CLM0000003453,MBR00000226,Medical_Professional,Denied,Electronic_EDI,2023-12-14,2023-12-14,2023-12-14,2023-12-17,Manual_Review,3,1292920374,1105871325,207RG0100X,Gastroenterology,24,In_Network,I10,,84443,,0,Medicare_Advantage,MA_PPO,84,M,1.0796,5,Timely_Filing,1343.3,499.14,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.107,none,0,1,0,0,0,0.0,0,0,AWV_Annual_Wellness_Visit,FFS
CLM0000003454,MBR00000176,Medical_Professional,Paid,Electronic_EDI,2023-01-26,2023-01-26,2023-01-26,2023-02-15,Manual_Review,20,1108756266,1355732274,2086S0122X,Orthopedic Surgery,23,In_Network,I10,,99202,,0,Commercial,POS,4,M,0.8792,,,548.64,276.93,0.0,276.93,0.0,0.0,271.71,0.0,0.0,0,,0.1673,billing_spike_recent,0,1,0,0,0,0.0,0,0,CBP_Controlling_BP,FFS
CLM0000003455,MBR00000285,Medical_Professional,Paid,Electronic_EDI,2023-04-27,2023-04-27,2023-04-27,2023-05-11,Manual_Review,14,1542851144,1874728994,207RN0300X,Nephrology,23,In_Network,I10,I10|OTHER,99392,,0,Commercial,HDHP_HSA,56,M,0.9226,,,421.91,312.96,0.0,312.96,0.0,0.0,108.95,0.0,0.0,0,,0.0371,none,0,1,0,0,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,Capitation
CLM0000003456,MBR00000176,Medical_Professional,Paid,Electronic_EDI,2023-09-17,2023-09-17,2023-09-17,2023-10-17,Auto_Adjudicated,30,1487261286,1577226132,208600000X,Surgery General,21,Out_of_Network,C50.911,M54.5,99395,,0,Commercial,POS,4,M,0.8792,,,1219.75,499.22,26.47,445.13,21.0,6.62,720.53,0.0,0.0,0,,0.1489,high_volume_same_code,0,1,0,0,0,2e-06,1,0,DDE_Diabetes_Short_Term_Complications,Capitation
CLM0000003457,MBR00000159,Medical_Institutional,Paid,Provider_Portal,2023-11-25,2023-11-25,2023-11-27,2023-12-22,Auto_Adjudicated,27,1379875145,1388050552,101YP2500X,Psychologist Clinical,21,In_Network,Z00.00,,revenue_code:0110,682,0,Commercial,PPO,70,F,1.2009,,,23545.58,11319.63,8967.6,39.13,71.0,2241.9,12225.95,0.0,0.0,0,,0.1423,high_volume_same_code|upcoding_pattern,0,1,1,0,0,0.00083,0,0,COA_Care_Transitions,FFS
CLM0000003458,MBR00000085,Medical_Institutional,Paid,Electronic_EDI,2023-07-13,2023-07-13,2023-07-13,2023-07-16,Auto_Adjudicated,3,1159640414,1321680994,2084P0800X,Psychiatry,11,In_Network,OTHER,L70.0,revenue_code:0210,,0,Medicare_Advantage,SNP,2,M,0.7823,,,33701.13,25661.0,20488.74,13.08,37.0,5122.18,8040.13,0.0,0.0,0,,0.1126,controlled_substance_high_volume,0,1,1,1,0,0.001896,0,0,,FFS
CLM0000003459,MBR00000088,Medical_Institutional,Paid,Electronic_EDI,2023-02-05,2023-02-05,2023-02-09,2023-02-16,Auto_Adjudicated,11,1317654726,1825450791,207RE0101X,Endocrinology,23,In_Network,M25.511,,revenue_code:0100,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,,,21360.33,13441.25,9010.66,478.88,90.0,3861.71,7919.08,0.0,0.0,0,,0.1077,none,0,1,1,0,0,0.000834,0,0,,P4P
CLM0000003460,MBR00000215,Medical_Professional,Paid,Electronic_EDI,2023-08-14,2023-08-14,2023-08-14,2023-08-27,Auto_Adjudicated,13,1313352855,1704466150,207R00000X,Internal Medicine,11,In_Network,Z23,,43239,,0,ACA_Marketplace,ACA_Silver,69,M,0.8895,,,593.63,369.26,0.0,369.26,0.0,0.0,224.37,0.0,0.0,0,,0.0292,none,0,1,0,0,0,0.0,0,0,POD_Persistence_of_Beta_Blocker,Shared_Savings
CLM0000003461,MBR00000106,Medical_Institutional,Paid,Electronic_EDI,2023-06-21,2023-06-21,2023-06-23,2023-07-03,Auto_Adjudicated,12,1731980913,1867626800,207RC0000X,Cardiovascular Disease,22,In_Network,Z23,E78.5,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,4163.89,2071.87,1606.65,28.56,35.0,401.66,2092.02,0.0,0.0,0,,0.116,none,0,1,0,0,0,0.000149,0,0,,Shared_Savings
CLM0000003462,MBR00000214,Pharmacy,Paid,Electronic_EDI,2023-10-06,2023-10-06,2023-10-06,2023-10-28,Auto_Adjudicated,22,1746688640,1878017518,207Q00000X,Family Medicine,65,In_Network,K57.30,E78.5|F41.1|L70.0,00310075090,,2,Commercial,HDHP_HSA,76,M,1.7526,,,97.27,38.55,0.0,38.55,0.0,0.0,58.72,0.0,0.0,0,,0.0615,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003463,MBR00000289,Medical_Professional,Paid,Provider_Portal,2023-07-18,2023-07-18,2023-07-18,2023-07-29,Auto_Adjudicated,11,1597245892,1564636990,207Q00000X,Family Medicine,23,In_Network,Z00.00,,97010,,0,Commercial,POS,51,M,1.0534,,,382.12,299.02,202.27,7.18,39.0,50.57,83.1,0.0,0.0,0,,0.0295,none,0,1,0,0,0,1.9e-05,0,0,HBD_Hemoglobin_A1c_Testing,Capitation
CLM0000003464,MBR00000138,Medical_Professional,Paid,Electronic_EDI,2023-11-19,2023-11-19,2023-11-19,2023-11-24,Auto_Adjudicated,5,1327415110,1291071007,2086S0122X,Orthopedic Surgery,11,In_Network,Z12.11,Z00.00,97010,,0,Commercial,HDHP_HSA,47,M,0.996,,,278.87,122.92,0.0,122.92,0.0,0.0,155.95,0.0,0.0,0,,0.0045,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003465,MBR00000029,Medical_Institutional,Denied,Electronic_EDI,2023-02-14,2023-02-14,2023-02-17,2023-02-25,Auto_Adjudicated,11,1048378959,1789540567,207V00000X,Obstetrics & Gynecology,22,In_Network,I10,I10,revenue_code:0300,,0,Medicaid_MCO,MCO,13,F,0.9053,22,Network,9271.31,5686.35,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0649,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003466,MBR00000198,Medical_Professional,Denied,Provider_Portal,2023-08-12,2023-08-12,2023-08-12,2023-09-05,Auto_Adjudicated,24,1956215244,1809122260,207RN0300X,Nephrology,22,In_Network,I10,OTHER|J06.9,99283,,0,Medicaid_MCO,MCO,81,F,1.4199,256,COB,280.45,181.23,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1476,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,POD_Persistence_of_Beta_Blocker,FFS
CLM0000003467,MBR00000003,Medical_Professional,Paid,Electronic_EDI,2023-09-22,2023-09-22,2023-09-22,2023-10-05,Auto_Adjudicated,13,1421421733,1012893364,207RP1001X,Pulmonary Disease,31,In_Network,J20.9,OTHER,74177,,0,Commercial,PPO,79,F,1.3879,,,1496.57,880.74,684.41,0.23,25.0,171.1,615.83,0.0,0.0,0,,0.1165,upcoding_pattern,0,1,0,1,0,6.3e-05,0,0,,FFS
CLM0000003468,MBR00000233,Medical_Institutional,Paid,Electronic_EDI,2023-05-26,2023-05-26,2023-05-26,2023-06-04,Auto_Adjudicated,9,1054449469,1128148362,207RC0000X,Cardiovascular Disease,24,In_Network,E11.9,I10|OTHER,revenue_code:0370,,0,Medicare_Advantage,MA_PPO,87,M,0.8034,,,4056.08,3069.44,2374.04,53.88,48.0,593.51,986.64,0.0,0.0,0,,0.1422,npi_mismatch,0,1,0,0,0,0.00022,0,0,,Shared_Savings
CLM0000003469,MBR00000160,Medical_Professional,Paid,Electronic_EDI,2023-06-20,2023-06-20,2023-06-20,2023-07-14,Auto_Adjudicated,24,1928139578,1177602659,207RP1001X,Pulmonary Disease,21,In_Network,Z12.11,F33.0|I10,99204,,0,Commercial,HMO,73,M,1.9608,,,437.36,154.17,10.09,118.56,23.0,2.52,283.19,0.0,0.0,0,,0.0054,none,0,1,0,0,0,1e-06,0,0,,Capitation
CLM0000003470,MBR00000152,Pharmacy,Paid,Electronic_EDI,2023-09-07,2023-09-07,2023-09-07,2023-09-09,Manual_Review,2,1618564043,1625992541,208600000X,Surgery General,65,In_Network,N40.0,,00071012831,,2,Commercial,HMO,82,F,1.2506,,,223.07,118.51,0.0,118.51,0.0,0.0,104.56,0.0,0.0,0,,0.0158,none,0,1,0,1,0,0.0,0,1,,FFS
CLM0000003471,MBR00000170,Pharmacy,Paid,Electronic_EDI,2023-06-13,2023-06-13,2023-06-13,2023-06-27,Auto_Adjudicated,14,1216417633,1432077493,207RC0000X,Cardiovascular Disease,11,In_Network,F33.0,Z00.00|OTHER,00078043215,,1,Medicare_Advantage,MA_PPO,86,M,1.7691,,,243.27,170.31,114.9,23.68,3.0,28.73,72.96,0.0,0.0,0,,0.0096,none,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000003472,MBR00000158,Medical_Institutional,Paid,Electronic_EDI,2023-05-21,2023-05-21,2023-05-22,2023-05-25,Auto_Adjudicated,4,1468401280,1105871325,207RP1001X,Pulmonary Disease,11,In_Network,M54.5,,revenue_code:0120,,0,Commercial,HMO,65,M,1.5361,,,11004.81,4117.05,3114.14,174.37,50.0,778.54,6887.76,0.0,0.0,0,,0.106,none,0,1,0,0,0,0.000288,0,0,,FFS
CLM0000003473,MBR00000102,Medical_Institutional,Paid,Electronic_EDI,2023-07-28,2023-07-28,2023-07-29,2023-08-16,Auto_Adjudicated,19,1986485249,1643323506,207RP1001X,Pulmonary Disease,11,In_Network,Z00.00,E78.5|E11.9,revenue_code:0370,,0,Commercial,POS,68,M,1.6864,,,78855.66,63910.03,50749.89,407.67,65.0,12687.47,14945.63,0.0,0.0,0,,0.102,outlier_billing_amount,0,1,1,0,0,0.004697,0,0,,Capitation
CLM0000003474,MBR00000088,Vision,Denied,Electronic_EDI,2023-10-16,2023-10-16,2023-10-16,2023-11-12,Auto_Adjudicated,27,1906448800,1013600387,208600000X,Surgery General,11,In_Network,Z00.00,I10,92002,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,97,Network,188.99,101.95,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0622,diagnosis_procedure_mismatch,0,1,0,1,0,0.0,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000003475,MBR00000132,Medical_Institutional,Denied,Paper,2023-02-18,2023-02-18,2023-02-21,2023-03-04,Auto_Adjudicated,14,1950560596,1589482133,207RC0000X,Cardiovascular Disease,21,Out_of_Network,F41.1,J06.9,revenue_code:0100,470,0,Medicare_Advantage,MA_PPO,84,F,1.3018,3,Authorization,7260.09,4701.46,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0827,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003476,MBR00000271,Behavioral_Health,Paid,Electronic_EDI,2023-11-10,2023-11-10,2023-11-10,2023-12-10,Manual_Review,30,1154652946,1013600387,207Q00000X,Family Medicine,11,In_Network,Z23,N39.0,99387,,0,Medicaid_MCO,MCO,4,F,0.6696,,,233.34,82.77,82.77,0.0,0.0,0.0,150.57,0.0,0.0,0,,0.004,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000003477,MBR00000042,Pharmacy,Paid,Provider_Portal,2023-03-13,2023-03-13,2023-03-13,2023-04-09,Manual_Review,27,1897146144,1007652766,207RN0300X,Nephrology,11,In_Network,OTHER,F41.1,00310075090,,4,Commercial,HMO,78,F,1.1448,,,247.01,153.07,81.57,31.11,20.0,20.39,93.94,0.0,0.0,0,,0.0587,unusual_service_frequency,0,1,0,1,0,8e-06,0,1,,FFS
CLM0000003478,MBR00000102,Medical_Professional,Paid,Electronic_EDI,2023-02-05,2023-02-05,2023-02-05,2023-02-27,Auto_Adjudicated,22,1059948944,1296566243,207RC0000X,Cardiovascular Disease,11,In_Network,Z00.01,,99396,,0,Commercial,POS,68,M,1.6864,,,313.33,142.02,0.0,142.02,0.0,0.0,171.31,0.0,0.0,0,,0.1087,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003479,MBR00000060,Medical_Professional,Denied,Electronic_EDI,2023-03-06,2023-03-06,2023-03-06,2023-03-12,Auto_Adjudicated,6,1836409547,1469881892,207RN0300X,Nephrology,65,In_Network,OTHER,OTHER,99394,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,2,Eligibility,273.1,141.44,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0019,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003480,MBR00000135,Medical_Professional,Paid,Electronic_EDI,2023-01-28,2023-01-28,2023-01-28,2023-01-29,Auto_Adjudicated,1,1414670047,1164525386,207RG0100X,Gastroenterology,24,In_Network,E11.9,E11.9,99203,,0,Commercial,PPO,58,F,2.2702,,,364.31,298.35,208.29,0.99,37.0,52.07,65.96,0.0,0.0,0,,0.1765,impossible_service_combo,0,1,0,0,0,1.9e-05,0,0,,Bundled_Payment
CLM0000003481,MBR00000041,Pharmacy,Paid,Provider_Portal,2023-12-08,2023-12-08,2023-12-08,2023-12-12,Auto_Adjudicated,4,1324084461,1728466420,208600000X,Surgery General,23,In_Network,J06.9,I48.91,00071015523,,2,Commercial,PPO,42,F,0.8283,,,291.27,206.49,65.18,101.02,24.0,16.29,84.78,0.0,0.0,0,,0.1376,none,0,1,0,0,0,6e-06,0,0,,Shared_Savings
CLM0000003482,MBR00000224,Medical_Professional,Paid,Electronic_EDI,2023-04-15,2023-04-15,2023-04-15,2023-04-26,Manual_Review,11,1211612843,1432077493,246ZN0300X,Neuropsychology,24,In_Network,OTHER,OTHER,99284,,0,Medicaid_MCO,MCO,86,F,1.3289,,,274.65,184.85,181.85,0.0,3.0,0.0,89.8,0.0,0.0,0,,0.0563,npi_mismatch,0,1,0,1,0,1.7e-05,0,0,AMR_Asthma_Medication_Ratio,Capitation
CLM0000003483,MBR00000031,Pharmacy,Paid,Electronic_EDI,2023-10-05,2023-10-05,2023-10-05,2023-10-18,Manual_Review,13,1454203715,1995553359,2084P0800X,Psychiatry,23,Emergency,OTHER,Z00.00,00071012831,,1,Commercial,PPO,71,M,0.6746,,,782.39,660.63,495.07,25.79,16.0,123.77,121.76,0.0,0.0,0,,0.2068,billing_spike_recent|phantom_billing_indicator,0,2,0,0,0,4.6e-05,0,1,,FFS
CLM0000003484,MBR00000198,Medical_Institutional,Paid,Electronic_EDI,2023-03-07,2023-03-07,2023-03-10,2023-03-14,Auto_Adjudicated,7,1484613641,1020312030,225100000X,Physical Therapist,11,In_Network,M17.11,M25.511|E78.5,revenue_code:0120,,0,Medicaid_MCO,MCO,81,F,1.4199,,,17856.64,7845.99,7843.99,0.0,2.0,0.0,10010.65,0.0,0.0,0,,0.1381,none,0,1,1,0,0,0.000726,0,0,DAE_Drug_Alcohol_Dependence,FFS
CLM0000003485,MBR00000083,Pharmacy,Paid,Provider_Portal,2023-07-09,2023-07-09,2023-07-09,2023-08-08,Auto_Adjudicated,30,1658382624,1132693989,2084P0800X,Psychiatry,65,In_Network,Z00.01,K21.0,00169751112,,2,Commercial,PPO,76,M,0.6621,,,144.39,54.93,0.0,54.93,0.0,0.0,89.46,0.0,0.0,0,,0.1923,unbundling_pattern,0,1,0,0,0,0.0,0,1,CDC_HbA1c_Poor_Control,FFS
CLM0000003486,MBR00000144,Pharmacy,Paid,Paper,2023-06-02,2023-06-02,2023-06-02,2023-06-25,Auto_Adjudicated,23,1495592428,1319611206,207R00000X,Internal Medicine,21,In_Network,J44.1,Z00.00,00071015523,,3,Commercial,HDHP_HSA,56,F,2.5926,,,486.73,357.4,0.0,357.4,0.0,0.0,129.33,0.0,0.0,0,,0.1384,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003487,MBR00000061,Medical_Professional,Denied,Electronic_EDI,2023-08-25,2023-08-25,2023-08-25,2023-09-15,Auto_Adjudicated,21,1746688640,1847196500,207RG0100X,Gastroenterology,22,Out_of_Network,OTHER,M54.5|Z00.01|E11.9,99283,,0,Commercial,PPO,66,M,2.3575,PR-1,Duplicate,101.51,36.7,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0825,high_oop_waiver,0,1,0,0,0,0.0,1,0,SPD_Spirometry_Testing,FFS
CLM0000003488,MBR00000214,Medical_Professional,Denied,Paper,2023-12-21,2023-12-21,2023-12-21,2024-01-10,Auto_Adjudicated,20,1793630905,1509799493,207RP1001X,Pulmonary Disease,32,In_Network,E78.5,,99204,,0,Commercial,HDHP_HSA,76,M,1.7526,2,COB,159.52,117.98,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0261,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003489,MBR00000287,Medical_Institutional,Paid,Electronic_EDI,2023-08-22,2023-08-22,2023-08-25,2023-09-10,Auto_Adjudicated,19,1863796345,1951488764,101YP2500X,Psychologist Clinical,11,In_Network,I10,,revenue_code:0120,,0,Commercial,PPO,4,M,0.7685,,,9987.78,6023.19,4763.33,12.03,57.0,1190.83,3964.59,0.0,0.0,0,,0.0656,none,0,1,0,0,0,0.000441,0,0,,FFS
CLM0000003490,MBR00000069,Pharmacy,Paid,Electronic_EDI,2023-09-10,2023-09-10,2023-09-10,2023-10-07,Manual_Review,27,1718336220,1447186817,207R00000X,Internal Medicine,21,In_Network,F41.1,Z00.00|OTHER|N39.0,00169751112,,5,Medicare_Advantage,MA_PPO,2,M,0.5765,,,70.15,32.51,0.0,25.31,7.2,0.0,37.64,0.0,0.0,0,,0.1762,upcoding_pattern,0,1,0,0,0,0.0,0,1,COA_Care_Transitions,Shared_Savings
CLM0000003491,MBR00000289,Pharmacy,Paid,Electronic_EDI,2023-04-05,2023-04-05,2023-04-05,2023-04-17,Auto_Adjudicated,12,1220710861,1228356980,2086S0122X,Orthopedic Surgery,31,Out_of_Network,I48.91,M54.5|OTHER,00085163102,,2,Commercial,POS,51,M,1.0534,,,342.27,229.38,138.98,16.66,39.0,34.74,112.89,0.0,0.0,0,,0.0874,provider_specialty_mismatch,0,1,0,0,0,1.3e-05,1,0,,Shared_Savings
CLM0000003492,MBR00000103,Medical_Institutional,Denied,Electronic_EDI,2023-02-13,2023-02-13,2023-02-14,2023-02-18,Auto_Adjudicated,5,1875632885,1288028182,207RG0100X,Gastroenterology,22,In_Network,M17.11,OTHER,revenue_code:0110,,0,Medicaid_MCO,MCO,24,M,0.4785,18,Timely_Filing,23980.47,14317.77,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1376,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000003493,MBR00000168,Pharmacy,Partially_Paid,Electronic_EDI,2023-02-01,2023-02-01,2023-02-01,2023-02-10,Auto_Adjudicated,9,1331903993,1706603847,208600000X,Surgery General,21,Emergency,E11.9,,00169751112,,3,Commercial,HMO,76,M,1.2791,PR-1,Medical_Necessity,663.71,295.14,0.0,167.25,0.0,0.0,496.46,0.0,0.0,0,,0.0926,unbundling_pattern,0,1,0,0,0,0.0,0,0,FUM_Follow_Up_ED_Mental_Health,Bundled_Payment
CLM0000003494,MBR00000208,Medical_Institutional,Paid,Electronic_EDI,2023-04-18,2023-04-18,2023-04-19,2023-04-25,Auto_Adjudicated,7,1915327071,1619587398,207RE0101X,Endocrinology,71,Emergency,OTHER,OTHER,revenue_code:0300,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,7135.27,5372.52,4236.73,22.61,54.0,1059.18,1762.75,0.0,0.0,0,,0.0161,none,0,1,0,1,0,0.000392,0,0,AWV_Annual_Wellness_Visit,Shared_Savings
CLM0000003495,MBR00000061,Medical_Professional,Denied,Electronic_EDI,2023-07-19,2023-07-19,2023-07-19,2023-08-17,Auto_Adjudicated,29,1042080259,1690197969,207RN0300X,Nephrology,32,In_Network,OTHER,K57.30|M54.5,97010,,0,Commercial,PPO,66,M,2.3575,16,Duplicate,967.02,478.3,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.069,none,0,1,0,0,0,0.0,0,0,FUM_Follow_Up_ED_Mental_Health,Bundled_Payment
CLM0000003496,MBR00000139,Dental,Paid,Electronic_EDI,2023-01-22,2023-01-22,2023-01-22,2023-02-09,Auto_Adjudicated,18,1618546650,1029818813,207Q00000X,Family Medicine,32,In_Network,G47.33,OTHER,D1110,,0,Commercial,PPO,74,M,1.7701,,,754.29,356.41,108.91,199.27,21.0,27.23,397.88,0.0,0.0,0,,0.0781,none,0,1,0,1,0,1e-05,0,0,,Shared_Savings
CLM0000003497,MBR00000021,Medical_Institutional,Paid,Electronic_EDI,2023-04-05,2023-04-05,2023-04-05,2023-04-18,Auto_Adjudicated,13,1879212418,1587454801,207RP1001X,Pulmonary Disease,11,In_Network,Z00.00,M17.11|Z79.4,revenue_code:0360,,0,Commercial,POS,72,M,0.6126,,,13890.31,9693.09,7627.97,99.13,59.0,1906.99,4197.22,0.0,0.0,0,,0.0862,impossible_service_combo,0,1,1,0,0,0.000706,0,0,,FFS
CLM0000003498,MBR00000207,Pharmacy,Paid,Electronic_EDI,2023-08-15,2023-08-15,2023-08-15,2023-08-16,Auto_Adjudicated,1,1112402001,1007652766,207RN0300X,Nephrology,31,In_Network,E11.9,,00310075090,,4,Medicaid_MCO,MLTSS,11,F,1.6522,,,396.1,221.73,221.73,0.0,0.0,0.0,174.37,168.14,33.12,0,,0.0703,none,0,1,0,0,0,2.1e-05,0,1,,Bundled_Payment
CLM0000003499,MBR00000132,Medical_Professional,Denied,Electronic_EDI,2023-11-10,2023-11-10,2023-11-10,2023-12-02,Auto_Adjudicated,22,1484613641,1553094822,208600000X,Surgery General,23,In_Network,F33.0,I10,97140,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,5,COB,606.03,316.24,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0345,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003500,MBR00000270,Medical_Institutional,Paid,Electronic_EDI,2023-12-22,2023-12-22,2023-12-23,2024-01-11,Auto_Adjudicated,20,1172766349,1133410177,207Q00000X,Family Medicine,23,In_Network,OTHER,,revenue_code:0450,,0,Commercial,POS,1,F,1.6363,,,39179.32,24684.05,19408.44,347.5,76.0,4852.11,14495.27,0.0,0.0,0,,0.1194,none,0,1,1,0,0,0.001796,0,0,,P4P
CLM0000003501,MBR00000085,Medical_Professional,Paid,Electronic_EDI,2023-03-26,2023-03-26,2023-03-26,2023-04-20,Auto_Adjudicated,25,1532359759,1330485436,207RN0300X,Nephrology,11,In_Network,F32.9,Z00.00,20610,,0,Medicare_Advantage,SNP,2,M,0.7823,,,381.56,259.37,189.22,7.84,15.0,47.31,122.19,0.0,0.0,0,,0.1783,impossible_service_combo,0,1,0,0,0,1.8e-05,0,0,,FFS
CLM0000003502,MBR00000279,Medical_Institutional,Paid,Paper,2023-02-06,2023-02-06,2023-02-06,2023-02-10,Clinical_Review,4,1015411732,1187669363,225100000X,Physical Therapist,22,In_Network,M54.5,OTHER|F33.0,revenue_code:0360,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,,,2969.92,1224.2,947.57,9.74,30.0,236.89,1745.72,0.0,0.0,0,,0.1211,none,0,1,0,0,0,8.8e-05,0,0,,Capitation
CLM0000003503,MBR00000044,Medical_Professional,Denied,Electronic_EDI,2023-07-25,2023-07-25,2023-07-25,2023-08-14,Auto_Adjudicated,20,1747318937,1747935894,207RP1001X,Pulmonary Disease,11,Out_of_Network,OTHER,,97110,,0,Commercial,PPO,29,M,0.7512,22,Coding_Error,498.57,397.69,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1377,upcoding_pattern,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003504,MBR00000183,Pharmacy,Denied,Electronic_EDI,2023-12-03,2023-12-03,2023-12-03,2023-12-14,Auto_Adjudicated,11,1838794554,1930040953,207R00000X,Internal Medicine,65,In_Network,Z12.11,E13.9,00003014960,,2,Commercial,PPO,51,M,0.8463,3,Eligibility,167.78,89.96,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0572,none,0,1,0,0,0,0.0,0,0,AWV_Annual_Wellness_Visit,Shared_Savings
CLM0000003505,MBR00000097,Medical_Professional,Denied,Electronic_EDI,2023-05-31,2023-05-31,2023-05-31,2023-06-07,Auto_Adjudicated,7,1963647323,1114756459,208600000X,Surgery General,22,In_Network,OTHER,Z00.00,83036,,0,Commercial,EPO,34,M,1.3765,97,Timely_Filing,882.94,395.28,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0862,none,0,1,0,1,0,0.0,0,0,LCS_Lung_Cancer_Screening,Capitation
CLM0000003506,MBR00000057,Medical_Professional,Partially_Paid,Electronic_EDI,2023-11-21,2023-11-21,2023-11-21,2023-11-28,Auto_Adjudicated,7,1560886857,1469642907,207V00000X,Obstetrics & Gynecology,22,In_Network,N39.0,Z23,99213,,0,Medicare_Advantage,MA_PPO,45,M,0.6701,4,Medical_Necessity,350.83,145.49,29.0,45.49,2.0,7.25,267.09,24.06,3.55,0,,0.1452,none,0,1,0,0,0,3e-06,0,0,COL_Colorectal_Cancer_Screening,Capitation
CLM0000003507,MBR00000028,Medical_Professional,Paid,Electronic_EDI,2023-09-24,2023-09-24,2023-09-24,2023-10-03,Auto_Adjudicated,9,1793630905,1039962073,101YP2500X,Psychologist Clinical,11,In_Network,F33.0,,99213,,0,Commercial,HMO,3,F,2.116,,,196.39,157.03,0.0,157.03,0.0,0.0,39.36,0.0,0.0,0,,0.0005,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003508,MBR00000195,Medical_Institutional,Paid,Electronic_EDI,2023-11-19,2023-11-19,2023-11-23,2023-12-11,Auto_Adjudicated,22,1750232347,1965244699,2086S0122X,Orthopedic Surgery,21,In_Network,I10,E78.5,revenue_code:0100,871,0,Commercial,PPO,13,F,0.5967,,,4885.29,1865.15,1393.85,90.84,32.0,348.46,3020.14,1234.37,84.65,0,,0.057,none,0,1,0,0,0,0.000129,0,0,COL_Colorectal_Cancer_Screening,Shared_Savings
CLM0000003509,MBR00000073,Medical_Institutional,Paid,Electronic_EDI,2023-12-08,2023-12-08,2023-12-11,2023-12-09,Clinical_Review,1,1274357072,1694343357,207Q00000X,Family Medicine,22,In_Network,E78.5,OTHER|F41.1|Z12.11,revenue_code:0210,,0,Commercial,POS,79,M,1.1768,,,51867.81,36532.24,29019.99,185.26,72.0,7255.0,15335.57,0.0,0.0,0,,0.0712,outlier_billing_amount,0,1,1,0,0,0.002686,0,0,BPD_BP_Declined,FFS
CLM0000003510,MBR00000172,Pharmacy,Paid,Electronic_EDI,2023-02-08,2023-02-08,2023-02-08,2023-03-09,Auto_Adjudicated,29,1986485249,1986847322,207RG0100X,Gastroenterology,24,In_Network,OTHER,,50458085930,,1,Medicaid_MCO,MCO,50,F,0.2787,,,161.22,58.07,58.07,0.0,0.0,0.0,103.15,0.0,0.0,0,,0.1122,npi_mismatch,0,1,0,0,0,5e-06,0,1,,FFS
CLM0000003511,MBR00000295,Pharmacy,Paid,Electronic_EDI,2023-05-28,2023-05-28,2023-05-28,2023-06-27,Auto_Adjudicated,30,1810800968,1847196500,207RG0100X,Gastroenterology,22,In_Network,F10.10,,00078043215,,2,Commercial,HDHP_HSA,78,F,0.8618,,,123.02,97.11,0.0,97.11,0.0,0.0,25.91,0.0,0.0,0,,0.009,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003512,MBR00000100,Medical_Institutional,Denied,Paper,2023-01-18,2023-01-18,2023-01-21,2023-02-17,Manual_Review,30,1556072255,1151295616,207RE0101X,Endocrinology,11,In_Network,F41.1,,revenue_code:0450,,0,ACA_Marketplace,ACA_Gold,87,M,1.435,PR-1,Duplicate,15989.45,12874.75,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1074,none,0,1,0,0,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,Shared_Savings
CLM0000003513,MBR00000011,Medical_Institutional,Paid,Electronic_EDI,2023-01-16,2023-01-16,2023-01-20,2023-02-11,Auto_Adjudicated,26,1496489953,1623053477,208600000X,Surgery General,22,In_Network,N39.0,I10,revenue_code:0360,,0,Medicare_Advantage,SNP,35,F,1.0833,,,5013.29,2424.65,1906.89,0.03,41.0,476.72,2588.64,0.0,0.0,0,,0.0667,none,0,1,0,1,0,0.000177,0,0,,Shared_Savings
CLM0000003514,MBR00000045,Medical_Professional,Paid,Electronic_EDI,2023-06-20,2023-06-20,2023-06-20,2023-06-30,Auto_Adjudicated,10,1906448800,1055872102,207Q00000X,Family Medicine,11,In_Network,Z00.01,,97035,,0,Commercial,HMO,78,F,1.0658,,,394.08,150.17,83.94,13.25,32.0,20.98,243.91,0.0,0.0,0,,0.0508,none,0,1,0,0,0,8e-06,0,0,TRC_Transition_of_Care,FFS
CLM0000003515,MBR00000036,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-08-26,2023-08-26,2023-08-29,2023-09-08,Manual_Review,13,1816378991,1560230600,207R00000X,Internal Medicine,22,In_Network,OTHER,Z12.11|J06.9|OTHER,revenue_code:0370,,0,Commercial,EPO,17,M,2.0136,4,Medical_Necessity,24473.6,9045.56,4975.74,159.44,40.0,1243.93,18054.49,0.0,0.0,0,,0.0893,none,0,1,0,0,0,0.000461,0,0,,Bundled_Payment
CLM0000003516,MBR00000143,Dental,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-11-19,Auto_Adjudicated,4,1871348663,1880530717,207RN0300X,Nephrology,22,In_Network,Z00.00,OTHER|Z12.11,D2391,,0,Commercial,POS,85,M,1.6078,,,190.42,157.86,0.0,157.86,0.0,0.0,32.56,0.0,0.0,0,,0.0748,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003517,MBR00000218,Medical_Institutional,Denied,Electronic_EDI,2023-02-16,2023-02-16,2023-02-17,2023-03-15,Auto_Adjudicated,27,1055717021,1938465393,207R00000X,Internal Medicine,11,In_Network,Z12.11,Z23,revenue_code:0120,,0,Commercial,HDHP_HSA,11,F,0.4964,CO-45,Network,3627.73,2433.01,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0249,none,0,1,0,1,0,0.0,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000003518,MBR00000092,Vision,Paid,Electronic_EDI,2023-01-12,2023-01-12,2023-01-12,2023-02-05,Manual_Review,24,1557212800,1538261819,207RN0300X,Nephrology,11,In_Network,Z23,,V2103,,0,Medicaid_MCO,MLTSS,68,F,1.3217,,,234.39,193.67,190.67,0.0,3.0,0.0,40.72,0.0,0.0,0,,0.122,upcoding_pattern,0,1,0,1,0,1.8e-05,0,0,,Shared_Savings
CLM0000003519,MBR00000046,Medical_Professional,Paid,Electronic_EDI,2023-02-07,2023-02-07,2023-02-07,2023-02-12,Auto_Adjudicated,5,1836409547,1945682535,207RP1001X,Pulmonary Disease,23,In_Network,N18.3,OTHER,85025,,0,Commercial,HMO,76,F,0.9613,,,779.23,459.89,244.36,119.44,35.0,61.09,319.34,0.0,0.0,0,,0.0121,none,0,1,0,0,0,2.3e-05,0,0,,FFS
CLM0000003520,MBR00000190,Pharmacy,Paid,Electronic_EDI,2023-11-29,2023-11-29,2023-11-29,2023-12-29,Auto_Adjudicated,30,1719850506,1774401124,2084P0800X,Psychiatry,22,In_Network,Z23,Z12.11|Z79.4,16590051660,,2,Commercial,PPO,24,F,0.3232,,,540.62,406.04,97.42,249.26,35.0,24.36,134.58,0.0,0.0,0,,0.1417,none,0,1,0,1,0,9e-06,0,0,,Capitation
CLM0000003521,MBR00000095,Pharmacy,Paid,Electronic_EDI,2023-08-26,2023-08-26,2023-08-26,2023-08-28,Auto_Adjudicated,2,1594587354,1574982369,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,I10,59148001506,,1,Commercial,HMO,28,M,0.5827,,,587.02,483.88,362.95,8.19,22.0,90.74,103.14,0.0,0.0,1,DME Fraud,0.9759,geographic_mismatch|temporal_clustering|impossible_service_combo|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|npi_mismatch|high_oop_waiver,1,5,0,0,0,3.4e-05,0,1,,Capitation
CLM0000003522,MBR00000173,Pharmacy,Denied,Provider_Portal,2023-06-22,2023-06-22,2023-06-22,2023-07-16,Auto_Adjudicated,24,1732193518,1589482133,207RP1001X,Pulmonary Disease,22,In_Network,OTHER,K21.0|E11.9,16590051660,,2,Medicare_Advantage,PFFS,23,F,1.0279,22,Timely_Filing,151.64,72.11,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Duplicate Billing,0.8991,outlier_billing_amount|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|billing_spike_recent|upcoding_pattern|unbundling_pattern|high_oop_waiver,1,5,0,0,0,0.0,0,0,,FFS
CLM0000003523,MBR00000282,Pharmacy,Paid,Electronic_EDI,2023-02-06,2023-02-06,2023-02-06,2023-02-11,Auto_Adjudicated,5,1092800235,1469697158,246ZN0300X,Neuropsychology,22,In_Network,OTHER,E11.9|M17.11,00071015523,,2,Medicare_Advantage,MA_HMO,16,M,0.7304,,,73.52,29.03,0.0,29.03,0.0,0.0,44.49,0.0,0.0,0,,0.1372,none,0,1,0,0,0,0.0,0,1,DAE_Drug_Alcohol_Dependence,FFS
CLM0000003524,MBR00000091,Medical_Professional,Denied,Electronic_EDI,2023-05-14,2023-05-14,2023-05-14,2023-06-06,Auto_Adjudicated,23,1426424205,1867626800,207V00000X,Obstetrics & Gynecology,11,In_Network,M17.11,M54.5|OTHER|K21.0,97010,,0,Commercial,PPO,13,F,1.2451,1,COB,1233.69,604.98,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.05,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003525,MBR00000157,Pharmacy,Paid,Electronic_EDI,2023-02-16,2023-02-16,2023-02-16,2023-03-15,Auto_Adjudicated,27,1966338974,1878874025,207RN0300X,Nephrology,11,In_Network,M54.5,Z00.00,16590051660,,1,Medicare_Advantage,MA_HMO,26,F,0.9164,,,197.12,123.0,80.23,5.72,17.0,20.06,74.12,0.0,0.0,0,,0.1218,impossible_service_combo,0,1,0,1,0,7e-06,0,0,SPC_Statin_Therapy,FFS
CLM0000003526,MBR00000239,Medical_Institutional,Denied,Paper,2023-01-11,2023-01-11,2023-01-12,2023-02-09,Auto_Adjudicated,29,1232573801,1177602659,246ZN0300X,Neuropsychology,21,In_Network,OTHER,K21.0|Z00.01,revenue_code:0110,871,0,Commercial,HMO,1,F,1.1193,5,Duplicate,11453.39,7991.32,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1052,service_date_weekend,0,1,0,1,1,0.0,0,0,,FFS
CLM0000003527,MBR00000206,Medical_Institutional,Paid,Provider_Portal,2023-06-07,2023-06-07,2023-06-07,2023-06-12,Auto_Adjudicated,5,1901547390,1164525386,2084P0800X,Psychiatry,24,Out_of_Network,Z00.01,,revenue_code:0360,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,18915.86,15848.41,15843.41,0.0,5.0,0.0,3067.45,0.0,0.0,0,,0.0237,none,0,1,1,0,0,0.001466,1,0,,FFS
CLM0000003528,MBR00000221,Medical_Professional,Paid,Provider_Portal,2023-06-30,2023-06-30,2023-06-30,2023-07-05,Clinical_Review,5,1932483309,1402472115,207Q00000X,Family Medicine,11,In_Network,OTHER,I10,99212,,0,Commercial,HDHP_HSA,28,M,1.6683,,,219.09,162.64,30.15,124.95,0.0,7.54,56.45,0.0,0.0,0,,0.06,none,0,1,0,0,0,3e-06,0,0,,P4P
CLM0000003529,MBR00000227,Medical_Professional,Paid,Electronic_EDI,2023-06-12,2023-06-12,2023-06-12,2023-06-15,Manual_Review,3,1119083414,1865266296,207RP1001X,Pulmonary Disease,71,In_Network,Z00.01,I10,99283,,0,Medicare_Advantage,MA_PPO,2,F,0.7835,,,219.7,86.51,57.81,0.25,14.0,14.45,133.19,0.0,0.0,0,,0.1345,controlled_substance_high_volume,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000003530,MBR00000164,Dental,Denied,Provider_Portal,2023-11-09,2023-11-09,2023-11-09,2023-12-04,Manual_Review,25,1331264469,1469642907,207RG0100X,Gastroenterology,22,In_Network,OTHER,OTHER,D2140,,0,ACA_Marketplace,ACA_Silver,3,F,0.7155,1,Network,197.82,160.29,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0498,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000003531,MBR00000163,Medical_Professional,Paid,Electronic_EDI,2023-11-25,2023-11-25,2023-11-25,2023-12-01,Auto_Adjudicated,6,1976304517,1105871325,207RE0101X,Endocrinology,24,In_Network,OTHER,,17000,,0,Medicaid_MCO,MCO,21,F,0.9607,,,2261.39,1746.87,1742.87,0.0,4.0,0.0,514.52,0.0,0.0,0,,0.1733,high_volume_same_code,0,1,0,0,0,0.000161,0,0,MPT_Annual_Monitoring,FFS
CLM0000003532,MBR00000212,Medical_Professional,Paid,Electronic_EDI,2023-02-13,2023-02-13,2023-02-13,2023-02-25,Auto_Adjudicated,12,1956215244,1012893364,2084P0800X,Psychiatry,81,Out_of_Network,G47.33,K21.0,99386,,0,Commercial,HMO,57,F,2.5456,,,249.85,114.33,0.0,114.33,0.0,0.0,135.52,0.0,0.0,0,,0.0809,none,0,1,0,1,0,0.0,1,0,BPD_BP_Declined,Shared_Savings
CLM0000003533,MBR00000207,Medical_Professional,Paid,Electronic_EDI,2023-04-10,2023-04-10,2023-04-10,2023-04-23,Auto_Adjudicated,13,1954226809,1098360555,207Q00000X,Family Medicine,11,In_Network,OTHER,,99214,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,239.08,190.35,190.35,0.0,0.0,0.0,48.73,0.0,0.0,0,,0.1222,none,0,1,0,1,0,1.8e-05,0,0,,P4P
CLM0000003534,MBR00000199,Medical_Institutional,Paid,Electronic_EDI,2023-06-29,2023-06-29,2023-07-02,2023-07-10,Auto_Adjudicated,11,1411619682,1039962073,2086S0122X,Orthopedic Surgery,22,Out_of_Network,Z00.01,Z00.00,revenue_code:0100,,0,Medicaid_MCO,MLTSS,17,F,1.0776,,,58560.02,27147.66,27147.66,0.0,0.0,0.0,31412.36,0.0,0.0,1,Medically Unnecessary Services,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|impossible_service_combo|service_date_weekend|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|npi_mismatch|controlled_substance_high_volume,1,5,1,0,0,0.002513,0,0,,FFS
CLM0000003535,MBR00000121,Pharmacy,Denied,Paper,2023-05-24,2023-05-24,2023-05-24,2023-06-08,Auto_Adjudicated,15,1097563011,1493836023,208600000X,Surgery General,21,In_Network,Z12.11,,00071012831,,3,Medicare_Advantage,MA_PPO,58,M,1.226,256,Medical_Necessity,28.1,17.2,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0459,none,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,Capitation
CLM0000003536,MBR00000247,Vision,Denied,Electronic_EDI,2023-06-06,2023-06-06,2023-06-06,2023-06-17,Auto_Adjudicated,11,1501282310,1040061910,207RE0101X,Endocrinology,11,In_Network,J06.9,M17.11,V2320,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,256,Eligibility,769.83,565.45,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1309,none,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000003537,MBR00000074,Medical_Institutional,Paid,Electronic_EDI,2023-09-12,2023-09-12,2023-09-16,2023-09-20,Manual_Review,8,1683994149,1977073565,2086S0122X,Orthopedic Surgery,24,In_Network,OTHER,E11.9,revenue_code:0100,,0,Medicare_Advantage,MA_PPO,21,F,0.8719,,,7792.89,3100.71,2427.17,19.75,47.0,606.79,4692.18,0.0,0.0,0,,0.0729,none,0,1,0,0,0,0.000225,0,0,,Shared_Savings
CLM0000003538,MBR00000049,Medical_Professional,Denied,Electronic_EDI,2023-03-06,2023-03-06,2023-03-06,2023-03-18,Auto_Adjudicated,12,1424104563,1884259357,207RG0100X,Gastroenterology,11,In_Network,F32.9,,90847,,0,Medicare_Advantage,PFFS,67,M,0.978,97,Duplicate,361.11,254.11,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.083,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003539,MBR00000109,Medical_Professional,Paid,Electronic_EDI,2023-10-24,2023-10-24,2023-10-24,2023-11-18,Auto_Adjudicated,25,1213747973,1903401648,208600000X,Surgery General,32,In_Network,Z00.00,N40.0,99284,,0,Commercial,HMO,8,F,0.5723,,,258.13,157.17,0.0,143.65,13.52,0.0,100.96,0.0,0.0,0,,0.016,none,0,1,0,0,0,0.0,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000003540,MBR00000078,Medical_Professional,Paid,Electronic_EDI,2023-04-06,2023-04-06,2023-04-06,2023-04-10,Clinical_Review,4,1637260822,1267212691,207RN0300X,Nephrology,24,In_Network,E78.5,OTHER,90837,,0,Commercial,EPO,65,F,1.3174,,,452.91,273.92,185.05,5.61,37.0,46.26,178.99,0.0,0.0,0,,0.1378,none,0,1,0,0,0,1.7e-05,0,0,BPD_BP_Declined,FFS
CLM0000003541,MBR00000197,Medical_Institutional,Paid,Electronic_EDI,2023-05-06,2023-05-06,2023-05-09,2023-06-04,Auto_Adjudicated,29,1594322174,1791502603,208600000X,Surgery General,23,In_Network,OTHER,I10,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,59,M,1.1414,,,7672.62,5059.15,4013.78,5.93,36.0,1003.44,2613.47,3048.4,693.73,0,,0.0993,none,0,1,0,0,0,0.000372,0,0,,P4P
CLM0000003542,MBR00000073,Behavioral_Health,Paid,Electronic_EDI,2023-03-21,2023-03-21,2023-03-21,2023-04-03,Auto_Adjudicated,13,1838794554,1188760037,208600000X,Surgery General,22,In_Network,OTHER,E78.5|N40.0,99284,,0,Commercial,POS,79,M,1.1768,,,233.17,90.44,0.0,90.44,0.0,0.0,142.73,0.0,0.0,0,,0.1331,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003543,MBR00000196,Medical_Professional,Paid,Electronic_EDI,2023-08-15,2023-08-15,2023-08-15,2023-08-24,Auto_Adjudicated,9,1700802848,1354959095,207RP1001X,Pulmonary Disease,31,In_Network,OTHER,Z79.4|OTHER,99203,,0,Commercial,PPO,16,F,1.6015,,,110.47,45.69,0.0,45.69,0.0,0.0,64.78,0.0,0.0,0,,0.1364,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003544,MBR00000158,Medical_Professional,Paid,Electronic_EDI,2023-09-07,2023-09-07,2023-09-07,2023-09-21,Auto_Adjudicated,14,1394029346,1252125670,207RC0000X,Cardiovascular Disease,11,In_Network,I10,R05.9,99222,,0,Commercial,HMO,65,M,1.5361,,,404.31,177.21,43.92,108.3,14.0,10.98,227.1,0.0,0.0,0,,0.0128,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000003545,MBR00000048,Pharmacy,Paid,Electronic_EDI,2023-08-13,2023-08-13,2023-08-13,2023-09-10,Manual_Review,28,1083045036,1489434038,246ZN0300X,Neuropsychology,24,In_Network,E13.9,I10,00071012831,,1,Commercial,POS,27,F,0.639,,,386.17,164.44,44.2,84.19,25.0,11.05,221.73,0.0,0.0,0,,0.0022,none,0,1,0,1,0,4e-06,0,0,,Shared_Savings
CLM0000003546,MBR00000080,Medical_Institutional,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-29,2023-07-22,Clinical_Review,25,1731980913,1055872102,207RP1001X,Pulmonary Disease,11,In_Network,Z23,OTHER,revenue_code:0300,,0,Commercial,HDHP_HSA,74,M,0.5935,,,2623.06,1507.22,885.21,400.71,0.0,221.3,1115.84,0.0,0.0,0,,0.1036,none,0,1,0,0,0,8.2e-05,0,0,,FFS
CLM0000003547,MBR00000159,Pharmacy,Paid,Electronic_EDI,2023-04-19,2023-04-19,2023-04-19,2023-05-14,Auto_Adjudicated,25,1256824549,1354265777,2084P0800X,Psychiatry,11,In_Network,H52.4,I10,50458085930,,1,Commercial,PPO,70,F,1.2009,,,259.15,168.47,100.86,28.4,14.0,25.21,90.68,0.0,0.0,0,,0.0335,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000003548,MBR00000214,Medical_Institutional,Paid,Electronic_EDI,2023-09-04,2023-09-04,2023-09-05,2023-09-11,Manual_Review,7,1905691248,1368666316,207RE0101X,Endocrinology,11,In_Network,OTHER,,revenue_code:0300,,0,Commercial,HDHP_HSA,76,M,1.7526,,,5553.96,2315.51,1753.37,123.8,0.0,438.34,3238.45,0.0,0.0,0,,0.0714,none,0,1,0,0,0,0.000162,0,0,,FFS
CLM0000003549,MBR00000127,Medical_Professional,Paid,Electronic_EDI,2023-02-12,2023-02-12,2023-02-12,2023-03-11,Auto_Adjudicated,27,1369267360,1789540567,207RN0300X,Nephrology,21,In_Network,E78.5,,12001,,0,Commercial,HMO,31,F,0.3336,,,478.42,345.64,0.0,345.64,0.0,0.0,132.78,0.0,0.0,0,,0.099,none,0,1,0,0,0,0.0,0,0,AMR_Asthma_Medication_Ratio,Bundled_Payment
CLM0000003550,MBR00000073,Medical_Institutional,Paid,Electronic_EDI,2023-04-22,2023-04-22,2023-04-24,2023-05-14,Manual_Review,22,1661091022,1039962073,207Q00000X,Family Medicine,11,Emergency,M17.11,Z00.01|OTHER|I25.10,revenue_code:0300,,0,Commercial,POS,79,M,1.1768,,,16468.67,12751.93,9794.77,436.47,72.0,2448.69,3716.74,0.0,0.0,0,,0.057,unusual_service_frequency,0,1,1,0,0,0.000907,0,0,,Bundled_Payment
CLM0000003551,MBR00000092,Medical_Professional,Paid,Electronic_EDI,2023-09-03,2023-09-03,2023-09-03,2023-09-05,Manual_Review,2,1891821845,1581533104,207Q00000X,Family Medicine,23,In_Network,M54.5,,71250,,0,Medicaid_MCO,MLTSS,68,F,1.3217,,,1192.09,474.83,471.83,0.0,3.0,0.0,717.26,0.0,0.0,0,,0.1923,high_oop_waiver,0,1,0,0,0,4.4e-05,0,0,,Bundled_Payment
CLM0000003552,MBR00000028,Pharmacy,Paid,Electronic_EDI,2023-09-06,2023-09-06,2023-09-06,2023-09-19,Auto_Adjudicated,13,1909649019,1267212691,207RP1001X,Pulmonary Disease,22,In_Network,F32.9,M54.5,00078043215,,5,Commercial,HMO,3,F,2.116,,,234.58,101.84,0.0,101.84,0.0,0.0,132.74,0.0,0.0,0,,0.0538,none,0,1,0,0,0,0.0,0,1,,Capitation
CLM0000003553,MBR00000008,Medical_Professional,Paid,Electronic_EDI,2023-04-07,2023-04-07,2023-04-07,2023-05-03,Auto_Adjudicated,26,1637260822,1878874025,2086S0122X,Orthopedic Surgery,65,Emergency,E78.5,,97140,,0,Medicaid_MCO,MCO,74,M,0.8375,,,245.8,131.42,130.42,0.0,1.0,0.0,114.38,0.0,0.0,0,,0.0373,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000003554,MBR00000293,Medical_Institutional,Paid,Electronic_EDI,2023-05-03,2023-05-03,2023-05-04,2023-05-19,Clinical_Review,16,1475070784,1903401648,207RC0000X,Cardiovascular Disease,24,In_Network,J06.9,,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,12713.06,8626.09,6861.77,16.88,32.0,1715.44,4086.97,0.0,0.0,0,,0.152,temporal_clustering,0,1,1,0,0,0.000635,0,0,,FFS
CLM0000003555,MBR00000028,Vision,Paid,Paper,2023-04-25,2023-04-25,2023-04-25,2023-05-13,Auto_Adjudicated,18,1145887050,1738617370,2084P0800X,Psychiatry,31,In_Network,E78.5,,V2115,,0,Commercial,HMO,3,F,2.116,,,357.64,140.45,0.0,140.45,0.0,0.0,217.19,0.0,0.0,0,,0.1332,benford_violation,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003556,MBR00000038,Medical_Institutional,Denied,Paper,2023-11-15,2023-11-15,2023-11-15,2023-11-27,Auto_Adjudicated,12,1201027197,1903401648,207RN0300X,Nephrology,65,In_Network,M54.5,E78.5,revenue_code:0210,,0,Commercial,EPO,46,M,1.1295,PR-1,Timely_Filing,5986.34,3134.75,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0283,none,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000003557,MBR00000263,Medical_Professional,Paid,Electronic_EDI,2023-07-25,2023-07-25,2023-07-25,2023-07-27,Auto_Adjudicated,2,1887698203,1738617370,208600000X,Surgery General,24,In_Network,I25.10,Z00.01,99383,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,,,183.44,155.08,97.89,13.72,19.0,24.47,28.36,82.53,11.23,0,,0.0727,upcoding_pattern,0,1,0,1,0,9e-06,0,0,,FFS
CLM0000003558,MBR00000197,Vision,Paid,Electronic_EDI,2023-02-12,2023-02-12,2023-02-12,2023-03-11,Auto_Adjudicated,27,1414670047,1469881892,2086S0122X,Orthopedic Surgery,11,In_Network,J44.1,E11.65|OTHER,V2100,,0,Medicare_Advantage,MA_HMO,59,M,1.1414,,,270.17,164.83,116.72,5.93,13.0,29.18,105.34,0.0,0.0,0,,0.0636,none,0,1,0,1,0,1.1e-05,0,0,,FFS
CLM0000003559,MBR00000136,Medical_Professional,Paid,Electronic_EDI,2023-02-27,2023-02-27,2023-02-27,2023-03-22,Auto_Adjudicated,23,1522998767,1148612764,207R00000X,Internal Medicine,11,In_Network,OTHER,K57.30|OTHER,99285,,0,Commercial,POS,2,F,1.2611,,,373.01,162.87,87.97,42.91,10.0,21.99,210.14,0.0,0.0,0,,0.0824,none,0,1,0,0,0,8e-06,0,0,PPC_Prenatal_Care,Capitation
CLM0000003560,MBR00000193,Pharmacy,Paid,Electronic_EDI,2023-01-25,2023-01-25,2023-01-25,2023-02-03,Auto_Adjudicated,9,1558692441,1408846353,207RG0100X,Gastroenterology,21,Emergency,Z12.11,J44.1|Z00.00,00310075090,,1,Commercial,PPO,11,M,0.5266,,,114.39,75.02,0.0,75.02,0.0,0.0,39.37,0.0,0.0,0,,0.0356,none,0,1,0,0,0,0.0,0,1,,P4P
CLM0000003561,MBR00000282,Medical_Professional,Paid,Electronic_EDI,2023-03-28,2023-03-28,2023-03-28,2023-04-05,Auto_Adjudicated,8,1220710861,1402472115,207RC0000X,Cardiovascular Disease,21,In_Network,R05.9,K21.0,90834,,0,Medicare_Advantage,MA_HMO,16,M,0.7304,,,769.14,406.28,300.1,13.16,18.0,75.02,362.86,0.0,0.0,0,,0.1237,none,0,1,0,0,0,2.8e-05,0,0,,FFS
CLM0000003562,MBR00000029,Dental,Paid,Electronic_EDI,2023-03-21,2023-03-21,2023-03-21,2023-04-06,Manual_Review,16,1054449469,1355732274,207RE0101X,Endocrinology,32,In_Network,OTHER,,D1110,,0,Medicaid_MCO,MCO,13,F,0.9053,,,164.29,130.59,129.59,0.0,1.0,0.0,33.7,0.0,0.0,0,,0.0988,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000003563,MBR00000076,Medical_Professional,Paid,Electronic_EDI,2023-06-10,2023-06-10,2023-06-10,2023-07-04,Auto_Adjudicated,24,1324084461,1763260577,207RN0300X,Nephrology,22,In_Network,F32.9,Z00.00|Z00.01,99231,,0,Commercial,HMO,26,M,2.1785,,,320.55,264.55,174.43,14.52,32.0,43.61,56.0,0.0,0.0,0,,0.1235,provider_specialty_mismatch,0,1,0,0,0,1.6e-05,0,0,,Shared_Savings
CLM0000003564,MBR00000259,Medical_Professional,Paid,Electronic_EDI,2023-09-26,2023-09-26,2023-09-26,2023-09-29,Manual_Review,3,1901054209,1765164601,208600000X,Surgery General,32,In_Network,OTHER,I10,99204,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,112.63,52.67,36.36,0.22,7.0,9.09,59.96,0.0,0.0,0,,0.0948,none,0,1,0,0,0,3e-06,0,0,LCS_Lung_Cancer_Screening,Shared_Savings
CLM0000003565,MBR00000231,Vision,Paid,Electronic_EDI,2023-11-12,2023-11-12,2023-11-12,2023-12-01,Manual_Review,19,1990244466,1489993356,207RN0300X,Nephrology,21,In_Network,OTHER,OTHER|E11.9,V2100,,0,ACA_Marketplace,ACA_Silver,12,M,0.6456,,,326.91,264.61,116.34,57.41,41.0,49.86,62.3,0.0,0.0,0,,0.0963,none,0,1,0,0,0,1.1e-05,0,0,,Shared_Savings
CLM0000003566,MBR00000299,Medical_Institutional,Paid,Electronic_EDI,2023-07-20,2023-07-20,2023-07-22,2023-08-15,Auto_Adjudicated,26,1495592428,1320546364,246ZN0300X,Neuropsychology,65,In_Network,OTHER,,revenue_code:0200,,0,Medicaid_MCO,MCO,74,F,0.8833,,,26527.09,19574.34,19572.34,0.0,2.0,0.0,6952.75,0.0,0.0,0,,0.1425,none,0,1,1,0,0,0.001812,0,0,,FFS
CLM0000003567,MBR00000100,Medical_Professional,Paid,Electronic_EDI,2023-10-05,2023-10-05,2023-10-05,2023-10-20,Auto_Adjudicated,15,1484613641,1128148362,2084P0800X,Psychiatry,11,In_Network,Z00.00,K21.0,97110,,0,ACA_Marketplace,ACA_Gold,87,M,1.435,,,578.33,247.42,103.95,105.48,12.0,25.99,330.91,0.0,0.0,0,,0.2017,benford_violation,0,2,0,1,0,1e-05,0,0,CBP_Controlling_BP,FFS
CLM0000003568,MBR00000286,Medical_Professional,Paid,Provider_Portal,2023-08-24,2023-08-24,2023-08-24,2023-08-26,Manual_Review,2,1457568950,1880530717,207Q00000X,Family Medicine,22,In_Network,E11.9,OTHER,99396,,0,Medicare_Advantage,PFFS,40,F,1.2751,,,369.99,282.34,200.07,29.26,3.0,50.02,87.65,0.0,0.0,0,,0.1141,benford_violation,0,1,0,0,0,1.9e-05,0,0,,FFS
CLM0000003569,MBR00000107,Medical_Professional,Paid,Paper,2023-04-25,2023-04-25,2023-04-25,2023-04-26,Clinical_Review,1,1215358845,1810068286,208600000X,Surgery General,65,In_Network,M54.5,,74177,,0,Medicare_Advantage,MA_PPO,44,M,1.0439,,,771.76,338.72,249.06,19.39,8.0,62.27,433.04,0.0,0.0,0,,0.0569,none,0,1,0,0,0,2.3e-05,0,0,,FFS
CLM0000003570,MBR00000212,Medical_Professional,Paid,Electronic_EDI,2023-08-08,2023-08-08,2023-08-08,2023-08-13,Auto_Adjudicated,5,1172766349,1896197144,207R00000X,Internal Medicine,22,In_Network,E13.9,K57.30|I10,97140,,0,Commercial,HMO,57,F,2.5456,,,247.89,87.96,0.0,87.96,0.0,0.0,159.93,0.0,0.0,0,,0.1492,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000003571,MBR00000266,Medical_Institutional,Paid,Electronic_EDI,2023-04-19,2023-04-19,2023-04-20,2023-05-16,Auto_Adjudicated,27,1049153238,1098360555,207RE0101X,Endocrinology,24,In_Network,I50.9,F32.9|OTHER,revenue_code:0250,,0,Commercial,EPO,14,M,1.075,,,4145.15,3063.1,2356.43,84.56,33.0,589.11,1082.05,0.0,0.0,0,,0.0786,none,0,1,0,0,0,0.000218,0,0,,FFS
CLM0000003572,MBR00000054,Medical_Institutional,Denied,Electronic_EDI,2023-04-21,2023-04-21,2023-04-24,2023-05-05,Manual_Review,14,1950560596,1274911960,207V00000X,Obstetrics & Gynecology,21,In_Network,I10,K21.0|E11.9,revenue_code:0200,470,0,Medicare_Advantage,MA_HMO,66,F,0.8625,50,Eligibility,8663.04,4531.37,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0619,provider_specialty_mismatch,0,1,0,1,0,0.0,0,0,,FFS
CLM0000003573,MBR00000062,Vision,Paid,Electronic_EDI,2023-12-21,2023-12-21,2023-12-21,2023-12-26,Auto_Adjudicated,5,1326896487,1623053477,207RP1001X,Pulmonary Disease,31,In_Network,K21.0,M79.3|Z23,V2320,,0,Commercial,HMO,46,F,0.5516,,,259.95,210.77,120.44,39.22,21.0,30.11,49.18,85.17,29.45,0,,0.0842,none,0,1,0,1,0,1.1e-05,0,0,,Capitation
CLM0000003574,MBR00000175,Pharmacy,Paid,Electronic_EDI,2023-11-23,2023-11-23,2023-11-23,2023-12-21,Auto_Adjudicated,28,1059948944,1144950506,207RP1001X,Pulmonary Disease,23,In_Network,Z23,M17.11|I10,00071012831,,1,Commercial,PPO,14,F,1.5785,,,96.25,55.0,0.0,55.0,0.0,0.0,41.25,0.0,0.0,0,,0.0345,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003575,MBR00000253,Vision,Paid,Electronic_EDI,2023-08-23,2023-08-23,2023-08-23,2023-09-17,Auto_Adjudicated,25,1997577166,1177602659,2084P0800X,Psychiatry,24,In_Network,E13.9,OTHER|E11.9,V2320,,0,Commercial,EPO,44,M,0.3882,,,152.12,99.67,16.11,59.53,20.0,4.03,52.45,0.0,0.0,0,,0.0958,none,0,1,0,0,0,1e-06,0,0,AMR_Asthma_Medication_Ratio,Shared_Savings
CLM0000003576,MBR00000024,Medical_Institutional,Paid,Electronic_EDI,2023-08-01,2023-08-01,2023-08-05,2023-08-06,Manual_Review,5,1402424417,1788579687,246ZN0300X,Neuropsychology,22,In_Network,E78.5,E78.5|I10,revenue_code:0370,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,917.8,663.49,661.49,0.0,2.0,0.0,254.31,0.0,0.0,0,,0.0712,none,0,1,0,0,0,6.1e-05,0,0,,FFS
CLM0000003577,MBR00000256,Medical_Institutional,Paid,Electronic_EDI,2023-09-04,2023-09-04,2023-09-04,2023-09-25,Auto_Adjudicated,21,1739169232,1300957944,207Q00000X,Family Medicine,23,In_Network,E11.9,I25.10|E11.9,revenue_code:0300,,0,Commercial,HDHP_HSA,71,F,0.3642,,,54115.72,41788.22,32964.93,582.05,0.0,8241.23,12327.5,0.0,0.0,0,,0.1569,outlier_billing_amount,0,1,1,0,0,0.003051,0,0,,Shared_Savings
CLM0000003578,MBR00000107,Medical_Institutional,Paid,Electronic_EDI,2023-09-28,2023-09-28,2023-09-28,2023-10-08,Auto_Adjudicated,10,1804302686,1746676564,2084P0800X,Psychiatry,22,In_Network,J44.1,,revenue_code:0300,,0,Medicare_Advantage,MA_PPO,44,M,1.0439,,,55653.55,24416.04,19502.03,7.5,31.0,4875.51,31237.51,0.0,0.0,0,,0.1276,outlier_billing_amount|impossible_service_combo,0,1,1,0,0,0.001805,0,0,,FFS
CLM0000003579,MBR00000129,Medical_Professional,Paid,Provider_Portal,2023-01-20,2023-01-20,2023-01-20,2023-01-23,Auto_Adjudicated,3,1461820376,1972530373,207RE0101X,Endocrinology,22,Emergency,Z00.01,F33.0|OTHER|I10,99285,,0,Medicare_Advantage,MA_PPO,9,F,0.8196,,,183.52,82.96,48.33,5.55,17.0,12.08,100.56,0.0,0.0,0,,0.1139,none,0,1,0,1,0,4e-06,0,0,DDE_Diabetes_Short_Term_Complications,Capitation
CLM0000003580,MBR00000106,Medical_Professional,Paid,Electronic_EDI,2023-05-09,2023-05-09,2023-05-09,2023-05-11,Manual_Review,2,1310250833,1034732777,207Q00000X,Family Medicine,23,In_Network,I50.9,E11.9,85025,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,237.14,188.27,116.66,36.45,6.0,29.16,48.87,0.0,0.0,0,,0.0299,none,0,1,0,0,0,1.1e-05,0,0,POD_Persistence_of_Beta_Blocker,FFS
CLM0000003581,MBR00000275,Pharmacy,Paid,Electronic_EDI,2023-02-07,2023-02-07,2023-02-07,2023-02-24,Auto_Adjudicated,17,1893327624,1825450791,207V00000X,Obstetrics & Gynecology,11,In_Network,K21.0,,00169751112,,2,Medicare_Advantage,MA_PPO,67,M,0.8169,,,576.49,285.93,212.67,5.09,15.0,53.17,290.56,0.0,0.0,0,,0.0812,none,0,1,0,0,0,2e-05,0,0,ACR_Urine_Protein,FFS
CLM0000003582,MBR00000040,Pharmacy,Paid,Electronic_EDI,2023-07-09,2023-07-09,2023-07-09,2023-08-04,Auto_Adjudicated,26,1231231881,1985590322,207Q00000X,Family Medicine,24,In_Network,N39.0,Z00.01,16590051660,,1,Medicare_Advantage,MA_HMO,66,F,0.6755,,,33.02,22.08,0.0,13.05,9.03,0.0,10.94,0.0,0.0,0,,0.0798,none,0,1,0,0,0,0.0,0,1,CBP_Controlling_BP,Capitation
CLM0000003583,MBR00000173,Medical_Professional,Paid,Electronic_EDI,2023-04-16,2023-04-16,2023-04-16,2023-05-15,Manual_Review,29,1874914200,1509799493,207RP1001X,Pulmonary Disease,21,In_Network,OTHER,M54.5|OTHER,83036,,0,Medicare_Advantage,PFFS,23,F,1.0279,,,1334.73,514.47,375.43,31.18,14.0,93.86,820.26,0.0,0.0,0,,0.1644,unbundling_pattern,0,1,0,1,0,3.5e-05,0,0,,Capitation
CLM0000003584,MBR00000046,Medical_Institutional,Paid,Electronic_EDI,2023-04-29,2023-04-29,2023-05-03,2023-05-21,Auto_Adjudicated,22,1273835569,1267212691,246ZN0300X,Neuropsychology,11,In_Network,I10,Z00.00|Z79.4,revenue_code:0360,,0,Commercial,HMO,76,F,0.9613,,,21284.91,14556.37,11544.19,85.14,41.0,2886.05,6728.54,0.0,0.0,0,,0.0727,none,0,1,1,0,0,0.001069,0,0,,Bundled_Payment
CLM0000003585,MBR00000280,Medical_Professional,Paid,Electronic_EDI,2023-10-30,2023-10-30,2023-10-30,2023-11-27,Clinical_Review,28,1568777164,1978943761,207RN0300X,Nephrology,23,In_Network,E11.9,,97035,,0,Commercial,PPO,79,F,0.6697,,,508.9,225.5,0.0,225.5,0.0,0.0,283.4,0.0,0.0,0,,0.093,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003586,MBR00000236,Medical_Institutional,Paid,Electronic_EDI,2023-03-15,2023-03-15,2023-03-16,2023-03-23,Auto_Adjudicated,8,1875632885,1685903362,207RG0100X,Gastroenterology,22,Emergency,OTHER,Z12.11,revenue_code:0210,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,42040.39,31484.35,31478.35,0.0,6.0,0.0,10556.04,24018.77,4094.63,0,,0.1255,none,0,1,1,0,0,0.002914,0,0,,Capitation
CLM0000003587,MBR00000074,Medical_Professional,Partially_Paid,Electronic_EDI,2023-11-23,2023-11-23,2023-11-23,2023-11-28,Auto_Adjudicated,5,1042080259,1983760474,207RE0101X,Endocrinology,23,In_Network,K29.70,M54.5|I10,99396,,0,Medicare_Advantage,MA_PPO,21,F,0.8719,50,Medical_Necessity,201.32,145.15,70.47,2.0,19.0,17.62,92.23,0.0,0.0,0,,0.1259,benford_violation,0,1,0,0,0,7e-06,0,0,IET_Initiation_Substance_Use,FFS
CLM0000003588,MBR00000093,Dental,Paid,Electronic_EDI,2023-06-01,2023-06-01,2023-06-01,2023-06-05,Manual_Review,4,1374847145,1643323506,207RP1001X,Pulmonary Disease,81,In_Network,E78.5,OTHER|Z00.00,D7140,,0,Medicare_Advantage,MA_HMO,43,F,0.6162,,,579.54,373.23,268.88,18.13,19.0,67.22,206.31,0.0,0.0,0,,0.0709,none,0,1,0,0,0,2.5e-05,0,0,,Bundled_Payment
CLM0000003589,MBR00000121,Medical_Institutional,Paid,Paper,2023-03-10,2023-03-10,2023-03-11,2023-03-16,Auto_Adjudicated,6,1069440570,1049766043,207V00000X,Obstetrics & Gynecology,22,In_Network,F10.10,,revenue_code:0120,,0,Medicare_Advantage,MA_PPO,58,M,1.226,,,9585.1,4076.08,3213.3,3.46,56.0,803.32,5509.02,0.0,0.0,0,,0.0793,service_date_weekend,0,1,0,0,0,0.000297,0,0,,FFS
CLM0000003590,MBR00000129,Medical_Institutional,Paid,Provider_Portal,2023-02-21,2023-02-21,2023-02-25,2023-03-16,Auto_Adjudicated,23,1700802848,1163639177,2086S0122X,Orthopedic Surgery,81,In_Network,F32.9,I25.10|Z23,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,9,F,0.8196,,,4014.55,1937.45,1497.2,6.95,59.0,374.3,2077.1,0.0,0.0,0,,0.1866,service_date_weekend,0,1,0,0,0,0.000139,0,0,AWV_Annual_Wellness_Visit,Shared_Savings
CLM0000003591,MBR00000243,Pharmacy,Paid,Paper,2023-09-14,2023-09-14,2023-09-14,2023-09-19,Auto_Adjudicated,5,1821999097,1887266184,2086S0122X,Orthopedic Surgery,22,Out_of_Network,F33.0,Z00.00|M54.5,00078043215,,1,Medicaid_MCO,MCO,21,M,0.4834,,,922.67,342.4,338.4,0.0,4.0,0.0,580.27,0.0,0.0,0,,0.0153,none,0,1,0,0,0,3.1e-05,0,1,,FFS
CLM0000003592,MBR00000170,Dental,Partially_Paid,Electronic_EDI,2023-11-21,2023-11-21,2023-11-21,2023-12-04,Manual_Review,13,1878057972,1574982369,207RC0000X,Cardiovascular Disease,21,In_Network,OTHER,,D2140,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,4,Medical_Necessity,228.8,116.12,53.02,22.18,3.0,13.25,137.34,36.94,9.6,0,,0.063,npi_mismatch,0,1,0,1,0,5e-06,0,0,AMR_Asthma_Medication_Ratio,Capitation
CLM0000003593,MBR00000135,Pharmacy,Paid,Electronic_EDI,2023-11-10,2023-11-10,2023-11-10,2023-12-03,Auto_Adjudicated,23,1211612843,1763260577,246ZN0300X,Neuropsychology,23,In_Network,Z00.00,I10,00085163102,,4,Commercial,PPO,58,F,2.2702,,,127.68,68.99,23.39,2.76,37.0,5.85,58.69,17.14,4.9,0,,0.1162,none,0,1,0,1,0,2e-06,0,1,,Bundled_Payment
CLM0000003594,MBR00000212,Medical_Institutional,Paid,Electronic_EDI,2023-03-03,2023-03-03,2023-03-07,2023-03-31,Auto_Adjudicated,28,1215358845,1012893364,246ZN0300X,Neuropsychology,11,In_Network,N18.3,OTHER,revenue_code:0370,,0,Commercial,HMO,57,F,2.5456,,,24952.01,14537.48,11375.6,249.98,68.0,2843.9,10414.53,0.0,0.0,0,,0.1317,none,0,1,1,1,0,0.001053,0,0,,Capitation
CLM0000003595,MBR00000142,Medical_Professional,Paid,Electronic_EDI,2023-11-12,2023-11-12,2023-11-12,2023-11-17,Auto_Adjudicated,5,1972755666,1188760037,207RG0100X,Gastroenterology,81,In_Network,J06.9,K21.0|OTHER,99382,,0,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,520.58,441.65,40.02,356.48,28.0,17.15,78.93,0.0,0.0,0,,0.1359,none,0,1,0,1,0,4e-06,0,0,,FFS
CLM0000003596,MBR00000039,Pharmacy,Denied,Electronic_EDI,2023-03-22,2023-03-22,2023-03-22,2023-03-28,Manual_Review,6,1356331863,1746676564,207V00000X,Obstetrics & Gynecology,22,Out_of_Network,M17.11,OTHER|Z23|J20.9,00071015523,,3,Medicaid_MCO,MCO,20,F,0.5358,22,Duplicate,62.68,44.67,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1295,impossible_service_combo|upcoding_pattern,0,1,0,1,0,0.0,0,1,DAE_Drug_Alcohol_Dependence,Bundled_Payment
CLM0000003597,MBR00000033,Pharmacy,Denied,Electronic_EDI,2023-06-14,2023-06-14,2023-06-14,2023-06-16,Auto_Adjudicated,2,1843445592,1301833092,207R00000X,Internal Medicine,11,In_Network,J06.9,OTHER|I10|Z00.00,00069420020,,1,Medicare_Advantage,PFFS,31,F,0.821,18,Network,570.0,311.48,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0324,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000003598,MBR00000103,Behavioral_Health,Paid,Electronic_EDI,2023-01-02,2023-01-02,2023-01-02,2023-01-06,Auto_Adjudicated,4,1881358103,1196833348,207RP1001X,Pulmonary Disease,23,In_Network,OTHER,F32.9|F41.1,12001,,0,Medicaid_MCO,MCO,24,M,0.4785,,,219.31,169.49,168.49,0.0,1.0,0.0,49.82,0.0,0.0,0,,0.0445,none,0,1,0,1,0,1.6e-05,0,0,,FFS
CLM0000003599,MBR00000182,Medical_Institutional,Paid,Electronic_EDI,2023-04-03,2023-04-03,2023-04-05,2023-04-15,Manual_Review,12,1913217838,1114756459,101YP2500X,Psychologist Clinical,11,Out_of_Network,J44.1,OTHER,revenue_code:0300,,0,Commercial,HMO,82,F,0.8489,,,11087.31,5912.2,4521.97,225.74,34.0,1130.49,5175.11,0.0,0.0,0,,0.1035,none,0,1,0,0,0,0.000419,0,0,,FFS
CLM0000003600,MBR00000042,Pharmacy,Paid,Paper,2023-04-25,2023-04-25,2023-04-25,2023-05-05,Auto_Adjudicated,10,1001149267,1522426351,207R00000X,Internal Medicine,11,In_Network,OTHER,,00169751112,,4,Commercial,HMO,78,F,1.1448,,,157.43,83.63,40.5,13.01,20.0,10.12,73.8,0.0,0.0,0,,0.1255,temporal_clustering,0,1,0,0,0,4e-06,0,0,DAE_Drug_Alcohol_Dependence,Bundled_Payment
CLM0000003601,MBR00000166,Medical_Professional,Paid,Electronic_EDI,2023-12-10,2023-12-10,2023-12-10,2024-01-09,Auto_Adjudicated,30,1064567615,1477113725,2084P0800X,Psychiatry,11,In_Network,E78.5,F32.9,90837,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,642.44,245.32,0.0,245.32,0.0,0.0,397.12,0.0,0.0,0,,0.0056,none,0,1,0,0,0,0.0,0,0,BPD_BP_Declined,FFS
CLM0000003602,MBR00000083,Medical_Professional,Paid,Provider_Portal,2023-04-10,2023-04-10,2023-04-10,2023-04-24,Auto_Adjudicated,14,1808451151,1390802135,225100000X,Physical Therapist,32,In_Network,J06.9,K21.0,74177,,0,Commercial,PPO,76,M,0.6621,,,218.21,156.59,40.85,86.53,19.0,10.21,61.62,0.0,0.0,0,,0.0913,none,0,1,0,0,0,4e-06,0,0,,Capitation
CLM0000003603,MBR00000207,Medical_Professional,Paid,Electronic_EDI,2023-04-10,2023-04-10,2023-04-10,2023-04-20,Auto_Adjudicated,10,1389116733,1538261819,101YP2500X,Psychologist Clinical,11,In_Network,OTHER,F41.1|K21.0,99202,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,343.12,154.8,154.8,0.0,0.0,0.0,188.32,0.0,0.0,0,,0.145,none,0,1,0,0,0,1.4e-05,0,0,MPT_Annual_Monitoring,Shared_Savings
CLM0000003604,MBR00000010,Medical_Professional,Paid,Electronic_EDI,2023-04-09,2023-04-09,2023-04-09,2023-04-24,Manual_Review,15,1175978429,1747596016,208600000X,Surgery General,22,In_Network,E11.9,OTHER|F33.0|Z00.01,17000,,0,Medicare_Advantage,MA_HMO,44,F,1.4631,,,749.89,350.63,239.31,47.49,4.0,59.83,399.26,0.0,0.0,0,,0.1461,none,0,1,0,0,0,2.2e-05,0,0,,Capitation
CLM0000003605,MBR00000144,Medical_Institutional,Denied,Electronic_EDI,2023-04-01,2023-04-01,2023-04-01,2023-04-23,Auto_Adjudicated,22,1706476585,1402472115,207RN0300X,Nephrology,22,In_Network,OTHER,,revenue_code:0120,,0,Commercial,HDHP_HSA,56,F,2.5926,16,Eligibility,8622.06,4510.56,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1564,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003606,MBR00000014,Medical_Professional,Denied,Electronic_EDI,2023-07-13,2023-07-13,2023-07-13,2023-07-24,Auto_Adjudicated,11,1334227781,1433350836,207RN0300X,Nephrology,65,In_Network,G47.33,OTHER,99223,,0,Commercial,HMO,77,M,2.8513,CO-45,Authorization,310.33,236.15,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1425,high_volume_same_code,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003607,MBR00000104,Pharmacy,Paid,Electronic_EDI,2023-03-15,2023-03-15,2023-03-15,2023-03-20,Auto_Adjudicated,5,1637260822,1765164601,2086S0122X,Orthopedic Surgery,65,In_Network,OTHER,OTHER,00085163102,,4,Medicaid_MCO,MCO,87,F,1.2297,,,152.76,119.2,119.2,0.0,0.0,0.0,33.56,0.0,0.0,0,,0.1187,none,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000003608,MBR00000005,Medical_Institutional,Paid,Electronic_EDI,2023-04-15,2023-04-15,2023-04-18,2023-04-28,Auto_Adjudicated,13,1789174420,1985590322,207RN0300X,Nephrology,65,Out_of_Network,Z00.01,OTHER,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,8,M,0.566,,,11226.24,7021.54,5592.83,9.5,21.0,1398.21,4204.7,0.0,0.0,0,,0.1295,none,0,1,1,0,0,0.000518,0,0,,FFS
CLM0000003609,MBR00000144,Medical_Professional,Paid,Electronic_EDI,2023-07-11,2023-07-11,2023-07-11,2023-07-30,Manual_Review,19,1508520529,1867626800,207V00000X,Obstetrics & Gynecology,21,In_Network,Z23,,43239,,0,Commercial,HDHP_HSA,56,F,2.5926,,,870.71,707.71,531.26,43.63,0.0,132.82,163.0,0.0,0.0,0,,0.1361,none,0,1,0,0,0,4.9e-05,0,0,TRC_Transition_of_Care,FFS
CLM0000003610,MBR00000226,Pharmacy,Paid,Electronic_EDI,2023-09-29,2023-09-29,2023-09-29,2023-10-09,Auto_Adjudicated,10,1213747973,1619587398,207R00000X,Internal Medicine,22,In_Network,J06.9,OTHER,00006001954,,4,Medicare_Advantage,MA_PPO,84,M,1.0796,,,150.24,84.68,58.97,0.96,10.0,14.74,65.56,0.0,0.0,0,,0.0464,none,0,1,0,1,0,5e-06,0,0,,Shared_Savings
CLM0000003611,MBR00000029,Medical_Professional,Paid,Electronic_EDI,2023-02-08,2023-02-08,2023-02-08,2023-02-26,Auto_Adjudicated,18,1428403730,1461075342,207Q00000X,Family Medicine,31,In_Network,OTHER,,99213,,0,Medicaid_MCO,MCO,13,F,0.9053,,,189.83,123.85,122.85,0.0,1.0,0.0,65.98,0.0,0.0,0,,0.0729,none,0,1,0,0,0,1.1e-05,0,0,POD_Persistence_of_Beta_Blocker,Shared_Savings
CLM0000003612,MBR00000215,Medical_Professional,Paid,Electronic_EDI,2023-05-06,2023-05-06,2023-05-06,2023-05-16,Auto_Adjudicated,10,1067329999,1355732274,207Q00000X,Family Medicine,11,In_Network,I10,M47.816,90837,,0,ACA_Marketplace,ACA_Silver,69,M,0.8895,,,1105.62,900.66,372.86,347.01,21.0,159.8,204.96,0.0,0.0,0,,0.0625,none,0,1,0,0,0,3.5e-05,0,0,,FFS
CLM0000003613,MBR00000176,Behavioral_Health,Denied,Electronic_EDI,2023-07-24,2023-07-24,2023-07-24,2023-08-21,Auto_Adjudicated,28,1462532026,1175334579,207RG0100X,Gastroenterology,11,In_Network,I48.91,I50.9|Z00.00|E78.5,90837,,0,Commercial,POS,4,M,0.8792,1,Authorization,128.52,78.48,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2789,unusual_service_frequency|provider_specialty_mismatch|benford_violation,0,2,0,0,0,0.0,0,0,,FFS
CLM0000003614,MBR00000156,Medical_Professional,Paid,Paper,2023-11-26,2023-11-26,2023-11-26,2023-12-23,Auto_Adjudicated,27,1654042271,1643673796,225100000X,Physical Therapist,65,In_Network,Z79.4,OTHER,99284,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,473.68,274.96,198.15,14.28,13.0,49.54,198.72,0.0,0.0,0,,0.1111,none,0,1,0,0,0,1.8e-05,0,0,FLU_Flu_Vaccination,FFS
CLM0000003615,MBR00000181,Medical_Professional,Paid,Electronic_EDI,2023-12-05,2023-12-05,2023-12-05,2023-12-27,Auto_Adjudicated,22,1252009836,1649705287,207R00000X,Internal Medicine,11,In_Network,OTHER,,99222,,0,Commercial,PPO,82,F,1.0432,,,235.79,85.94,0.0,61.84,24.1,0.0,149.85,0.0,0.0,0,,0.0606,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003616,MBR00000106,Medical_Institutional,Denied,Electronic_EDI,2023-11-10,2023-11-10,2023-11-13,2023-12-06,Auto_Adjudicated,26,1269720844,1148659045,225100000X,Physical Therapist,21,Emergency,OTHER,J06.9|F33.0,revenue_code:0450,872,0,Medicare_Advantage,MA_PPO,69,M,1.7254,3,Duplicate,26392.64,20857.23,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.07,phantom_billing_indicator,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000003617,MBR00000210,Medical_Professional,Paid,Electronic_EDI,2023-07-01,2023-07-01,2023-07-01,2023-07-05,Manual_Review,4,1986485249,1827839595,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,,99231,,0,Medicare_Advantage,SNP,49,M,0.6952,,,574.62,255.42,160.6,36.67,18.0,40.15,319.2,0.0,0.0,0,,0.0493,none,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000003618,MBR00000230,Medical_Professional,Paid,Electronic_EDI,2023-02-05,2023-02-05,2023-02-05,2023-02-25,Auto_Adjudicated,20,1099247356,1151295616,207Q00000X,Family Medicine,11,Emergency,E78.5,,90837,,0,Commercial,HMO,9,M,0.4087,,,623.56,360.74,258.72,24.33,13.0,64.68,262.82,0.0,0.0,0,,0.0629,none,0,1,0,0,0,2.4e-05,0,0,KED_ESRD_Patients,FFS
CLM0000003619,MBR00000229,Pharmacy,Denied,Electronic_EDI,2023-12-13,2023-12-13,2023-12-13,2023-12-26,Auto_Adjudicated,13,1231231881,1489993356,207RN0300X,Nephrology,81,In_Network,OTHER,I25.10|Z12.11|OTHER,00071012831,,2,Medicare_Advantage,PFFS,63,M,1.1626,3,COB,361.63,270.15,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1441,none,0,1,0,1,0,0.0,0,1,,Capitation
CLM0000003620,MBR00000083,Medical_Institutional,Paid,Electronic_EDI,2023-08-12,2023-08-12,2023-08-14,2023-09-05,Auto_Adjudicated,24,1346717076,1049766043,207RN0300X,Nephrology,11,In_Network,N39.0,E78.5|OTHER,revenue_code:0120,,0,Commercial,PPO,76,M,0.6621,,,21162.03,12831.14,9909.65,380.07,64.0,2477.41,8330.89,0.0,0.0,0,,0.0066,none,0,1,1,0,0,0.000917,0,0,,Capitation
CLM0000003621,MBR00000194,Medical_Institutional,Paid,Electronic_EDI,2023-11-22,2023-11-22,2023-11-24,2023-11-23,Auto_Adjudicated,1,1869706360,1148612764,101YP2500X,Psychologist Clinical,21,In_Network,R05.9,Z00.00,revenue_code:0210,292,0,Commercial,PPO,77,M,0.9783,,,14145.96,10474.97,8222.1,160.34,37.0,2055.53,3670.99,0.0,0.0,0,,0.1531,high_oop_waiver,0,1,1,0,0,0.000761,0,0,,P4P
CLM0000003622,MBR00000046,Dental,Paid,Electronic_EDI,2023-11-27,2023-11-27,2023-11-27,2023-12-03,Auto_Adjudicated,6,1713741288,1985590322,207R00000X,Internal Medicine,11,In_Network,E78.5,OTHER,D2140,,0,Commercial,HMO,76,F,0.9613,,,502.48,386.09,237.88,53.74,35.0,59.47,116.39,0.0,0.0,0,,0.052,none,0,1,0,0,0,2.2e-05,0,0,,Shared_Savings
CLM0000003623,MBR00000154,Medical_Professional,Denied,Electronic_EDI,2023-10-12,2023-10-12,2023-10-12,2023-10-20,Auto_Adjudicated,8,1928139578,1391074619,101YP2500X,Psychologist Clinical,22,In_Network,OTHER,OTHER,90837,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,2,Duplicate,534.36,415.54,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0534,none,0,1,0,1,0,0.0,0,0,SPC_Statin_Therapy,Shared_Savings
CLM0000003624,MBR00000002,Medical_Institutional,Paid,Electronic_EDI,2023-05-31,2023-05-31,2023-06-02,2023-06-17,Auto_Adjudicated,17,1426424205,1320546364,246ZN0300X,Neuropsychology,24,In_Network,K21.0,OTHER|Z00.01,revenue_code:0210,,0,Commercial,PPO,42,F,0.9012,,,52594.44,20500.63,16366.88,6.03,36.0,4091.72,32093.81,14332.92,1451.88,0,,0.1295,outlier_billing_amount|provider_specialty_mismatch,0,1,1,0,0,0.001515,0,0,W30_Well_Child_Visit,Shared_Savings
CLM0000003625,MBR00000060,Medical_Professional,Paid,Electronic_EDI,2023-08-07,2023-08-07,2023-08-07,2023-09-06,Manual_Review,30,1542851144,1831337866,2086S0122X,Orthopedic Surgery,23,In_Network,OTHER,OTHER,99393,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,292.05,132.38,0.0,132.38,0.0,0.0,159.67,0.0,0.0,0,,0.0292,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003626,MBR00000187,Medical_Professional,Paid,Electronic_EDI,2023-09-06,2023-09-06,2023-09-06,2023-10-03,Manual_Review,27,1629674542,1469642907,207RG0100X,Gastroenterology,22,In_Network,Z23,M54.5|E78.5,47562,,0,Medicaid_MCO,MCO,36,F,1.191,,,389.84,313.72,310.72,0.0,3.0,0.0,76.12,0.0,0.0,0,,0.1172,high_volume_same_code|unbundling_pattern,0,1,0,0,0,2.9e-05,0,0,,Bundled_Payment
CLM0000003627,MBR00000263,Behavioral_Health,Paid,Electronic_EDI,2023-11-13,2023-11-13,2023-11-13,2023-11-27,Auto_Adjudicated,14,1390393668,1903401648,2086S0122X,Orthopedic Surgery,22,In_Network,F33.0,,70553,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,,,177.08,85.24,38.53,18.08,19.0,9.63,91.84,0.0,0.0,0,,0.1222,impossible_service_combo,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000003628,MBR00000014,Pharmacy,Denied,Electronic_EDI,2023-03-23,2023-03-23,2023-03-23,2023-03-24,Clinical_Review,1,1466478716,1704466150,225100000X,Physical Therapist,11,In_Network,Z00.01,,00078043215,,4,Commercial,HMO,77,M,2.8513,PR-1,Authorization,366.12,257.5,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1038,high_volume_same_code,0,1,0,0,0,0.0,0,0,,P4P
CLM0000003629,MBR00000168,Medical_Professional,Denied,Electronic_EDI,2023-07-19,2023-07-19,2023-07-19,2023-08-15,Auto_Adjudicated,27,1918578486,1098360555,207RE0101X,Endocrinology,21,In_Network,Z00.01,,99393,,0,Commercial,HMO,76,M,1.2791,96,Duplicate,176.72,108.6,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1074,npi_mismatch,0,1,0,0,0,0.0,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000003630,MBR00000188,Medical_Institutional,Paid,Electronic_EDI,2023-08-02,2023-08-02,2023-08-05,2023-08-20,Auto_Adjudicated,18,1396168768,1662516615,101YP2500X,Psychologist Clinical,65,In_Network,OTHER,E11.9,revenue_code:0450,,0,Commercial,HMO,8,F,1.5853,,,65871.26,53915.03,43061.97,41.57,46.0,10765.49,11956.23,0.0,0.0,0,,0.1624,outlier_billing_amount|diagnosis_procedure_mismatch,0,1,1,0,0,0.003986,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000003631,MBR00000281,Medical_Professional,Paid,Electronic_EDI,2023-03-16,2023-03-16,2023-03-16,2023-03-17,Auto_Adjudicated,1,1220235547,1878017518,208600000X,Surgery General,31,In_Network,G43.909,F10.10,90837,,0,Medicare_Advantage,MA_HMO,3,M,0.8531,,,1621.16,774.44,616.09,1.33,3.0,154.02,846.72,0.0,0.0,0,,0.1446,none,0,1,0,1,0,5.7e-05,0,0,,FFS
CLM0000003632,MBR00000195,Pharmacy,Paid,Electronic_EDI,2023-05-25,2023-05-25,2023-05-25,2023-06-14,Auto_Adjudicated,20,1958171947,1912895973,225100000X,Physical Therapist,11,In_Network,I10,OTHER,50458085930,,1,Commercial,PPO,13,F,0.5967,,,67.22,50.63,0.0,50.63,0.0,0.0,16.59,0.0,0.0,0,,0.0468,none,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000003633,MBR00000031,Medical_Professional,Paid,Electronic_EDI,2023-11-29,2023-11-29,2023-11-29,2023-12-26,Auto_Adjudicated,27,1513278494,1312595355,101YP2500X,Psychologist Clinical,31,In_Network,J44.1,,99233,,0,Commercial,PPO,71,M,0.6746,,,412.18,228.69,156.64,16.9,16.0,39.16,183.49,0.0,0.0,0,,0.0347,none,0,1,0,0,0,1.4e-05,0,0,,Bundled_Payment
CLM0000003634,MBR00000046,Dental,Denied,Electronic_EDI,2023-01-06,2023-01-06,2023-01-06,2023-02-02,Auto_Adjudicated,27,1111846258,1289435414,246ZN0300X,Neuropsychology,31,In_Network,OTHER,R05.9,D7140,,0,Commercial,HMO,76,F,0.9613,CO-45,Authorization,195.83,92.08,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1134,high_volume_same_code,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000003635,MBR00000188,Medical_Professional,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-27,Auto_Adjudicated,27,1394029346,1402472115,207RN0300X,Nephrology,24,In_Network,J44.1,,81001,,0,Commercial,HMO,8,F,1.5853,,,362.67,215.94,120.96,39.74,25.0,30.24,146.73,0.0,0.0,0,,0.1594,provider_specialty_mismatch,0,1,0,0,0,1.1e-05,0,0,,Capitation
CLM0000003636,MBR00000066,Medical_Professional,Paid,Electronic_EDI,2023-08-07,2023-08-07,2023-08-07,2023-09-06,Auto_Adjudicated,30,1496340237,1662516615,208600000X,Surgery General,31,In_Network,K21.0,E78.5|Z23,99221,,0,Medicaid_MCO,MCO,54,M,0.6083,,,221.48,137.42,134.42,0.0,3.0,0.0,84.06,0.0,0.0,0,,0.0068,none,0,1,0,0,0,1.2e-05,0,0,,Shared_Savings
CLM0000003637,MBR00000280,Vision,Paid,Electronic_EDI,2023-11-22,2023-11-22,2023-11-22,2023-12-12,Auto_Adjudicated,20,1965812565,1607833568,207RG0100X,Gastroenterology,81,In_Network,OTHER,E11.9|Z00.00,92012,,0,Commercial,PPO,79,F,0.6697,,,193.18,78.26,0.0,78.26,0.0,0.0,114.92,0.0,0.0,0,,0.0936,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003638,MBR00000277,Dental,Paid,Electronic_EDI,2023-04-12,2023-04-12,2023-04-12,2023-05-01,Clinical_Review,19,1218294278,1196833348,207RE0101X,Endocrinology,11,In_Network,Z00.00,OTHER,D0150,,0,Medicaid_MCO,MCO,30,M,1.8495,,,540.88,241.29,238.29,0.0,3.0,0.0,299.59,0.0,0.0,0,,0.202,geographic_mismatch,0,2,0,0,0,2.2e-05,0,0,,FFS
CLM0000003639,MBR00000287,Medical_Professional,Paid,Electronic_EDI,2023-05-22,2023-05-22,2023-05-22,2023-05-26,Manual_Review,4,1909649019,1747935894,207RN0300X,Nephrology,21,In_Network,Z79.4,Z00.01|R05.9|K21.0,99394,,0,Commercial,PPO,4,M,0.7685,,,317.85,255.75,111.96,89.8,26.0,27.99,62.1,0.0,0.0,0,,0.1382,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000003640,MBR00000092,Medical_Institutional,Paid,Electronic_EDI,2023-01-29,2023-01-29,2023-01-31,2023-02-17,Auto_Adjudicated,19,1719850506,1157814306,207RN0300X,Nephrology,81,In_Network,F32.9,Z00.00,revenue_code:0110,,0,Medicaid_MCO,MLTSS,68,F,1.3217,,,17554.19,11986.93,11977.93,0.0,9.0,0.0,5567.26,0.0,0.0,0,,0.1426,none,0,1,1,0,0,0.001109,0,0,,FFS
CLM0000003641,MBR00000212,Dental,Paid,Electronic_EDI,2023-05-01,2023-05-01,2023-05-01,2023-05-28,Auto_Adjudicated,27,1264953395,1747935894,207RN0300X,Nephrology,22,Out_of_Network,R05.9,M54.5,D3310,,0,Commercial,HMO,57,F,2.5456,,,350.63,246.17,0.0,246.17,0.0,0.0,104.46,0.0,0.0,0,,0.0667,geographic_mismatch,0,1,0,0,0,0.0,0,0,DDE_Diabetes_Short_Term_Complications,Bundled_Payment
CLM0000003642,MBR00000197,Pharmacy,Denied,Electronic_EDI,2023-12-25,2023-12-25,2023-12-25,2024-01-19,Manual_Review,25,1388662212,1013600387,207RE0101X,Endocrinology,23,In_Network,E78.5,Z00.00,00169751112,,1,Medicare_Advantage,MA_HMO,59,M,1.1414,22,Timely_Filing,118.0,62.18,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1347,impossible_service_combo,0,1,0,0,0,0.0,0,1,,Capitation
CLM0000003643,MBR00000011,Medical_Institutional,Partially_Paid,Paper,2023-10-02,2023-10-02,2023-10-06,2023-10-29,Auto_Adjudicated,27,1995916350,1977073565,101YP2500X,Psychologist Clinical,21,In_Network,I10,,revenue_code:0120,292,0,Medicare_Advantage,SNP,35,F,1.0833,18,Medical_Necessity,7510.71,4655.77,2002.07,0.75,41.0,500.52,4966.38,0.0,0.0,0,,0.1796,benford_violation,0,1,0,0,0,0.000185,0,0,,FFS
CLM0000003644,MBR00000081,Pharmacy,Paid,Electronic_EDI,2023-06-03,2023-06-03,2023-06-03,2023-06-09,Clinical_Review,6,1699074676,1267212691,207RG0100X,Gastroenterology,11,In_Network,OTHER,,50458085930,,1,Medicare_Advantage,SNP,66,F,2.159,,,435.92,160.97,109.65,18.91,5.0,27.41,274.95,0.0,0.0,0,,0.116,none,0,1,0,1,0,1e-05,0,0,,FFS
CLM0000003645,MBR00000063,Vision,Paid,Paper,2023-08-16,2023-08-16,2023-08-16,2023-08-23,Auto_Adjudicated,7,1702283246,1175334579,101YP2500X,Psychologist Clinical,81,In_Network,OTHER,Z79.4,92002,,0,ACA_Marketplace,ACA_Silver,56,M,0.8198,,,235.19,99.16,0.0,99.16,0.0,0.0,136.03,0.0,0.0,0,,0.0316,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003646,MBR00000118,Medical_Institutional,Paid,Paper,2023-12-13,2023-12-13,2023-12-13,2024-01-08,Manual_Review,26,1205349488,1977073565,2086S0122X,Orthopedic Surgery,21,In_Network,OTHER,,revenue_code:0110,248,0,Medicaid_MCO,MCO,69,M,1.2773,,,42140.5,35303.68,35298.68,0.0,5.0,0.0,6836.82,0.0,0.0,0,,0.0027,none,0,1,1,0,0,0.003267,0,0,,FFS
CLM0000003647,MBR00000289,Medical_Professional,Paid,Electronic_EDI,2023-06-07,2023-06-07,2023-06-07,2023-07-06,Auto_Adjudicated,29,1637260822,1831337866,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,I50.9|OTHER,99394,,0,Commercial,POS,51,M,1.0534,,,203.78,92.68,34.95,10.0,39.0,8.74,111.1,0.0,0.0,0,,0.1344,none,0,1,0,0,0,3e-06,0,0,CBP_Controlling_BP,Shared_Savings
CLM0000003648,MBR00000254,Medical_Institutional,Paid,Electronic_EDI,2023-04-16,2023-04-16,2023-04-16,2023-05-02,Auto_Adjudicated,16,1213747973,1049766043,207RP1001X,Pulmonary Disease,11,In_Network,Z00.00,,revenue_code:0450,,0,Commercial,PPO,22,F,0.9285,,,12507.06,7447.26,5902.29,26.4,43.0,1475.57,5059.8,0.0,0.0,0,,0.1495,none,0,1,1,1,0,0.000546,0,0,,Shared_Savings
CLM0000003649,MBR00000092,Pharmacy,Paid,Electronic_EDI,2023-11-12,2023-11-12,2023-11-12,2023-12-09,Auto_Adjudicated,27,1205744244,1577226132,207RC0000X,Cardiovascular Disease,81,In_Network,Z79.4,E78.5,16590051660,,2,Medicaid_MCO,MLTSS,68,F,1.3217,,,230.55,187.94,184.94,0.0,3.0,0.0,42.61,143.34,22.08,0,,0.0737,none,0,1,0,0,0,1.7e-05,0,1,,FFS
CLM0000003650,MBR00000161,Medical_Institutional,Paid,Provider_Portal,2023-11-02,2023-11-02,2023-11-02,2023-11-23,Auto_Adjudicated,21,1092800235,1764064254,207RN0300X,Nephrology,11,In_Network,Z12.11,I10,revenue_code:0300,,0,Medicaid_MCO,MLTSS,9,F,0.8354,,,34766.43,23525.32,23520.32,0.0,5.0,0.0,11241.11,0.0,0.0,0,,0.0367,none,0,1,1,0,0,0.002177,0,0,,Shared_Savings
CLM0000003651,MBR00000060,Medical_Professional,Paid,Electronic_EDI,2023-07-05,2023-07-05,2023-07-05,2023-07-12,Auto_Adjudicated,7,1990849102,1164525386,101YP2500X,Psychologist Clinical,65,Out_of_Network,J06.9,,99283,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,454.62,196.89,0.0,196.89,0.0,0.0,257.73,0.0,0.0,0,,0.0306,none,0,1,0,0,0,0.0,0,0,KED_ESRD_Patients,Capitation
CLM0000003652,MBR00000087,Pharmacy,Paid,Electronic_EDI,2023-01-05,2023-01-05,2023-01-05,2023-01-21,Auto_Adjudicated,16,1510562885,1039962073,207RG0100X,Gastroenterology,11,In_Network,E78.5,,00003014960,,3,Medicaid_MCO,MCO,70,F,0.9232,,,230.18,132.27,131.27,0.0,1.0,0.0,97.91,0.0,0.0,0,,0.1658,duplicate_claim_indicator,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000003653,MBR00000020,Medical_Institutional,Denied,Electronic_EDI,2023-01-05,2023-01-05,2023-01-05,2023-01-17,Manual_Review,12,1706018784,1049766043,207V00000X,Obstetrics & Gynecology,71,In_Network,I10,F32.9,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,63,F,0.7119,96,Medical_Necessity,12834.23,7461.12,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0325,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003654,MBR00000191,Vision,Denied,Electronic_EDI,2023-02-12,2023-02-12,2023-02-12,2023-03-08,Manual_Review,24,1084831484,1643323506,207Q00000X,Family Medicine,21,In_Network,I10,,92012,,0,Commercial,POS,85,F,0.9729,5,Network,177.76,104.48,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1198,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,P4P
CLM0000003655,MBR00000196,Medical_Professional,Paid,Electronic_EDI,2023-09-06,2023-09-06,2023-09-06,2023-09-17,Auto_Adjudicated,11,1706018784,1809122260,207Q00000X,Family Medicine,32,In_Network,Z00.01,,74177,,0,Commercial,PPO,16,F,1.6015,,,568.08,437.82,240.09,114.71,23.0,60.02,130.26,0.0,0.0,0,,0.074,none,0,1,0,0,0,2.2e-05,0,0,,Bundled_Payment
CLM0000003656,MBR00000251,Pharmacy,Paid,Electronic_EDI,2023-03-05,2023-03-05,2023-03-05,2023-03-11,Auto_Adjudicated,6,1739169232,1040061910,207V00000X,Obstetrics & Gynecology,22,In_Network,C50.911,,00310075090,,1,Commercial,PPO,65,M,0.7737,,,1100.08,690.68,505.56,45.73,13.0,126.39,409.4,0.0,0.0,0,,0.0409,none,0,1,0,0,0,4.7e-05,0,0,,FFS
CLM0000003657,MBR00000263,Medical_Institutional,Denied,Electronic_EDI,2023-01-23,2023-01-23,2023-01-25,2023-02-07,Manual_Review,15,1151127621,1209882852,207R00000X,Internal Medicine,11,In_Network,OTHER,OTHER,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,96,Medical_Necessity,5064.55,3711.79,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.074,billing_spike_recent,0,1,0,0,0,0.0,0,0,SPD_Spirometry_Testing,Capitation
CLM0000003658,MBR00000051,Medical_Professional,Paid,Electronic_EDI,2023-09-02,2023-09-02,2023-09-02,2023-09-17,Auto_Adjudicated,15,1952322604,1477113725,207RC0000X,Cardiovascular Disease,11,In_Network,Z12.11,E11.65|OTHER,10060,,0,Medicare_Advantage,MA_PPO,17,F,1.0695,,,438.43,233.51,130.2,56.76,14.0,32.55,204.92,0.0,0.0,0,,0.1041,none,0,1,0,0,0,1.2e-05,0,0,,Shared_Savings
CLM0000003659,MBR00000217,Medical_Institutional,Denied,Electronic_EDI,2023-06-22,2023-06-22,2023-06-22,2023-07-19,Auto_Adjudicated,27,1462532026,1619587398,207V00000X,Obstetrics & Gynecology,24,In_Network,Z00.01,Z00.01|F10.10,revenue_code:0110,,0,ACA_Marketplace,ACA_Bronze,11,F,1.1619,16,Medical_Necessity,3459.04,2414.21,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1653,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,DDE_Diabetes_Short_Term_Complications,Shared_Savings
CLM0000003660,MBR00000042,Medical_Professional,Partially_Paid,Electronic_EDI,2023-07-10,2023-07-10,2023-07-10,2023-07-11,Auto_Adjudicated,1,1702283246,1829216053,101YP2500X,Psychologist Clinical,23,In_Network,E11.9,G47.33,99222,,0,Commercial,HMO,78,F,1.1448,50,Medical_Necessity,192.7,108.7,22.38,20.27,20.0,5.59,124.46,0.0,0.0,0,,0.0259,none,0,1,0,0,0,2e-06,0,0,,Shared_Savings
CLM0000003661,MBR00000118,Pharmacy,Paid,Electronic_EDI,2023-03-10,2023-03-10,2023-03-10,2023-04-06,Auto_Adjudicated,27,1637260822,1287935251,246ZN0300X,Neuropsychology,21,In_Network,I48.91,E11.9|Z23,59148001506,,1,Medicaid_MCO,MCO,69,M,1.2773,,,69.86,51.26,50.26,0.0,1.0,0.0,18.6,0.0,0.0,0,,0.0101,none,0,1,0,0,0,5e-06,0,0,ACR_Urine_Protein,FFS
CLM0000003662,MBR00000158,Pharmacy,Paid,Electronic_EDI,2023-03-19,2023-03-19,2023-03-19,2023-03-26,Manual_Review,7,1006539337,1321680994,208600000X,Surgery General,11,In_Network,J06.9,M54.5|J06.9|F10.10,00310075090,,3,Commercial,HMO,65,M,1.5361,,,67.51,48.45,0.0,48.45,0.0,0.0,19.06,0.0,0.0,0,,0.0133,none,0,1,0,0,0,0.0,0,0,ACR_Urine_Protein,FFS
CLM0000003663,MBR00000014,Medical_Professional,Paid,Electronic_EDI,2023-03-28,2023-03-28,2023-03-28,2023-04-03,Auto_Adjudicated,6,1816378991,1791502603,101YP2500X,Psychologist Clinical,31,In_Network,G47.33,Z00.01,27447,,0,Commercial,HMO,77,M,2.8513,,,22564.01,11737.38,9180.67,223.54,38.0,2295.17,10826.63,0.0,0.0,0,,0.1288,unusual_service_frequency,0,1,1,1,0,0.00085,0,0,,Shared_Savings
CLM0000003664,MBR00000050,Medical_Institutional,Paid,Electronic_EDI,2023-08-20,2023-08-20,2023-08-20,2023-09-02,Auto_Adjudicated,13,1590338573,1789540567,207RP1001X,Pulmonary Disease,22,In_Network,E11.9,I48.91|M17.11|I10,revenue_code:0120,,0,Medicare_Advantage,MA_PPO,12,F,0.8486,,,23157.18,12232.07,9756.77,3.11,33.0,2439.19,10925.11,0.0,0.0,0,,0.141,none,0,1,1,0,0,0.000903,0,0,,P4P
CLM0000003665,MBR00000084,Vision,Denied,Electronic_EDI,2023-12-18,2023-12-18,2023-12-18,2024-01-04,Auto_Adjudicated,17,1994365754,1469642907,101YP2500X,Psychologist Clinical,23,In_Network,Z00.121,I50.9|Z12.11,V2103,,0,Medicare_Advantage,MA_HMO,15,F,0.8004,170,Medical_Necessity,333.99,254.33,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2572,impossible_service_combo|phantom_billing_indicator,0,2,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003666,MBR00000039,Medical_Professional,Paid,Electronic_EDI,2023-11-25,2023-11-25,2023-11-25,2023-12-23,Auto_Adjudicated,28,1915327071,1013600387,207RE0101X,Endocrinology,22,Out_of_Network,R05.9,,47562,,0,Medicaid_MCO,MCO,20,F,0.5358,,,317.92,206.26,206.26,0.0,0.0,0.0,111.66,0.0,0.0,0,,0.0852,none,0,1,0,0,0,1.9e-05,1,0,KED_ESRD_Patients,FFS
CLM0000003667,MBR00000282,Dental,Paid,Provider_Portal,2023-02-10,2023-02-10,2023-02-10,2023-02-27,Manual_Review,17,1986485249,1321680994,207V00000X,Obstetrics & Gynecology,21,In_Network,E11.9,I10,D2391,,0,Medicare_Advantage,MA_HMO,16,M,0.7304,,,211.86,139.39,74.24,28.59,18.0,18.56,72.47,0.0,0.0,1,Medically Unnecessary Services,1.0,outlier_billing_amount|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|impossible_service_combo|duplicate_claim_indicator|upcoding_pattern|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,7e-06,0,0,,FFS
CLM0000003668,MBR00000091,Medical_Professional,Paid,Electronic_EDI,2023-09-01,2023-09-01,2023-09-01,2023-09-06,Auto_Adjudicated,5,1793406356,1774401124,225100000X,Physical Therapist,21,In_Network,OTHER,J44.1|M54.5|E78.5,97140,,0,Commercial,PPO,13,F,1.2451,,,276.91,229.63,0.0,214.34,15.29,0.0,47.28,0.0,0.0,0,,0.1482,geographic_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003669,MBR00000155,Medical_Professional,Denied,Electronic_EDI,2023-09-30,2023-09-30,2023-09-30,2023-10-14,Auto_Adjudicated,14,1097702209,1741177636,101YP2500X,Psychologist Clinical,11,In_Network,N39.0,,99386,,0,ACA_Marketplace,ACA_Bronze,9,F,0.8196,1,Medical_Necessity,167.64,77.39,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1313,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003670,MBR00000299,Medical_Institutional,Paid,Electronic_EDI,2023-01-15,2023-01-15,2023-01-17,2023-02-12,Auto_Adjudicated,28,1813729693,1408846353,246ZN0300X,Neuropsychology,71,In_Network,E11.9,,revenue_code:0200,,0,Medicaid_MCO,MCO,74,F,0.8833,,,7940.25,4851.36,4849.36,0.0,2.0,0.0,3088.89,0.0,0.0,0,,0.0031,none,0,1,0,0,0,0.000449,0,0,,FFS
CLM0000003671,MBR00000170,Medical_Professional,Denied,Electronic_EDI,2023-08-17,2023-08-17,2023-08-17,2023-09-08,Auto_Adjudicated,22,1981853293,1354265777,207RC0000X,Cardiovascular Disease,21,In_Network,E11.65,,81001,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,CO-45,Eligibility,780.98,349.77,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1459,benford_violation,0,1,0,1,0,0.0,0,0,,P4P
CLM0000003672,MBR00000131,Dental,Denied,Provider_Portal,2023-06-09,2023-06-09,2023-06-09,2023-06-16,Auto_Adjudicated,7,1064567615,1396850418,207RP1001X,Pulmonary Disease,22,In_Network,Z23,,D7140,,0,Commercial,EPO,15,F,0.9228,18,Authorization,277.51,130.37,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0002,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003673,MBR00000280,Pharmacy,Paid,Provider_Portal,2023-03-12,2023-03-12,2023-03-12,2023-04-01,Auto_Adjudicated,20,1855186422,1415734567,207R00000X,Internal Medicine,21,In_Network,OTHER,,00069420020,,1,Commercial,PPO,79,F,0.6697,,,639.39,418.49,209.32,121.84,35.0,52.33,220.9,0.0,0.0,0,,0.0755,none,0,1,0,0,0,1.9e-05,0,0,,Shared_Savings
CLM0000003674,MBR00000069,Pharmacy,Paid,Electronic_EDI,2023-10-11,2023-10-11,2023-10-11,2023-11-03,Auto_Adjudicated,23,1797494973,1995553359,2084P0800X,Psychiatry,21,In_Network,M54.5,F41.1,00071012831,,1,Medicare_Advantage,MA_PPO,2,M,0.5765,,,1139.5,464.44,323.47,52.1,8.0,80.87,675.06,0.0,0.0,0,,0.0528,none,0,1,0,1,0,3e-05,0,0,COL_Colorectal_Cancer_Screening,Shared_Savings
CLM0000003675,MBR00000056,Pharmacy,Paid,Electronic_EDI,2023-12-02,2023-12-02,2023-12-02,2023-12-11,Manual_Review,9,1699074676,1007652766,207Q00000X,Family Medicine,23,In_Network,OTHER,N39.0|Z87.891,00169751112,,2,Commercial,EPO,74,F,1.3941,,,165.31,70.18,0.0,70.18,0.0,0.0,95.13,0.0,0.0,0,,0.1773,temporal_clustering|benford_violation|impossible_service_combo,0,1,0,1,0,0.0,0,0,,FFS
CLM0000003676,MBR00000162,Pharmacy,Paid,Electronic_EDI,2023-08-03,2023-08-03,2023-08-03,2023-08-19,Auto_Adjudicated,16,1466478716,1765164601,207RN0300X,Nephrology,23,In_Network,J45.20,,00071015523,,1,Medicaid_MCO,MLTSS,84,F,1.324,,,38.93,18.36,17.36,0.0,1.0,0.0,20.57,0.0,0.0,0,,0.0185,none,0,1,0,0,0,2e-06,0,0,,Capitation
CLM0000003677,MBR00000135,Pharmacy,Paid,Electronic_EDI,2023-03-14,2023-03-14,2023-03-14,2023-03-25,Auto_Adjudicated,11,1451329728,1513198866,207RN0300X,Nephrology,24,In_Network,K57.30,F41.1|N39.0,59148001506,,2,Commercial,PPO,58,F,2.2702,,,117.15,70.76,24.38,3.29,37.0,6.09,46.39,0.0,0.0,0,,0.0657,none,0,1,0,0,0,2e-06,0,1,,FFS
CLM0000003678,MBR00000236,Pharmacy,Paid,Electronic_EDI,2023-06-03,2023-06-03,2023-06-03,2023-06-09,Auto_Adjudicated,6,1424416273,1878874025,207R00000X,Internal Medicine,11,In_Network,I10,E11.65|OTHER|Z00.01,00069420020,,1,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,145.41,120.62,117.62,0.0,3.0,0.0,24.79,0.0,0.0,0,,0.0632,none,0,1,0,0,0,1.1e-05,0,1,LCS_Lung_Cancer_Screening,Capitation
CLM0000003679,MBR00000013,Pharmacy,Paid,Electronic_EDI,2023-07-05,2023-07-05,2023-07-05,2023-08-01,Auto_Adjudicated,27,1220710861,1694343357,225100000X,Physical Therapist,32,In_Network,Z00.01,G47.33,59148001506,,2,Commercial,PPO,64,F,1.428,,,311.61,215.15,0.0,215.15,0.0,0.0,96.46,0.0,0.0,0,,0.2452,geographic_mismatch|upcoding_pattern,0,2,0,1,0,0.0,0,1,,Shared_Savings
CLM0000003680,MBR00000185,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-11-20,2023-11-20,2023-11-24,2023-11-30,Manual_Review,10,1603037534,1012893364,246ZN0300X,Neuropsychology,71,In_Network,OTHER,Z00.00|E78.5|OTHER,revenue_code:0100,,0,Medicaid_MCO,MCO,73,M,1.5417,22,Medical_Necessity,3605.33,2439.52,1726.63,0.0,8.0,0.0,1870.7,0.0,0.0,0,,0.0838,none,0,1,0,0,0,0.00016,0,0,FLU_Flu_Vaccination,Shared_Savings
CLM0000003681,MBR00000211,Medical_Professional,Paid,Electronic_EDI,2023-10-11,2023-10-11,2023-10-11,2023-10-21,Auto_Adjudicated,10,1496489953,1175334579,246ZN0300X,Neuropsychology,81,In_Network,E11.65,J06.9,99232,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,,,124.37,66.53,43.17,0.57,12.0,10.79,57.84,0.0,0.0,0,,0.006,none,0,1,0,0,0,4e-06,0,0,,Shared_Savings
CLM0000003682,MBR00000293,Medical_Institutional,Paid,Electronic_EDI,2023-08-29,2023-08-29,2023-09-02,2023-09-02,Auto_Adjudicated,4,1983779639,1005335812,208600000X,Surgery General,11,In_Network,OTHER,,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,15191.61,5995.59,4763.95,8.66,32.0,1190.99,9196.02,0.0,0.0,0,,0.1633,geographic_mismatch|service_date_weekend,0,1,0,0,0,0.000441,0,0,ACR_Urine_Protein,FFS
CLM0000003683,MBR00000046,Medical_Institutional,Paid,Electronic_EDI,2023-10-02,2023-10-02,2023-10-03,2023-10-16,Auto_Adjudicated,14,1263063839,1433350836,101YP2500X,Psychologist Clinical,22,In_Network,M17.11,,revenue_code:0100,,0,Commercial,HMO,76,F,0.9613,,,7335.76,5485.55,4314.55,51.36,41.0,1078.64,1850.21,0.0,0.0,0,,0.0999,none,0,1,0,0,0,0.000399,0,0,,FFS
CLM0000003684,MBR00000076,Medical_Professional,Paid,Provider_Portal,2023-09-07,2023-09-07,2023-09-07,2023-09-27,Auto_Adjudicated,20,1700802848,1829216053,101YP2500X,Psychologist Clinical,71,In_Network,J44.1,Z00.00,33510,,0,Commercial,HMO,26,M,2.1785,,,438.4,161.97,103.24,0.93,32.0,25.81,276.43,82.39,10.56,0,,0.0422,none,0,1,0,0,0,1e-05,0,0,MMA_Medication_Management,FFS
CLM0000003685,MBR00000281,Medical_Institutional,Paid,Electronic_EDI,2023-04-25,2023-04-25,2023-04-25,2023-05-25,Auto_Adjudicated,30,1881358103,1020312030,207V00000X,Obstetrics & Gynecology,24,Out_of_Network,OTHER,M17.11|K21.0|OTHER,revenue_code:0300,,0,Medicare_Advantage,MA_HMO,3,M,0.8531,,,5436.68,3911.67,3104.45,1.11,30.0,776.11,1525.01,0.0,0.0,0,,0.0757,impossible_service_combo,0,1,0,0,0,0.000287,1,0,IET_Initiation_Substance_Use,FFS
CLM0000003686,MBR00000187,Medical_Professional,Paid,Electronic_EDI,2023-02-17,2023-02-17,2023-02-17,2023-03-13,Auto_Adjudicated,24,1415701059,1831337866,2084P0800X,Psychiatry,11,In_Network,N40.0,,99384,,0,Medicaid_MCO,MCO,36,F,1.191,,,228.81,121.63,118.63,0.0,3.0,0.0,107.18,0.0,0.0,0,,0.1253,billing_spike_recent,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000003687,MBR00000012,Medical_Professional,Paid,Electronic_EDI,2023-10-29,2023-10-29,2023-10-29,2023-11-24,Auto_Adjudicated,26,1078576574,1196833348,207RN0300X,Nephrology,32,In_Network,J06.9,OTHER,99394,,0,Commercial,HMO,84,M,1.3904,,,309.31,181.92,58.35,80.98,28.0,14.59,127.39,0.0,0.0,0,,0.0852,provider_specialty_mismatch,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000003688,MBR00000024,Pharmacy,Denied,Electronic_EDI,2023-07-18,2023-07-18,2023-07-18,2023-08-17,Auto_Adjudicated,30,1215358845,1489434038,207Q00000X,Family Medicine,31,In_Network,OTHER,E78.5|OTHER,00071012831,,2,Medicaid_MCO,FFS_Medicaid,82,M,1.315,5,Network,26.32,16.06,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1768,geographic_mismatch,0,1,0,0,0,0.0,0,1,DAE_Drug_Alcohol_Dependence,Capitation
CLM0000003689,MBR00000232,Pharmacy,Paid,Electronic_EDI,2023-12-12,2023-12-12,2023-12-12,2024-01-02,Auto_Adjudicated,21,1145887050,1666461892,2084P0800X,Psychiatry,24,In_Network,M54.5,M17.11|J20.9|Z00.01,00006001954,,3,Medicaid_MCO,MCO,40,M,1.1083,,,182.37,86.23,84.23,0.0,2.0,0.0,96.14,0.0,0.0,0,,0.0052,none,0,1,0,1,0,8e-06,0,1,COA_Care_Transitions,FFS
CLM0000003690,MBR00000170,Medical_Professional,Paid,Electronic_EDI,2023-09-02,2023-09-02,2023-09-02,2023-09-28,Auto_Adjudicated,26,1871348663,1896197144,207Q00000X,Family Medicine,21,In_Network,N39.0,OTHER|N18.3|I25.10,90837,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,1051.84,719.52,556.39,21.04,3.0,139.1,332.32,0.0,0.0,0,,0.202,temporal_clustering,0,2,0,0,0,5.1e-05,0,0,,FFS
CLM0000003691,MBR00000170,Vision,Paid,Electronic_EDI,2023-06-20,2023-06-20,2023-06-20,2023-06-30,Auto_Adjudicated,10,1898658234,1522426351,207RN0300X,Nephrology,23,In_Network,E11.9,,92002,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,350.15,171.42,122.76,14.97,3.0,30.69,178.73,0.0,0.0,0,,0.1141,none,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000003692,MBR00000266,Vision,Paid,Electronic_EDI,2023-08-21,2023-08-21,2023-08-21,2023-09-12,Auto_Adjudicated,22,1832660692,1705448933,207Q00000X,Family Medicine,23,In_Network,OTHER,,V2100,,0,Commercial,EPO,14,M,1.075,,,803.04,339.65,112.55,165.97,33.0,28.14,463.39,0.0,0.0,0,,0.0499,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000003693,MBR00000076,Dental,Paid,Electronic_EDI,2023-08-23,2023-08-23,2023-08-23,2023-09-11,Manual_Review,19,1310400164,1128148362,207RN0300X,Nephrology,21,In_Network,OTHER,,D2391,,0,Commercial,HMO,26,M,2.1785,,,553.61,293.41,193.22,19.89,32.0,48.3,260.2,0.0,0.0,1,Kickback Arrangement,1.0,geographic_mismatch|provider_specialty_mismatch|benford_violation|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,1.8e-05,0,0,,P4P
CLM0000003694,MBR00000051,Medical_Professional,Paid,Electronic_EDI,2023-12-19,2023-12-19,2023-12-19,2024-01-02,Auto_Adjudicated,14,1484613641,1978943761,207V00000X,Obstetrics & Gynecology,24,In_Network,OTHER,,99204,,0,Medicare_Advantage,MA_PPO,17,F,1.0695,,,529.31,406.22,294.69,23.86,14.0,73.67,123.09,0.0,0.0,0,,0.1149,none,0,1,0,0,0,2.7e-05,0,0,,Shared_Savings
CLM0000003695,MBR00000184,Medical_Professional,Paid,Paper,2023-05-11,2023-05-11,2023-05-11,2023-05-31,Auto_Adjudicated,20,1875632885,1415734567,208600000X,Surgery General,11,In_Network,Z23,F32.9|OTHER,70553,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,675.06,376.77,374.77,0.0,2.0,0.0,298.29,0.0,0.0,0,,0.1297,none,0,1,0,1,0,3.5e-05,0,0,,Shared_Savings
CLM0000003696,MBR00000266,Medical_Institutional,Denied,Electronic_EDI,2023-05-17,2023-05-17,2023-05-20,2023-06-08,Auto_Adjudicated,22,1734752728,1662516615,207RP1001X,Pulmonary Disease,11,In_Network,L70.0,M54.5,revenue_code:0360,,0,Commercial,EPO,14,M,1.075,CO-45,Network,46518.15,38690.89,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0066,none,0,1,0,0,0,0.0,0,0,SPD_Spirometry_Testing,Bundled_Payment
CLM0000003697,MBR00000081,Pharmacy,Paid,Electronic_EDI,2023-05-08,2023-05-08,2023-05-08,2023-05-21,Auto_Adjudicated,13,1159640414,1829216053,207Q00000X,Family Medicine,31,In_Network,E78.5,OTHER|Z00.01|J06.9,00310075090,,3,Medicare_Advantage,SNP,66,F,2.159,,,346.0,127.53,93.25,5.96,5.0,23.31,218.47,0.0,0.0,0,,0.0256,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000003698,MBR00000202,Medical_Institutional,Paid,Electronic_EDI,2023-02-08,2023-02-08,2023-02-11,2023-03-06,Manual_Review,26,1211372728,1691162131,246ZN0300X,Neuropsychology,21,Out_of_Network,Z12.11,OTHER,revenue_code:0300,683,0,Commercial,PPO,87,F,0.6213,,,13658.61,4905.76,3602.68,372.41,30.0,900.67,8752.85,0.0,0.0,0,,0.0346,none,0,1,0,0,0,0.000333,1,0,AMR_Asthma_Medication_Ratio,Shared_Savings
CLM0000003699,MBR00000048,Pharmacy,Paid,Electronic_EDI,2023-06-18,2023-06-18,2023-06-18,2023-06-20,Auto_Adjudicated,2,1636337876,1123879500,207RE0101X,Endocrinology,11,In_Network,OTHER,Z00.00,50458085930,,1,Commercial,POS,27,F,0.639,,,178.36,142.36,11.63,102.82,25.0,2.91,36.0,0.0,0.0,0,,0.0869,controlled_substance_high_volume,0,1,0,0,0,1e-06,0,0,,P4P
CLM0000003700,MBR00000054,Pharmacy,Paid,Electronic_EDI,2023-06-09,2023-06-09,2023-06-09,2023-06-19,Manual_Review,10,1590338573,1297948643,246ZN0300X,Neuropsychology,31,In_Network,Z00.00,,00085163102,,1,Medicare_Advantage,MA_HMO,66,F,0.8625,,,149.18,66.54,49.65,3.47,1.0,12.41,82.64,0.0,0.0,0,,0.1445,none,0,1,0,1,0,5e-06,0,0,,Bundled_Payment
CLM0000003701,MBR00000273,Vision,Paid,Electronic_EDI,2023-03-12,2023-03-12,2023-03-12,2023-03-23,Auto_Adjudicated,11,1699014308,1765164601,225100000X,Physical Therapist,24,In_Network,Z00.00,OTHER,92012,,0,ACA_Marketplace,ACA_Bronze,4,M,1.3569,,,275.18,126.1,0.0,126.1,0.0,0.0,149.08,0.0,0.0,0,,0.0628,none,0,1,0,0,0,0.0,0,0,TRC_Transition_of_Care,Bundled_Payment
CLM0000003702,MBR00000036,Medical_Institutional,Denied,Electronic_EDI,2023-10-20,2023-10-20,2023-10-24,2023-11-14,Manual_Review,25,1462532026,1763260577,207V00000X,Obstetrics & Gynecology,24,In_Network,G47.33,Z00.00|G47.33,revenue_code:0250,,0,Commercial,EPO,17,M,2.0136,22,Network,5606.55,4154.07,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1077,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003703,MBR00000008,Dental,Paid,Electronic_EDI,2023-09-05,2023-09-05,2023-09-05,2023-09-21,Manual_Review,16,1403662694,1151295616,207V00000X,Obstetrics & Gynecology,21,Out_of_Network,OTHER,M79.3|Z00.00,D0150,,0,Medicaid_MCO,MCO,74,M,0.8375,,,525.51,231.42,230.42,0.0,1.0,0.0,294.09,0.0,0.0,0,,0.1041,none,0,1,0,0,0,2.1e-05,1,0,,Shared_Savings
CLM0000003704,MBR00000228,Pharmacy,Paid,Provider_Portal,2023-03-28,2023-03-28,2023-03-28,2023-04-25,Auto_Adjudicated,28,1666911728,1764064254,225100000X,Physical Therapist,22,In_Network,Z12.11,OTHER|Z00.01,00085163102,,1,Commercial,PPO,55,F,0.7203,,,832.47,547.06,381.61,31.04,39.0,95.4,285.41,0.0,0.0,0,,0.0759,unusual_service_frequency,0,1,0,0,0,3.5e-05,0,1,,FFS
CLM0000003705,MBR00000114,Medical_Professional,Paid,Electronic_EDI,2023-03-01,2023-03-01,2023-03-01,2023-03-30,Auto_Adjudicated,29,1706065807,1789540567,208600000X,Surgery General,11,Out_of_Network,I50.9,OTHER|M17.11,99232,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,113.17,42.14,1.74,20.97,19.0,0.43,71.03,0.0,0.0,0,,0.2413,duplicate_claim_indicator|diagnosis_procedure_mismatch,0,2,0,0,0,0.0,1,0,BPD_BP_Declined,Shared_Savings
CLM0000003706,MBR00000126,Pharmacy,Paid,Electronic_EDI,2023-08-10,2023-08-10,2023-08-10,2023-08-24,Auto_Adjudicated,14,1629674542,1140170394,2084P0800X,Psychiatry,11,Emergency,OTHER,,59148001506,,1,Medicaid_MCO,MLTSS,48,F,0.637,,,462.22,364.21,362.21,0.0,2.0,0.0,98.01,224.18,83.87,0,,0.112,npi_mismatch,0,1,0,0,0,3.4e-05,0,1,FLU_Flu_Vaccination,FFS
CLM0000003707,MBR00000236,Medical_Professional,Paid,Electronic_EDI,2023-01-02,2023-01-02,2023-01-02,2023-01-24,Auto_Adjudicated,22,1292920374,1388050552,101YP2500X,Psychologist Clinical,11,In_Network,Z00.01,,99394,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,316.02,200.8,197.8,0.0,3.0,0.0,115.22,0.0,0.0,0,,0.0631,unusual_service_frequency,0,1,0,0,0,1.8e-05,0,0,CBP_Controlling_BP,FFS
CLM0000003708,MBR00000056,Medical_Professional,Paid,Electronic_EDI,2023-02-24,2023-02-24,2023-02-24,2023-03-04,Auto_Adjudicated,8,1167433253,1287935251,208600000X,Surgery General,22,In_Network,OTHER,OTHER|F33.0,99284,,0,Commercial,EPO,74,F,1.3941,,,472.01,271.17,65.5,178.29,11.0,16.38,200.84,0.0,0.0,0,,0.1287,provider_specialty_mismatch,0,1,0,0,0,6e-06,0,0,BCS_Breast_Cancer_Screening,P4P
CLM0000003709,MBR00000193,Behavioral_Health,Paid,Electronic_EDI,2023-06-07,2023-06-07,2023-06-07,2023-06-11,Manual_Review,4,1369267360,1040061910,2084P0800X,Psychiatry,22,In_Network,I25.10,OTHER,90837,,0,Commercial,PPO,11,M,0.5266,,,164.04,87.19,0.0,87.19,0.0,0.0,76.85,0.0,0.0,0,,0.0617,none,0,1,0,0,0,0.0,0,0,PPC_Prenatal_Care,Capitation
CLM0000003710,MBR00000100,Medical_Institutional,Paid,Electronic_EDI,2023-12-22,2023-12-22,2023-12-24,2024-01-06,Auto_Adjudicated,15,1091395764,1330485436,207Q00000X,Family Medicine,11,In_Network,Z23,,revenue_code:0450,,0,ACA_Marketplace,ACA_Gold,87,M,1.435,,,10192.78,5160.55,4069.14,15.13,59.0,1017.28,5032.23,0.0,0.0,0,,0.0851,none,0,1,0,0,0,0.000377,0,0,,Shared_Savings
CLM0000003711,MBR00000032,Medical_Institutional,Paid,Electronic_EDI,2023-01-28,2023-01-28,2023-01-28,2023-02-07,Auto_Adjudicated,10,1986485249,1469881892,207RN0300X,Nephrology,32,In_Network,Z00.00,,revenue_code:0120,,0,Medicaid_MCO,FFS_Medicaid,87,M,0.4839,,,37482.91,18069.1,18063.1,0.0,6.0,0.0,19413.81,0.0,0.0,0,,0.0105,none,0,1,1,0,0,0.001672,0,0,COA_Care_Transitions,FFS
CLM0000003712,MBR00000205,Vision,Paid,Electronic_EDI,2023-07-09,2023-07-09,2023-07-09,2023-07-31,Auto_Adjudicated,22,1878057972,1649705287,207RE0101X,Endocrinology,81,In_Network,Z12.11,OTHER|K57.30|J06.9,V2115,,0,Medicaid_MCO,MCO,1,F,0.9425,,,273.18,228.81,227.81,0.0,1.0,0.0,44.37,0.0,0.0,0,,0.2017,service_date_weekend,0,2,0,0,0,2.1e-05,0,0,,P4P
CLM0000003713,MBR00000101,Medical_Professional,Paid,Electronic_EDI,2023-07-21,2023-07-21,2023-07-21,2023-08-06,Auto_Adjudicated,16,1713741288,1972530373,207RN0300X,Nephrology,11,In_Network,OTHER,F41.1|OTHER,99384,,0,Commercial,PPO,83,M,0.3627,,,422.96,212.56,152.33,0.15,22.0,38.08,210.4,0.0,0.0,0,,0.0311,none,0,1,0,0,0,1.4e-05,0,0,W30_Well_Child_Visit,Shared_Savings
CLM0000003714,MBR00000262,Medical_Professional,Paid,Electronic_EDI,2023-04-01,2023-04-01,2023-04-01,2023-04-06,Manual_Review,5,1154652946,1622950074,2086S0122X,Orthopedic Surgery,31,In_Network,J20.9,I50.9,97140,,0,Medicare_Advantage,PFFS,77,F,1.7452,,,979.85,459.39,364.03,0.35,4.0,91.01,520.46,0.0,0.0,1,Kickback Arrangement,0.9139,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|high_volume_same_code|impossible_service_combo|service_date_weekend|duplicate_claim_indicator|unbundling_pattern|high_oop_waiver,1,5,0,1,0,3.4e-05,0,0,IET_Initiation_Substance_Use,Bundled_Payment
CLM0000003715,MBR00000277,Medical_Professional,Paid,Electronic_EDI,2023-07-06,2023-07-06,2023-07-06,2023-07-20,Auto_Adjudicated,14,1466478716,1163639177,2084P0800X,Psychiatry,22,In_Network,I10,I10,99222,,0,Medicaid_MCO,MCO,30,M,1.8495,,,361.21,209.12,206.12,0.0,3.0,0.0,152.09,0.0,0.0,0,,0.0112,none,0,1,0,0,0,1.9e-05,0,0,PPC_Prenatal_Care,Bundled_Payment
CLM0000003716,MBR00000255,Medical_Institutional,Paid,Electronic_EDI,2023-08-16,2023-08-16,2023-08-20,2023-08-29,Manual_Review,13,1733777382,1157814306,101YP2500X,Psychologist Clinical,22,In_Network,E11.9,,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,21,M,0.6945,,,17272.36,8268.46,6589.88,7.1,24.0,1647.47,9003.9,0.0,0.0,0,,0.15,diagnosis_procedure_mismatch,0,1,1,0,0,0.00061,0,0,,Shared_Savings
CLM0000003717,MBR00000102,Medical_Professional,Paid,Electronic_EDI,2023-02-19,2023-02-19,2023-02-19,2023-02-20,Auto_Adjudicated,1,1373899620,1274911960,208600000X,Surgery General,22,In_Network,OTHER,,99213,,0,Commercial,POS,68,M,1.6864,,,423.36,205.65,0.0,205.65,0.0,0.0,217.71,0.0,0.0,0,,0.0636,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003718,MBR00000074,Medical_Professional,Denied,Electronic_EDI,2023-12-09,2023-12-09,2023-12-09,2023-12-26,Auto_Adjudicated,17,1469009511,1170002937,208600000X,Surgery General,24,In_Network,K21.0,M54.5,85025,,0,Medicare_Advantage,MA_PPO,21,F,0.8719,97,Timely_Filing,511.99,247.13,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0274,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000003719,MBR00000270,Pharmacy,Denied,Electronic_EDI,2023-03-30,2023-03-30,2023-03-30,2023-04-28,Manual_Review,29,1292920374,1157814306,207RG0100X,Gastroenterology,11,In_Network,Z00.01,,00071015523,,4,Commercial,POS,1,F,1.6363,1,Network,180.0,75.41,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0196,none,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000003720,MBR00000141,Medical_Professional,Paid,Electronic_EDI,2023-05-13,2023-05-13,2023-05-13,2023-06-09,Clinical_Review,27,1133265917,1020312030,207RE0101X,Endocrinology,22,In_Network,OTHER,I25.10|Z00.00|M17.11,99212,,0,Commercial,HMO,47,F,0.6724,,,454.58,360.68,264.1,4.55,26.0,66.03,93.9,0.0,0.0,0,,0.132,benford_violation,0,1,0,0,0,2.4e-05,0,0,,Capitation
CLM0000003721,MBR00000209,Medical_Institutional,Paid,Electronic_EDI,2023-01-09,2023-01-09,2023-01-10,2023-02-06,Auto_Adjudicated,28,1334227781,1542515060,208600000X,Surgery General,11,In_Network,E78.5,,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,10,F,0.5199,,,43959.35,19434.02,15510.7,22.65,23.0,3877.67,24525.33,0.0,0.0,0,,0.1366,none,0,1,1,0,0,0.001436,0,0,,FFS
CLM0000003722,MBR00000247,Medical_Professional,Paid,Provider_Portal,2023-08-02,2023-08-02,2023-08-02,2023-08-29,Auto_Adjudicated,27,1988579666,1368666316,207RG0100X,Gastroenterology,11,In_Network,OTHER,E11.9,99386,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,184.06,66.44,47.02,2.66,5.0,11.76,117.62,0.0,0.0,0,,0.1017,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000003723,MBR00000087,Medical_Institutional,Paid,Electronic_EDI,2023-08-02,2023-08-02,2023-08-03,2023-08-30,Auto_Adjudicated,28,1098094939,1564636990,207RN0300X,Nephrology,22,In_Network,Z00.00,E11.9|OTHER,revenue_code:0370,,0,Medicaid_MCO,MCO,70,F,0.9232,,,34957.43,25826.62,25823.62,0.0,3.0,0.0,9130.81,0.0,0.0,0,,0.1063,service_date_weekend,0,1,1,0,0,0.00239,0,0,,Shared_Savings
CLM0000003724,MBR00000036,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-02-11,2023-02-11,2023-02-13,2023-02-14,Manual_Review,3,1338575285,1388050552,208600000X,Surgery General,11,In_Network,E78.5,,revenue_code:0200,,0,Commercial,EPO,17,M,2.0136,18,Medical_Necessity,6007.98,3459.25,1657.93,145.35,40.0,414.48,3750.21,0.0,0.0,0,,0.0728,none,0,1,0,0,0,0.000153,0,0,PPC_Prenatal_Care,FFS
CLM0000003725,MBR00000186,Medical_Institutional,Denied,Paper,2023-04-16,2023-04-16,2023-04-20,2023-04-29,Manual_Review,13,1327415110,1564636990,207Q00000X,Family Medicine,24,Emergency,J06.9,E78.5,revenue_code:0300,,0,Commercial,PPO,65,M,1.6983,96,Coding_Error,14467.63,7625.58,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1002,none,0,1,0,0,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000003726,MBR00000177,Medical_Professional,Paid,Electronic_EDI,2023-10-03,2023-10-03,2023-10-03,2023-10-20,Manual_Review,17,1560886857,1352413270,207RN0300X,Nephrology,23,In_Network,OTHER,OTHER,71250,,0,Commercial,HMO,42,F,1.2774,,,791.95,488.25,312.23,70.97,27.0,78.06,303.7,0.0,0.0,0,,0.0631,none,0,1,0,0,0,2.9e-05,0,0,,FFS
CLM0000003727,MBR00000084,Medical_Professional,Paid,Electronic_EDI,2023-09-13,2023-09-13,2023-09-13,2023-10-09,Clinical_Review,26,1821999097,1288028182,246ZN0300X,Neuropsychology,11,In_Network,I48.91,,11200,,0,Medicare_Advantage,MA_HMO,15,F,0.8004,,,462.14,290.4,219.81,4.64,11.0,54.95,171.74,0.0,0.0,0,,0.2055,controlled_substance_high_volume,0,2,0,0,0,2e-05,0,0,,FFS
CLM0000003728,MBR00000176,Medical_Professional,Paid,Provider_Portal,2023-04-21,2023-04-21,2023-04-21,2023-05-03,Auto_Adjudicated,12,1419204214,1564636990,207RG0100X,Gastroenterology,31,In_Network,M54.5,,99212,,0,Commercial,POS,4,M,0.8792,,,256.21,138.98,0.0,138.98,0.0,0.0,117.23,0.0,0.0,0,,0.1468,none,0,1,0,0,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000003729,MBR00000235,Medical_Professional,Paid,Electronic_EDI,2023-08-15,2023-08-15,2023-08-15,2023-09-06,Auto_Adjudicated,22,1647029816,1985590322,2086S0122X,Orthopedic Surgery,21,In_Network,OTHER,N39.0|OTHER,27130,,0,Commercial,HDHP_HSA,85,F,1.4308,,,5217.09,4047.17,2847.58,487.7,0.0,711.89,1169.92,0.0,0.0,0,,0.1492,none,0,1,0,0,0,0.000264,0,0,,Capitation
CLM0000003730,MBR00000110,Medical_Institutional,Paid,Electronic_EDI,2023-09-26,2023-09-26,2023-09-27,2023-10-20,Auto_Adjudicated,24,1098094939,1034732777,225100000X,Physical Therapist,23,In_Network,OTHER,L70.0,revenue_code:0200,,0,Medicare_Advantage,MA_HMO,83,F,1.127,,,23039.24,17772.41,14170.38,6.44,53.0,3542.59,5266.83,0.0,0.0,0,,0.1025,none,0,1,1,1,0,0.001312,0,0,MPT_Annual_Monitoring,FFS
CLM0000003731,MBR00000076,Medical_Professional,Paid,Electronic_EDI,2023-05-15,2023-05-15,2023-05-15,2023-05-31,Auto_Adjudicated,16,1210349885,1175334579,246ZN0300X,Neuropsychology,11,Out_of_Network,M17.11,,70553,,0,Commercial,HMO,26,M,2.1785,,,535.21,285.09,174.2,35.34,32.0,43.55,250.12,0.0,0.0,0,,0.1974,billing_spike_recent,0,1,0,0,0,1.6e-05,1,0,,Shared_Savings
CLM0000003732,MBR00000213,Medical_Professional,Paid,Electronic_EDI,2023-03-05,2023-03-05,2023-03-05,2023-03-13,Manual_Review,8,1364214492,1513198866,2086S0122X,Orthopedic Surgery,11,In_Network,M17.11,Z23,47562,,0,Commercial,PPO,17,M,1.5857,,,631.23,291.03,84.74,157.1,28.0,21.19,340.2,0.0,0.0,0,,0.1975,service_date_weekend,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000003733,MBR00000232,Medical_Professional,Paid,Electronic_EDI,2023-01-08,2023-01-08,2023-01-08,2023-01-11,Auto_Adjudicated,3,1119160702,1764064254,207RP1001X,Pulmonary Disease,31,In_Network,M17.11,Z00.00|OTHER,99396,,0,Medicaid_MCO,MCO,40,M,1.1083,,,210.32,124.77,122.77,0.0,2.0,0.0,85.55,0.0,0.0,0,,0.0073,none,0,1,0,0,0,1.1e-05,0,0,,Capitation
CLM0000003734,MBR00000289,Pharmacy,Denied,Electronic_EDI,2023-12-09,2023-12-09,2023-12-09,2023-12-23,Auto_Adjudicated,14,1625939855,1140170394,101YP2500X,Psychologist Clinical,65,In_Network,I10,C50.911|I10,16590051660,,4,Commercial,POS,51,M,1.0534,3,Timely_Filing,322.27,137.96,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2418,provider_specialty_mismatch|upcoding_pattern,0,2,0,0,0,0.0,0,0,,Capitation
CLM0000003735,MBR00000046,Medical_Institutional,Paid,Electronic_EDI,2023-04-25,2023-04-25,2023-04-27,2023-05-01,Auto_Adjudicated,6,1855186422,1296566243,207RE0101X,Endocrinology,21,In_Network,OTHER,OTHER|F41.1|Z00.00,revenue_code:0200,683,0,Commercial,HMO,76,F,0.9613,,,14177.7,6963.53,5497.07,51.19,41.0,1374.27,7214.17,0.0,0.0,0,,0.118,none,0,1,1,0,1,0.000509,0,0,,Shared_Savings
CLM0000003736,MBR00000270,Medical_Institutional,Paid,Paper,2023-10-17,2023-10-17,2023-10-19,2023-11-06,Auto_Adjudicated,20,1510562885,1884259357,207RN0300X,Nephrology,21,In_Network,N40.0,M54.5|OTHER,revenue_code:0360,292,0,Commercial,POS,1,F,1.6363,,,7191.88,3894.97,2736.62,398.19,76.0,684.16,3296.91,0.0,0.0,1,Medically Unnecessary Services,0.9121,temporal_clustering|high_volume_same_code|impossible_service_combo|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|high_oop_waiver,1,5,0,0,0,0.000253,0,0,,Capitation
CLM0000003737,MBR00000225,Medical_Institutional,Denied,Electronic_EDI,2023-04-27,2023-04-27,2023-05-01,2023-05-05,Auto_Adjudicated,8,1923332120,1163639177,2084P0800X,Psychiatry,23,In_Network,OTHER,,revenue_code:0250,,0,Commercial,PPO,27,F,0.5948,18,Duplicate,4727.32,2559.45,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1683,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003738,MBR00000208,Medical_Professional,Paid,Electronic_EDI,2023-09-13,2023-09-13,2023-09-13,2023-10-10,Auto_Adjudicated,27,1865750966,1144950506,207R00000X,Internal Medicine,11,In_Network,OTHER,,20610,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,659.33,289.91,211.71,19.27,6.0,52.93,369.42,0.0,0.0,0,,0.1819,provider_specialty_mismatch,0,1,0,0,0,2e-05,0,0,,Shared_Savings
CLM0000003739,MBR00000099,Medical_Professional,Paid,Electronic_EDI,2023-04-30,2023-04-30,2023-04-30,2023-05-27,Auto_Adjudicated,27,1671999102,1388050552,208600000X,Surgery General,31,In_Network,OTHER,Z23,99203,,0,Commercial,HMO,10,F,0.7843,,,393.93,238.23,26.07,190.64,15.0,6.52,155.7,0.0,0.0,0,,0.0055,none,0,1,0,0,0,2e-06,0,0,COA_Care_Transitions,Shared_Savings
CLM0000003740,MBR00000007,Medical_Professional,Paid,Electronic_EDI,2023-08-07,2023-08-07,2023-08-07,2023-09-02,Auto_Adjudicated,26,1956107350,1489434038,2086S0122X,Orthopedic Surgery,11,In_Network,OTHER,OTHER,71250,,0,Commercial,HDHP_HSA,72,F,0.7578,,,743.85,488.64,0.0,488.64,0.0,0.0,255.21,0.0,0.0,0,,0.0904,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000003741,MBR00000156,Medical_Institutional,Paid,Electronic_EDI,2023-12-09,2023-12-09,2023-12-13,2023-12-29,Auto_Adjudicated,20,1026612378,1575884274,207RN0300X,Nephrology,11,Out_of_Network,OTHER,Z23,revenue_code:0300,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,17740.06,11634.6,9270.71,17.21,29.0,2317.68,6105.46,0.0,0.0,0,,0.0635,none,0,1,1,0,0,0.000858,1,0,CDC_HbA1c_Poor_Control,Capitation
CLM0000003742,MBR00000089,Medical_Professional,Paid,Electronic_EDI,2023-09-28,2023-09-28,2023-09-28,2023-10-02,Manual_Review,4,1477762002,1396850418,207RC0000X,Cardiovascular Disease,11,In_Network,N18.3,I10|E11.9,99203,,0,Commercial,PPO,14,M,0.5668,,,475.01,356.8,166.43,114.76,34.0,41.61,118.21,0.0,0.0,0,,0.0857,none,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000003743,MBR00000091,Medical_Professional,Paid,Electronic_EDI,2023-03-01,2023-03-01,2023-03-01,2023-03-31,Clinical_Review,30,1627776731,1903401648,207V00000X,Obstetrics & Gynecology,21,In_Network,OTHER,,12001,,0,Commercial,PPO,13,F,1.2451,,,366.47,142.4,0.0,142.4,0.0,0.0,224.07,0.0,0.0,0,,0.1458,geographic_mismatch,0,1,0,1,0,0.0,0,0,,FFS
CLM0000003744,MBR00000279,Dental,Paid,Electronic_EDI,2023-07-08,2023-07-08,2023-07-08,2023-07-10,Auto_Adjudicated,2,1855186422,1874728994,207RP1001X,Pulmonary Disease,32,Out_of_Network,OTHER,OTHER|I10|E78.5,D0120,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,,,269.01,115.26,69.27,19.67,9.0,17.32,153.75,60.76,7.6,0,,0.1512,provider_specialty_mismatch,0,1,0,0,0,6e-06,0,0,CDC_BP_Control,FFS
CLM0000003745,MBR00000049,Pharmacy,Paid,Electronic_EDI,2023-04-07,2023-04-07,2023-04-07,2023-04-24,Auto_Adjudicated,17,1167433253,1408846353,207RP1001X,Pulmonary Disease,23,In_Network,E78.5,OTHER,00085163102,,1,Medicare_Advantage,PFFS,67,M,0.978,,,42.65,24.25,0.0,24.25,0.0,0.0,18.4,0.0,0.0,0,,0.0435,none,0,1,0,0,0,0.0,0,1,ACR_Urine_Protein,FFS
CLM0000003746,MBR00000282,Medical_Professional,Partially_Paid,Electronic_EDI,2023-03-20,2023-03-20,2023-03-20,2023-04-14,Auto_Adjudicated,25,1263063839,1179350099,246ZN0300X,Neuropsychology,11,In_Network,E11.65,Z00.01|J20.9,90847,,0,Medicare_Advantage,MA_HMO,16,M,0.7304,PR-1,Medical_Necessity,498.36,294.73,97.83,33.25,18.0,24.46,324.82,0.0,0.0,0,,0.0209,none,0,1,0,0,0,9e-06,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000003747,MBR00000156,Dental,Paid,Electronic_EDI,2023-10-26,2023-10-26,2023-10-26,2023-10-29,Auto_Adjudicated,3,1213747973,1039962073,207RN0300X,Nephrology,11,In_Network,L70.0,Z00.00,D0120,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,242.25,109.67,64.63,15.88,13.0,16.16,132.58,53.33,7.61,0,,0.0442,none,0,1,0,0,0,6e-06,0,0,COA_Care_Transitions,FFS
CLM0000003748,MBR00000250,Medical_Professional,Paid,Provider_Portal,2023-12-19,2023-12-19,2023-12-19,2024-01-03,Manual_Review,15,1519595029,1884259357,208600000X,Surgery General,11,In_Network,Z00.01,E78.5|OTHER,99214,,0,Commercial,PPO,41,M,0.9245,,,388.31,194.03,0.0,184.92,9.11,0.0,194.28,0.0,0.0,0,,0.071,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003749,MBR00000088,Medical_Professional,Paid,Electronic_EDI,2023-11-29,2023-11-29,2023-11-29,2023-12-14,Auto_Adjudicated,15,1997577166,1827839595,207RN0300X,Nephrology,22,In_Network,N39.0,I10|OTHER|J44.1,90847,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,,,897.77,385.77,207.94,50.72,38.0,89.12,512.0,0.0,0.0,0,,0.0989,duplicate_claim_indicator,0,1,0,0,0,1.9e-05,0,0,,Bundled_Payment
CLM0000003750,MBR00000188,Medical_Professional,Paid,Electronic_EDI,2023-10-29,2023-10-29,2023-10-29,2023-11-04,Manual_Review,6,1404237143,1588993671,225100000X,Physical Therapist,22,In_Network,Z00.00,,90837,,0,Commercial,HMO,8,F,1.5853,,,1858.61,1154.88,840.71,78.99,25.0,210.18,703.73,0.0,0.0,0,,0.0868,none,0,1,0,1,0,7.8e-05,0,0,,FFS
CLM0000003751,MBR00000168,Vision,Paid,Electronic_EDI,2023-06-18,2023-06-18,2023-06-18,2023-06-22,Auto_Adjudicated,4,1633089013,1012893364,225100000X,Physical Therapist,11,In_Network,E11.9,G43.909,V2115,,0,Commercial,HMO,76,M,1.2791,,,217.91,128.26,0.0,128.26,0.0,0.0,89.65,0.0,0.0,0,,0.0535,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003752,MBR00000279,Medical_Professional,Paid,Electronic_EDI,2023-07-08,2023-07-08,2023-07-08,2023-08-05,Auto_Adjudicated,28,1124477249,1985590322,207R00000X,Internal Medicine,24,In_Network,F41.1,J06.9|OTHER,99284,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,,,341.41,236.93,164.69,22.07,9.0,41.17,104.48,0.0,0.0,0,,0.2036,benford_violation|impossible_service_combo,0,2,0,0,0,1.5e-05,0,0,,FFS
CLM0000003753,MBR00000056,Pharmacy,Paid,Electronic_EDI,2023-07-13,2023-07-13,2023-07-13,2023-08-10,Manual_Review,28,1836409547,1105733833,208600000X,Surgery General,23,Out_of_Network,M54.5,OTHER|Z00.01,00006001954,,2,Commercial,EPO,74,F,1.3941,,,325.45,216.51,0.0,216.51,0.0,0.0,108.94,0.0,0.0,0,,0.025,none,0,1,0,0,0,0.0,1,0,,Bundled_Payment
CLM0000003754,MBR00000061,Medical_Institutional,Paid,Paper,2023-09-22,2023-09-22,2023-09-25,2023-09-25,Manual_Review,3,1055717021,1581533104,207RN0300X,Nephrology,81,In_Network,OTHER,E78.5,revenue_code:0100,,0,Commercial,PPO,66,M,2.3575,,,94356.85,45805.02,36607.39,11.78,34.0,9151.85,48551.83,26962.95,5506.49,0,,0.1167,outlier_billing_amount,0,1,1,0,0,0.003388,0,0,AWV_Annual_Wellness_Visit,FFS
CLM0000003755,MBR00000287,Medical_Institutional,Paid,Electronic_EDI,2023-01-19,2023-01-19,2023-01-19,2023-01-28,Auto_Adjudicated,9,1374458552,1540743888,207RP1001X,Pulmonary Disease,22,In_Network,M79.3,,revenue_code:0100,,0,Commercial,PPO,4,M,0.7685,,,17759.37,12966.35,10196.56,163.64,57.0,2549.14,4793.02,0.0,0.0,0,,0.0993,none,0,1,1,0,0,0.000944,0,0,,Shared_Savings
CLM0000003756,MBR00000029,Medical_Professional,Paid,Electronic_EDI,2023-10-24,2023-10-24,2023-10-24,2023-11-05,Auto_Adjudicated,12,1713741288,1354265777,225100000X,Physical Therapist,21,In_Network,E78.5,OTHER,71046,,0,Medicaid_MCO,MCO,13,F,0.9053,,,628.5,267.69,266.69,0.0,1.0,0.0,360.81,0.0,0.0,0,,0.0677,none,0,1,0,0,0,2.5e-05,0,0,LCS_Lung_Cancer_Screening,Shared_Savings
CLM0000003757,MBR00000188,Medical_Professional,Denied,Paper,2023-10-18,2023-10-18,2023-10-18,2023-10-24,Auto_Adjudicated,6,1075661656,1291071007,207RE0101X,Endocrinology,11,In_Network,Z00.00,I50.9,99204,,0,Commercial,HMO,8,F,1.5853,CO-45,Medical_Necessity,298.15,198.33,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1047,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003758,MBR00000018,Pharmacy,Paid,Electronic_EDI,2023-12-24,2023-12-24,2023-12-24,2023-12-26,Auto_Adjudicated,2,1496489953,1469697158,101YP2500X,Psychologist Clinical,65,In_Network,E78.5,,00169751112,,4,Commercial,EPO,5,F,0.5555,,,261.18,172.39,126.59,0.16,14.0,31.65,88.79,0.0,0.0,0,,0.0803,none,0,1,0,0,0,1.2e-05,0,1,,FFS
CLM0000003759,MBR00000024,Medical_Professional,Paid,Electronic_EDI,2023-08-02,2023-08-02,2023-08-02,2023-08-18,Auto_Adjudicated,16,1216417633,1402472115,207RE0101X,Endocrinology,11,In_Network,M17.11,Z12.11,71046,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,1699.92,795.06,792.06,0.0,3.0,0.0,904.86,0.0,0.0,0,,0.002,none,0,1,0,0,0,7.3e-05,0,0,,Shared_Savings
CLM0000003760,MBR00000180,Medical_Institutional,Paid,Electronic_EDI,2023-06-14,2023-06-14,2023-06-15,2023-06-28,Auto_Adjudicated,14,1330688043,1804282800,207R00000X,Internal Medicine,21,In_Network,OTHER,F32.9,revenue_code:0250,292,0,Medicare_Advantage,MA_PPO,72,F,1.1909,,,8182.17,3663.07,2872.79,21.08,51.0,718.2,4519.1,0.0,0.0,0,,0.0151,none,0,1,0,0,1,0.000266,0,0,,FFS
CLM0000003761,MBR00000166,Medical_Professional,Denied,Electronic_EDI,2023-06-21,2023-06-21,2023-06-21,2023-07-16,Auto_Adjudicated,25,1706476585,1114756459,207RN0300X,Nephrology,22,In_Network,N18.3,,99232,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,5,COB,196.24,79.16,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1026,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000003762,MBR00000172,Pharmacy,Paid,Provider_Portal,2023-08-11,2023-08-11,2023-08-11,2023-08-20,Auto_Adjudicated,9,1909649019,1391074619,225100000X,Physical Therapist,22,In_Network,Z00.00,,59148001506,,1,Medicaid_MCO,MCO,50,F,0.2787,,,1466.28,968.02,968.02,0.0,0.0,0.0,498.26,0.0,0.0,0,,0.0928,service_date_weekend,0,1,0,0,0,9e-05,0,1,,Capitation
CLM0000003763,MBR00000145,Pharmacy,Paid,Electronic_EDI,2023-04-19,2023-04-19,2023-04-19,2023-05-05,Clinical_Review,16,1207676414,1972530373,2084P0800X,Psychiatry,22,In_Network,F32.9,K21.0|E11.65,00078043215,,1,Medicaid_MCO,MLTSS,46,M,0.5813,,,73.08,38.88,35.88,0.0,3.0,0.0,34.2,0.0,0.0,0,,0.1214,temporal_clustering,0,1,0,1,0,3e-06,0,1,,FFS
CLM0000003764,MBR00000217,Medical_Institutional,Paid,Paper,2023-10-06,2023-10-06,2023-10-09,2023-10-16,Auto_Adjudicated,10,1159268684,1179350099,207RC0000X,Cardiovascular Disease,23,Out_of_Network,OTHER,,revenue_code:0450,,0,ACA_Marketplace,ACA_Bronze,11,F,1.1619,,,25919.06,22014.56,12991.79,361.58,0.0,8661.19,3904.5,0.0,0.0,0,,0.0629,none,0,1,1,0,0,0.001203,1,0,,P4P
CLM0000003765,MBR00000298,Medical_Institutional,Paid,Electronic_EDI,2023-06-09,2023-06-09,2023-06-13,2023-06-11,Auto_Adjudicated,2,1360102160,1945682535,225100000X,Physical Therapist,11,In_Network,OTHER,,revenue_code:0360,,0,Medicaid_MCO,MCO,75,M,0.8324,,,17453.18,11649.5,11649.5,0.0,0.0,0.0,5803.68,0.0,0.0,0,,0.1301,none,0,1,1,0,0,0.001078,0,0,,FFS
CLM0000003766,MBR00000086,Medical_Professional,Denied,Electronic_EDI,2023-04-12,2023-04-12,2023-04-12,2023-05-04,Auto_Adjudicated,22,1330688043,1354959095,207R00000X,Internal Medicine,23,In_Network,J45.20,F41.1|F32.9,47562,,0,Medicare_Advantage,MA_PPO,8,M,0.5427,96,Coding_Error,814.32,289.04,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0093,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003767,MBR00000102,Medical_Professional,Partially_Paid,Electronic_EDI,2023-09-21,2023-09-21,2023-09-21,2023-10-14,Auto_Adjudicated,23,1375098560,1662516615,207RP1001X,Pulmonary Disease,32,Out_of_Network,E78.5,,99222,,0,Commercial,POS,68,M,1.6864,16,Medical_Necessity,151.56,81.37,0.0,61.58,0.0,0.0,89.98,0.0,0.0,0,,0.0652,none,0,1,0,0,0,0.0,1,0,BPD_BP_Declined,Bundled_Payment
CLM0000003768,MBR00000102,Medical_Professional,Denied,Electronic_EDI,2023-05-01,2023-05-01,2023-05-01,2023-05-21,Auto_Adjudicated,20,1327415110,1133410177,207R00000X,Internal Medicine,11,In_Network,Z00.00,,99285,,0,Commercial,POS,68,M,1.6864,96,COB,1084.99,387.45,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0799,impossible_service_combo,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003769,MBR00000224,Pharmacy,Paid,Paper,2023-01-29,2023-01-29,2023-01-29,2023-01-31,Auto_Adjudicated,2,1092800235,1289435414,207RP1001X,Pulmonary Disease,11,In_Network,F32.9,M54.5|K21.0|I10,59148001506,,3,Medicaid_MCO,MCO,86,F,1.3289,,,207.29,137.49,134.49,0.0,3.0,0.0,69.8,81.73,29.05,0,,0.1314,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000003770,MBR00000110,Medical_Professional,Paid,Electronic_EDI,2023-07-07,2023-07-07,2023-07-07,2023-07-28,Auto_Adjudicated,21,1424104563,1325999602,207R00000X,Internal Medicine,81,In_Network,Z12.11,I10,99222,,0,Medicare_Advantage,MA_HMO,83,F,1.127,,,216.42,175.04,132.07,0.96,9.0,33.02,41.38,0.0,0.0,0,,0.1485,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000003771,MBR00000201,Medical_Professional,Paid,Electronic_EDI,2023-07-01,2023-07-01,2023-07-01,2023-07-20,Manual_Review,19,1557212800,1527857018,2084P0800X,Psychiatry,11,In_Network,K57.30,,99282,,0,Medicare_Advantage,MA_PPO,74,M,1.1575,,,144.02,104.05,74.6,4.8,6.0,18.65,39.97,0.0,0.0,0,,0.1052,none,0,1,0,0,0,7e-06,0,0,,P4P
CLM0000003772,MBR00000139,Medical_Professional,Paid,Electronic_EDI,2023-04-15,2023-04-15,2023-04-15,2023-04-29,Manual_Review,14,1273835569,1287472731,208600000X,Surgery General,22,In_Network,Z00.00,,99214,,0,Commercial,PPO,74,M,1.7701,,,102.45,49.45,0.0,49.45,0.0,0.0,53.0,0.0,0.0,0,,0.0971,none,0,1,0,0,0,0.0,0,0,FUH_Follow_Up_Hospitalization,Shared_Savings
CLM0000003773,MBR00000183,Medical_Professional,Paid,Electronic_EDI,2023-01-13,2023-01-13,2023-01-13,2023-02-01,Auto_Adjudicated,19,1462532026,1415734567,225100000X,Physical Therapist,11,In_Network,OTHER,,99222,,0,Commercial,PPO,51,M,0.8463,,,788.22,346.31,40.4,256.81,39.0,10.1,441.91,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|benford_violation|impossible_service_combo|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,4e-06,0,0,,FFS
CLM0000003774,MBR00000248,Medical_Institutional,Paid,Electronic_EDI,2023-06-20,2023-06-20,2023-06-23,2023-06-24,Auto_Adjudicated,4,1750232347,1365397818,207RG0100X,Gastroenterology,22,In_Network,H52.4,E13.9|OTHER,revenue_code:0450,,0,Commercial,PPO,40,F,0.6665,,,9427.26,7435.21,5479.27,526.12,60.0,1369.82,1992.05,0.0,0.0,0,,0.066,none,0,1,1,0,0,0.000507,0,0,,FFS
CLM0000003775,MBR00000158,Pharmacy,Denied,Paper,2023-10-05,2023-10-05,2023-10-05,2023-10-12,Auto_Adjudicated,7,1424104563,1791502603,101YP2500X,Psychologist Clinical,23,Out_of_Network,OTHER,E11.9,00003014960,,1,Commercial,HMO,65,M,1.5361,3,Medical_Necessity,111.17,45.54,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1186,none,0,1,0,0,0,0.0,1,0,FLU_Flu_Vaccination,Shared_Savings
CLM0000003776,MBR00000145,Medical_Institutional,Paid,Electronic_EDI,2023-10-15,2023-10-15,2023-10-17,2023-10-19,Auto_Adjudicated,4,1175978429,1301833092,207V00000X,Obstetrics & Gynecology,24,In_Network,OTHER,,revenue_code:0300,,0,Medicaid_MCO,MLTSS,46,M,0.5813,,,19471.21,13725.66,13724.66,0.0,1.0,0.0,5745.55,0.0,0.0,0,,0.0966,none,0,1,1,0,0,0.00127,0,0,,Shared_Savings
CLM0000003777,MBR00000082,Medical_Institutional,Paid,Electronic_EDI,2023-03-17,2023-03-17,2023-03-20,2023-03-31,Auto_Adjudicated,14,1454749898,1564691686,207RE0101X,Endocrinology,21,In_Network,K21.0,OTHER|F33.0|M54.5,revenue_code:0210,193,0,Medicare_Advantage,MA_HMO,39,F,0.5376,,,17038.76,8045.25,6393.8,9.0,44.0,1598.45,8993.51,0.0,0.0,0,,0.2033,service_date_weekend,0,2,1,0,0,0.000592,0,0,,Capitation
CLM0000003778,MBR00000158,Medical_Institutional,Paid,Electronic_EDI,2023-06-04,2023-06-04,2023-06-05,2023-07-01,Auto_Adjudicated,27,1810800968,1209882852,208600000X,Surgery General,11,In_Network,G47.33,E13.9|J20.9,revenue_code:0100,,0,Commercial,HMO,65,M,1.5361,,,23612.33,11824.79,9342.93,96.12,50.0,2335.73,11787.54,0.0,0.0,0,,0.0253,none,0,1,1,0,0,0.000865,0,0,,FFS
CLM0000003779,MBR00000081,Medical_Institutional,Denied,Electronic_EDI,2023-11-21,2023-11-21,2023-11-24,2023-11-22,Auto_Adjudicated,1,1679629515,1469881892,2086S0122X,Orthopedic Surgery,22,In_Network,OTHER,OTHER|Z00.00,revenue_code:0360,,0,Medicare_Advantage,SNP,66,F,2.159,1,Duplicate,24437.28,9124.12,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0302,none,0,1,0,0,0,0.0,0,0,LCS_Lung_Cancer_Screening,Bundled_Payment
CLM0000003780,MBR00000253,Pharmacy,Paid,Electronic_EDI,2023-05-04,2023-05-04,2023-05-04,2023-05-18,Auto_Adjudicated,14,1918160357,1304018750,207V00000X,Obstetrics & Gynecology,21,Out_of_Network,E11.9,Z00.00|OTHER,00310075090,,1,Commercial,EPO,44,M,0.3882,,,101.51,44.15,0.0,44.15,0.0,0.0,57.36,0.0,0.0,0,,0.0438,none,0,1,0,1,0,0.0,0,1,,Capitation
CLM0000003781,MBR00000124,Pharmacy,Denied,Electronic_EDI,2023-06-20,2023-06-20,2023-06-20,2023-06-29,Auto_Adjudicated,9,1944105498,1049766043,225100000X,Physical Therapist,22,In_Network,Z00.00,Z00.00|OTHER|Z00.01,00310075090,,1,Commercial,EPO,40,F,0.4583,2,COB,61.29,22.66,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1318,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003782,MBR00000040,Pharmacy,Paid,Electronic_EDI,2023-09-01,2023-09-01,2023-09-01,2023-09-30,Auto_Adjudicated,29,1334227781,1301833092,225100000X,Physical Therapist,22,In_Network,M54.5,Z00.01,00069420020,,2,Medicare_Advantage,MA_HMO,66,F,0.6755,,,159.84,97.54,64.68,2.69,14.0,16.17,62.3,0.0,0.0,0,,0.0488,none,0,1,0,0,0,6e-06,0,0,POD_Persistence_of_Beta_Blocker,Capitation
CLM0000003783,MBR00000075,Pharmacy,Paid,Electronic_EDI,2023-06-14,2023-06-14,2023-06-14,2023-07-03,Auto_Adjudicated,19,1167433253,1574982369,207R00000X,Internal Medicine,32,In_Network,K21.0,,00310075090,,1,Medicaid_MCO,MCO,5,M,1.0573,,,272.28,156.55,152.55,0.0,4.0,0.0,115.73,0.0,0.0,0,,0.0113,none,0,1,0,0,0,1.4e-05,0,1,,Shared_Savings
CLM0000003784,MBR00000162,Dental,Paid,Electronic_EDI,2023-10-30,2023-10-30,2023-10-30,2023-11-06,Manual_Review,7,1788188920,1355732274,207RN0300X,Nephrology,11,In_Network,F33.0,,D1110,,0,Medicaid_MCO,MLTSS,84,F,1.324,,,373.49,230.15,229.15,0.0,1.0,0.0,143.34,197.4,24.81,0,,0.1376,unusual_service_frequency,0,1,0,0,0,2.1e-05,0,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000003785,MBR00000277,Medical_Institutional,Denied,Electronic_EDI,2023-05-10,2023-05-10,2023-05-12,2023-05-19,Auto_Adjudicated,9,1666911728,1498781755,207RN0300X,Nephrology,11,In_Network,E78.5,,revenue_code:0100,,0,Medicaid_MCO,MCO,30,M,1.8495,PR-1,Authorization,2231.19,853.81,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0828,none,0,1,0,0,0,0.0,0,0,IET_Initiation_Substance_Use,Shared_Savings
CLM0000003786,MBR00000095,Medical_Institutional,Paid,Electronic_EDI,2023-06-26,2023-06-26,2023-06-29,2023-07-14,Auto_Adjudicated,18,1207676414,1068662623,207V00000X,Obstetrics & Gynecology,24,In_Network,K21.0,M54.5|G43.909,revenue_code:0110,,0,Commercial,HMO,28,M,0.5827,,,12637.18,9516.44,7517.24,64.9,55.0,1879.31,3120.74,0.0,0.0,0,,0.0928,none,0,1,1,0,0,0.000696,0,0,PPC_Prenatal_Care,Capitation
CLM0000003787,MBR00000081,Pharmacy,Partially_Paid,Paper,2023-07-05,2023-07-05,2023-07-05,2023-07-07,Auto_Adjudicated,2,1078527460,1267212691,101YP2500X,Psychologist Clinical,22,In_Network,R05.9,I25.10,00069420020,,2,Medicare_Advantage,SNP,66,F,2.159,97,Medical_Necessity,80.84,33.31,5.83,13.76,5.0,1.46,54.8,0.0,0.0,0,,0.067,diagnosis_procedure_mismatch,0,1,0,0,0,1e-06,0,0,,Capitation
CLM0000003788,MBR00000129,Medical_Professional,Denied,Paper,2023-09-25,2023-09-25,2023-09-25,2023-09-28,Clinical_Review,3,1487261286,1898471307,225100000X,Physical Therapist,11,In_Network,OTHER,,99232,,0,Medicare_Advantage,MA_PPO,9,F,0.8196,5,Timely_Filing,283.12,216.86,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0525,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003789,MBR00000293,Medical_Professional,Paid,Electronic_EDI,2023-05-02,2023-05-02,2023-05-02,2023-05-23,Manual_Review,21,1310400164,1473869105,2086S0122X,Orthopedic Surgery,71,In_Network,E11.9,,99215,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,453.53,231.78,150.05,33.21,11.0,37.51,221.75,0.0,0.0,0,,0.0147,none,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000003790,MBR00000254,Dental,Paid,Electronic_EDI,2023-04-09,2023-04-09,2023-04-09,2023-05-04,Auto_Adjudicated,25,1611521069,1887266184,207Q00000X,Family Medicine,23,In_Network,OTHER,OTHER|Z79.4,D2391,,0,Commercial,PPO,22,F,0.9285,,,78.41,44.85,0.0,23.08,21.77,0.0,33.56,0.0,0.0,0,,0.1145,none,0,1,0,0,0,0.0,0,0,POD_Persistence_of_Beta_Blocker,Capitation
CLM0000003791,MBR00000047,Medical_Institutional,Denied,Electronic_EDI,2023-05-10,2023-05-10,2023-05-14,2023-06-02,Auto_Adjudicated,23,1793630905,1140170394,101YP2500X,Psychologist Clinical,22,In_Network,OTHER,J44.1,revenue_code:0120,,0,Commercial,PPO,37,M,0.565,16,Eligibility,46586.48,31507.33,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0324,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003792,MBR00000184,Medical_Professional,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-25,2023-03-31,Auto_Adjudicated,6,1856989511,1304018750,225100000X,Physical Therapist,24,In_Network,Z23,E11.65|Z23,99212,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,165.96,108.32,106.32,0.0,2.0,0.0,57.64,0.0,0.0,0,,0.0919,none,0,1,0,0,0,1e-05,0,0,BPD_BP_Declined,Bundled_Payment
CLM0000003793,MBR00000235,Medical_Institutional,Paid,Electronic_EDI,2023-03-12,2023-03-12,2023-03-16,2023-04-07,Auto_Adjudicated,26,1543927384,1662516615,2084P0800X,Psychiatry,22,In_Network,J20.9,M79.3|OTHER|Z00.01,revenue_code:0110,,0,Commercial,HDHP_HSA,85,F,1.4308,,,29406.73,18611.65,14579.35,387.47,0.0,3644.84,10795.08,0.0,0.0,0,,0.0344,none,0,1,1,0,0,0.001349,0,0,,Bundled_Payment
CLM0000003794,MBR00000226,Medical_Professional,Paid,Electronic_EDI,2023-10-22,2023-10-22,2023-10-22,2023-10-29,Auto_Adjudicated,7,1368580443,1489993356,207RC0000X,Cardiovascular Disease,21,Out_of_Network,Z00.00,F32.9|J44.1,71250,,0,Medicare_Advantage,MA_PPO,84,M,1.0796,,,1171.1,644.19,506.97,0.48,10.0,126.74,526.91,0.0,0.0,0,,0.0121,none,0,1,0,0,0,4.7e-05,0,0,CDC_HbA1c_Poor_Control,Shared_Savings
CLM0000003795,MBR00000152,Medical_Professional,Paid,Electronic_EDI,2023-05-04,2023-05-04,2023-05-04,2023-05-31,Auto_Adjudicated,27,1682685390,1040061910,2086S0122X,Orthopedic Surgery,11,In_Network,C50.911,,99204,,0,Commercial,HMO,82,F,1.2506,,,240.86,142.09,0.0,134.82,7.27,0.0,98.77,0.0,0.0,0,,0.0402,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003796,MBR00000214,Medical_Institutional,Paid,Provider_Portal,2023-04-07,2023-04-07,2023-04-10,2023-04-16,Auto_Adjudicated,9,1838794554,1352413270,246ZN0300X,Neuropsychology,22,In_Network,OTHER,N40.0,revenue_code:0120,,0,Commercial,HDHP_HSA,76,M,1.7526,,,18063.91,6914.23,5252.43,348.7,0.0,1313.11,11149.68,0.0,0.0,0,,0.0006,none,0,1,1,0,0,0.000486,0,0,,FFS
CLM0000003797,MBR00000176,Medical_Institutional,Denied,Electronic_EDI,2023-10-19,2023-10-19,2023-10-22,2023-11-03,Manual_Review,15,1594322174,1469881892,208600000X,Surgery General,22,In_Network,Z00.00,M54.5,revenue_code:0200,,0,Commercial,POS,4,M,0.8792,CO-45,Eligibility,6382.61,2751.16,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0852,none,0,1,0,0,0,0.0,0,0,AWV_Annual_Wellness_Visit,Shared_Savings
CLM0000003798,MBR00000061,Medical_Institutional,Paid,Provider_Portal,2023-10-11,2023-10-11,2023-10-11,2023-11-09,Auto_Adjudicated,29,1231231881,1319611206,207Q00000X,Family Medicine,23,In_Network,OTHER,OTHER|Z23,revenue_code:0200,,0,Commercial,PPO,66,M,2.3575,,,2538.56,1818.58,1416.22,14.3,34.0,354.06,719.98,0.0,0.0,0,,0.1986,npi_mismatch,0,1,0,0,0,0.000131,0,0,,FFS
CLM0000003799,MBR00000015,Medical_Professional,Paid,Electronic_EDI,2023-03-30,2023-03-30,2023-03-30,2023-04-12,Auto_Adjudicated,13,1673449362,1330485436,208600000X,Surgery General,22,In_Network,I10,,99222,,0,Medicaid_MCO,MCO,43,F,0.3775,,,494.56,339.33,335.33,0.0,4.0,0.0,155.23,0.0,0.0,0,,0.1153,impossible_service_combo,0,1,0,0,0,3.1e-05,0,0,,Shared_Savings
CLM0000003800,MBR00000117,Medical_Institutional,Denied,Electronic_EDI,2023-04-20,2023-04-20,2023-04-20,2023-05-11,Auto_Adjudicated,21,1119083414,1188760037,2086S0122X,Orthopedic Surgery,11,Emergency,OTHER,E78.5|OTHER,revenue_code:0450,,0,Medicaid_MCO,MLTSS,72,F,0.8628,96,Network,6488.65,3363.75,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0821,none,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,Shared_Savings
CLM0000003801,MBR00000018,Medical_Professional,Paid,Electronic_EDI,2023-10-22,2023-10-22,2023-10-22,2023-11-09,Clinical_Review,18,1879212418,1358873132,225100000X,Physical Therapist,23,In_Network,J20.9,J44.1,99214,,0,Commercial,EPO,5,F,0.5555,,,688.96,514.1,380.08,24.99,14.0,95.02,174.86,0.0,0.0,0,,0.0169,none,0,1,0,1,0,3.5e-05,0,0,,FFS
CLM0000003802,MBR00000125,Medical_Institutional,Denied,Electronic_EDI,2023-04-10,2023-04-10,2023-04-14,2023-04-13,Manual_Review,3,1145498455,1291071007,246ZN0300X,Neuropsychology,11,In_Network,Z12.11,OTHER,revenue_code:0300,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,1,Network,26565.83,20006.19,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1086,npi_mismatch,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003803,MBR00000247,Medical_Institutional,Paid,Electronic_EDI,2023-11-06,2023-11-06,2023-11-08,2023-11-30,Auto_Adjudicated,24,1376791933,1105871325,207RG0100X,Gastroenterology,31,In_Network,OTHER,,revenue_code:0300,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,5611.18,3443.87,2699.13,17.96,52.0,674.78,2167.31,0.0,0.0,0,,0.076,none,0,1,0,0,0,0.00025,0,0,,FFS
CLM0000003804,MBR00000253,Medical_Professional,Denied,Electronic_EDI,2023-08-10,2023-08-10,2023-08-10,2023-08-21,Auto_Adjudicated,11,1642333103,1581533104,208600000X,Surgery General,23,In_Network,N18.3,,99393,,0,Commercial,EPO,44,M,0.3882,96,Duplicate,375.8,315.64,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1071,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003805,MBR00000011,Dental,Paid,Electronic_EDI,2023-08-28,2023-08-28,2023-08-28,2023-09-12,Manual_Review,15,1592228076,1352413270,101YP2500X,Psychologist Clinical,22,In_Network,Z00.00,Z00.01|Z00.00,D0150,,0,Medicare_Advantage,SNP,35,F,1.0833,,,480.42,232.17,171.51,0.78,17.0,42.88,248.25,0.0,0.0,0,,0.17,temporal_clustering,0,1,0,1,0,1.6e-05,0,0,FUH_Follow_Up_Hospitalization,Bundled_Payment
CLM0000003806,MBR00000022,Medical_Institutional,Paid,Electronic_EDI,2023-07-11,2023-07-11,2023-07-13,2023-07-21,Auto_Adjudicated,10,1994365754,1061149198,207RE0101X,Endocrinology,22,In_Network,OTHER,,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,34,M,0.9472,,,56553.62,28128.03,22432.74,36.11,51.0,5608.18,28425.59,0.0,0.0,0,,0.1,outlier_billing_amount,0,1,1,0,0,0.002076,0,0,,Shared_Savings
CLM0000003807,MBR00000199,Medical_Professional,Paid,Electronic_EDI,2023-01-12,2023-01-12,2023-01-12,2023-02-11,Auto_Adjudicated,30,1843445592,1978943761,207RN0300X,Nephrology,11,In_Network,I10,OTHER,47562,,0,Medicaid_MCO,MLTSS,17,F,1.0776,,,461.6,163.71,161.71,0.0,2.0,0.0,297.89,0.0,0.0,0,,0.0649,provider_specialty_mismatch,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000003808,MBR00000154,Medical_Professional,Paid,Electronic_EDI,2023-10-24,2023-10-24,2023-10-24,2023-11-10,Auto_Adjudicated,17,1732193518,1842149518,246ZN0300X,Neuropsychology,23,In_Network,OTHER,K21.0,99386,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,249.3,105.93,76.82,9.9,0.0,19.21,143.37,0.0,0.0,0,,0.1477,none,0,1,0,0,0,7e-06,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000003809,MBR00000047,Medical_Professional,Paid,Electronic_EDI,2023-07-21,2023-07-21,2023-07-21,2023-08-10,Auto_Adjudicated,20,1514646292,1339359594,101YP2500X,Psychologist Clinical,11,In_Network,I10,E11.9,99232,,0,Commercial,PPO,37,M,0.565,,,347.73,263.92,140.69,52.06,36.0,35.17,83.81,0.0,0.0,0,,0.0336,none,0,1,0,0,0,1.3e-05,0,0,,Bundled_Payment
CLM0000003810,MBR00000239,Medical_Professional,Paid,Paper,2023-03-04,2023-03-04,2023-03-04,2023-03-20,Manual_Review,16,1068197532,1847196500,246ZN0300X,Neuropsychology,22,In_Network,F41.1,J45.20|OTHER,99386,,0,Commercial,HMO,1,F,1.1193,,,282.55,187.79,107.76,34.09,19.0,26.94,94.76,0.0,0.0,0,,0.1421,none,0,1,0,1,0,1e-05,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000003811,MBR00000066,Dental,Paid,Electronic_EDI,2023-10-27,2023-10-27,2023-10-27,2023-11-06,Manual_Review,10,1707022770,1560230600,207RG0100X,Gastroenterology,11,In_Network,N39.0,OTHER,D1110,,0,Medicaid_MCO,MCO,54,M,0.6083,,,151.98,67.64,64.64,0.0,3.0,0.0,84.34,0.0,0.0,0,,0.0949,none,0,1,0,0,0,6e-06,0,0,,Capitation
CLM0000003812,MBR00000024,Pharmacy,Paid,Electronic_EDI,2023-04-16,2023-04-16,2023-04-16,2023-05-04,Auto_Adjudicated,18,1797494973,1304018750,101YP2500X,Psychologist Clinical,22,In_Network,E11.65,OTHER,59148001506,,4,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,405.38,279.16,276.16,0.0,3.0,0.0,126.22,0.0,0.0,0,,0.142,none,0,1,0,0,0,2.6e-05,0,0,,Shared_Savings
CLM0000003813,MBR00000220,Pharmacy,Paid,Electronic_EDI,2023-05-12,2023-05-12,2023-05-12,2023-06-05,Auto_Adjudicated,24,1900799244,1689327034,207R00000X,Internal Medicine,11,In_Network,N39.0,,50458085930,,1,Commercial,HMO,38,M,0.7736,,,646.45,279.12,164.61,38.36,35.0,41.15,367.33,0.0,0.0,0,,0.1076,none,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000003814,MBR00000184,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-08-18,2023-08-18,2023-08-21,2023-08-21,Auto_Adjudicated,3,1821999097,1301869102,207RG0100X,Gastroenterology,11,In_Network,K21.0,I10,revenue_code:0100,,0,Medicaid_MCO,MLTSS,30,M,2.8302,96,Medical_Necessity,13775.61,7622.7,4875.27,0.0,0.0,0.0,8900.34,0.0,0.0,0,,0.1029,none,0,1,0,0,0,0.000451,0,0,,P4P
CLM0000003815,MBR00000125,Dental,Paid,Electronic_EDI,2023-04-12,2023-04-12,2023-04-12,2023-04-17,Auto_Adjudicated,5,1321381114,1985590322,208600000X,Surgery General,22,In_Network,N40.0,OTHER,D1110,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,163.1,138.48,100.29,2.12,11.0,25.07,24.62,0.0,0.0,0,,0.0717,none,0,1,0,0,0,9e-06,0,0,CCS_Cervical_Cancer_Screening,Bundled_Payment
CLM0000003816,MBR00000206,Dental,Partially_Paid,Electronic_EDI,2023-01-03,2023-01-03,2023-01-03,2023-01-08,Auto_Adjudicated,5,1638309014,1352413270,207V00000X,Obstetrics & Gynecology,23,Out_of_Network,I10,I10|J06.9,D7140,,0,Medicaid_MCO,MLTSS,21,M,1.4038,PR-1,Medical_Necessity,327.04,166.19,98.97,0.0,1.0,0.0,227.07,0.0,0.0,0,,0.0609,none,0,1,0,0,0,9e-06,1,0,IET_Initiation_Substance_Use,Bundled_Payment
CLM0000003817,MBR00000275,Medical_Professional,Paid,Electronic_EDI,2023-04-26,2023-04-26,2023-04-26,2023-05-25,Auto_Adjudicated,29,1899326088,1985590322,207RE0101X,Endocrinology,11,Out_of_Network,OTHER,,90837,,0,Medicare_Advantage,MA_PPO,67,M,0.8169,,,590.22,407.03,278.52,43.88,15.0,69.63,183.19,0.0,0.0,1,Prescription Drug Diversion,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|temporal_clustering|benford_violation|impossible_service_combo|service_date_weekend|billing_spike_recent|unbundling_pattern|high_oop_waiver,1,5,0,0,0,2.6e-05,1,0,,FFS
CLM0000003818,MBR00000011,Medical_Professional,Paid,Electronic_EDI,2023-09-03,2023-09-03,2023-09-03,2023-09-21,Auto_Adjudicated,18,1389534304,1930040953,2086S0122X,Orthopedic Surgery,22,In_Network,Z00.00,I10,70553,,0,Medicare_Advantage,SNP,35,F,1.0833,,,740.1,261.28,193.22,2.76,17.0,48.3,478.82,0.0,0.0,0,,0.0212,none,0,1,0,0,0,1.8e-05,0,0,,Bundled_Payment
CLM0000003819,MBR00000186,Medical_Professional,Paid,Electronic_EDI,2023-06-01,2023-06-01,2023-06-01,2023-06-12,Manual_Review,11,1853233709,1540743888,207RE0101X,Endocrinology,24,In_Network,OTHER,,99212,,0,Commercial,PPO,65,M,1.6983,,,388.7,194.26,0.0,187.28,6.98,0.0,194.44,0.0,0.0,0,,0.1443,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003820,MBR00000067,Medical_Professional,Paid,Paper,2023-09-13,2023-09-13,2023-09-13,2023-09-19,Manual_Review,6,1593056613,1282319940,207RP1001X,Pulmonary Disease,22,In_Network,M25.511,,70553,,0,Medicaid_MCO,MCO,55,M,0.4175,,,1738.17,873.96,871.96,0.0,2.0,0.0,864.21,0.0,0.0,0,,0.0432,none,0,1,0,0,0,8.1e-05,0,0,TRC_Transition_of_Care,Bundled_Payment
CLM0000003821,MBR00000145,Medical_Institutional,Paid,Electronic_EDI,2023-01-26,2023-01-26,2023-01-26,2023-02-16,Auto_Adjudicated,21,1770431137,1938465393,225100000X,Physical Therapist,22,In_Network,OTHER,J06.9,revenue_code:0120,,0,Medicaid_MCO,MLTSS,46,M,0.5813,,,38840.15,29867.41,29866.41,0.0,1.0,0.0,8972.74,0.0,0.0,1,Prescription Drug Diversion,0.9458,geographic_mismatch|high_volume_same_code|impossible_service_combo|service_date_weekend|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,1,0,0,0.002764,0,0,,Bundled_Payment
CLM0000003822,MBR00000134,Medical_Professional,Paid,Electronic_EDI,2023-04-03,2023-04-03,2023-04-03,2023-04-19,Auto_Adjudicated,16,1816378991,1151295616,207Q00000X,Family Medicine,11,In_Network,M54.5,E78.5|OTHER|I10,10060,,0,Medicare_Advantage,MA_PPO,33,M,1.115,,,1047.62,455.95,344.86,11.87,13.0,86.22,591.67,0.0,0.0,0,,0.1457,impossible_service_combo,0,1,0,0,0,3.2e-05,0,0,,Shared_Savings
CLM0000003823,MBR00000125,Pharmacy,Paid,Electronic_EDI,2023-03-27,2023-03-27,2023-03-27,2023-04-15,Auto_Adjudicated,19,1946657989,1985590322,101YP2500X,Psychologist Clinical,11,Emergency,OTHER,I10,00078043215,,1,Medicare_Advantage,MA_HMO,3,F,1.9037,,,143.22,73.19,45.59,5.21,11.0,11.4,70.03,0.0,0.0,0,,0.0319,none,0,1,0,0,0,4e-06,0,0,,Shared_Savings
CLM0000003824,MBR00000059,Medical_Professional,Paid,Electronic_EDI,2023-01-24,2023-01-24,2023-01-24,2023-02-15,Clinical_Review,22,1102590784,1228356980,207RP1001X,Pulmonary Disease,11,In_Network,E13.9,,27447,,0,Medicare_Advantage,SNP,12,F,1.266,,,15947.65,6881.66,5485.3,9.04,16.0,1371.32,9065.99,4815.73,525.77,0,,0.0909,none,0,1,1,0,0,0.000508,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000003825,MBR00000237,Pharmacy,Paid,Electronic_EDI,2023-08-21,2023-08-21,2023-08-21,2023-08-24,Auto_Adjudicated,3,1389534304,1789540567,207Q00000X,Family Medicine,81,In_Network,OTHER,I10|E11.65|OTHER,00071012831,,2,Commercial,PPO,45,M,0.7983,,,177.99,104.7,0.0,104.7,0.0,0.0,73.29,0.0,0.0,0,,0.0643,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000003826,MBR00000120,Medical_Professional,Paid,Electronic_EDI,2023-03-17,2023-03-17,2023-03-17,2023-04-07,Manual_Review,21,1485543430,1433350836,207V00000X,Obstetrics & Gynecology,11,In_Network,Z00.00,I48.91|Z23,74178,,0,Commercial,PPO,62,F,1.0823,,,714.46,347.22,257.25,8.66,17.0,64.31,367.24,0.0,0.0,0,,0.0906,none,0,1,0,0,0,2.4e-05,0,0,,FFS
CLM0000003827,MBR00000269,Medical_Professional,Paid,Electronic_EDI,2023-06-19,2023-06-19,2023-06-19,2023-07-11,Clinical_Review,22,1874109311,1132693989,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,OTHER,99232,,0,Commercial,EPO,10,F,0.718,,,464.56,203.98,85.96,65.53,31.0,21.49,260.58,0.0,0.0,0,,0.0803,unusual_service_frequency,0,1,0,0,0,8e-06,0,0,TRC_Transition_of_Care,Bundled_Payment
CLM0000003828,MBR00000112,Pharmacy,Paid,Electronic_EDI,2023-12-22,2023-12-22,2023-12-22,2023-12-31,Manual_Review,9,1508520529,1831337866,246ZN0300X,Neuropsychology,11,In_Network,F33.0,J20.9|OTHER,50458085930,,2,Medicare_Advantage,MA_HMO,18,M,1.01,,,267.85,151.54,99.25,21.48,6.0,24.81,116.31,62.85,28.5,0,,0.1166,none,0,1,0,0,0,9e-06,0,0,W30_Well_Child_Visit,FFS
CLM0000003829,MBR00000251,Medical_Institutional,Paid,Electronic_EDI,2023-03-30,2023-03-30,2023-03-30,2023-04-09,Auto_Adjudicated,10,1913217838,1553094822,207RN0300X,Nephrology,24,In_Network,OTHER,M17.11,revenue_code:0210,,0,Commercial,PPO,65,M,0.7737,,,4128.6,2421.2,1764.08,161.1,55.0,441.02,1707.4,0.0,0.0,0,,0.1023,none,0,1,0,1,0,0.000163,0,0,,FFS
CLM0000003830,MBR00000166,Pharmacy,Denied,Electronic_EDI,2023-03-11,2023-03-11,2023-03-11,2023-03-29,Manual_Review,18,1923332120,1469697158,207Q00000X,Family Medicine,21,Out_of_Network,K21.0,G47.33|Z12.11,59148001506,,4,ACA_Marketplace,ACA_Silver,35,F,2.2266,50,Medical_Necessity,54.12,27.3,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.064,none,0,1,0,0,0,0.0,1,0,MPT_Annual_Monitoring,P4P
CLM0000003831,MBR00000122,Dental,Paid,Electronic_EDI,2023-12-01,2023-12-01,2023-12-01,2023-12-13,Auto_Adjudicated,12,1451329728,1894215172,246ZN0300X,Neuropsychology,24,In_Network,E78.5,,D2140,,0,Commercial,EPO,64,F,0.8625,,,517.01,430.89,276.04,47.84,38.0,69.01,86.12,0.0,0.0,0,,0.0793,unusual_service_frequency,0,1,0,0,0,2.6e-05,0,0,,FFS
CLM0000003832,MBR00000208,Medical_Professional,Denied,Electronic_EDI,2023-05-09,2023-05-09,2023-05-09,2023-06-06,Manual_Review,28,1593056613,1765164601,207V00000X,Obstetrics & Gynecology,21,In_Network,OTHER,Z00.00,99384,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,PR-1,Timely_Filing,366.55,154.98,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.137,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003833,MBR00000233,Medical_Professional,Paid,Electronic_EDI,2023-04-17,2023-04-17,2023-04-17,2023-04-20,Auto_Adjudicated,3,1324084461,1741177636,207RP1001X,Pulmonary Disease,24,In_Network,M54.5,N18.3|E78.5,90837,,0,Medicare_Advantage,MA_PPO,87,M,0.8034,,,1571.46,1110.93,867.44,23.63,3.0,216.86,460.53,0.0,0.0,0,,0.115,none,0,1,0,0,0,8e-05,0,0,IET_Initiation_Substance_Use,P4P
CLM0000003834,MBR00000149,Medical_Professional,Paid,Provider_Portal,2023-09-16,2023-09-16,2023-09-16,2023-09-22,Auto_Adjudicated,6,1373899620,1301869102,246ZN0300X,Neuropsychology,32,In_Network,Z87.891,J20.9|R05.9|K21.0,71250,,0,Commercial,PPO,42,F,0.5458,,,606.71,372.32,223.31,61.18,32.0,55.83,234.39,0.0,0.0,0,,0.1445,none,0,1,0,0,0,2.1e-05,0,0,PPC_Prenatal_Care,FFS
CLM0000003835,MBR00000135,Medical_Professional,Paid,Electronic_EDI,2023-02-16,2023-02-16,2023-02-16,2023-03-13,Manual_Review,25,1990244466,1607833568,207V00000X,Obstetrics & Gynecology,22,In_Network,M54.5,I10,84443,,0,Commercial,PPO,58,F,2.2702,,,790.74,428.86,311.21,2.85,37.0,77.8,361.88,0.0,0.0,0,,0.105,phantom_billing_indicator,0,1,0,0,0,2.9e-05,0,0,BPD_BP_Declined,Shared_Savings
CLM0000003836,MBR00000174,Vision,Paid,Electronic_EDI,2023-05-16,2023-05-16,2023-05-16,2023-06-06,Auto_Adjudicated,21,1485543430,1945682535,207RN0300X,Nephrology,81,In_Network,OTHER,,92012,,0,Medicare_Advantage,MA_HMO,85,M,0.3901,,,355.49,244.24,170.98,12.51,18.0,42.75,111.25,0.0,0.0,0,,0.1341,none,0,1,0,0,0,1.6e-05,0,0,POD_Persistence_of_Beta_Blocker,FFS
CLM0000003837,MBR00000176,Pharmacy,Paid,Electronic_EDI,2023-03-13,2023-03-13,2023-03-13,2023-04-08,Manual_Review,26,1091395764,1527857018,207V00000X,Obstetrics & Gynecology,65,In_Network,N39.0,OTHER|I10|E78.5,00310075090,,3,Commercial,POS,4,M,0.8792,,,51.91,22.16,0.0,22.16,0.0,0.0,29.75,0.0,0.0,0,,0.1174,high_volume_same_code,0,1,0,0,0,0.0,0,1,KED_ESRD_Patients,FFS
CLM0000003838,MBR00000135,Medical_Professional,Paid,Electronic_EDI,2023-11-17,2023-11-17,2023-11-17,2023-11-18,Auto_Adjudicated,1,1012271279,1581533104,207Q00000X,Family Medicine,11,In_Network,M54.5,Z00.00,99204,,0,Commercial,PPO,58,F,2.2702,,,125.04,101.91,50.95,1.22,37.0,12.74,23.13,0.0,0.0,0,,0.1132,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000003839,MBR00000222,Pharmacy,Paid,Electronic_EDI,2023-04-17,2023-04-17,2023-04-17,2023-04-22,Auto_Adjudicated,5,1233824762,1509799493,101YP2500X,Psychologist Clinical,22,In_Network,OTHER,J06.9,00071012831,,2,Commercial,PPO,48,F,0.6945,,,324.3,248.6,21.12,183.2,39.0,5.28,75.7,0.0,0.0,0,,0.056,none,0,1,0,0,0,2e-06,0,1,,FFS
CLM0000003840,MBR00000128,Dental,Denied,Electronic_EDI,2023-07-23,2023-07-23,2023-07-23,2023-08-18,Auto_Adjudicated,26,1154652946,1029818813,101YP2500X,Psychologist Clinical,23,In_Network,Z00.00,,D2140,,0,Commercial,PPO,13,F,1.4203,50,Duplicate,436.8,315.36,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1118,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003841,MBR00000141,Medical_Professional,Paid,Electronic_EDI,2023-07-07,2023-07-07,2023-07-07,2023-08-01,Auto_Adjudicated,25,1898865801,1867626800,207RN0300X,Nephrology,31,In_Network,Z00.01,OTHER|J06.9,27447,,0,Commercial,HMO,47,F,0.6724,,,46204.75,38310.11,30581.11,57.73,26.0,7645.28,7894.64,0.0,0.0,0,,0.0073,none,0,1,1,0,0,0.002831,0,0,,FFS
CLM0000003842,MBR00000183,Medical_Professional,Paid,Electronic_EDI,2023-06-26,2023-06-26,2023-06-26,2023-07-21,Auto_Adjudicated,25,1374847145,1300957944,207RP1001X,Pulmonary Disease,23,Out_of_Network,OTHER,I10,99396,,0,Commercial,PPO,51,M,0.8463,,,703.92,577.47,142.55,360.29,39.0,35.64,126.45,0.0,0.0,0,,0.1092,unbundling_pattern,0,1,0,0,0,1.3e-05,0,0,IET_Initiation_Substance_Use,Bundled_Payment
CLM0000003843,MBR00000297,Pharmacy,Denied,Electronic_EDI,2023-01-24,2023-01-24,2023-01-24,2023-02-20,Auto_Adjudicated,27,1699014308,1662516615,207R00000X,Internal Medicine,23,In_Network,M54.5,OTHER|Z00.00|F41.1,59148001506,,2,Commercial,HMO,88,M,1.5311,3,Medical_Necessity,141.55,63.83,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0054,none,0,1,0,0,0,0.0,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000003844,MBR00000081,Pharmacy,Paid,Provider_Portal,2023-04-05,2023-04-05,2023-04-05,2023-04-12,Manual_Review,7,1918160357,1352413270,207RN0300X,Nephrology,11,In_Network,I10,OTHER,00169751112,,3,Medicare_Advantage,SNP,66,F,2.159,,,135.77,107.7,80.07,2.61,5.0,20.02,28.07,0.0,0.0,0,,0.1912,impossible_service_combo|unbundling_pattern,0,1,0,0,0,7e-06,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000003845,MBR00000073,Medical_Professional,Denied,Electronic_EDI,2023-11-03,2023-11-03,2023-11-03,2023-11-06,Auto_Adjudicated,3,1647029816,1554490060,207RP1001X,Pulmonary Disease,31,In_Network,J44.1,,97140,,0,Commercial,POS,79,M,1.1768,18,Medical_Necessity,251.48,187.51,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0556,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003846,MBR00000055,Medical_Institutional,Paid,Electronic_EDI,2023-07-16,2023-07-16,2023-07-16,2023-07-25,Auto_Adjudicated,9,1083045036,1123879500,2084P0800X,Psychiatry,11,In_Network,E78.5,OTHER|Z23,revenue_code:0100,,0,Commercial,PPO,68,F,1.2896,,,19128.48,10843.69,8471.61,180.18,74.0,2117.9,8284.79,0.0,0.0,0,,0.1379,none,0,1,1,0,0,0.000784,0,0,,Shared_Savings
CLM0000003847,MBR00000206,Medical_Professional,Paid,Paper,2023-11-12,2023-11-12,2023-11-12,2023-12-12,Auto_Adjudicated,30,1485543430,1368666316,101YP2500X,Psychologist Clinical,23,In_Network,OTHER,,99214,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,100.05,61.6,60.6,0.0,1.0,0.0,38.45,0.0,0.0,0,,0.0757,none,0,1,0,0,0,6e-06,0,0,,FFS
CLM0000003848,MBR00000140,Medical_Institutional,Paid,Electronic_EDI,2023-07-20,2023-07-20,2023-07-22,2023-08-05,Auto_Adjudicated,16,1484438840,1588993671,207R00000X,Internal Medicine,11,In_Network,OTHER,,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,7,M,1.3997,,,5010.9,3162.07,2465.35,25.38,55.0,616.34,1848.83,0.0,0.0,0,,0.0954,none,0,1,0,0,0,0.000228,0,0,,Capitation
CLM0000003849,MBR00000124,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-04-25,2023-04-25,2023-04-25,2023-04-26,Auto_Adjudicated,1,1918359820,1884259357,207RG0100X,Gastroenterology,24,In_Network,OTHER,N18.3|F33.0|L70.0,revenue_code:0360,,0,Commercial,EPO,40,F,0.4583,96,Medical_Necessity,15842.44,9648.17,4607.1,208.09,58.0,1151.77,9817.48,0.0,0.0,0,,0.1076,none,0,1,0,0,0,0.000426,0,0,,FFS
CLM0000003850,MBR00000061,Medical_Professional,Paid,Electronic_EDI,2023-05-04,2023-05-04,2023-05-04,2023-05-27,Auto_Adjudicated,23,1324084461,1123879500,207RP1001X,Pulmonary Disease,24,In_Network,OTHER,OTHER|F32.9|Z00.00,99283,,0,Commercial,PPO,66,M,2.3575,,,201.41,113.24,0.0,100.83,12.41,0.0,88.17,0.0,0.0,0,,0.0114,none,0,1,0,0,0,0.0,0,0,CBP_Controlling_BP,Bundled_Payment
CLM0000003851,MBR00000270,Pharmacy,Paid,Electronic_EDI,2023-10-06,2023-10-06,2023-10-06,2023-11-01,Auto_Adjudicated,26,1257723293,1728466420,225100000X,Physical Therapist,11,In_Network,OTHER,F10.10|OTHER,00169751112,,1,Commercial,POS,1,F,1.6363,,,173.32,114.6,50.27,39.77,12.0,12.57,58.72,0.0,0.0,0,,0.0258,none,0,1,0,1,0,5e-06,0,0,,FFS
CLM0000003852,MBR00000139,Medical_Institutional,Denied,Electronic_EDI,2023-03-27,2023-03-27,2023-03-27,2023-03-31,Auto_Adjudicated,4,1214787184,1447657873,246ZN0300X,Neuropsychology,24,In_Network,J06.9,,revenue_code:0450,,0,Commercial,PPO,74,M,1.7701,18,Medical_Necessity,9960.14,7587.33,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1443,none,0,1,0,0,0,0.0,0,0,COL_Colorectal_Cancer_Screening,Capitation
CLM0000003853,MBR00000183,Pharmacy,Paid,Electronic_EDI,2023-08-04,2023-08-04,2023-08-04,2023-08-21,Auto_Adjudicated,17,1633089013,1994275960,225100000X,Physical Therapist,31,In_Network,I50.9,OTHER|Z00.00,16590051660,,4,Commercial,PPO,51,M,0.8463,,,73.95,61.13,0.0,61.13,0.0,0.0,12.82,0.0,0.0,0,,0.0597,billing_spike_recent,0,1,0,0,0,0.0,0,1,,Capitation
CLM0000003854,MBR00000035,Medical_Institutional,Denied,Electronic_EDI,2023-12-02,2023-12-02,2023-12-05,2023-12-25,Auto_Adjudicated,23,1443292773,1728466420,207RN0300X,Nephrology,11,In_Network,OTHER,OTHER,revenue_code:0100,,0,ACA_Marketplace,ACA_Platinum,46,M,0.6598,1,Network,1869.44,1276.83,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1269,duplicate_claim_indicator,0,1,0,1,0,0.0,0,0,,FFS
CLM0000003855,MBR00000033,Medical_Institutional,Paid,Electronic_EDI,2023-10-31,2023-10-31,2023-11-03,2023-11-29,Auto_Adjudicated,29,1424104563,1576271272,207RE0101X,Endocrinology,21,Out_of_Network,E13.9,I10,revenue_code:0300,247,0,Medicare_Advantage,PFFS,31,F,0.821,,,22533.03,18551.6,14774.72,43.2,40.0,3693.68,3981.43,0.0,0.0,0,,0.1479,none,0,1,1,1,0,0.001368,1,0,BCS_Breast_Cancer_Screening,Capitation
CLM0000003856,MBR00000021,Medical_Professional,Paid,Electronic_EDI,2023-05-20,2023-05-20,2023-05-20,2023-06-08,Auto_Adjudicated,19,1485543430,1765164601,208600000X,Surgery General,11,In_Network,OTHER,OTHER,99205,,0,Commercial,POS,72,M,0.6126,,,256.18,212.95,0.0,212.95,0.0,0.0,43.23,0.0,0.0,0,,0.1161,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003857,MBR00000116,Medical_Professional,Denied,Electronic_EDI,2023-04-10,2023-04-10,2023-04-10,2023-04-21,Auto_Adjudicated,11,1950560596,1209882852,207RG0100X,Gastroenterology,11,In_Network,OTHER,K29.70,99284,,0,Medicaid_MCO,MLTSS,79,F,0.4614,256,Medical_Necessity,331.81,224.03,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0228,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003858,MBR00000144,Pharmacy,Paid,Electronic_EDI,2023-08-12,2023-08-12,2023-08-12,2023-09-09,Auto_Adjudicated,28,1898865801,1301869102,101YP2500X,Psychologist Clinical,24,In_Network,Z00.00,I10,00078043215,,1,Commercial,HDHP_HSA,56,F,2.5926,,,171.77,84.44,0.0,84.44,0.0,0.0,87.33,0.0,0.0,0,,0.1599,unbundling_pattern,0,1,0,0,0,0.0,0,1,,FFS
CLM0000003859,MBR00000076,Medical_Institutional,Paid,Electronic_EDI,2023-08-08,2023-08-08,2023-08-09,2023-08-19,Auto_Adjudicated,11,1464997678,1587454801,246ZN0300X,Neuropsychology,11,In_Network,M17.11,Z00.01,revenue_code:0200,,0,Commercial,HMO,26,M,2.1785,,,11203.29,6826.12,5412.1,20.99,40.0,1353.03,4377.17,0.0,0.0,0,,0.1389,benford_violation,0,1,1,0,0,0.000501,0,0,,Shared_Savings
CLM0000003860,MBR00000110,Medical_Professional,Denied,Electronic_EDI,2023-09-17,2023-09-17,2023-09-17,2023-10-06,Auto_Adjudicated,19,1986485249,1144950506,207RP1001X,Pulmonary Disease,23,In_Network,E78.5,,27447,,0,Medicare_Advantage,MA_HMO,83,F,1.127,50,Coding_Error,20182.56,16187.77,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.103,npi_mismatch,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003861,MBR00000003,Vision,Denied,Electronic_EDI,2023-01-27,2023-01-27,2023-01-27,2023-02-22,Auto_Adjudicated,26,1170257806,1007652766,207R00000X,Internal Medicine,11,In_Network,OTHER,E78.5|E11.9,92002,,0,Commercial,PPO,79,F,1.3879,96,Medical_Necessity,254.33,105.17,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0282,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000003862,MBR00000111,Pharmacy,Denied,Electronic_EDI,2023-07-13,2023-07-13,2023-07-13,2023-07-29,Auto_Adjudicated,16,1710617771,1132693989,208600000X,Surgery General,11,In_Network,OTHER,Z00.00|OTHER,00071015523,,1,Medicare_Advantage,MA_PPO,44,M,0.7462,3,Medical_Necessity,137.29,99.02,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0579,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003863,MBR00000036,Medical_Professional,Partially_Paid,Electronic_EDI,2023-01-04,2023-01-04,2023-01-04,2023-01-26,Manual_Review,22,1496340237,1829216053,207RP1001X,Pulmonary Disease,22,In_Network,E11.65,I10,99283,,0,Commercial,EPO,17,M,2.0136,18,Medical_Necessity,169.4,139.43,0.0,78.97,0.0,0.0,90.43,0.0,0.0,0,,0.1306,none,0,1,0,0,0,0.0,0,0,CBP_Controlling_BP,Shared_Savings
CLM0000003864,MBR00000039,Medical_Professional,Denied,Electronic_EDI,2023-12-22,2023-12-22,2023-12-22,2024-01-17,Auto_Adjudicated,26,1893886964,1007652766,207RN0300X,Nephrology,21,In_Network,Z00.00,OTHER|E78.5|I25.10,84443,,0,Medicaid_MCO,MCO,20,F,0.5358,97,Medical_Necessity,3694.96,2619.25,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2001,provider_specialty_mismatch,0,2,0,0,0,0.0,0,0,,P4P
CLM0000003865,MBR00000002,Medical_Institutional,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-14,2023-11-30,Auto_Adjudicated,19,1114266188,1894215172,207RN0300X,Nephrology,32,In_Network,J06.9,M47.816|M54.5,revenue_code:0250,,0,Commercial,PPO,42,F,0.9012,,,29700.91,24476.1,19539.54,15.68,36.0,4884.88,5224.81,0.0,0.0,0,,0.1618,unbundling_pattern,0,1,1,0,0,0.001809,0,0,HBD_Hemoglobin_A1c_Testing,Bundled_Payment
CLM0000003866,MBR00000207,Medical_Professional,Paid,Electronic_EDI,2023-09-23,2023-09-23,2023-09-23,2023-10-06,Auto_Adjudicated,13,1774425033,1148612764,2086S0122X,Orthopedic Surgery,11,In_Network,I10,F32.9|OTHER,74178,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,2881.87,2049.42,2049.42,0.0,0.0,0.0,832.45,0.0,0.0,1,Kickback Arrangement,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|benford_violation|impossible_service_combo|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,0.00019,0,0,,FFS
CLM0000003867,MBR00000281,Vision,Paid,Electronic_EDI,2023-04-16,2023-04-16,2023-04-16,2023-05-06,Manual_Review,20,1274357072,1027261156,246ZN0300X,Neuropsychology,22,In_Network,N39.0,Z00.00|J06.9,V2320,,0,Medicare_Advantage,MA_HMO,3,M,0.8531,,,243.51,205.32,161.14,0.9,3.0,40.28,38.19,122.46,32.79,0,,0.0671,none,0,1,0,1,0,1.5e-05,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000003868,MBR00000185,Medical_Institutional,Paid,Electronic_EDI,2023-09-25,2023-09-25,2023-09-25,2023-10-08,Manual_Review,13,1866366547,1912895973,246ZN0300X,Neuropsychology,23,In_Network,OTHER,OTHER,revenue_code:0200,,0,Medicaid_MCO,MCO,73,M,1.5417,,,10189.29,8461.94,8453.94,0.0,8.0,0.0,1727.35,0.0,0.0,0,,0.0579,high_volume_same_code,0,1,1,0,0,0.000782,0,0,,Capitation
CLM0000003869,MBR00000028,Medical_Professional,Paid,Electronic_EDI,2023-06-09,2023-06-09,2023-06-09,2023-06-30,Auto_Adjudicated,21,1356408757,1450837722,207RE0101X,Endocrinology,22,In_Network,J06.9,M54.5|Z00.00,73721,,0,Commercial,HMO,3,F,2.116,,,651.31,432.31,78.46,320.24,14.0,19.61,219.0,0.0,0.0,0,,0.0959,high_oop_waiver,0,1,0,0,0,7e-06,0,0,,P4P
CLM0000003870,MBR00000297,Medical_Institutional,Paid,Electronic_EDI,2023-08-21,2023-08-21,2023-08-23,2023-08-24,Auto_Adjudicated,3,1175448241,1985590322,207RE0101X,Endocrinology,23,In_Network,H52.4,,revenue_code:0450,,0,Commercial,HMO,88,M,1.5311,,,8646.48,5620.57,4453.66,14.49,39.0,1113.42,3025.91,0.0,0.0,0,,0.1391,duplicate_claim_indicator,0,1,0,0,0,0.000412,0,0,,P4P
CLM0000003871,MBR00000294,Medical_Professional,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-25,2023-03-27,Manual_Review,2,1618564043,1144950506,2084P0800X,Psychiatry,11,In_Network,OTHER,I10|K57.30|OTHER,97035,,0,Medicare_Advantage,MA_HMO,8,M,0.6878,,,1201.72,959.49,741.42,14.72,18.0,185.35,242.23,0.0,0.0,0,,0.1464,none,0,1,0,0,0,6.9e-05,0,0,,P4P
CLM0000003872,MBR00000144,Medical_Institutional,Denied,Electronic_EDI,2023-06-20,2023-06-20,2023-06-21,2023-07-05,Auto_Adjudicated,15,1055095309,1301833092,207RP1001X,Pulmonary Disease,24,In_Network,OTHER,E11.9,revenue_code:0300,,0,Commercial,HDHP_HSA,56,F,2.5926,18,Coding_Error,5770.7,4242.48,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0727,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000003873,MBR00000033,Medical_Professional,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-11-15,Auto_Adjudicated,4,1170257806,1662516615,207RG0100X,Gastroenterology,22,Out_of_Network,I10,M17.11|E11.9,17000,,0,Medicare_Advantage,PFFS,31,F,0.821,,,308.02,199.89,120.69,44.03,5.0,30.17,108.13,0.0,0.0,0,,0.0232,none,0,1,0,0,0,1.1e-05,1,0,,FFS
CLM0000003874,MBR00000212,Pharmacy,Paid,Electronic_EDI,2023-03-10,2023-03-10,2023-03-10,2023-04-01,Auto_Adjudicated,22,1207676414,1140170394,207RN0300X,Nephrology,24,In_Network,E11.9,OTHER,00069420020,,1,Commercial,HMO,57,F,2.5456,,,63.81,45.11,0.0,45.11,0.0,0.0,18.7,0.0,0.0,0,,0.1376,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000003875,MBR00000291,Pharmacy,Paid,Electronic_EDI,2023-05-19,2023-05-19,2023-05-19,2023-05-25,Auto_Adjudicated,6,1735391772,1977073565,207V00000X,Obstetrics & Gynecology,11,In_Network,E11.9,,00069420020,,3,Commercial,PPO,78,M,1.4773,,,138.9,53.52,0.0,53.52,0.0,0.0,85.38,0.0,0.0,0,,0.1083,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003876,MBR00000229,Dental,Denied,Electronic_EDI,2023-04-15,2023-04-15,2023-04-15,2023-04-30,Auto_Adjudicated,15,1243052462,1301869102,225100000X,Physical Therapist,11,In_Network,M54.5,,D2140,,0,Medicare_Advantage,PFFS,63,M,1.1626,3,Eligibility,263.7,218.24,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0214,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003877,MBR00000186,Medical_Professional,Paid,Electronic_EDI,2023-03-06,2023-03-06,2023-03-06,2023-03-12,Auto_Adjudicated,6,1705084901,1209882852,207R00000X,Internal Medicine,21,Emergency,Z00.00,,81001,,0,Commercial,PPO,65,M,1.6983,,,421.49,237.1,126.06,67.52,12.0,31.52,184.39,0.0,0.0,0,,0.0186,none,0,1,0,0,0,1.2e-05,0,0,SPD_Spirometry_Testing,Shared_Savings
CLM0000003878,MBR00000184,Medical_Professional,Paid,Electronic_EDI,2023-05-23,2023-05-23,2023-05-23,2023-06-20,Auto_Adjudicated,28,1388566092,1625992541,2086S0122X,Orthopedic Surgery,21,In_Network,J20.9,OTHER,99385,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,291.97,115.28,113.28,0.0,2.0,0.0,176.69,0.0,0.0,0,,0.0618,none,0,1,0,0,0,1e-05,0,0,,Shared_Savings
CLM0000003879,MBR00000295,Pharmacy,Paid,Electronic_EDI,2023-08-07,2023-08-07,2023-08-07,2023-09-02,Auto_Adjudicated,26,1721465780,1301869102,207RE0101X,Endocrinology,11,In_Network,K29.70,,00169751112,,5,Commercial,HDHP_HSA,78,F,0.8618,,,70.83,38.21,0.0,38.21,0.0,0.0,32.62,0.0,0.0,0,,0.1979,provider_specialty_mismatch|unbundling_pattern|phantom_billing_indicator,0,1,0,0,0,0.0,0,0,AMR_Asthma_Medication_Ratio,Shared_Savings
CLM0000003880,MBR00000023,Medical_Professional,Paid,Electronic_EDI,2023-01-20,2023-01-20,2023-01-20,2023-01-21,Manual_Review,1,1898865801,1098360555,207V00000X,Obstetrics & Gynecology,11,In_Network,E78.5,Z12.11|Z00.00|N18.3,99282,,0,Medicare_Advantage,MA_PPO,87,M,1.084,,,405.83,246.33,150.63,43.05,15.0,37.66,159.5,0.0,0.0,0,,0.0165,none,0,1,0,0,0,1.4e-05,0,0,,Shared_Savings
CLM0000003881,MBR00000047,Medical_Professional,Partially_Paid,Electronic_EDI,2023-03-15,2023-03-15,2023-03-15,2023-03-27,Manual_Review,12,1918359820,1860951128,225100000X,Physical Therapist,11,In_Network,M79.3,Z79.4|F33.0,99383,,0,Commercial,PPO,37,M,0.565,PR-1,Medical_Necessity,161.79,137.25,0.0,103.76,4.28,0.0,53.75,0.0,0.0,0,,0.022,none,0,1,0,0,0,0.0,0,0,PPC_Prenatal_Care,Capitation
CLM0000003882,MBR00000248,Behavioral_Health,Paid,Provider_Portal,2023-10-21,2023-10-21,2023-10-21,2023-11-19,Manual_Review,29,1789174420,1312595355,225100000X,Physical Therapist,11,In_Network,J20.9,M54.5,99203,,0,Commercial,PPO,40,F,0.6665,,,122.4,79.56,0.0,79.56,0.0,0.0,42.84,0.0,0.0,0,,0.1107,none,0,1,0,0,0,0.0,0,0,FUH_Follow_Up_Hospitalization,Capitation
CLM0000003883,MBR00000045,Pharmacy,Paid,Electronic_EDI,2023-04-04,2023-04-04,2023-04-04,2023-04-19,Auto_Adjudicated,15,1433357203,1391074619,101YP2500X,Psychologist Clinical,11,In_Network,Z00.01,Z00.00|OTHER,50458085930,,1,Commercial,HMO,78,F,1.0658,,,107.56,40.08,0.0,27.16,12.92,0.0,67.48,0.0,0.0,0,,0.032,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003884,MBR00000121,Dental,Paid,Provider_Portal,2023-05-01,2023-05-01,2023-05-01,2023-05-27,Auto_Adjudicated,26,1580443769,1509799493,2086S0122X,Orthopedic Surgery,24,In_Network,E11.9,N39.0,D3310,,0,Medicare_Advantage,MA_PPO,58,M,1.226,,,706.64,272.85,202.41,1.84,18.0,50.6,433.79,0.0,0.0,1,Identity Theft,0.9871,outlier_billing_amount|temporal_clustering|service_date_weekend|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,1.9e-05,0,0,CDC_BP_Control,Capitation
CLM0000003885,MBR00000088,Medical_Institutional,Paid,Electronic_EDI,2023-08-30,2023-08-30,2023-08-31,2023-09-02,Auto_Adjudicated,3,1042080259,1965244699,207RG0100X,Gastroenterology,65,In_Network,E11.9,E78.5|OTHER|Z79.4,revenue_code:0110,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,,,11220.34,6215.44,4167.66,171.64,90.0,1786.14,5004.9,0.0,0.0,0,,0.1494,npi_mismatch,0,1,0,0,0,0.000386,0,0,,Capitation
CLM0000003886,MBR00000076,Medical_Institutional,Denied,Electronic_EDI,2023-09-25,2023-09-25,2023-09-29,2023-10-08,Auto_Adjudicated,13,1788188920,1209882852,2086S0122X,Orthopedic Surgery,21,Out_of_Network,F41.1,F33.0|N39.0,revenue_code:0200,439,0,Commercial,HMO,26,M,2.1785,PR-1,Authorization,2831.2,2214.43,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0815,none,0,1,0,0,0,0.0,1,0,AWV_Annual_Wellness_Visit,Shared_Savings
CLM0000003887,MBR00000008,Medical_Institutional,Paid,Electronic_EDI,2023-12-11,2023-12-11,2023-12-11,2024-01-07,Auto_Adjudicated,27,1164721841,1358873132,207Q00000X,Family Medicine,11,In_Network,Z79.4,I10|G43.909,revenue_code:0200,,0,Medicaid_MCO,MCO,74,M,0.8375,,,18609.71,9865.03,9862.03,0.0,3.0,0.0,8744.68,0.0,0.0,0,,0.0513,none,0,1,1,0,0,0.000913,0,0,,Shared_Savings
CLM0000003888,MBR00000170,Medical_Institutional,Paid,Provider_Portal,2023-02-27,2023-02-27,2023-03-02,2023-03-05,Auto_Adjudicated,6,1151127621,1419347445,207RN0300X,Nephrology,21,In_Network,M54.5,,revenue_code:0210,247,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,18290.65,15404.56,12259.99,33.57,46.0,3065.0,2886.09,0.0,0.0,0,,0.0744,none,0,1,1,1,0,0.001135,0,0,,P4P
CLM0000003889,MBR00000128,Medical_Professional,Paid,Electronic_EDI,2023-09-28,2023-09-28,2023-09-28,2023-09-29,Auto_Adjudicated,1,1393200616,1788579687,207RN0300X,Nephrology,31,In_Network,I10,N39.0|J20.9,99394,,0,Commercial,PPO,13,F,1.4203,,,209.48,74.81,9.69,49.69,13.0,2.42,134.67,0.0,0.0,0,,0.0558,unbundling_pattern,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000003890,MBR00000166,Pharmacy,Paid,Electronic_EDI,2023-09-17,2023-09-17,2023-09-17,2023-10-10,Manual_Review,23,1484613641,1196833348,207Q00000X,Family Medicine,65,In_Network,E78.5,E13.9|Z12.11,00006001954,,1,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,206.36,128.7,0.0,128.7,0.0,0.0,77.66,0.0,0.0,0,,0.0539,none,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000003891,MBR00000096,Medical_Professional,Paid,Electronic_EDI,2023-02-14,2023-02-14,2023-02-14,2023-02-17,Auto_Adjudicated,3,1882720848,1267212691,207RP1001X,Pulmonary Disease,11,Emergency,Z00.00,,99203,,0,Medicaid_MCO,MCO,62,M,0.7948,,,573.69,480.95,478.95,0.0,2.0,0.0,92.74,0.0,0.0,0,,0.1944,upcoding_pattern,0,1,0,0,0,4.4e-05,0,0,,Capitation
CLM0000003892,MBR00000285,Medical_Institutional,Denied,Electronic_EDI,2023-11-11,2023-11-11,2023-11-12,2023-11-21,Auto_Adjudicated,10,1292994726,1144950506,208600000X,Surgery General,11,Emergency,I48.91,,revenue_code:0300,,0,Commercial,HDHP_HSA,56,M,0.9226,18,Duplicate,11832.86,7001.43,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Duplicate Billing,0.9469,unusual_service_frequency|high_volume_same_code|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|phantom_billing_indicator|npi_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,1,0,0.0,0,0,,FFS
CLM0000003893,MBR00000178,Dental,Denied,Paper,2023-04-23,2023-04-23,2023-04-23,2023-05-18,Clinical_Review,25,1856989511,1356856197,208600000X,Surgery General,11,In_Network,Z87.891,Z87.891|E78.5,D7140,,0,Medicaid_MCO,MCO,89,M,0.7057,50,Authorization,747.9,451.66,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0476,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000003894,MBR00000291,Pharmacy,Denied,Electronic_EDI,2023-06-01,2023-06-01,2023-06-01,2023-06-28,Auto_Adjudicated,27,1257723293,1274911960,207RN0300X,Nephrology,21,In_Network,I50.9,OTHER|J44.1|E78.5,50458085930,,1,Commercial,PPO,78,M,1.4773,4,COB,207.19,105.61,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0714,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003895,MBR00000110,Medical_Professional,Paid,Electronic_EDI,2023-10-13,2023-10-13,2023-10-13,2023-10-17,Auto_Adjudicated,4,1969707582,1469697158,207RE0101X,Endocrinology,11,In_Network,F33.0,E78.5,99283,,0,Medicare_Advantage,MA_HMO,83,F,1.127,,,151.46,113.61,78.76,6.16,9.0,19.69,37.85,0.0,0.0,0,,0.0261,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000003896,MBR00000002,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-07-08,2023-07-08,2023-07-10,2023-07-23,Auto_Adjudicated,15,1369267360,1140170394,207RE0101X,Endocrinology,23,In_Network,M54.5,,revenue_code:0100,,0,Commercial,PPO,42,F,0.9012,50,Medical_Necessity,38905.25,31712.95,12863.04,34.26,36.0,3215.76,22756.19,0.0,0.0,0,,0.1439,none,0,1,1,1,0,0.001191,0,0,,Capitation
CLM0000003897,MBR00000231,Medical_Institutional,Paid,Electronic_EDI,2023-04-09,2023-04-09,2023-04-10,2023-05-03,Auto_Adjudicated,24,1262622669,1339359594,207RC0000X,Cardiovascular Disease,11,In_Network,Z00.01,OTHER,revenue_code:0360,,0,ACA_Marketplace,ACA_Silver,12,M,0.6456,,,27365.93,15422.17,10436.26,438.23,75.0,4472.68,11943.76,0.0,0.0,0,,0.1332,none,0,1,1,0,0,0.000966,0,0,,Shared_Savings
CLM0000003898,MBR00000247,Medical_Professional,Paid,Electronic_EDI,2023-04-26,2023-04-26,2023-04-26,2023-05-08,Auto_Adjudicated,12,1965812565,1789540567,207R00000X,Internal Medicine,11,In_Network,J44.1,,99204,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,368.33,297.03,217.85,19.71,5.0,54.46,71.3,0.0,0.0,0,,0.0873,billing_spike_recent,0,1,0,0,0,2e-05,0,0,,P4P
CLM0000003899,MBR00000017,Medical_Professional,Paid,Electronic_EDI,2023-09-23,2023-09-23,2023-09-23,2023-10-04,Auto_Adjudicated,11,1630305772,1588993671,207R00000X,Internal Medicine,23,In_Network,L70.0,M54.5|OTHER,99213,,0,Commercial,PPO,55,F,0.6174,,,272.76,114.51,45.86,18.19,39.0,11.46,158.25,36.76,5.18,0,,0.1935,duplicate_claim_indicator,0,1,0,0,0,4e-06,0,0,,Bundled_Payment
CLM0000003900,MBR00000186,Medical_Institutional,Paid,Electronic_EDI,2023-03-07,2023-03-07,2023-03-10,2023-03-24,Auto_Adjudicated,17,1424104563,1728466420,207R00000X,Internal Medicine,24,In_Network,OTHER,,revenue_code:0360,,0,Commercial,PPO,65,M,1.6983,,,34006.48,23377.87,18587.61,93.35,50.0,4646.9,10628.61,0.0,0.0,0,,0.1203,none,0,1,1,0,0,0.00172,0,0,,Capitation
CLM0000003901,MBR00000196,Pharmacy,Paid,Electronic_EDI,2023-06-19,2023-06-19,2023-06-19,2023-07-13,Auto_Adjudicated,24,1631060535,1148612764,207RP1001X,Pulmonary Disease,11,In_Network,G43.909,Z23,00078043215,,3,Commercial,PPO,16,F,1.6015,,,91.19,45.94,6.87,14.36,23.0,1.72,45.25,0.0,0.0,0,,0.0614,billing_spike_recent,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000003902,MBR00000046,Vision,Paid,Electronic_EDI,2023-09-26,2023-09-26,2023-09-26,2023-09-28,Auto_Adjudicated,2,1327415110,1321680994,207RN0300X,Nephrology,24,In_Network,G47.33,OTHER,V2103,,0,Commercial,HMO,76,F,0.9613,,,429.81,173.2,39.2,89.21,35.0,9.8,256.61,0.0,0.0,0,,0.002,none,0,1,0,0,0,4e-06,0,0,,Shared_Savings
CLM0000003903,MBR00000167,Medical_Professional,Paid,Electronic_EDI,2023-11-14,2023-11-14,2023-11-14,2023-11-16,Auto_Adjudicated,2,1424643153,1355732274,2084P0800X,Psychiatry,11,In_Network,OTHER,K21.0|I25.10,99212,,0,Commercial,PPO,77,F,0.9377,,,238.4,156.99,0.0,156.99,0.0,0.0,81.41,0.0,0.0,0,,0.1237,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003904,MBR00000076,Medical_Professional,Paid,Electronic_EDI,2023-10-24,2023-10-24,2023-10-24,2023-10-28,Auto_Adjudicated,4,1015096289,1522426351,207RN0300X,Nephrology,11,In_Network,OTHER,I10|OTHER|E11.65,11200,,0,Commercial,HMO,26,M,2.1785,,,201.03,124.98,50.99,29.25,32.0,12.75,76.05,0.0,0.0,0,,0.013,none,0,1,0,0,0,5e-06,0,0,,Bundled_Payment
CLM0000003905,MBR00000006,Medical_Professional,Denied,Electronic_EDI,2023-05-09,2023-05-09,2023-05-09,2023-05-20,Auto_Adjudicated,11,1115589144,1296566243,2086S0122X,Orthopedic Surgery,11,In_Network,OTHER,F33.0,97110,,0,Commercial,EPO,88,M,1.4365,2,COB,321.74,203.87,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0077,none,0,1,0,1,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000003906,MBR00000262,Behavioral_Health,Paid,Electronic_EDI,2023-03-13,2023-03-13,2023-03-13,2023-03-22,Auto_Adjudicated,9,1462532026,1789540567,207R00000X,Internal Medicine,11,In_Network,Z00.00,,99221,,0,Medicare_Advantage,PFFS,77,F,1.7452,,,269.24,193.52,150.6,1.27,4.0,37.65,75.72,0.0,0.0,0,,0.1235,none,0,1,0,0,0,1.4e-05,0,0,FLU_Flu_Vaccination,Bundled_Payment
CLM0000003907,MBR00000152,Pharmacy,Paid,Electronic_EDI,2023-12-02,2023-12-02,2023-12-02,2023-12-17,Auto_Adjudicated,15,1035707913,1164525386,2086S0122X,Orthopedic Surgery,11,In_Network,I10,,00078043215,,3,Commercial,HMO,82,F,1.2506,,,215.02,126.4,20.58,83.68,17.0,5.14,88.62,0.0,0.0,0,,0.1461,duplicate_claim_indicator,0,1,0,0,0,2e-06,0,0,MPT_Annual_Monitoring,P4P
CLM0000003908,MBR00000231,Vision,Paid,Electronic_EDI,2023-08-03,2023-08-03,2023-08-03,2023-08-13,Auto_Adjudicated,10,1113370285,1140170394,207RP1001X,Pulmonary Disease,23,In_Network,I25.10,I10|E13.9,V2320,,0,ACA_Marketplace,ACA_Silver,12,M,0.6456,,,349.47,188.88,0.0,188.88,0.0,0.0,160.59,0.0,0.0,0,,0.12,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003909,MBR00000212,Medical_Institutional,Paid,Electronic_EDI,2023-05-27,2023-05-27,2023-05-27,2023-06-15,Auto_Adjudicated,19,1344162462,1319611206,207RP1001X,Pulmonary Disease,31,In_Network,Z23,,revenue_code:0360,,0,Commercial,HMO,57,F,2.5456,,,8624.09,6214.59,4624.08,366.49,68.0,1156.02,2409.5,0.0,0.0,0,,0.2413,high_volume_same_code|unbundling_pattern,0,2,0,0,0,0.000428,0,0,ACR_Urine_Protein,Shared_Savings
CLM0000003910,MBR00000299,Medical_Professional,Paid,Electronic_EDI,2023-11-20,2023-11-20,2023-11-20,2023-11-30,Auto_Adjudicated,10,1170319307,1619587398,225100000X,Physical Therapist,11,Out_of_Network,J06.9,Z23|F41.1,99397,,0,Medicaid_MCO,MCO,74,F,0.8833,,,311.16,221.46,219.46,0.0,2.0,0.0,89.7,0.0,0.0,0,,0.0534,none,0,1,0,0,0,2e-05,1,0,KED_ESRD_Patients,FFS
CLM0000003911,MBR00000137,Medical_Institutional,Paid,Electronic_EDI,2023-09-18,2023-09-18,2023-09-18,2023-10-14,Auto_Adjudicated,26,1300740186,1746676564,207V00000X,Obstetrics & Gynecology,11,In_Network,I48.91,N39.0,revenue_code:0250,,0,Commercial,PPO,87,M,0.5201,,,21069.54,12925.69,10247.9,55.82,60.0,2561.97,8143.85,0.0,0.0,0,,0.059,none,0,1,1,1,0,0.000949,0,0,CBP_Controlling_BP,Bundled_Payment
CLM0000003912,MBR00000135,Medical_Professional,Paid,Paper,2023-06-21,2023-06-21,2023-06-21,2023-07-01,Auto_Adjudicated,10,1897146144,1747596016,246ZN0300X,Neuropsychology,21,In_Network,N39.0,OTHER,99203,,0,Commercial,PPO,58,F,2.2702,,,911.2,601.35,450.68,1.0,37.0,112.67,309.85,376.61,41.19,0,,0.08,none,0,1,0,0,0,4.2e-05,0,0,,FFS
CLM0000003913,MBR00000088,Medical_Professional,Denied,Electronic_EDI,2023-03-12,2023-03-12,2023-03-12,2023-03-20,Manual_Review,8,1175448241,1012893364,2086S0122X,Orthopedic Surgery,21,In_Network,N39.0,,99213,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,2,Eligibility,230.15,139.08,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1006,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003914,MBR00000186,Medical_Professional,Paid,Paper,2023-01-30,2023-01-30,2023-01-30,2023-02-25,Auto_Adjudicated,26,1097702209,1842149518,207RP1001X,Pulmonary Disease,31,In_Network,Z00.00,J06.9|OTHER|Z00.01,71250,,0,Commercial,PPO,65,M,1.6983,,,1331.8,883.0,622.81,92.49,12.0,155.7,448.8,0.0,0.0,0,,0.0162,none,0,1,0,0,0,5.8e-05,0,0,,Shared_Savings
CLM0000003915,MBR00000151,Medical_Professional,Denied,Paper,2023-07-10,2023-07-10,2023-07-10,2023-07-30,Auto_Adjudicated,20,1901547390,1354265777,207RC0000X,Cardiovascular Disease,11,In_Network,F32.9,N39.0|K57.30,99284,,0,Medicare_Advantage,MA_HMO,77,M,0.8709,50,Coding_Error,386.87,212.69,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1522,temporal_clustering|billing_spike_recent,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003916,MBR00000214,Medical_Professional,Denied,Electronic_EDI,2023-02-11,2023-02-11,2023-02-11,2023-02-13,Manual_Review,2,1154652946,1747596016,101YP2500X,Psychologist Clinical,22,In_Network,N18.3,OTHER,85025,,0,Commercial,HDHP_HSA,76,M,1.7526,5,Timely_Filing,708.27,536.11,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0934,none,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000003917,MBR00000113,Vision,Paid,Electronic_EDI,2023-04-22,2023-04-22,2023-04-22,2023-04-27,Manual_Review,5,1394029346,1704466150,207Q00000X,Family Medicine,22,In_Network,E78.5,Z12.11,92012,,0,Medicaid_MCO,MLTSS,29,F,1.1621,,,146.07,102.75,101.75,0.0,1.0,0.0,43.32,0.0,0.0,0,,0.0652,none,0,1,0,0,0,9e-06,0,0,IET_Initiation_Substance_Use,Bundled_Payment
CLM0000003918,MBR00000040,Pharmacy,Paid,Electronic_EDI,2023-09-02,2023-09-02,2023-09-02,2023-09-04,Manual_Review,2,1965682436,1128148362,101YP2500X,Psychologist Clinical,31,In_Network,E11.9,K57.30,59148001506,,1,Medicare_Advantage,MA_HMO,66,F,0.6755,,,547.22,386.6,292.37,7.14,14.0,73.09,160.62,0.0,0.0,0,,0.1794,impossible_service_combo,0,1,0,0,0,2.7e-05,0,1,,Capitation
CLM0000003919,MBR00000260,Pharmacy,Paid,Electronic_EDI,2023-01-05,2023-01-05,2023-01-05,2023-01-29,Auto_Adjudicated,24,1928139578,1623053477,207V00000X,Obstetrics & Gynecology,11,In_Network,J20.9,OTHER,00078043215,,2,Medicare_Advantage,SNP,59,M,0.3786,,,219.65,184.62,132.92,12.46,6.0,33.23,35.03,0.0,0.0,0,,0.138,none,0,1,0,1,0,1.2e-05,0,1,FUH_Follow_Up_Hospitalization,FFS
CLM0000003920,MBR00000247,Medical_Professional,Paid,Electronic_EDI,2023-12-22,2023-12-22,2023-12-22,2024-01-10,Auto_Adjudicated,19,1313352855,1365397818,2084P0800X,Psychiatry,11,In_Network,OTHER,OTHER|E78.5,99392,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,208.38,125.49,93.42,3.72,5.0,23.35,82.89,0.0,0.0,0,,0.0362,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000003921,MBR00000111,Pharmacy,Denied,Electronic_EDI,2023-06-06,2023-06-06,2023-06-06,2023-07-04,Auto_Adjudicated,28,1433357203,1649705287,208600000X,Surgery General,11,In_Network,Z00.01,OTHER,00003014960,,5,Medicare_Advantage,MA_PPO,44,M,0.7462,50,COB,88.72,73.22,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0777,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000003922,MBR00000206,Medical_Institutional,Paid,Electronic_EDI,2023-11-09,2023-11-09,2023-11-10,2023-11-19,Auto_Adjudicated,10,1292994726,1287935251,207R00000X,Internal Medicine,23,In_Network,M54.5,,revenue_code:0200,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,15177.42,8320.21,8315.21,0.0,5.0,0.0,6857.21,0.0,0.0,0,,0.0134,none,0,1,1,0,0,0.00077,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000003923,MBR00000153,Medical_Professional,Paid,Paper,2023-03-03,2023-03-03,2023-03-03,2023-03-05,Auto_Adjudicated,2,1627776731,1157814306,208600000X,Surgery General,22,In_Network,Z00.00,OTHER|F32.9|E13.9,82947,,0,Commercial,POS,12,F,0.6525,,,337.13,271.37,61.75,169.18,25.0,15.44,65.76,0.0,0.0,0,,0.1409,none,0,1,0,0,0,6e-06,0,0,,Shared_Savings
CLM0000003924,MBR00000224,Medical_Professional,Paid,Electronic_EDI,2023-06-15,2023-06-15,2023-06-15,2023-06-29,Manual_Review,14,1356331863,1809122260,207R00000X,Internal Medicine,22,In_Network,M54.5,M54.5,99213,,0,Medicaid_MCO,MCO,86,F,1.3289,,,210.7,133.37,130.37,0.0,3.0,0.0,77.33,0.0,0.0,0,,0.0709,high_volume_same_code,0,1,0,0,0,1.2e-05,0,0,,P4P
CLM0000003925,MBR00000125,Medical_Professional,Paid,Electronic_EDI,2023-12-11,2023-12-11,2023-12-11,2023-12-14,Auto_Adjudicated,3,1469009511,1847196500,208600000X,Surgery General,11,In_Network,M47.816,,99204,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,208.33,132.3,96.04,1.24,11.0,24.01,76.03,0.0,0.0,0,,0.187,phantom_billing_indicator,0,1,0,0,0,9e-06,0,0,KED_ESRD_Patients,Bundled_Payment
CLM0000003926,MBR00000163,Dental,Denied,Electronic_EDI,2023-08-16,2023-08-16,2023-08-16,2023-08-21,Manual_Review,5,1435110996,1105871325,207RC0000X,Cardiovascular Disease,11,In_Network,M54.5,,D0120,,0,Medicaid_MCO,MCO,21,F,0.9607,1,Eligibility,359.83,283.28,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1056,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000003927,MBR00000016,Pharmacy,Denied,Electronic_EDI,2023-10-18,2023-10-18,2023-10-18,2023-11-11,Auto_Adjudicated,24,1641779816,1289435414,207R00000X,Internal Medicine,22,In_Network,Z12.11,E78.5,00071015523,,1,Commercial,HDHP_HSA,20,F,0.5843,256,Network,291.01,240.73,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0447,none,0,1,0,0,0,0.0,0,0,COL_Colorectal_Cancer_Screening,Bundled_Payment
CLM0000003928,MBR00000055,Medical_Professional,Paid,Provider_Portal,2023-09-03,2023-09-03,2023-09-03,2023-09-15,Auto_Adjudicated,12,1485543430,1020312030,207RG0100X,Gastroenterology,11,In_Network,OTHER,E78.5,90847,,0,Commercial,PPO,68,F,1.2896,,,520.39,234.06,140.24,48.76,10.0,35.06,286.33,0.0,0.0,0,,0.1214,provider_specialty_mismatch,0,1,0,1,0,1.3e-05,0,0,SPC_Statin_Therapy,FFS
CLM0000003929,MBR00000231,Medical_Institutional,Paid,Electronic_EDI,2023-09-23,2023-09-23,2023-09-27,2023-10-20,Manual_Review,27,1394029346,1903401648,207RC0000X,Cardiovascular Disease,65,In_Network,J06.9,Z00.00|I25.10|OTHER,revenue_code:0100,,0,ACA_Marketplace,ACA_Silver,12,M,0.6456,,,9910.38,4112.12,2633.63,274.79,75.0,1128.7,5798.26,0.0,0.0,0,,0.2019,geographic_mismatch|duplicate_claim_indicator,0,2,0,1,0,0.000244,0,0,CCS_Cervical_Cancer_Screening,Capitation
CLM0000003930,MBR00000121,Medical_Professional,Paid,Electronic_EDI,2023-05-11,2023-05-11,2023-05-11,2023-05-27,Auto_Adjudicated,16,1327415110,1746676564,2084P0800X,Psychiatry,24,In_Network,J20.9,,12001,,0,Medicare_Advantage,MA_PPO,58,M,1.226,,,701.17,517.85,391.64,10.31,18.0,97.91,183.32,0.0,0.0,0,,0.0857,none,0,1,0,0,0,3.6e-05,0,0,SPD_Spirometry_Testing,Shared_Savings
CLM0000003931,MBR00000011,Medical_Professional,Paid,Electronic_EDI,2023-06-12,2023-06-12,2023-06-12,2023-07-02,Auto_Adjudicated,20,1263063839,1356856197,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,E78.5,74177,,0,Medicare_Advantage,SNP,35,F,1.0833,,,384.91,203.66,147.14,2.74,17.0,36.78,181.25,0.0,0.0,0,,0.0134,none,0,1,0,0,0,1.4e-05,0,0,,Bundled_Payment
CLM0000003932,MBR00000053,Medical_Institutional,Denied,Provider_Portal,2023-01-18,2023-01-18,2023-01-18,2023-02-13,Auto_Adjudicated,26,1816378991,1513198866,2086S0122X,Orthopedic Surgery,22,In_Network,M17.11,,revenue_code:0450,,0,Medicaid_MCO,MLTSS,74,F,0.9277,5,Timely_Filing,7073.78,2964.53,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1081,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003933,MBR00000131,Pharmacy,Paid,Electronic_EDI,2023-04-04,2023-04-04,2023-04-04,2023-04-18,Manual_Review,14,1356562955,1689327034,2086S0122X,Orthopedic Surgery,11,In_Network,I10,Z00.00,00085163102,,2,Commercial,EPO,15,F,0.9228,,,123.85,57.64,0.0,57.64,0.0,0.0,66.21,0.0,0.0,0,,0.1246,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003934,MBR00000212,Pharmacy,Paid,Electronic_EDI,2023-01-24,2023-01-24,2023-01-24,2023-02-03,Auto_Adjudicated,10,1946657989,1930040953,208600000X,Surgery General,65,Out_of_Network,I10,E78.5|OTHER,00310075090,,1,Commercial,HMO,57,F,2.5456,,,226.64,118.82,0.0,118.82,0.0,0.0,107.82,0.0,0.0,0,,0.112,none,0,1,0,0,0,0.0,1,1,,FFS
CLM0000003935,MBR00000114,Medical_Professional,Paid,Electronic_EDI,2023-04-27,2023-04-27,2023-04-27,2023-05-21,Auto_Adjudicated,24,1007414142,1625992541,207RP1001X,Pulmonary Disease,22,In_Network,OTHER,,97110,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,2004.45,1476.26,1144.7,26.38,19.0,286.18,528.19,0.0,0.0,0,,0.1046,none,0,1,0,0,0,0.000106,0,0,,Shared_Savings
CLM0000003936,MBR00000218,Medical_Institutional,Denied,Electronic_EDI,2023-09-18,2023-09-18,2023-09-18,2023-10-13,Auto_Adjudicated,25,1838794554,1144950506,207RP1001X,Pulmonary Disease,21,In_Network,OTHER,K21.0|OTHER|E11.9,revenue_code:0210,291,0,Commercial,HDHP_HSA,11,F,0.4964,5,Network,3910.96,1513.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0737,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003937,MBR00000259,Medical_Professional,Paid,Electronic_EDI,2023-03-15,2023-03-15,2023-03-15,2023-03-24,Auto_Adjudicated,9,1699074676,1498781755,207R00000X,Internal Medicine,23,In_Network,E78.5,,99281,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,315.56,190.38,137.95,10.94,7.0,34.49,125.18,0.0,0.0,0,,0.0005,none,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000003938,MBR00000107,Medical_Professional,Paid,Electronic_EDI,2023-06-21,2023-06-21,2023-06-21,2023-07-16,Manual_Review,25,1788188920,1643323506,101YP2500X,Psychologist Clinical,11,In_Network,F33.0,M79.3|L70.0,99212,,0,Medicare_Advantage,MA_PPO,44,M,1.0439,,,249.64,89.56,57.63,9.52,8.0,14.41,160.08,0.0,0.0,0,,0.0704,billing_spike_recent,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000003939,MBR00000236,Medical_Professional,Paid,Electronic_EDI,2023-07-18,2023-07-18,2023-07-18,2023-08-17,Auto_Adjudicated,30,1477762002,1447657873,246ZN0300X,Neuropsychology,11,In_Network,I10,OTHER,99386,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,257.21,179.87,176.87,0.0,3.0,0.0,77.34,0.0,0.0,0,,0.0053,none,0,1,0,0,0,1.6e-05,0,0,FLU_Flu_Vaccination,Bundled_Payment
CLM0000003940,MBR00000038,Medical_Professional,Paid,Electronic_EDI,2023-02-28,2023-02-28,2023-02-28,2023-03-06,Auto_Adjudicated,6,1257723293,1114756459,208600000X,Surgery General,11,In_Network,E11.9,E13.9,11200,,0,Commercial,EPO,46,M,1.1295,,,461.91,384.15,266.51,13.01,38.0,66.63,77.76,0.0,0.0,0,,0.075,none,0,1,0,0,0,2.5e-05,0,0,,Capitation
CLM0000003941,MBR00000132,Medical_Professional,Paid,Electronic_EDI,2023-10-19,2023-10-19,2023-10-19,2023-11-14,Auto_Adjudicated,26,1159640414,1622950074,2084P0800X,Psychiatry,21,In_Network,OTHER,OTHER|I10,81001,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,,,1444.97,763.56,605.93,0.15,6.0,151.48,681.41,0.0,0.0,0,,0.1282,none,0,1,0,0,0,5.6e-05,0,0,,FFS
CLM0000003942,MBR00000029,Medical_Professional,Paid,Electronic_EDI,2023-10-04,2023-10-04,2023-10-04,2023-10-07,Auto_Adjudicated,3,1124477249,1321680994,207RG0100X,Gastroenterology,11,In_Network,Z23,J20.9,83036,,0,Medicaid_MCO,MCO,13,F,0.9053,,,118.97,96.54,95.54,0.0,1.0,0.0,22.43,0.0,0.0,0,,0.0104,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000003943,MBR00000014,Pharmacy,Paid,Electronic_EDI,2023-03-09,2023-03-09,2023-03-09,2023-04-05,Auto_Adjudicated,27,1706046899,1994275960,207RP1001X,Pulmonary Disease,81,In_Network,E11.9,K21.0|OTHER,59148001506,,2,Commercial,HMO,77,M,2.8513,,,72.56,57.49,4.85,13.43,38.0,1.21,15.07,0.0,0.0,0,,0.0829,none,0,1,0,0,0,0.0,0,1,KED_ESRD_Patients,FFS
CLM0000003944,MBR00000020,Medical_Professional,Paid,Provider_Portal,2023-01-13,2023-01-13,2023-01-13,2023-02-09,Auto_Adjudicated,27,1611521069,1942423230,246ZN0300X,Neuropsychology,22,In_Network,N39.0,J20.9,27447,,0,Medicare_Advantage,MA_PPO,63,F,0.7119,,,38604.92,20234.01,16159.2,29.01,6.0,4039.8,18370.91,0.0,0.0,0,,0.0584,none,0,1,1,0,0,0.001496,0,0,,P4P
CLM0000003945,MBR00000032,Medical_Professional,Paid,Electronic_EDI,2023-01-02,2023-01-02,2023-01-02,2023-01-28,Clinical_Review,26,1466478716,1368666316,208600000X,Surgery General,31,In_Network,OTHER,E13.9|OTHER,99397,,0,Medicaid_MCO,FFS_Medicaid,87,M,0.4839,,,501.3,227.66,225.66,0.0,2.0,0.0,273.64,0.0,0.0,0,,0.1647,service_date_weekend,0,1,0,0,0,2.1e-05,0,0,,Shared_Savings
CLM0000003946,MBR00000250,Vision,Paid,Electronic_EDI,2023-04-16,2023-04-16,2023-04-16,2023-04-27,Auto_Adjudicated,11,1048378959,1763260577,208600000X,Surgery General,11,In_Network,OTHER,,92012,,0,Commercial,PPO,41,M,0.9245,,,675.04,347.69,181.2,97.19,24.0,45.3,327.35,0.0,0.0,0,,0.0299,none,0,1,0,0,0,1.7e-05,0,0,MPT_Annual_Monitoring,Shared_Savings
CLM0000003947,MBR00000165,Dental,Paid,Electronic_EDI,2023-02-15,2023-02-15,2023-02-15,2023-03-15,Auto_Adjudicated,28,1014995735,1774401124,2086S0122X,Orthopedic Surgery,31,In_Network,G47.33,I10,D0150,,0,ACA_Marketplace,ACA_Bronze,55,M,0.9775,,,420.7,339.83,132.14,119.59,0.0,88.09,80.87,0.0,0.0,0,,0.0568,none,0,1,0,1,0,1.2e-05,0,0,AWV_Annual_Wellness_Visit,FFS
CLM0000003948,MBR00000287,Medical_Professional,Denied,Electronic_EDI,2023-01-07,2023-01-07,2023-01-07,2023-01-24,Manual_Review,17,1490172833,1983760474,207RN0300X,Nephrology,23,In_Network,OTHER,J06.9|M54.5,74178,,0,Commercial,PPO,4,M,0.7685,97,Network,910.97,512.69,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0526,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003949,MBR00000163,Medical_Professional,Paid,Electronic_EDI,2023-06-15,2023-06-15,2023-06-15,2023-06-17,Auto_Adjudicated,2,1078576574,1025886739,207RN0300X,Nephrology,23,Emergency,OTHER,Z00.01|E11.65,85025,,0,Medicaid_MCO,MCO,21,F,0.9607,,,176.41,105.7,101.7,0.0,4.0,0.0,70.71,0.0,0.0,0,,0.047,none,0,1,0,0,0,9e-06,0,0,,P4P
CLM0000003950,MBR00000187,Medical_Professional,Paid,Electronic_EDI,2023-07-08,2023-07-08,2023-07-08,2023-08-03,Auto_Adjudicated,26,1002224900,1007652766,207RN0300X,Nephrology,24,In_Network,OTHER,M54.5|I10,99396,,0,Medicaid_MCO,MCO,36,F,1.191,,,280.41,118.67,115.67,0.0,3.0,0.0,161.74,0.0,0.0,0,,0.1247,upcoding_pattern,0,1,0,0,0,1.1e-05,0,0,ACR_Urine_Protein,FFS
CLM0000003951,MBR00000058,Vision,Paid,Electronic_EDI,2023-01-07,2023-01-07,2023-01-07,2023-02-04,Manual_Review,28,1495592428,1650774392,207R00000X,Internal Medicine,22,In_Network,R05.9,Z00.00|Z12.11|R05.9,92002,,0,Commercial,PPO,56,F,1.1626,,,370.4,171.9,36.13,111.73,15.0,9.03,198.5,0.0,0.0,0,,0.0592,none,0,1,0,0,0,3e-06,0,0,,Capitation
CLM0000003952,MBR00000164,Medical_Professional,Paid,Electronic_EDI,2023-08-03,2023-08-03,2023-08-03,2023-08-13,Auto_Adjudicated,10,1051254008,1945682535,207R00000X,Internal Medicine,23,Out_of_Network,J44.1,,90834,,0,ACA_Marketplace,ACA_Silver,3,F,0.7155,,,461.94,375.61,138.02,139.44,39.0,59.15,86.33,89.81,31.1,0,,0.0456,none,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000003953,MBR00000122,Medical_Professional,Paid,Electronic_EDI,2023-05-25,2023-05-25,2023-05-25,2023-06-02,Manual_Review,8,1946657989,1880530717,207R00000X,Internal Medicine,65,In_Network,OTHER,E11.9|OTHER,99387,,0,Commercial,EPO,64,F,0.8625,,,267.38,215.82,85.99,70.33,38.0,21.5,51.56,0.0,0.0,0,,0.1039,none,0,1,0,0,0,8e-06,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000003954,MBR00000281,Pharmacy,Paid,Electronic_EDI,2023-03-13,2023-03-13,2023-03-13,2023-03-31,Clinical_Review,18,1901054209,1691162131,207RN0300X,Nephrology,11,In_Network,J06.9,E11.9|E78.5,00071012831,,2,Medicare_Advantage,MA_HMO,3,M,0.8531,,,482.37,240.31,188.66,1.48,3.0,47.17,242.06,0.0,0.0,0,,0.081,none,0,1,0,0,0,1.7e-05,0,1,CBP_Controlling_BP,Shared_Savings
CLM0000003955,MBR00000282,Pharmacy,Paid,Electronic_EDI,2023-02-09,2023-02-09,2023-02-09,2023-02-20,Auto_Adjudicated,11,1901508637,1564636990,207R00000X,Internal Medicine,11,Emergency,F41.1,,00085163102,,2,Medicare_Advantage,MA_HMO,16,M,0.7304,,,577.3,404.17,306.11,3.53,18.0,76.53,173.13,0.0,0.0,0,,0.016,none,0,1,0,1,0,2.8e-05,0,1,AMR_Asthma_Medication_Ratio,FFS
CLM0000003956,MBR00000061,Medical_Professional,Paid,Electronic_EDI,2023-09-30,2023-09-30,2023-09-30,2023-10-20,Auto_Adjudicated,20,1046207613,1616762819,207V00000X,Obstetrics & Gynecology,81,Out_of_Network,OTHER,,90837,,0,Commercial,PPO,66,M,2.3575,,,774.48,536.99,358.29,76.12,13.0,89.57,237.49,318.75,33.23,0,,0.2802,high_volume_same_code|duplicate_claim_indicator|unbundling_pattern,0,2,0,1,0,3.3e-05,0,0,,Capitation
CLM0000003957,MBR00000185,Medical_Professional,Paid,Electronic_EDI,2023-02-08,2023-02-08,2023-02-08,2023-02-20,Manual_Review,12,1102040918,1054984734,101YP2500X,Psychologist Clinical,32,In_Network,OTHER,,10060,,0,Medicaid_MCO,MCO,73,M,1.5417,,,627.27,351.82,348.82,0.0,3.0,0.0,275.45,0.0,0.0,0,,0.1194,phantom_billing_indicator,0,1,0,0,0,3.2e-05,0,0,,FFS
CLM0000003958,MBR00000189,Medical_Institutional,Paid,Electronic_EDI,2023-03-13,2023-03-13,2023-03-15,2023-03-20,Auto_Adjudicated,7,1836409547,1012893364,207RG0100X,Gastroenterology,22,In_Network,Z23,M54.5|I10,revenue_code:0360,,0,Medicaid_MCO,MCO,71,F,0.9722,,,23125.51,16347.4,16340.4,0.0,7.0,0.0,6778.11,0.0,0.0,0,,0.1752,high_volume_same_code|duplicate_claim_indicator,0,1,1,0,0,0.001512,0,0,ACR_Urine_Protein,FFS
CLM0000003959,MBR00000169,Medical_Professional,Paid,Electronic_EDI,2023-09-13,2023-09-13,2023-09-13,2023-09-20,Auto_Adjudicated,7,1878453830,1061149198,225100000X,Physical Therapist,24,In_Network,J44.1,OTHER|N40.0|M54.5,99203,,0,Commercial,EPO,30,M,1.4348,,,232.78,185.67,24.47,133.09,22.0,6.12,47.11,0.0,0.0,0,,0.0744,npi_mismatch,0,1,0,0,0,2e-06,0,0,,FFS
CLM0000003960,MBR00000038,Medical_Professional,Paid,Electronic_EDI,2023-08-15,2023-08-15,2023-08-15,2023-09-04,Auto_Adjudicated,20,1331903993,1747935894,207RC0000X,Cardiovascular Disease,32,In_Network,OTHER,OTHER|Z79.4|E78.5,99205,,0,Commercial,EPO,46,M,1.1295,,,471.92,347.92,195.45,65.61,38.0,48.86,124.0,0.0,0.0,0,,0.0046,none,0,1,0,0,0,1.8e-05,0,0,,FFS
CLM0000003961,MBR00000195,Pharmacy,Denied,Electronic_EDI,2023-12-25,2023-12-25,2023-12-25,2024-01-08,Auto_Adjudicated,14,1388566092,1938465393,207RG0100X,Gastroenterology,22,In_Network,M17.11,E11.9,00069420020,,2,Commercial,PPO,13,F,0.5967,16,Timely_Filing,118.28,73.96,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0282,none,0,1,0,0,0,0.0,0,0,CDC_BP_Control,Capitation
CLM0000003962,MBR00000236,Pharmacy,Paid,Electronic_EDI,2023-01-15,2023-01-15,2023-01-15,2023-01-16,Manual_Review,1,1264432433,1616762819,207RG0100X,Gastroenterology,11,In_Network,Z23,K21.0|Z23,59148001506,,4,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,611.95,408.56,405.56,0.0,3.0,0.0,203.39,0.0,0.0,1,Phantom Billing,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|benford_violation|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|unbundling_pattern|phantom_billing_indicator|npi_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,3.8e-05,0,1,,Shared_Savings
CLM0000003963,MBR00000109,Pharmacy,Paid,Electronic_EDI,2023-03-11,2023-03-11,2023-03-11,2023-03-27,Auto_Adjudicated,16,1453331651,1581533104,208600000X,Surgery General,22,In_Network,Z00.00,,00003014960,,1,Commercial,HMO,8,F,0.5723,,,109.69,84.34,21.45,19.53,38.0,5.36,25.35,0.0,0.0,0,,0.0488,none,0,1,0,0,0,2e-06,0,0,,Shared_Savings
CLM0000003964,MBR00000158,Pharmacy,Paid,Electronic_EDI,2023-08-26,2023-08-26,2023-08-26,2023-09-19,Manual_Review,24,1707022770,1622950074,207RN0300X,Nephrology,21,In_Network,E11.9,OTHER|I10|F41.1,16590051660,,1,Commercial,HMO,65,M,1.5361,,,239.92,173.91,80.82,58.89,14.0,20.2,66.01,0.0,0.0,0,,0.0491,none,0,1,0,0,0,7e-06,0,1,COA_Care_Transitions,FFS
CLM0000003965,MBR00000036,Medical_Institutional,Paid,Electronic_EDI,2023-03-24,2023-03-24,2023-03-24,2023-03-29,Auto_Adjudicated,5,1733777382,1878874025,207R00000X,Internal Medicine,11,In_Network,M54.5,E11.65|J20.9|Z23,revenue_code:0110,,0,Commercial,EPO,17,M,2.0136,,,8430.38,6908.78,5351.03,180.0,40.0,1337.76,1521.6,0.0,0.0,0,,0.0348,none,0,1,1,0,0,0.000495,0,0,BPD_BP_Declined,FFS
CLM0000003966,MBR00000281,Medical_Professional,Paid,Electronic_EDI,2023-05-17,2023-05-17,2023-05-17,2023-05-25,Auto_Adjudicated,8,1769163673,1867389043,207RP1001X,Pulmonary Disease,81,In_Network,Z23,J06.9,70553,,0,Medicare_Advantage,MA_HMO,3,M,0.8531,,,1303.71,1003.61,798.65,2.3,3.0,199.66,300.1,0.0,0.0,0,,0.0349,none,0,1,0,0,0,7.4e-05,0,0,,FFS
CLM0000003967,MBR00000034,Pharmacy,Paid,Electronic_EDI,2023-04-17,2023-04-17,2023-04-17,2023-04-28,Auto_Adjudicated,11,1641660170,1339359594,246ZN0300X,Neuropsychology,23,In_Network,OTHER,,00071012831,,1,Medicare_Advantage,MA_HMO,35,M,0.7712,,,81.25,30.76,0.0,30.66,0.1,0.0,50.49,0.0,0.0,0,,0.0189,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000003968,MBR00000063,Medical_Professional,Paid,Electronic_EDI,2023-10-18,2023-10-18,2023-10-18,2023-11-15,Manual_Review,28,1739169232,1685903362,2084P0800X,Psychiatry,24,In_Network,I10,Z00.01|OTHER|K21.0,90834,,0,ACA_Marketplace,ACA_Silver,56,M,0.8198,,,760.71,538.79,209.7,217.22,22.0,89.87,221.92,0.0,0.0,0,,0.1497,none,0,1,0,0,0,1.9e-05,0,0,,Capitation
CLM0000003969,MBR00000093,Medical_Professional,Denied,Electronic_EDI,2023-10-09,2023-10-09,2023-10-09,2023-10-20,Auto_Adjudicated,11,1625939855,1461075342,207RC0000X,Cardiovascular Disease,22,In_Network,Z00.00,OTHER|F41.1,90832,,0,Medicare_Advantage,MA_HMO,43,F,0.6162,1,Medical_Necessity,389.36,162.34,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1266,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000003970,MBR00000247,Medical_Professional,Paid,Electronic_EDI,2023-10-17,2023-10-17,2023-10-17,2023-11-12,Auto_Adjudicated,26,1218947226,1986847322,207Q00000X,Family Medicine,11,In_Network,J44.1,OTHER|E11.65|N18.3,99396,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,510.48,391.47,304.02,6.44,5.0,76.01,119.01,226.62,54.49,0,,0.0663,none,0,1,0,0,0,2.8e-05,0,0,,Shared_Savings
CLM0000003971,MBR00000208,Pharmacy,Paid,Paper,2023-07-01,2023-07-01,2023-07-01,2023-07-22,Auto_Adjudicated,21,1735391772,1447657873,207RN0300X,Nephrology,22,In_Network,Z00.00,Z00.01,00169751112,,1,Medicare_Advantage,MA_HMO,66,M,2.1466,,,318.84,127.55,91.33,7.39,6.0,22.83,191.29,0.0,0.0,0,,0.0617,none,0,1,0,0,0,8e-06,0,1,,Shared_Savings
CLM0000003972,MBR00000003,Medical_Institutional,Denied,Electronic_EDI,2023-06-25,2023-06-25,2023-06-27,2023-07-25,Auto_Adjudicated,30,1315569619,1396850418,246ZN0300X,Neuropsychology,23,In_Network,OTHER,Z00.01,revenue_code:0370,,0,Commercial,PPO,79,F,1.3879,PR-1,Duplicate,11525.91,5691.55,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0119,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000003973,MBR00000057,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-07-24,2023-07-24,2023-07-25,2023-08-11,Auto_Adjudicated,18,1972755666,1157814306,246ZN0300X,Neuropsychology,22,In_Network,E78.5,Z87.891,revenue_code:0200,,0,Medicare_Advantage,MA_PPO,45,M,0.6701,CO-45,Medical_Necessity,11836.02,6004.97,2616.15,43.65,25.0,654.04,8497.18,0.0,0.0,0,,0.1788,benford_violation,0,1,0,0,0,0.000242,0,0,,P4P
CLM0000003974,MBR00000220,Medical_Institutional,Paid,Electronic_EDI,2023-01-25,2023-01-25,2023-01-28,2023-02-04,Auto_Adjudicated,10,1650193199,1576271272,207RP1001X,Pulmonary Disease,11,Emergency,OTHER,Z00.00,revenue_code:0200,,0,Commercial,HMO,38,M,0.7736,,,54645.51,44613.5,35429.96,271.04,55.0,8857.49,10032.01,0.0,0.0,0,,0.0672,outlier_billing_amount,0,1,1,0,0,0.003279,0,0,KED_ESRD_Patients,Capitation
CLM0000003975,MBR00000128,Pharmacy,Paid,Provider_Portal,2023-07-16,2023-07-16,2023-07-16,2023-08-07,Auto_Adjudicated,22,1928139578,1878874025,207RE0101X,Endocrinology,31,In_Network,Z12.11,C50.911|E11.9|Z12.11,59148001506,,4,Commercial,PPO,13,F,1.4203,,,330.38,278.87,127.79,106.13,13.0,31.95,51.51,0.0,0.0,0,,0.1555,service_date_weekend,0,1,0,0,0,1.2e-05,0,0,MPT_Annual_Monitoring,FFS
CLM0000003976,MBR00000009,Medical_Professional,Paid,Electronic_EDI,2023-04-10,2023-04-10,2023-04-10,2023-04-13,Auto_Adjudicated,3,1375098560,1643673796,207RE0101X,Endocrinology,11,In_Network,OTHER,,47562,,0,Commercial,HMO,11,F,0.5327,,,382.96,237.2,137.52,30.3,35.0,34.38,145.76,0.0,0.0,0,,0.0118,none,0,1,0,0,0,1.3e-05,0,0,,Bundled_Payment
CLM0000003977,MBR00000292,Medical_Professional,Paid,Electronic_EDI,2023-12-03,2023-12-03,2023-12-03,2023-12-27,Auto_Adjudicated,24,1898865801,1829216053,246ZN0300X,Neuropsychology,21,In_Network,M17.11,OTHER,33510,,0,Medicare_Advantage,MA_HMO,4,M,1.1779,,,1250.46,764.06,587.73,26.4,3.0,146.93,486.4,0.0,0.0,0,,0.1465,none,0,1,0,0,0,5.4e-05,0,0,,Shared_Savings
CLM0000003978,MBR00000048,Pharmacy,Paid,Electronic_EDI,2023-03-08,2023-03-08,2023-03-08,2023-03-16,Auto_Adjudicated,8,1454749898,1282319940,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,C50.911|M25.511|OTHER,00003014960,,1,Commercial,POS,27,F,0.639,,,114.75,71.16,0.0,46.79,24.37,0.0,43.59,0.0,0.0,0,,0.0412,none,0,1,0,1,0,0.0,0,1,,FFS
CLM0000003979,MBR00000157,Pharmacy,Paid,Electronic_EDI,2023-01-13,2023-01-13,2023-01-13,2023-02-03,Clinical_Review,21,1324084461,1977073565,207RN0300X,Nephrology,81,In_Network,F32.9,,00069420020,,2,Medicare_Advantage,MA_HMO,26,F,0.9164,,,203.44,136.32,88.24,9.02,17.0,22.06,67.12,0.0,0.0,0,,0.019,none,0,1,0,1,0,8e-06,0,0,,Capitation
CLM0000003980,MBR00000077,Medical_Institutional,Denied,Provider_Portal,2023-12-12,2023-12-12,2023-12-12,2023-12-30,Auto_Adjudicated,18,1648123576,1587454801,2084P0800X,Psychiatry,21,In_Network,N40.0,OTHER,revenue_code:0100,470,0,Medicare_Advantage,MA_HMO,27,F,0.9229,1,Duplicate,1815.74,698.01,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0098,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003981,MBR00000216,Medical_Professional,Paid,Electronic_EDI,2023-02-26,2023-02-26,2023-02-26,2023-03-06,Auto_Adjudicated,8,1368580443,1860951128,246ZN0300X,Neuropsychology,11,Out_of_Network,Z00.00,I10|OTHER,99383,,0,Medicare_Advantage,MA_HMO,71,F,0.7117,,,420.84,209.68,145.73,17.51,10.0,36.43,211.16,128.96,13.1,0,,0.1216,none,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000003982,MBR00000229,Vision,Partially_Paid,Electronic_EDI,2023-07-05,2023-07-05,2023-07-05,2023-07-20,Auto_Adjudicated,15,1388566092,1527857018,2086S0122X,Orthopedic Surgery,81,Out_of_Network,K21.0,Z12.11,92002,,0,Medicare_Advantage,PFFS,63,M,1.1626,18,Medical_Necessity,200.33,131.4,16.96,31.79,14.0,4.24,133.34,0.0,0.0,0,,0.0693,none,0,1,0,0,0,2e-06,1,0,,FFS
CLM0000003983,MBR00000126,Medical_Institutional,Paid,Electronic_EDI,2023-05-18,2023-05-18,2023-05-18,2023-06-03,Auto_Adjudicated,16,1215358845,1140170394,207RG0100X,Gastroenterology,71,In_Network,E78.5,E11.65,revenue_code:0200,,0,Medicaid_MCO,MLTSS,48,F,0.637,,,9954.8,4652.5,4646.5,0.0,6.0,0.0,5302.3,0.0,0.0,0,,0.0784,none,0,1,0,0,0,0.00043,0,0,,Shared_Savings
CLM0000003984,MBR00000196,Dental,Paid,Paper,2023-04-07,2023-04-07,2023-04-07,2023-05-01,Manual_Review,24,1421421733,1105733833,246ZN0300X,Neuropsychology,11,In_Network,OTHER,OTHER|Z12.11,D4341,,0,Commercial,PPO,16,F,1.6015,,,151.72,99.32,59.91,1.43,23.0,14.98,52.4,0.0,0.0,0,,0.0357,none,0,1,0,0,0,6e-06,0,0,,P4P
CLM0000003985,MBR00000274,Pharmacy,Paid,Electronic_EDI,2023-06-25,2023-06-25,2023-06-25,2023-07-09,Auto_Adjudicated,14,1456447970,1898471307,2084P0800X,Psychiatry,31,In_Network,N39.0,,00003014960,,1,Medicare_Advantage,MA_HMO,58,F,2.1025,,,207.94,166.43,108.59,30.69,0.0,27.15,41.51,77.42,17.19,0,,0.0906,none,0,1,0,0,0,1e-05,0,0,,Capitation
CLM0000003986,MBR00000242,Dental,Paid,Electronic_EDI,2023-09-20,2023-09-20,2023-09-20,2023-09-22,Auto_Adjudicated,2,1666911728,1878874025,207RN0300X,Nephrology,65,In_Network,M79.3,J20.9|Z23,D3310,,0,Medicaid_MCO,MLTSS,75,F,0.7104,,,365.11,268.07,267.07,0.0,1.0,0.0,97.04,0.0,0.0,0,,0.2052,npi_mismatch,0,2,0,0,0,2.5e-05,0,0,AMR_Asthma_Medication_Ratio,Shared_Savings
CLM0000003987,MBR00000132,Medical_Professional,Paid,Electronic_EDI,2023-02-10,2023-02-10,2023-02-10,2023-02-13,Auto_Adjudicated,3,1501282310,1747935894,207RP1001X,Pulmonary Disease,11,In_Network,E78.5,Z00.00|R05.9|K57.30,20610,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,,,266.37,164.3,126.16,0.6,6.0,31.54,102.07,0.0,0.0,0,,0.0017,none,0,1,0,0,0,1.2e-05,0,0,PPC_Prenatal_Care,Capitation
CLM0000003988,MBR00000138,Medical_Institutional,Paid,Electronic_EDI,2023-08-26,2023-08-26,2023-08-26,2023-09-15,Auto_Adjudicated,20,1735391772,1355732274,2086S0122X,Orthopedic Surgery,24,In_Network,Z00.01,,revenue_code:0120,,0,Commercial,HDHP_HSA,47,M,0.996,,,12357.56,6048.3,4534.82,379.77,0.0,1133.71,6309.26,0.0,0.0,0,,0.1081,none,0,1,0,1,0,0.00042,0,0,,Shared_Savings
CLM0000003989,MBR00000269,Medical_Professional,Paid,Electronic_EDI,2023-11-17,2023-11-17,2023-11-17,2023-12-14,Auto_Adjudicated,27,1496340237,1791502603,246ZN0300X,Neuropsychology,11,In_Network,K57.30,,99223,,0,Commercial,EPO,10,F,0.718,,,245.23,136.3,50.99,41.56,31.0,12.75,108.93,0.0,0.0,0,,0.1263,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000003990,MBR00000011,Medical_Professional,Paid,Electronic_EDI,2023-04-15,2023-04-15,2023-04-15,2023-04-29,Auto_Adjudicated,14,1855186422,1880530717,208600000X,Surgery General,31,In_Network,K21.0,,71046,,0,Medicare_Advantage,SNP,35,F,1.0833,,,1531.09,601.67,467.34,0.5,17.0,116.83,929.42,0.0,0.0,0,,0.0377,none,0,1,0,0,0,4.3e-05,0,0,,FFS
CLM0000003991,MBR00000007,Medical_Professional,Paid,Electronic_EDI,2023-09-01,2023-09-01,2023-09-01,2023-09-04,Auto_Adjudicated,3,1364214492,1575884274,207RN0300X,Nephrology,11,In_Network,Z23,F32.9|Z00.00,85025,,0,Commercial,HDHP_HSA,72,F,0.7578,,,395.85,167.26,0.0,167.26,0.0,0.0,228.59,0.0,0.0,0,,0.0646,none,0,1,0,0,0,0.0,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000003992,MBR00000062,Medical_Professional,Paid,Provider_Portal,2023-11-27,2023-11-27,2023-11-27,2023-12-03,Auto_Adjudicated,6,1918578486,1098360555,207R00000X,Internal Medicine,23,In_Network,OTHER,E11.65,12001,,0,Commercial,HMO,46,F,0.5516,,,908.93,771.94,523.16,96.98,21.0,130.79,136.99,0.0,0.0,0,,0.108,none,0,1,0,0,0,4.8e-05,0,0,,Shared_Savings
CLM0000003993,MBR00000247,Medical_Institutional,Denied,Electronic_EDI,2023-12-01,2023-12-01,2023-12-04,2023-12-31,Auto_Adjudicated,30,1878453830,1994275960,246ZN0300X,Neuropsychology,31,In_Network,Z00.01,Z00.01,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,97,Timely_Filing,3194.76,2582.65,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0264,none,0,1,0,0,0,0.0,0,0,IET_Initiation_Substance_Use,Capitation
CLM0000003994,MBR00000049,Medical_Institutional,Paid,Electronic_EDI,2023-08-21,2023-08-21,2023-08-24,2023-09-12,Auto_Adjudicated,22,1299958874,1842149518,101YP2500X,Psychologist Clinical,11,In_Network,M79.3,F32.9|OTHER,revenue_code:0200,,0,Medicare_Advantage,PFFS,67,M,0.978,,,12895.82,8495.4,6721.79,42.16,51.0,1680.45,4400.42,0.0,0.0,0,,0.1168,diagnosis_procedure_mismatch,0,1,1,1,0,0.000622,0,0,,FFS
CLM0000003995,MBR00000089,Medical_Professional,Paid,Electronic_EDI,2023-12-04,2023-12-04,2023-12-04,2023-12-05,Auto_Adjudicated,1,1571330665,1352413270,101YP2500X,Psychologist Clinical,24,In_Network,Z00.00,E11.9,97110,,0,Commercial,PPO,14,M,0.5668,,,834.87,554.84,340.32,95.44,34.0,85.08,280.03,0.0,0.0,0,,0.0857,phantom_billing_indicator,0,1,0,0,0,3.1e-05,0,0,,P4P
CLM0000003996,MBR00000187,Medical_Professional,Paid,Electronic_EDI,2023-10-07,2023-10-07,2023-10-07,2023-10-15,Auto_Adjudicated,8,1995916350,1553094822,246ZN0300X,Neuropsychology,11,In_Network,E13.9,OTHER,99386,,0,Medicaid_MCO,MCO,36,F,1.191,,,708.76,347.51,344.51,0.0,3.0,0.0,361.25,0.0,0.0,1,Provider Impersonation,1.0,outlier_billing_amount|unusual_service_frequency|temporal_clustering|benford_violation|impossible_service_combo|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|npi_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,3.2e-05,0,0,,Bundled_Payment
CLM0000003997,MBR00000058,Medical_Professional,Denied,Electronic_EDI,2023-07-03,2023-07-03,2023-07-03,2023-07-25,Auto_Adjudicated,22,1315569619,1741177636,207RG0100X,Gastroenterology,11,In_Network,E11.65,C50.911|E78.5,20610,,0,Commercial,PPO,56,F,1.1626,4,Medical_Necessity,2184.65,1192.25,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1345,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000003998,MBR00000096,Pharmacy,Denied,Paper,2023-02-15,2023-02-15,2023-02-15,2023-03-06,Auto_Adjudicated,19,1368580443,1809122260,207RN0300X,Nephrology,65,In_Network,G43.909,E11.9,16590051660,,1,Medicaid_MCO,MCO,62,M,0.7948,16,Network,134.89,61.04,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1496,npi_mismatch,0,1,0,0,0,0.0,0,0,FLU_Flu_Vaccination,P4P
CLM0000003999,MBR00000144,Medical_Professional,Denied,Electronic_EDI,2023-11-03,2023-11-03,2023-11-03,2023-11-12,Auto_Adjudicated,9,1871417879,1133410177,225100000X,Physical Therapist,65,In_Network,M25.511,Z00.00|OTHER,80053,,0,Commercial,HDHP_HSA,56,F,2.5926,3,Coding_Error,910.67,751.46,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1449,npi_mismatch,0,1,0,0,0,0.0,0,0,COA_Care_Transitions,Bundled_Payment
CLM0000004000,MBR00000071,Pharmacy,Paid,Provider_Portal,2023-04-13,2023-04-13,2023-04-13,2023-05-04,Auto_Adjudicated,21,1130461876,1643673796,207RG0100X,Gastroenterology,24,In_Network,I10,Z00.00,00003014960,,4,Commercial,EPO,19,F,0.5699,,,139.92,106.0,41.34,32.33,22.0,10.33,33.92,0.0,0.0,0,,0.1234,phantom_billing_indicator,0,1,0,0,0,4e-06,0,0,COA_Care_Transitions,FFS
CLM0000004001,MBR00000298,Medical_Professional,Denied,Paper,2023-09-22,2023-09-22,2023-09-22,2023-10-20,Auto_Adjudicated,28,1650193199,1287472731,207RN0300X,Nephrology,32,In_Network,E78.5,Z79.4,99202,,0,Medicaid_MCO,MCO,75,M,0.8324,CO-45,Medical_Necessity,184.16,91.5,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1422,npi_mismatch,0,1,0,1,0,0.0,0,0,,P4P
CLM0000004002,MBR00000052,Medical_Institutional,Paid,Electronic_EDI,2023-08-20,2023-08-20,2023-08-20,2023-09-17,Auto_Adjudicated,28,1067329999,1865266296,207RC0000X,Cardiovascular Disease,11,In_Network,E78.5,,revenue_code:0110,,0,Commercial,PPO,0,F,1.325,,,4120.73,2189.26,1596.16,118.05,76.0,399.04,1931.47,1222.14,208.55,0,,0.0768,none,0,1,0,0,0,0.000148,0,0,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000004003,MBR00000255,Pharmacy,Paid,Paper,2023-05-10,2023-05-10,2023-05-10,2023-06-04,Manual_Review,25,1903785749,1827839595,101YP2500X,Psychologist Clinical,22,In_Network,N18.3,M25.511|E78.5,00310075090,,2,Medicare_Advantage,MA_HMO,21,M,0.6945,,,86.61,30.79,0.0,13.55,17.24,0.0,55.82,0.0,0.0,0,,0.1251,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004004,MBR00000144,Medical_Institutional,Paid,Electronic_EDI,2023-10-06,2023-10-06,2023-10-08,2023-10-17,Auto_Adjudicated,11,1205744244,1983760474,207RC0000X,Cardiovascular Disease,32,In_Network,E78.5,Z12.11,revenue_code:0100,,0,Commercial,HDHP_HSA,56,F,2.5926,,,20672.16,10004.06,7904.3,123.69,0.0,1976.07,10668.1,0.0,0.0,0,,0.0639,none,0,1,1,0,0,0.000732,0,0,,P4P
CLM0000004005,MBR00000040,Medical_Institutional,Paid,Electronic_EDI,2023-08-24,2023-08-24,2023-08-27,2023-08-25,Auto_Adjudicated,1,1331829614,1622950074,225100000X,Physical Therapist,32,In_Network,M17.11,M54.5|OTHER,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,66,F,0.6755,,,39617.24,19121.55,15269.85,2.24,32.0,3817.46,20495.69,0.0,0.0,0,,0.1346,none,0,1,1,0,0,0.001413,0,0,,FFS
CLM0000004006,MBR00000036,Dental,Paid,Electronic_EDI,2023-09-25,2023-09-25,2023-09-25,2023-10-07,Auto_Adjudicated,12,1898865801,1301869102,101YP2500X,Psychologist Clinical,21,In_Network,K21.0,OTHER,D7140,,0,Commercial,EPO,17,M,2.0136,,,502.05,214.29,124.83,25.25,33.0,31.21,287.76,0.0,0.0,0,,0.0696,none,0,1,0,0,0,1.2e-05,0,0,,Capitation
CLM0000004007,MBR00000154,Medical_Professional,Paid,Electronic_EDI,2023-12-09,2023-12-09,2023-12-09,2023-12-10,Auto_Adjudicated,1,1222934819,1747596016,207Q00000X,Family Medicine,21,Out_of_Network,I25.10,OTHER|Z00.00,99396,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,236.81,191.27,147.51,6.88,0.0,36.88,45.54,0.0,0.0,0,,0.1062,provider_specialty_mismatch,0,1,0,1,0,1.4e-05,1,0,KED_ESRD_Patients,Capitation
CLM0000004008,MBR00000112,Medical_Professional,Partially_Paid,Electronic_EDI,2023-04-09,2023-04-09,2023-04-09,2023-04-27,Auto_Adjudicated,18,1014995735,1352413270,246ZN0300X,Neuropsychology,23,In_Network,J06.9,,71250,,0,Medicare_Advantage,MA_HMO,18,M,1.01,16,Medical_Necessity,418.71,151.4,61.17,21.26,6.0,15.29,315.0,0.0,0.0,0,,0.088,none,0,1,0,0,0,6e-06,0,0,,Capitation
CLM0000004009,MBR00000074,Vision,Partially_Paid,Electronic_EDI,2023-10-02,2023-10-02,2023-10-02,2023-10-21,Auto_Adjudicated,19,1727787144,1554490060,207V00000X,Obstetrics & Gynecology,11,In_Network,OTHER,K57.30|I25.10,92002,,0,Medicare_Advantage,MA_PPO,21,F,0.8719,16,Medical_Necessity,303.97,191.6,64.28,27.13,19.0,16.07,177.49,0.0,0.0,0,,0.0058,none,0,1,0,0,0,6e-06,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000004010,MBR00000291,Pharmacy,Partially_Paid,Electronic_EDI,2023-01-15,2023-01-15,2023-01-15,2023-01-26,Auto_Adjudicated,11,1199465234,1365397818,2084P0800X,Psychiatry,24,In_Network,OTHER,OTHER,00003014960,,1,Commercial,PPO,78,M,1.4773,170,Medical_Necessity,78.25,43.71,0.0,30.88,0.0,0.0,47.37,0.0,0.0,0,,0.1149,temporal_clustering,0,1,0,0,0,0.0,0,1,,P4P
CLM0000004011,MBR00000143,Medical_Institutional,Paid,Electronic_EDI,2023-09-12,2023-09-12,2023-09-12,2023-09-17,Auto_Adjudicated,5,1393200616,1177602659,2086S0122X,Orthopedic Surgery,11,In_Network,J06.9,,revenue_code:0110,,0,Commercial,POS,85,M,1.6078,,,26583.7,14625.31,11524.15,180.12,40.0,2881.04,11958.39,0.0,0.0,0,,0.1043,service_date_weekend,0,1,1,1,0,0.001067,0,0,,FFS
CLM0000004012,MBR00000280,Medical_Professional,Denied,Electronic_EDI,2023-02-25,2023-02-25,2023-02-25,2023-03-13,Auto_Adjudicated,16,1323379997,1994275960,208600000X,Surgery General,22,In_Network,OTHER,I25.10,82947,,0,Commercial,PPO,79,F,0.6697,2,Duplicate,841.86,358.02,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0254,none,0,1,0,0,0,0.0,0,0,TRC_Transition_of_Care,FFS
CLM0000004013,MBR00000052,Medical_Professional,Paid,Electronic_EDI,2023-03-21,2023-03-21,2023-03-21,2023-03-22,Auto_Adjudicated,1,1874109311,1829216053,246ZN0300X,Neuropsychology,11,In_Network,OTHER,,12001,,0,Commercial,PPO,0,F,1.325,,,330.15,246.48,13.76,197.28,32.0,3.44,83.67,0.0,0.0,0,,0.1668,unusual_service_frequency,0,1,0,0,0,1e-06,0,0,,Capitation
CLM0000004014,MBR00000057,Dental,Paid,Provider_Portal,2023-03-12,2023-03-12,2023-03-12,2023-03-21,Auto_Adjudicated,9,1630305772,1365397818,208600000X,Surgery General,24,In_Network,E11.9,,D4341,,0,Medicare_Advantage,MA_PPO,45,M,0.6701,,,856.42,438.53,304.1,56.4,2.0,76.03,417.89,231.04,38.78,0,,0.1201,phantom_billing_indicator,0,1,0,1,0,2.8e-05,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000004015,MBR00000180,Pharmacy,Paid,Electronic_EDI,2023-10-26,2023-10-26,2023-10-26,2023-11-25,Clinical_Review,30,1014995735,1867389043,207R00000X,Internal Medicine,71,In_Network,E11.65,F32.9,00003014960,,2,Medicare_Advantage,MA_PPO,72,F,1.1909,,,68.58,47.47,9.44,18.67,17.0,2.36,21.11,6.1,1.9,0,,0.1209,unbundling_pattern,0,1,0,0,0,1e-06,0,0,,Capitation
CLM0000004016,MBR00000084,Medical_Professional,Paid,Electronic_EDI,2023-05-15,2023-05-15,2023-05-15,2023-06-12,Auto_Adjudicated,28,1154652946,1408846353,2084P0800X,Psychiatry,22,Out_of_Network,Z12.11,K21.0|OTHER|I50.9,20610,,0,Medicare_Advantage,MA_HMO,15,F,0.8004,,,673.98,342.33,255.46,12.01,11.0,63.86,331.65,0.0,0.0,0,,0.1835,temporal_clustering,0,1,0,0,0,2.4e-05,1,0,,Shared_Savings
CLM0000004017,MBR00000058,Medical_Professional,Denied,Electronic_EDI,2023-05-20,2023-05-20,2023-05-20,2023-06-08,Auto_Adjudicated,19,1232573801,1469697158,2086S0122X,Orthopedic Surgery,71,In_Network,OTHER,Z00.00|OTHER,84443,,0,Commercial,PPO,56,F,1.1626,18,Medical_Necessity,1165.16,937.07,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.034,none,0,1,0,1,0,0.0,0,0,W30_Well_Child_Visit,FFS
CLM0000004018,MBR00000028,Pharmacy,Partially_Paid,Provider_Portal,2023-05-10,2023-05-10,2023-05-10,2023-05-22,Auto_Adjudicated,12,1887363539,1301833092,208600000X,Surgery General,21,In_Network,OTHER,K57.30|I10|F32.9,00078043215,,1,Commercial,HMO,3,F,2.116,16,Medical_Necessity,323.9,150.19,0.0,75.1,0.0,0.0,248.8,0.0,0.0,0,,0.0952,upcoding_pattern,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,FFS
CLM0000004019,MBR00000024,Medical_Institutional,Paid,Electronic_EDI,2023-08-13,2023-08-13,2023-08-13,2023-08-14,Auto_Adjudicated,1,1141106555,1509799493,2086S0122X,Orthopedic Surgery,11,In_Network,F33.0,,revenue_code:0110,,0,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,6837.42,5238.32,5236.32,0.0,2.0,0.0,1599.1,0.0,0.0,0,,0.0765,none,0,1,1,0,0,0.000485,0,0,,P4P
CLM0000004020,MBR00000221,Vision,Paid,Electronic_EDI,2023-11-25,2023-11-25,2023-11-25,2023-12-15,Auto_Adjudicated,20,1526973051,1894215172,101YP2500X,Psychologist Clinical,31,In_Network,Z79.4,,92014,,0,Commercial,HDHP_HSA,28,M,1.6683,,,227.84,164.45,19.79,139.71,0.0,4.95,63.39,0.0,0.0,0,,0.1627,unbundling_pattern,0,1,0,0,0,2e-06,0,0,,FFS
CLM0000004021,MBR00000088,Medical_Institutional,Denied,Electronic_EDI,2023-09-01,2023-09-01,2023-09-04,2023-09-16,Auto_Adjudicated,15,1642333103,1123879500,2084P0800X,Psychiatry,11,In_Network,F10.10,,revenue_code:0200,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,4,Network,5077.11,3985.8,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1156,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004022,MBR00000295,Medical_Professional,Paid,Electronic_EDI,2023-02-06,2023-02-06,2023-02-06,2023-02-28,Auto_Adjudicated,22,1907932706,1763260577,246ZN0300X,Neuropsychology,11,Out_of_Network,F41.1,E78.5|J44.1,99393,,0,Commercial,HDHP_HSA,78,F,0.8618,,,312.37,263.44,0.0,263.44,0.0,0.0,48.93,0.0,0.0,0,,0.0575,geographic_mismatch,0,1,0,0,0,0.0,1,0,,FFS
CLM0000004023,MBR00000057,Medical_Professional,Paid,Electronic_EDI,2023-07-04,2023-07-04,2023-07-04,2023-07-09,Auto_Adjudicated,5,1830816512,1352413270,101YP2500X,Psychologist Clinical,23,In_Network,F32.9,E11.65|OTHER|Z00.00,33510,,0,Medicare_Advantage,MA_PPO,45,M,0.6701,,,1154.05,737.3,554.65,41.98,2.0,138.66,416.75,0.0,0.0,0,,0.1873,provider_specialty_mismatch,0,1,0,0,0,5.1e-05,0,0,,FFS
CLM0000004024,MBR00000112,Medical_Institutional,Paid,Electronic_EDI,2023-02-08,2023-02-08,2023-02-10,2023-03-05,Manual_Review,25,1429653002,1522426351,246ZN0300X,Neuropsychology,11,In_Network,E11.65,K21.0,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,18,M,1.01,,,2152.19,1538.74,1188.9,22.61,30.0,297.23,613.45,0.0,0.0,0,,0.1387,none,0,1,0,0,0,0.00011,0,0,MMA_Medication_Management,FFS
CLM0000004025,MBR00000118,Medical_Professional,Denied,Provider_Portal,2023-03-01,2023-03-01,2023-03-01,2023-03-26,Auto_Adjudicated,25,1086690796,1415734567,207V00000X,Obstetrics & Gynecology,32,In_Network,OTHER,I10,90837,,0,Medicaid_MCO,MCO,69,M,1.2773,96,COB,959.18,609.33,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1424,none,0,1,0,0,0,0.0,0,0,DAE_Drug_Alcohol_Dependence,FFS
CLM0000004026,MBR00000154,Medical_Professional,Paid,Electronic_EDI,2023-03-12,2023-03-12,2023-03-12,2023-03-25,Auto_Adjudicated,13,1190558906,1985590322,101YP2500X,Psychologist Clinical,22,In_Network,M79.3,,99284,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,218.95,174.54,132.03,9.5,0.0,33.01,44.41,0.0,0.0,0,,0.0969,none,0,1,0,0,0,1.2e-05,0,0,,Bundled_Payment
CLM0000004027,MBR00000263,Medical_Professional,Paid,Electronic_EDI,2023-09-08,2023-09-08,2023-09-08,2023-09-09,Auto_Adjudicated,1,1760186113,1197700958,208600000X,Surgery General,11,In_Network,I10,Z00.00,99213,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,,,267.28,176.0,105.2,25.5,19.0,26.3,91.28,0.0,0.0,0,,0.077,service_date_weekend,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000004028,MBR00000249,Medical_Professional,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-11-25,Manual_Review,14,1843445592,1297948643,207RN0300X,Nephrology,21,In_Network,I10,OTHER|K21.0|E11.9,97035,,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,308.46,238.46,101.17,63.93,30.0,43.36,70.0,0.0,0.0,0,,0.097,none,0,1,0,0,0,9e-06,0,0,KED_ESRD_Patients,FFS
CLM0000004029,MBR00000004,Pharmacy,Denied,Electronic_EDI,2023-03-30,2023-03-30,2023-03-30,2023-04-11,Manual_Review,12,1026612378,1007652766,246ZN0300X,Neuropsychology,11,In_Network,Z23,J06.9|N18.3,00078043215,,4,Medicare_Advantage,MA_PPO,68,M,1.23,96,Medical_Necessity,109.72,52.92,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0291,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004030,MBR00000130,Medical_Professional,Paid,Electronic_EDI,2023-12-05,2023-12-05,2023-12-05,2023-12-28,Clinical_Review,23,1470105939,1842149518,225100000X,Physical Therapist,23,In_Network,G47.33,Z79.4|Z00.00,99383,,0,Medicare_Advantage,MA_PPO,58,M,1.3394,,,758.2,282.42,221.4,1.67,4.0,55.35,475.78,0.0,0.0,0,,0.0882,none,0,1,0,0,0,2e-05,0,0,,Capitation
CLM0000004031,MBR00000247,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-04-06,2023-04-06,2023-04-09,2023-04-14,Auto_Adjudicated,8,1897231867,1112696614,207RC0000X,Cardiovascular Disease,11,Out_of_Network,Z12.11,OTHER,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,4,Medical_Necessity,8850.05,3534.84,2119.92,7.14,52.0,529.98,6141.01,0.0,0.0,0,,0.1239,none,0,1,0,0,0,0.000196,1,0,,FFS
CLM0000004032,MBR00000001,Pharmacy,Paid,Electronic_EDI,2023-04-21,2023-04-21,2023-04-21,2023-04-22,Auto_Adjudicated,1,1891821845,1688513262,207RN0300X,Nephrology,31,In_Network,Z12.11,OTHER,00071012831,,2,Commercial,EPO,73,M,0.6527,,,178.44,120.68,19.58,68.2,28.0,4.9,57.76,0.0,0.0,0,,0.0738,none,0,1,0,0,0,2e-06,0,1,CDC_HbA1c_Poor_Control,FFS
CLM0000004033,MBR00000162,Medical_Professional,Denied,Electronic_EDI,2023-02-15,2023-02-15,2023-02-15,2023-03-17,Clinical_Review,30,1882720848,1662516615,207RN0300X,Nephrology,11,In_Network,OTHER,OTHER,99223,,0,Medicaid_MCO,MLTSS,84,F,1.324,4,Authorization,177.21,136.04,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.021,none,0,1,0,0,0,0.0,0,0,BCS_Breast_Cancer_Screening,Capitation
CLM0000004034,MBR00000081,Medical_Institutional,Paid,Electronic_EDI,2023-01-17,2023-01-17,2023-01-19,2023-01-25,Manual_Review,8,1631060535,1579331190,246ZN0300X,Neuropsychology,11,In_Network,OTHER,E78.5|J06.9,revenue_code:0450,,0,Medicare_Advantage,SNP,66,F,2.159,,,122666.76,57789.09,46183.93,15.18,44.0,11545.98,64877.67,36675.69,6936.04,0,,0.1681,outlier_billing_amount,0,1,1,0,0,0.004275,0,0,,Bundled_Payment
CLM0000004035,MBR00000131,Pharmacy,Paid,Electronic_EDI,2023-08-11,2023-08-11,2023-08-11,2023-08-14,Manual_Review,3,1175448241,1148659045,207RN0300X,Nephrology,23,In_Network,F32.9,Z87.891,00310075090,,1,Commercial,EPO,15,F,0.9228,,,589.56,380.35,0.0,380.35,0.0,0.0,209.21,0.0,0.0,1,Unbundling,1.0,outlier_billing_amount|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|impossible_service_combo|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.0,0,0,BPD_BP_Declined,FFS
CLM0000004036,MBR00000133,Medical_Institutional,Paid,Electronic_EDI,2023-05-27,2023-05-27,2023-05-31,2023-06-22,Auto_Adjudicated,26,1590338573,1012893364,207RP1001X,Pulmonary Disease,21,In_Network,F10.10,,revenue_code:0120,248,0,Medicaid_MCO,MCO,57,M,0.9592,,,15964.71,9780.77,9774.77,0.0,6.0,0.0,6183.94,0.0,0.0,0,,0.25,impossible_service_combo|unbundling_pattern,0,2,1,0,0,0.000905,0,0,,Capitation
CLM0000004037,MBR00000125,Medical_Institutional,Paid,Provider_Portal,2023-02-12,2023-02-12,2023-02-12,2023-03-06,Manual_Review,22,1117755591,1025886739,101YP2500X,Psychologist Clinical,22,Out_of_Network,K21.0,M54.5,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,27473.86,18667.39,14895.53,2.98,45.0,3723.88,8806.47,0.0,0.0,0,,0.13,none,0,1,1,0,0,0.001379,0,0,CCS_Cervical_Cancer_Screening,Shared_Savings
CLM0000004038,MBR00000270,Pharmacy,Paid,Electronic_EDI,2023-07-22,2023-07-22,2023-07-22,2023-07-31,Auto_Adjudicated,9,1193571728,1767402068,225100000X,Physical Therapist,22,In_Network,N18.3,,00003014960,,1,Commercial,POS,1,F,1.6363,,,239.11,111.24,70.1,11.62,12.0,17.52,127.87,0.0,0.0,0,,0.0991,none,0,1,0,1,0,6e-06,0,1,IET_Initiation_Substance_Use,Capitation
CLM0000004039,MBR00000163,Vision,Paid,Electronic_EDI,2023-05-04,2023-05-04,2023-05-04,2023-05-19,Auto_Adjudicated,15,1658094898,1694343357,225100000X,Physical Therapist,11,In_Network,E78.5,,92012,,0,Medicaid_MCO,MCO,21,F,0.9607,,,256.91,118.45,114.45,0.0,4.0,0.0,138.46,0.0,0.0,0,,0.1648,provider_specialty_mismatch,0,1,0,0,0,1.1e-05,0,0,,P4P
CLM0000004040,MBR00000274,Pharmacy,Paid,Electronic_EDI,2023-05-22,2023-05-22,2023-05-22,2023-06-12,Clinical_Review,21,1988579666,1040061910,2086S0122X,Orthopedic Surgery,22,In_Network,F41.1,,00078043215,,1,Medicare_Advantage,MA_HMO,58,F,2.1025,,,162.44,120.17,90.61,6.9,0.0,22.65,42.27,0.0,0.0,0,,0.1357,none,0,1,0,0,0,8e-06,0,0,HBD_Hemoglobin_A1c_Testing,P4P
CLM0000004041,MBR00000213,Medical_Institutional,Paid,Electronic_EDI,2023-11-16,2023-11-16,2023-11-16,2023-12-11,Auto_Adjudicated,25,1298243993,1368666316,207RP1001X,Pulmonary Disease,71,In_Network,M79.3,Z12.11|I50.9,revenue_code:0110,,0,Commercial,PPO,17,M,1.5857,,,3002.95,1123.86,694.08,213.27,43.0,173.52,1879.09,0.0,0.0,0,,0.114,none,0,1,0,0,0,6.4e-05,0,0,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000004042,MBR00000111,Medical_Institutional,Paid,Electronic_EDI,2023-05-25,2023-05-25,2023-05-28,2023-06-06,Manual_Review,12,1826043246,1827839595,207RG0100X,Gastroenterology,11,In_Network,K21.0,,revenue_code:0200,,0,Medicare_Advantage,MA_PPO,44,M,0.7462,,,8635.72,6019.05,4790.14,3.37,28.0,1197.54,2616.67,0.0,0.0,0,,0.0018,none,0,1,0,1,0,0.000443,0,0,ACR_Urine_Protein,FFS
CLM0000004043,MBR00000153,Medical_Institutional,Paid,Provider_Portal,2023-06-12,2023-06-12,2023-06-16,2023-06-19,Auto_Adjudicated,7,1932483309,1368666316,207RN0300X,Nephrology,22,In_Network,OTHER,Z00.00|I10|Z12.11,revenue_code:0360,,0,Commercial,POS,12,F,0.6525,,,7614.98,2937.6,1992.56,376.91,70.0,498.14,4677.38,1694.41,227.77,0,,0.1159,none,0,1,0,0,0,0.000184,0,0,DAE_Drug_Alcohol_Dependence,Shared_Savings
CLM0000004044,MBR00000125,Medical_Professional,Paid,Provider_Portal,2023-09-04,2023-09-04,2023-09-04,2023-09-05,Auto_Adjudicated,1,1264432433,1587454801,2086S0122X,Orthopedic Surgery,21,In_Network,E78.5,F41.1,99397,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,328.76,132.03,94.73,2.61,11.0,23.68,196.73,0.0,0.0,0,,0.1218,none,0,1,0,0,0,9e-06,0,0,,P4P
CLM0000004045,MBR00000247,Medical_Institutional,Paid,Electronic_EDI,2023-11-18,2023-11-18,2023-11-18,2023-12-14,Auto_Adjudicated,26,1741980770,1538261819,2086S0122X,Orthopedic Surgery,31,Emergency,Z00.00,OTHER,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,9917.92,4675.61,3688.74,12.69,52.0,922.18,5242.31,0.0,0.0,0,,0.0161,none,0,1,0,1,0,0.000341,0,0,,Bundled_Payment
CLM0000004046,MBR00000058,Pharmacy,Paid,Electronic_EDI,2023-09-23,2023-09-23,2023-09-23,2023-10-18,Auto_Adjudicated,25,1853403237,1133410177,246ZN0300X,Neuropsychology,11,In_Network,OTHER,I10|J06.9,50458085930,,5,Commercial,PPO,56,F,1.1626,,,311.56,162.24,0.0,151.82,10.42,0.0,149.32,0.0,0.0,0,,0.1362,unbundling_pattern,0,1,0,0,0,0.0,0,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000004047,MBR00000283,Medical_Professional,Paid,Paper,2023-06-26,2023-06-26,2023-06-26,2023-07-25,Manual_Review,29,1853403237,1811797489,207V00000X,Obstetrics & Gynecology,11,In_Network,J06.9,,99203,,0,Medicare_Advantage,MA_HMO,21,M,0.5294,,,294.32,248.23,155.6,39.73,14.0,38.9,46.09,0.0,0.0,0,,0.0689,none,0,1,0,0,0,1.4e-05,0,0,,Shared_Savings
CLM0000004048,MBR00000175,Dental,Paid,Electronic_EDI,2023-04-20,2023-04-20,2023-04-20,2023-05-13,Auto_Adjudicated,23,1594322174,1368666316,208600000X,Surgery General,21,Emergency,E78.5,Z00.00|F32.9|Z12.11,D2140,,0,Commercial,PPO,14,F,1.5785,,,211.28,122.16,44.79,56.18,10.0,11.2,89.12,0.0,0.0,0,,0.093,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000004049,MBR00000184,Behavioral_Health,Paid,Electronic_EDI,2023-03-06,2023-03-06,2023-03-06,2023-03-13,Manual_Review,7,1560886857,1419347445,207V00000X,Obstetrics & Gynecology,23,In_Network,F32.9,OTHER|E78.5,99232,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,463.13,261.43,259.43,0.0,2.0,0.0,201.7,0.0,0.0,0,,0.0974,none,0,1,0,0,0,2.4e-05,0,0,,FFS
CLM0000004050,MBR00000158,Medical_Professional,Paid,Electronic_EDI,2023-02-14,2023-02-14,2023-02-14,2023-02-22,Auto_Adjudicated,8,1214787184,1542515060,207RC0000X,Cardiovascular Disease,11,In_Network,E78.5,,90834,,0,Commercial,HMO,65,M,1.5361,,,495.88,364.68,136.61,179.91,14.0,34.15,131.2,0.0,0.0,0,,0.0591,none,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000004051,MBR00000167,Medical_Professional,Paid,Provider_Portal,2023-09-30,2023-09-30,2023-09-30,2023-10-08,Auto_Adjudicated,8,1747318937,1791502603,207RE0101X,Endocrinology,24,In_Network,L70.0,E78.5|OTHER|M47.816,74177,,0,Commercial,PPO,77,F,0.9377,,,958.09,464.54,126.28,294.69,12.0,31.57,493.55,0.0,0.0,0,,0.1941,diagnosis_procedure_mismatch,0,1,0,0,0,1.2e-05,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000004052,MBR00000198,Vision,Paid,Electronic_EDI,2023-09-22,2023-09-22,2023-09-22,2023-10-06,Manual_Review,14,1155203600,1300957944,246ZN0300X,Neuropsychology,21,In_Network,M54.5,,V2103,,0,Medicaid_MCO,MCO,81,F,1.4199,,,145.37,94.27,92.27,0.0,2.0,0.0,51.1,0.0,0.0,0,,0.0611,none,0,1,0,0,0,9e-06,0,0,FUH_Follow_Up_Hospitalization,P4P
CLM0000004053,MBR00000195,Medical_Professional,Paid,Electronic_EDI,2023-05-07,2023-05-07,2023-05-07,2023-06-05,Clinical_Review,29,1976612978,1643673796,207R00000X,Internal Medicine,65,Emergency,OTHER,,27130,,0,Commercial,PPO,13,F,0.5967,,,30860.27,21599.58,17207.17,77.62,13.0,4301.79,9260.69,0.0,0.0,0,,0.1717,billing_spike_recent,0,1,1,0,0,0.001593,0,0,,FFS
CLM0000004054,MBR00000065,Pharmacy,Paid,Electronic_EDI,2023-12-04,2023-12-04,2023-12-04,2023-12-25,Auto_Adjudicated,21,1901508637,1287472731,207RG0100X,Gastroenterology,65,In_Network,E78.5,Z12.11|OTHER,50458085930,,1,Commercial,HDHP_HSA,63,M,0.7795,,,48.63,37.84,0.0,37.84,0.0,0.0,10.79,0.0,0.0,0,,0.1253,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004055,MBR00000175,Medical_Professional,Paid,Electronic_EDI,2023-12-13,2023-12-13,2023-12-13,2023-12-27,Manual_Review,14,1374361443,1140170394,225100000X,Physical Therapist,24,In_Network,J06.9,F32.9,99221,,0,Commercial,PPO,14,F,1.5785,,,737.55,303.28,211.1,29.4,10.0,52.78,434.27,0.0,0.0,0,,0.0993,billing_spike_recent,0,1,0,0,0,2e-05,0,0,,P4P
CLM0000004056,MBR00000112,Medical_Professional,Denied,Provider_Portal,2023-08-11,2023-08-11,2023-08-11,2023-09-03,Auto_Adjudicated,23,1475070784,1419347445,207RG0100X,Gastroenterology,24,In_Network,J20.9,OTHER|F10.10,11200,,0,Medicare_Advantage,MA_HMO,18,M,1.01,256,Duplicate,1049.72,711.1,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1759,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004057,MBR00000188,Medical_Professional,Paid,Electronic_EDI,2023-04-05,2023-04-05,2023-04-05,2023-05-01,Auto_Adjudicated,26,1629674542,1804282800,207RP1001X,Pulmonary Disease,22,In_Network,Z00.00,,70553,,0,Commercial,HMO,8,F,1.5853,,,558.19,196.7,92.43,56.17,25.0,23.11,361.49,0.0,0.0,0,,0.0415,none,0,1,0,0,0,9e-06,0,0,,Shared_Savings
CLM0000004058,MBR00000166,Medical_Professional,Partially_Paid,Electronic_EDI,2023-07-01,2023-07-01,2023-07-01,2023-07-14,Auto_Adjudicated,13,1451329728,1267212691,207RG0100X,Gastroenterology,24,Out_of_Network,Z00.00,Z00.01|E78.5|Z12.11,71046,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,2,Medical_Necessity,969.66,580.24,15.57,368.73,44.0,6.67,534.68,9.52,4.84,0,,0.075,none,0,1,0,0,0,1e-06,1,0,CDC_HbA1c_Poor_Control,FFS
CLM0000004059,MBR00000056,Dental,Paid,Electronic_EDI,2023-10-23,2023-10-23,2023-10-23,2023-11-18,Manual_Review,26,1702283246,1662516615,207RC0000X,Cardiovascular Disease,11,In_Network,E11.9,J45.20,D4341,,0,Commercial,EPO,74,F,1.3941,,,246.91,130.94,74.7,26.56,11.0,18.68,115.97,0.0,0.0,1,Kickback Arrangement,0.993,unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|benford_violation|service_date_weekend|duplicate_claim_indicator|upcoding_pattern|diagnosis_procedure_mismatch,1,5,0,1,0,7e-06,0,0,,Shared_Savings
CLM0000004060,MBR00000215,Medical_Professional,Paid,Paper,2023-07-01,2023-07-01,2023-07-01,2023-07-02,Clinical_Review,1,1264953395,1354265777,207RC0000X,Cardiovascular Disease,31,In_Network,Z00.01,,80053,,0,ACA_Marketplace,ACA_Silver,69,M,0.8895,,,1094.92,829.25,485.54,114.63,21.0,208.09,265.67,0.0,0.0,0,,0.07,none,0,1,0,0,0,4.5e-05,0,0,,Bundled_Payment
CLM0000004061,MBR00000142,Medical_Professional,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-27,2023-07-07,Auto_Adjudicated,10,1061181028,1912895973,101YP2500X,Psychologist Clinical,22,In_Network,OTHER,M54.5|E11.9|J06.9,99396,,0,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,372.9,266.1,91.24,107.76,28.0,39.1,106.8,0.0,0.0,0,,0.0055,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000004062,MBR00000166,Pharmacy,Paid,Electronic_EDI,2023-07-11,2023-07-11,2023-07-11,2023-07-17,Auto_Adjudicated,6,1083045036,1738617370,208600000X,Surgery General,24,In_Network,OTHER,M54.5|OTHER,00006001954,,1,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,178.89,124.46,0.0,124.46,0.0,0.0,54.43,0.0,0.0,0,,0.1513,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,FLU_Flu_Vaccination,Bundled_Payment
CLM0000004063,MBR00000199,Vision,Denied,Electronic_EDI,2023-10-30,2023-10-30,2023-10-30,2023-11-05,Auto_Adjudicated,6,1429653002,1811797489,208600000X,Surgery General,22,In_Network,Z23,OTHER|M54.5,V2100,,0,Medicaid_MCO,MLTSS,17,F,1.0776,18,COB,327.85,142.54,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0487,none,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000004064,MBR00000194,Medical_Professional,Paid,Electronic_EDI,2023-05-28,2023-05-28,2023-05-28,2023-06-04,Manual_Review,7,1404237143,1415734567,207RC0000X,Cardiovascular Disease,23,In_Network,M17.11,Z00.00,99223,,0,Commercial,PPO,77,M,0.9783,,,480.64,242.75,56.77,153.79,18.0,14.19,237.89,0.0,0.0,0,,0.0806,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000004065,MBR00000220,Pharmacy,Denied,Electronic_EDI,2023-03-07,2023-03-07,2023-03-07,2023-03-18,Manual_Review,11,1374458552,1312595355,207RG0100X,Gastroenterology,21,In_Network,N18.3,F10.10|F41.1,59148001506,,1,Commercial,HMO,38,M,0.7736,PR-1,Medical_Necessity,320.98,158.51,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0315,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004066,MBR00000063,Medical_Professional,Paid,Electronic_EDI,2023-07-04,2023-07-04,2023-07-04,2023-07-26,Auto_Adjudicated,22,1007266616,1847196500,207Q00000X,Family Medicine,21,In_Network,Z00.01,,99395,,0,ACA_Marketplace,ACA_Silver,56,M,0.8198,,,109.45,48.92,0.0,48.92,0.0,0.0,60.53,0.0,0.0,0,,0.0261,none,0,1,0,0,0,0.0,0,0,MPT_Annual_Monitoring,Bundled_Payment
CLM0000004067,MBR00000034,Pharmacy,Paid,Electronic_EDI,2023-08-16,2023-08-16,2023-08-16,2023-09-03,Manual_Review,18,1115589144,1040061910,207RC0000X,Cardiovascular Disease,21,In_Network,F32.9,K21.0,00071015523,,2,Medicare_Advantage,MA_HMO,35,M,0.7712,,,178.89,100.29,45.35,36.6,7.0,11.34,78.6,0.0,0.0,0,,0.0518,none,0,1,0,0,0,4e-06,0,0,MMA_Medication_Management,FFS
CLM0000004068,MBR00000198,Pharmacy,Paid,Electronic_EDI,2023-12-02,2023-12-02,2023-12-02,2023-12-16,Auto_Adjudicated,14,1641660170,1942423230,207RE0101X,Endocrinology,24,In_Network,OTHER,J06.9,00003014960,,2,Medicaid_MCO,MCO,81,F,1.4199,,,182.71,102.79,100.79,0.0,2.0,0.0,79.92,0.0,0.0,0,,0.1318,controlled_substance_high_volume,0,1,0,0,0,9e-06,0,0,,Bundled_Payment
CLM0000004069,MBR00000074,Dental,Paid,Electronic_EDI,2023-02-10,2023-02-10,2023-02-10,2023-02-25,Auto_Adjudicated,15,1667149552,1867389043,225100000X,Physical Therapist,11,Out_of_Network,E11.9,F32.9,D2391,,0,Medicare_Advantage,MA_PPO,21,F,0.8719,,,165.28,86.76,49.04,6.46,19.0,12.26,78.52,0.0,0.0,0,,0.0876,none,0,1,0,0,0,5e-06,0,0,,Bundled_Payment
CLM0000004070,MBR00000036,Medical_Institutional,Denied,Electronic_EDI,2023-12-05,2023-12-05,2023-12-08,2023-12-11,Auto_Adjudicated,6,1413983739,1912895973,101YP2500X,Psychologist Clinical,65,In_Network,Z00.01,,revenue_code:0210,,0,Commercial,EPO,17,M,2.0136,PR-1,Network,6761.97,5051.48,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Provider Impersonation,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|billing_spike_recent|duplicate_claim_indicator|unbundling_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.0,0,0,,FFS
CLM0000004071,MBR00000041,Vision,Paid,Electronic_EDI,2023-10-17,2023-10-17,2023-10-17,2023-11-09,Auto_Adjudicated,23,1519595029,1685903362,207R00000X,Internal Medicine,31,In_Network,E78.5,I10|N18.3,92014,,0,Commercial,PPO,42,F,0.8283,,,194.76,135.41,85.06,5.09,24.0,21.26,59.35,0.0,0.0,0,,0.0029,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000004072,MBR00000099,Medical_Professional,Paid,Electronic_EDI,2023-09-13,2023-09-13,2023-09-13,2023-10-06,Auto_Adjudicated,23,1084831484,1352413270,207RC0000X,Cardiovascular Disease,31,In_Network,J20.9,,85025,,0,Commercial,HMO,10,F,0.7843,,,483.27,361.23,78.9,247.61,15.0,19.72,122.04,0.0,0.0,0,,0.0864,none,0,1,0,1,0,7e-06,0,0,,Capitation
CLM0000004073,MBR00000298,Pharmacy,Paid,Electronic_EDI,2023-03-26,2023-03-26,2023-03-26,2023-04-12,Auto_Adjudicated,17,1732726112,1365397818,101YP2500X,Psychologist Clinical,65,In_Network,OTHER,OTHER,00006001954,,1,Medicaid_MCO,MCO,75,M,0.8324,,,94.94,71.6,71.6,0.0,0.0,0.0,23.34,0.0,0.0,0,,0.0964,none,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000004074,MBR00000050,Pharmacy,Paid,Paper,2023-03-16,2023-03-16,2023-03-16,2023-04-10,Clinical_Review,25,1338575285,1354265777,207RP1001X,Pulmonary Disease,21,In_Network,J06.9,OTHER|K29.70,00069420020,,3,Medicare_Advantage,MA_PPO,12,F,0.8486,,,250.53,115.33,82.89,11.72,0.0,20.72,135.2,0.0,0.0,0,,0.0074,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000004075,MBR00000093,Medical_Professional,Paid,Electronic_EDI,2023-06-03,2023-06-03,2023-06-03,2023-06-28,Auto_Adjudicated,25,1618546650,1140170394,207RG0100X,Gastroenterology,32,In_Network,J06.9,,17000,,0,Medicare_Advantage,MA_HMO,43,F,0.6162,,,790.39,650.58,467.92,46.68,19.0,116.98,139.81,0.0,0.0,0,,0.0083,none,0,1,0,0,0,4.3e-05,0,0,,Bundled_Payment
CLM0000004076,MBR00000277,Vision,Paid,Electronic_EDI,2023-03-07,2023-03-07,2023-03-07,2023-04-01,Auto_Adjudicated,25,1272115456,1312595355,207V00000X,Obstetrics & Gynecology,22,In_Network,J06.9,Z12.11,92014,,0,Medicaid_MCO,MCO,30,M,1.8495,,,738.05,498.36,495.36,0.0,3.0,0.0,239.69,0.0,0.0,0,,0.0822,none,0,1,0,0,0,4.6e-05,0,0,,Shared_Savings
CLM0000004077,MBR00000292,Pharmacy,Paid,Paper,2023-08-24,2023-08-24,2023-08-24,2023-08-28,Auto_Adjudicated,4,1326896487,1312595355,207RE0101X,Endocrinology,11,In_Network,OTHER,,00169751112,,4,Medicare_Advantage,MA_HMO,4,M,1.1779,,,117.18,87.78,49.7,22.66,3.0,12.42,29.4,0.0,0.0,0,,0.0171,none,0,1,0,0,0,5e-06,0,1,W30_Well_Child_Visit,FFS
CLM0000004078,MBR00000072,Dental,Paid,Electronic_EDI,2023-09-28,2023-09-28,2023-09-28,2023-10-01,Clinical_Review,3,1913217838,1133410177,207RG0100X,Gastroenterology,11,In_Network,F32.9,,D0120,,0,Medicare_Advantage,MA_PPO,39,M,0.4967,,,479.19,390.14,292.4,16.64,8.0,73.1,89.05,0.0,0.0,0,,0.0031,none,0,1,0,0,0,2.7e-05,0,0,CBP_Controlling_BP,Shared_Savings
CLM0000004079,MBR00000266,Medical_Professional,Paid,Electronic_EDI,2023-06-21,2023-06-21,2023-06-21,2023-07-05,Auto_Adjudicated,14,1627776731,1469697158,207RC0000X,Cardiovascular Disease,11,In_Network,M54.5,OTHER|G47.33,90837,,0,Commercial,EPO,14,M,1.075,,,173.5,131.45,0.0,131.45,0.0,0.0,42.05,0.0,0.0,0,,0.0493,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004080,MBR00000043,Pharmacy,Paid,Provider_Portal,2023-09-06,2023-09-06,2023-09-06,2023-09-08,Manual_Review,2,1932483309,1764064254,207Q00000X,Family Medicine,11,In_Network,I10,M17.11,16590051660,,2,Commercial,PPO,68,F,0.4593,,,57.88,36.45,0.0,36.45,0.0,0.0,21.43,0.0,0.0,0,,0.1584,high_oop_waiver,0,1,0,0,0,0.0,0,1,,FFS
CLM0000004081,MBR00000224,Medical_Professional,Paid,Electronic_EDI,2023-10-07,2023-10-07,2023-10-07,2023-10-08,Auto_Adjudicated,1,1091271799,1619587398,246ZN0300X,Neuropsychology,21,In_Network,I10,E78.5,99212,,0,Medicaid_MCO,MCO,86,F,1.3289,,,544.87,321.44,318.44,0.0,3.0,0.0,223.43,0.0,0.0,0,,0.0093,none,0,1,0,0,0,2.9e-05,0,0,IET_Initiation_Substance_Use,Shared_Savings
CLM0000004082,MBR00000004,Vision,Paid,Provider_Portal,2023-11-24,2023-11-24,2023-11-24,2023-11-28,Auto_Adjudicated,4,1869706360,1469697158,2084P0800X,Psychiatry,81,In_Network,OTHER,,V2115,,0,Medicare_Advantage,MA_PPO,68,M,1.23,,,486.55,303.59,225.14,14.17,8.0,56.28,182.96,0.0,0.0,0,,0.2,controlled_substance_high_volume,0,2,0,1,0,2.1e-05,0,0,,Shared_Savings
CLM0000004083,MBR00000130,Medical_Professional,Paid,Paper,2023-09-05,2023-09-05,2023-09-05,2023-09-09,Auto_Adjudicated,4,1324272690,1461075342,207Q00000X,Family Medicine,11,In_Network,F41.1,Z00.121,99213,,0,Medicare_Advantage,MA_PPO,58,M,1.3394,,,349.58,275.2,213.29,4.59,4.0,53.32,74.38,0.0,0.0,0,,0.1041,none,0,1,0,0,0,2e-05,0,0,,FFS
CLM0000004084,MBR00000076,Medical_Institutional,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-29,2023-04-04,Auto_Adjudicated,10,1424104563,1874728994,208600000X,Surgery General,65,In_Network,Z00.00,,revenue_code:0210,,0,Commercial,HMO,26,M,2.1785,,,33075.73,12670.61,10093.73,13.45,40.0,2523.43,20405.12,0.0,0.0,0,,0.2028,upcoding_pattern,0,2,1,0,0,0.000934,0,0,,FFS
CLM0000004085,MBR00000208,Medical_Professional,Paid,Electronic_EDI,2023-02-16,2023-02-16,2023-02-16,2023-02-26,Manual_Review,10,1901547390,1301833092,207R00000X,Internal Medicine,24,In_Network,OTHER,,99205,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,163.52,88.87,54.63,14.58,6.0,13.66,74.65,0.0,0.0,0,,0.1408,none,0,1,0,0,0,5e-06,0,0,FLU_Flu_Vaccination,FFS
CLM0000004086,MBR00000006,Pharmacy,Paid,Electronic_EDI,2023-12-04,2023-12-04,2023-12-04,2023-12-29,Auto_Adjudicated,25,1263063839,1694343357,2086S0122X,Orthopedic Surgery,31,In_Network,OTHER,OTHER,00071015523,,1,Commercial,EPO,88,M,1.4365,,,675.25,332.33,213.43,32.54,33.0,53.36,342.92,0.0,0.0,0,,0.0603,none,0,1,0,0,0,2e-05,0,0,AMR_Asthma_Medication_Ratio,FFS
CLM0000004087,MBR00000143,Medical_Professional,Paid,Electronic_EDI,2023-10-05,2023-10-05,2023-10-05,2023-11-02,Auto_Adjudicated,28,1893886964,1177602659,207RG0100X,Gastroenterology,24,In_Network,E11.9,E11.65|E78.5,99285,,0,Commercial,POS,85,M,1.6078,,,166.89,95.67,0.0,95.67,0.0,0.0,71.22,0.0,0.0,0,,0.0068,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000004088,MBR00000207,Dental,Paid,Electronic_EDI,2023-11-01,2023-11-01,2023-11-01,2023-11-07,Auto_Adjudicated,6,1918578486,1498781755,2084P0800X,Psychiatry,81,In_Network,M54.5,,D2140,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,425.15,276.81,276.81,0.0,0.0,0.0,148.34,0.0,0.0,0,,0.1025,none,0,1,0,0,0,2.6e-05,0,0,,P4P
CLM0000004089,MBR00000014,Dental,Paid,Electronic_EDI,2023-06-02,2023-06-02,2023-06-02,2023-06-14,Auto_Adjudicated,12,1513407277,1880530717,207R00000X,Internal Medicine,11,In_Network,OTHER,,D2140,,0,Commercial,HMO,77,M,2.8513,,,1846.56,1359.5,862.35,243.57,38.0,215.59,487.06,0.0,0.0,0,,0.0943,none,0,1,0,0,0,8e-05,0,0,,FFS
CLM0000004090,MBR00000272,Medical_Professional,Paid,Electronic_EDI,2023-02-26,2023-02-26,2023-02-26,2023-03-14,Auto_Adjudicated,16,1114266188,1574982369,225100000X,Physical Therapist,22,In_Network,Z00.00,Z12.11|F33.0,97110,,0,Medicare_Advantage,MA_HMO,15,M,0.8525,,,350.56,124.18,64.19,28.95,15.0,16.05,226.38,0.0,0.0,0,,0.1201,none,0,1,0,0,0,6e-06,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000004091,MBR00000114,Pharmacy,Paid,Provider_Portal,2023-08-03,2023-08-03,2023-08-03,2023-08-12,Auto_Adjudicated,9,1878453830,1706603847,207V00000X,Obstetrics & Gynecology,21,In_Network,M54.5,,00078043215,,3,Medicare_Advantage,MA_PPO,57,F,1.0712,,,529.39,299.52,218.73,7.1,19.0,54.68,229.87,0.0,0.0,0,,0.1381,none,0,1,0,0,0,2e-05,0,0,,FFS
CLM0000004092,MBR00000052,Pharmacy,Paid,Electronic_EDI,2023-08-18,2023-08-18,2023-08-18,2023-08-28,Auto_Adjudicated,10,1958171947,1977073565,207Q00000X,Family Medicine,11,In_Network,K21.0,,00006001954,,1,Commercial,PPO,0,F,1.325,,,389.97,193.1,58.19,88.36,32.0,14.55,196.87,0.0,0.0,0,,0.0211,none,0,1,0,0,0,5e-06,0,1,W30_Well_Child_Visit,Bundled_Payment
CLM0000004093,MBR00000070,Medical_Institutional,Denied,Electronic_EDI,2023-03-19,2023-03-19,2023-03-21,2023-04-09,Auto_Adjudicated,21,1611521069,1287472731,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,E11.9|F32.9|Z00.00,revenue_code:0200,,0,Commercial,POS,42,F,0.8468,18,Medical_Necessity,7423.41,5330.82,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1335,geographic_mismatch,0,1,0,0,0,0.0,0,0,FLU_Flu_Vaccination,Bundled_Payment
CLM0000004094,MBR00000106,Medical_Professional,Paid,Electronic_EDI,2023-06-18,2023-06-18,2023-06-18,2023-07-01,Clinical_Review,13,1034110592,1880530717,225100000X,Physical Therapist,22,In_Network,J06.9,,82947,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,2807.34,1367.78,1077.12,15.38,6.0,269.28,1439.56,0.0,0.0,0,,0.1298,none,0,1,0,0,0,0.0001,0,0,CCS_Cervical_Cancer_Screening,Bundled_Payment
CLM0000004095,MBR00000061,Medical_Professional,Paid,Electronic_EDI,2023-06-01,2023-06-01,2023-06-01,2023-06-23,Auto_Adjudicated,22,1871417879,1068662623,207Q00000X,Family Medicine,81,In_Network,J06.9,OTHER|Z12.11,99387,,0,Commercial,PPO,66,M,2.3575,,,177.5,82.91,0.0,82.91,0.0,0.0,94.59,0.0,0.0,0,,0.0693,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004096,MBR00000157,Medical_Professional,Paid,Electronic_EDI,2023-04-04,2023-04-04,2023-04-04,2023-04-07,Manual_Review,3,1995916350,1809122260,207RN0300X,Nephrology,11,In_Network,L70.0,K21.0|OTHER,97110,,0,Medicare_Advantage,MA_HMO,26,F,0.9164,,,633.55,276.5,203.06,5.67,17.0,50.77,357.05,0.0,0.0,0,,0.0426,none,0,1,0,0,0,1.9e-05,0,0,FUM_Follow_Up_ED_Mental_Health,Bundled_Payment
CLM0000004097,MBR00000188,Medical_Institutional,Paid,Electronic_EDI,2023-10-21,2023-10-21,2023-10-25,2023-11-05,Auto_Adjudicated,15,1034130209,1542515060,2084P0800X,Psychiatry,65,In_Network,OTHER,Z12.11,revenue_code:0360,,0,Commercial,HMO,8,F,1.5853,,,21376.43,12859.98,10241.34,12.31,46.0,2560.33,8516.45,6337.97,3163.56,0,,0.0654,temporal_clustering,0,1,1,0,0,0.000948,0,0,,FFS
CLM0000004098,MBR00000136,Medical_Institutional,Paid,Paper,2023-06-24,2023-06-24,2023-06-25,2023-07-04,Auto_Adjudicated,10,1139362508,1304018750,207RG0100X,Gastroenterology,11,In_Network,Z00.01,F32.9,revenue_code:0100,,0,Commercial,POS,2,F,1.2611,,,11010.99,4140.66,3111.91,178.77,72.0,777.98,6870.33,0.0,0.0,0,,0.0085,none,0,1,0,1,0,0.000288,0,0,,Shared_Savings
CLM0000004099,MBR00000135,Medical_Institutional,Paid,Electronic_EDI,2023-11-29,2023-11-29,2023-12-03,2023-12-08,Manual_Review,9,1403662694,1039962073,207Q00000X,Family Medicine,23,In_Network,I10,M54.5,revenue_code:0360,,0,Commercial,PPO,58,F,2.2702,,,196870.08,137585.17,110020.23,0.89,59.0,27505.06,59284.91,0.0,0.0,0,,0.1832,outlier_billing_amount,0,1,1,0,0,0.010183,0,0,,FFS
CLM0000004100,MBR00000231,Vision,Denied,Electronic_EDI,2023-01-01,2023-01-01,2023-01-01,2023-01-16,Auto_Adjudicated,15,1886537420,1579331190,225100000X,Physical Therapist,11,In_Network,G47.33,,V2320,,0,ACA_Marketplace,ACA_Silver,12,M,0.6456,170,COB,149.27,118.24,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.023,none,0,1,0,0,0,0.0,0,0,CBP_Controlling_BP,FFS
CLM0000004101,MBR00000095,Medical_Professional,Paid,Electronic_EDI,2023-12-03,2023-12-03,2023-12-03,2023-12-13,Auto_Adjudicated,10,1671999102,1469697158,101YP2500X,Psychologist Clinical,81,In_Network,M54.5,,83036,,0,Commercial,HMO,28,M,0.5827,,,2017.32,903.67,670.02,44.14,22.0,167.51,1113.65,0.0,0.0,0,,0.1886,upcoding_pattern,0,1,0,0,0,6.2e-05,0,0,,Shared_Savings
CLM0000004102,MBR00000186,Dental,Paid,Provider_Portal,2023-08-26,2023-08-26,2023-08-26,2023-09-18,Auto_Adjudicated,23,1888245409,1220755708,207V00000X,Obstetrics & Gynecology,23,In_Network,I50.9,OTHER|K21.0|F41.1,D0120,,0,Commercial,PPO,65,M,1.6983,,,90.06,53.81,0.0,53.81,0.0,0.0,36.25,0.0,0.0,0,,0.1174,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004103,MBR00000270,Pharmacy,Paid,Provider_Portal,2023-09-09,2023-09-09,2023-09-09,2023-09-15,Clinical_Review,6,1636337876,1672803287,207RE0101X,Endocrinology,11,In_Network,I10,,50458085930,,3,Commercial,POS,1,F,1.6363,,,17.82,14.08,0.0,14.08,0.0,0.0,3.74,0.0,0.0,0,,0.1494,geographic_mismatch|unbundling_pattern,0,1,0,0,0,0.0,0,1,,FFS
CLM0000004104,MBR00000068,Pharmacy,Paid,Electronic_EDI,2023-04-14,2023-04-14,2023-04-14,2023-05-11,Auto_Adjudicated,27,1474985672,1368666316,207RC0000X,Cardiovascular Disease,65,In_Network,OTHER,F41.1|K57.30,00006001954,,2,Medicare_Advantage,MA_HMO,28,F,0.8494,,,187.79,145.77,101.91,10.38,8.0,25.48,42.02,0.0,0.0,0,,0.195,benford_violation,0,1,0,0,0,9e-06,0,0,POD_Persistence_of_Beta_Blocker,Shared_Savings
CLM0000004105,MBR00000185,Medical_Institutional,Paid,Provider_Portal,2023-01-29,2023-01-29,2023-01-31,2023-02-09,Clinical_Review,11,1273835569,1625992541,207RG0100X,Gastroenterology,11,In_Network,M54.5,J20.9,revenue_code:0250,,0,Medicaid_MCO,MCO,73,M,1.5417,,,23295.44,17261.38,17253.38,0.0,8.0,0.0,6034.06,0.0,0.0,0,,0.0883,none,0,1,1,0,0,0.001597,0,0,,FFS
CLM0000004106,MBR00000287,Medical_Professional,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-25,2023-04-10,Manual_Review,16,1900799244,1128148362,207RN0300X,Nephrology,65,In_Network,J06.9,K21.0,82947,,0,Commercial,PPO,4,M,0.7685,,,1844.62,817.71,553.94,99.29,26.0,138.48,1026.91,0.0,0.0,0,,0.0156,none,0,1,0,0,0,5.1e-05,0,0,,FFS
CLM0000004107,MBR00000161,Dental,Denied,Electronic_EDI,2023-06-08,2023-06-08,2023-06-08,2023-06-14,Auto_Adjudicated,6,1756856314,1297948643,207RG0100X,Gastroenterology,11,In_Network,I10,R05.9,D2140,,0,Medicaid_MCO,MLTSS,9,F,0.8354,PR-1,Duplicate,918.69,522.28,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0715,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004108,MBR00000294,Pharmacy,Partially_Paid,Electronic_EDI,2023-05-02,2023-05-02,2023-05-02,2023-05-30,Auto_Adjudicated,28,1484438840,1538261819,2086S0122X,Orthopedic Surgery,11,In_Network,E11.9,M79.3,16590051660,,2,Medicare_Advantage,MA_HMO,8,M,0.6878,1,Medical_Necessity,211.23,177.78,62.61,10.16,18.0,15.65,104.81,0.0,0.0,0,,0.0309,none,0,1,0,0,0,6e-06,0,0,,P4P
CLM0000004109,MBR00000098,Pharmacy,Paid,Electronic_EDI,2023-03-11,2023-03-11,2023-03-11,2023-03-31,Auto_Adjudicated,20,1078576574,1685903362,207RN0300X,Nephrology,11,Emergency,J44.1,C50.911,00085163102,,1,Medicare_Advantage,MA_HMO,7,M,0.511,,,268.18,126.32,85.84,0.03,19.0,21.46,141.86,0.0,0.0,0,,0.0528,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000004110,MBR00000170,Medical_Professional,Paid,Electronic_EDI,2023-01-05,2023-01-05,2023-01-05,2023-01-29,Auto_Adjudicated,24,1539066691,1986847322,207RN0300X,Nephrology,23,In_Network,I25.10,F32.9,99213,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,316.17,131.74,96.04,8.69,3.0,24.01,184.43,0.0,0.0,0,,0.0025,none,0,1,0,1,0,9e-06,0,0,,Shared_Savings
CLM0000004111,MBR00000099,Medical_Institutional,Paid,Electronic_EDI,2023-09-08,2023-09-08,2023-09-09,2023-10-05,Auto_Adjudicated,27,1887698203,1896197144,2084P0800X,Psychiatry,24,In_Network,OTHER,OTHER|I25.10,revenue_code:0120,,0,Commercial,HMO,10,F,0.7843,,,47382.59,26373.1,20881.95,219.66,51.0,5220.49,21009.49,0.0,0.0,0,,0.0479,none,0,1,1,0,0,0.001933,0,0,,FFS
CLM0000004112,MBR00000002,Medical_Institutional,Paid,Electronic_EDI,2023-08-28,2023-08-28,2023-08-28,2023-09-27,Auto_Adjudicated,30,1156265220,1300957944,207RN0300X,Nephrology,23,In_Network,Z79.4,OTHER|F32.9,revenue_code:0200,,0,Commercial,PPO,42,F,0.9012,,,3947.25,1679.88,1270.9,55.25,36.0,317.73,2267.37,0.0,0.0,0,,0.1249,none,0,1,0,0,0,0.000118,0,0,,Bundled_Payment
CLM0000004113,MBR00000300,Medical_Institutional,Paid,Electronic_EDI,2023-02-27,2023-02-27,2023-03-03,2023-03-07,Auto_Adjudicated,8,1356408757,1040061910,207RC0000X,Cardiovascular Disease,11,Emergency,K21.0,,revenue_code:0450,,0,Commercial,PPO,64,F,1.0393,,,6596.93,3861.77,3018.84,40.22,48.0,754.71,2735.16,0.0,0.0,0,,0.0601,none,0,1,0,0,0,0.000279,0,0,MMA_Medication_Management,Capitation
CLM0000004114,MBR00000075,Pharmacy,Paid,Provider_Portal,2023-10-09,2023-10-09,2023-10-09,2023-10-19,Clinical_Review,10,1710668368,1809122260,246ZN0300X,Neuropsychology,21,In_Network,OTHER,,00003014960,,3,Medicaid_MCO,MCO,5,M,1.0573,,,357.05,235.5,231.5,0.0,4.0,0.0,121.55,0.0,0.0,0,,0.02,none,0,1,0,0,0,2.1e-05,0,0,,FFS
CLM0000004115,MBR00000293,Medical_Professional,Paid,Electronic_EDI,2023-12-17,2023-12-17,2023-12-17,2023-12-25,Auto_Adjudicated,8,1397401856,1789540567,2086S0122X,Orthopedic Surgery,22,Out_of_Network,Z00.00,J06.9|N39.0,71250,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,1358.2,743.67,567.63,23.13,11.0,141.91,614.53,0.0,0.0,0,,0.0377,none,0,1,0,0,0,5.3e-05,1,0,TRC_Transition_of_Care,FFS
CLM0000004116,MBR00000194,Medical_Professional,Paid,Paper,2023-12-25,2023-12-25,2023-12-25,2024-01-10,Auto_Adjudicated,16,1522998767,1396850418,207RN0300X,Nephrology,21,In_Network,Z87.891,,97110,,0,Commercial,PPO,77,M,0.9783,,,1667.4,794.34,591.01,37.58,18.0,147.75,873.06,0.0,0.0,0,,0.0629,none,0,1,0,0,0,5.5e-05,0,0,PPC_Prenatal_Care,P4P
CLM0000004117,MBR00000274,Medical_Professional,Denied,Electronic_EDI,2023-03-11,2023-03-11,2023-03-11,2023-04-07,Auto_Adjudicated,27,1641779816,1704466150,207RG0100X,Gastroenterology,21,Out_of_Network,J20.9,I25.10|M54.5,43239,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,170,Coding_Error,618.69,358.96,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0043,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000004118,MBR00000293,Medical_Professional,Paid,Electronic_EDI,2023-06-03,2023-06-03,2023-06-03,2023-06-26,Auto_Adjudicated,23,1965812565,1809122260,207R00000X,Internal Medicine,22,Out_of_Network,E11.9,,99205,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,218.27,162.69,87.08,42.84,11.0,21.77,55.58,0.0,0.0,0,,0.122,provider_specialty_mismatch,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000004119,MBR00000170,Medical_Professional,Paid,Electronic_EDI,2023-01-19,2023-01-19,2023-01-19,2023-02-06,Auto_Adjudicated,18,1855186422,1591405274,207RN0300X,Nephrology,22,In_Network,M79.3,,83036,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,2314.37,1756.18,1397.0,6.93,3.0,349.25,558.19,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|benford_violation|unbundling_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,1,0,0.000129,0,0,ACR_Urine_Protein,FFS
CLM0000004120,MBR00000300,Medical_Professional,Denied,Electronic_EDI,2023-01-05,2023-01-05,2023-01-05,2023-01-20,Manual_Review,15,1733777382,1396850418,207RN0300X,Nephrology,23,In_Network,OTHER,,99282,,0,Commercial,PPO,64,F,1.0393,5,Network,644.15,227.44,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1132,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000004121,MBR00000226,Medical_Professional,Paid,Electronic_EDI,2023-10-30,2023-10-30,2023-10-30,2023-11-21,Auto_Adjudicated,22,1856989511,1705448933,207Q00000X,Family Medicine,11,In_Network,J06.9,,99231,,0,Medicare_Advantage,MA_PPO,84,M,1.0796,,,217.75,81.11,54.78,2.64,10.0,13.69,136.64,0.0,0.0,0,,0.1104,none,0,1,0,1,0,5e-06,0,0,,FFS
CLM0000004122,MBR00000160,Pharmacy,Paid,Electronic_EDI,2023-12-14,2023-12-14,2023-12-14,2023-12-29,Auto_Adjudicated,15,1091271799,1123879500,207RE0101X,Endocrinology,65,In_Network,M79.3,Z00.121|K21.0,00169751112,,1,Commercial,HMO,73,M,1.9608,,,144.26,116.65,0.0,116.65,0.0,0.0,27.61,0.0,0.0,0,,0.0764,none,0,1,0,0,0,0.0,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000004123,MBR00000195,Pharmacy,Paid,Paper,2023-03-14,2023-03-14,2023-03-14,2023-04-10,Clinical_Review,27,1769163673,1509799493,207RN0300X,Nephrology,31,In_Network,K21.0,G47.33,00085163102,,3,Commercial,PPO,13,F,0.5967,,,328.32,152.31,58.14,66.64,13.0,14.53,176.01,0.0,0.0,0,,0.0963,provider_specialty_mismatch,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000004124,MBR00000060,Medical_Professional,Paid,Electronic_EDI,2023-06-16,2023-06-16,2023-06-16,2023-07-03,Manual_Review,17,1549436467,1493836023,2084P0800X,Psychiatry,24,In_Network,Z12.11,E78.5|F41.1|J06.9,99203,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,194.74,107.72,0.0,107.72,0.0,0.0,87.02,0.0,0.0,0,,0.0823,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004125,MBR00000004,Medical_Professional,Paid,Electronic_EDI,2023-01-09,2023-01-09,2023-01-09,2023-01-29,Auto_Adjudicated,20,1098094939,1105733833,207R00000X,Internal Medicine,24,In_Network,M54.5,Z23,74178,,0,Medicare_Advantage,MA_PPO,68,M,1.23,,,290.75,118.11,44.24,54.81,8.0,11.06,172.64,31.86,7.14,0,,0.1334,none,0,1,0,1,0,4e-06,0,0,,FFS
CLM0000004126,MBR00000080,Pharmacy,Paid,Electronic_EDI,2023-10-20,2023-10-20,2023-10-20,2023-11-10,Auto_Adjudicated,21,1145498455,1228356980,246ZN0300X,Neuropsychology,22,In_Network,E11.9,K57.30|I10,00169751112,,1,Commercial,HDHP_HSA,74,M,0.5935,,,452.67,234.15,0.0,234.15,0.0,0.0,218.52,0.0,0.0,0,,0.1112,none,0,1,0,0,0,0.0,0,1,AMR_Asthma_Medication_Ratio,Shared_Savings
CLM0000004127,MBR00000136,Medical_Professional,Denied,Electronic_EDI,2023-07-16,2023-07-16,2023-07-16,2023-08-08,Auto_Adjudicated,23,1682685390,1301833092,2086S0122X,Orthopedic Surgery,71,In_Network,E11.9,E11.9|J06.9,99284,,0,Commercial,POS,2,F,1.2611,256,Timely_Filing,166.21,121.43,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1898,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,SPD_Spirometry_Testing,FFS
CLM0000004128,MBR00000071,Medical_Professional,Paid,Electronic_EDI,2023-04-15,2023-04-15,2023-04-15,2023-04-30,Manual_Review,15,1344162462,1408846353,2084P0800X,Psychiatry,21,In_Network,OTHER,E78.5,12001,,0,Commercial,EPO,19,F,0.5699,,,779.66,293.54,207.27,12.45,22.0,51.82,486.12,0.0,0.0,0,,0.1689,provider_specialty_mismatch,0,1,0,0,0,1.9e-05,0,0,,FFS
CLM0000004129,MBR00000158,Medical_Institutional,Paid,Electronic_EDI,2023-12-14,2023-12-14,2023-12-17,2023-12-26,Auto_Adjudicated,12,1210349885,1354959095,207V00000X,Obstetrics & Gynecology,21,In_Network,M54.5,I10|OTHER,revenue_code:0210,871,0,Commercial,HMO,65,M,1.5361,,,12234.66,7024.98,5561.08,23.64,50.0,1390.27,5209.68,0.0,0.0,0,,0.1571,high_volume_same_code,0,1,1,0,0,0.000515,0,0,,Capitation
CLM0000004130,MBR00000196,Vision,Paid,Electronic_EDI,2023-02-18,2023-02-18,2023-02-18,2023-03-03,Manual_Review,13,1590338573,1228356980,2084P0800X,Psychiatry,31,In_Network,N39.0,I10,V2115,,0,Commercial,PPO,16,F,1.6015,,,108.32,71.26,0.0,71.26,0.0,0.0,37.06,0.0,0.0,0,,0.0793,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004131,MBR00000195,Medical_Professional,Paid,Paper,2023-04-07,2023-04-07,2023-04-07,2023-05-06,Auto_Adjudicated,29,1262622669,1791502603,207R00000X,Internal Medicine,32,Out_of_Network,E11.9,M79.3,99396,,0,Commercial,PPO,13,F,0.5967,,,165.91,81.84,35.58,24.36,13.0,8.9,84.07,0.0,0.0,0,,0.0436,none,0,1,0,0,0,3e-06,1,0,,Shared_Savings
CLM0000004132,MBR00000271,Vision,Paid,Electronic_EDI,2023-09-26,2023-09-26,2023-09-26,2023-09-30,Auto_Adjudicated,4,1389116733,1354265777,207V00000X,Obstetrics & Gynecology,22,In_Network,E11.9,K21.0,92012,,0,Medicaid_MCO,MCO,4,F,0.6696,,,334.32,254.29,254.29,0.0,0.0,0.0,80.03,0.0,0.0,0,,0.1869,upcoding_pattern,0,1,0,0,0,2.4e-05,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000004133,MBR00000293,Medical_Professional,Denied,Electronic_EDI,2023-05-27,2023-05-27,2023-05-27,2023-06-18,Auto_Adjudicated,22,1986485249,1540743888,101YP2500X,Psychologist Clinical,31,In_Network,J44.1,I10,12001,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,170,Medical_Necessity,1540.81,542.11,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1588,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004134,MBR00000270,Medical_Professional,Paid,Electronic_EDI,2023-09-09,2023-09-09,2023-09-09,2023-10-08,Auto_Adjudicated,29,1273835569,1591405274,101YP2500X,Psychologist Clinical,23,In_Network,I25.10,,90853,,0,Commercial,POS,1,F,1.6363,,,381.26,214.87,0.0,214.87,0.0,0.0,166.39,0.0,0.0,0,,0.1983,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004135,MBR00000185,Medical_Professional,Paid,Provider_Portal,2023-03-27,2023-03-27,2023-03-27,2023-03-30,Manual_Review,3,1154652946,1114756459,207RP1001X,Pulmonary Disease,21,In_Network,M17.11,M54.5,17000,,0,Medicaid_MCO,MCO,73,M,1.5417,,,349.6,271.29,268.29,0.0,3.0,0.0,78.31,0.0,0.0,0,,0.1214,none,0,1,0,0,0,2.5e-05,0,0,,Shared_Savings
CLM0000004136,MBR00000062,Pharmacy,Denied,Electronic_EDI,2023-08-25,2023-08-25,2023-08-25,2023-09-13,Auto_Adjudicated,19,1760186113,1325999602,207RC0000X,Cardiovascular Disease,65,In_Network,M47.816,Z00.01|J06.9|OTHER,59148001506,,3,Commercial,HMO,46,F,0.5516,1,Medical_Necessity,298.28,121.8,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0335,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004137,MBR00000286,Medical_Institutional,Denied,Electronic_EDI,2023-07-20,2023-07-20,2023-07-23,2023-08-07,Auto_Adjudicated,18,1924450526,1705448933,207RE0101X,Endocrinology,22,In_Network,Z79.4,Z12.11|E11.65,revenue_code:0360,,0,Medicare_Advantage,PFFS,40,F,1.2751,18,Timely_Filing,24694.08,11013.56,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0533,none,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,FFS
CLM0000004138,MBR00000055,Medical_Institutional,Paid,Electronic_EDI,2023-01-17,2023-01-17,2023-01-20,2023-01-28,Auto_Adjudicated,11,1067329999,1151295616,207RN0300X,Nephrology,31,In_Network,E11.9,I10|OTHER,revenue_code:0370,,0,Commercial,PPO,68,F,1.2896,,,27813.63,18846.4,14900.04,147.35,74.0,3725.01,8967.23,0.0,0.0,0,,0.1708,controlled_substance_high_volume,0,1,1,1,0,0.001379,0,0,,FFS
CLM0000004139,MBR00000048,Vision,Paid,Electronic_EDI,2023-04-26,2023-04-26,2023-04-26,2023-04-29,Auto_Adjudicated,3,1520692162,1461075342,207Q00000X,Family Medicine,24,In_Network,Z00.00,M54.5|I10,V2103,,0,Commercial,POS,27,F,0.639,,,312.68,158.61,26.0,101.11,25.0,6.5,154.07,0.0,0.0,0,,0.0656,none,0,1,0,0,0,2e-06,0,0,,FFS
CLM0000004140,MBR00000100,Medical_Institutional,Paid,Electronic_EDI,2023-04-17,2023-04-17,2023-04-18,2023-05-08,Auto_Adjudicated,21,1618564043,1029818813,207RC0000X,Cardiovascular Disease,11,In_Network,E78.5,J06.9|OTHER,revenue_code:0210,,0,ACA_Marketplace,ACA_Gold,87,M,1.435,,,7444.52,3524.87,2770.64,2.57,59.0,692.66,3919.65,2465.26,161.78,0,,0.0296,none,0,1,0,0,0,0.000256,0,0,,FFS
CLM0000004141,MBR00000173,Medical_Professional,Paid,Electronic_EDI,2023-08-01,2023-08-01,2023-08-01,2023-08-17,Auto_Adjudicated,16,1218947226,1282319940,207RN0300X,Nephrology,32,In_Network,K21.0,Z79.4|Z00.01,99387,,0,Medicare_Advantage,PFFS,23,F,1.0279,,,414.32,253.17,187.57,4.71,14.0,46.89,161.15,0.0,0.0,0,,0.1363,none,0,1,0,0,0,1.7e-05,0,0,,FFS
CLM0000004142,MBR00000202,Pharmacy,Denied,Electronic_EDI,2023-06-07,2023-06-07,2023-06-07,2023-06-30,Auto_Adjudicated,23,1076251878,1105733833,208600000X,Surgery General,11,In_Network,E11.9,I10,00078043215,,1,Commercial,PPO,87,F,0.6213,22,Coding_Error,168.31,112.1,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0799,none,0,1,0,0,0,0.0,0,1,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000004143,MBR00000004,Medical_Professional,Denied,Electronic_EDI,2023-06-21,2023-06-21,2023-06-21,2023-06-24,Auto_Adjudicated,3,1374847145,1039962073,246ZN0300X,Neuropsychology,31,In_Network,F41.1,OTHER|Z00.01|E78.5,99222,,0,Medicare_Advantage,MA_PPO,68,M,1.23,170,Authorization,391.62,277.09,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1378,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004144,MBR00000229,Medical_Institutional,Paid,Electronic_EDI,2023-03-02,2023-03-02,2023-03-02,2023-03-31,Auto_Adjudicated,29,1310250833,1965244699,207Q00000X,Family Medicine,24,In_Network,Z00.00,Z00.00,revenue_code:0360,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,7523.26,4070.56,3205.25,9.99,54.0,801.31,3452.7,2705.88,439.24,0,,0.0545,none,0,1,0,0,0,0.000297,0,0,,FFS
CLM0000004145,MBR00000055,Dental,Paid,Electronic_EDI,2023-11-30,2023-11-30,2023-11-30,2023-12-19,Auto_Adjudicated,19,1192302048,1643673796,207R00000X,Internal Medicine,24,In_Network,F41.1,I10,D0150,,0,Commercial,PPO,68,F,1.2896,,,308.58,198.9,24.28,158.55,10.0,6.07,109.68,0.0,0.0,0,,0.0658,none,0,1,0,0,0,2e-06,0,0,,Capitation
CLM0000004146,MBR00000092,Medical_Institutional,Paid,Electronic_EDI,2023-09-27,2023-09-27,2023-09-30,2023-10-11,Auto_Adjudicated,14,1956215244,1188760037,207RG0100X,Gastroenterology,65,In_Network,J06.9,I10,revenue_code:0370,,0,Medicaid_MCO,MLTSS,68,F,1.3217,,,19429.01,15717.31,15708.31,0.0,9.0,0.0,3711.7,0.0,0.0,0,,0.0406,none,0,1,1,0,0,0.001454,0,0,COA_Care_Transitions,Shared_Savings
CLM0000004147,MBR00000102,Medical_Professional,Denied,Electronic_EDI,2023-08-29,2023-08-29,2023-08-29,2023-09-12,Auto_Adjudicated,14,1555292468,1388050552,207RE0101X,Endocrinology,22,In_Network,OTHER,,99396,,0,Commercial,POS,68,M,1.6864,170,Eligibility,175.47,144.8,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Kickback Arrangement,1.0,unusual_service_frequency|provider_specialty_mismatch|high_volume_same_code|service_date_weekend|billing_spike_recent|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|controlled_substance_high_volume,1,5,0,0,0,0.0,0,0,IET_Initiation_Substance_Use,Shared_Savings
CLM0000004148,MBR00000105,Medical_Institutional,Paid,Electronic_EDI,2023-04-09,2023-04-09,2023-04-10,2023-05-08,Auto_Adjudicated,29,1774425033,1391074619,207RE0101X,Endocrinology,21,In_Network,OTHER,,revenue_code:0360,291,0,Commercial,HMO,74,M,1.1834,,,11468.06,7640.68,5687.2,481.68,50.0,1421.8,3827.38,0.0,0.0,0,,0.0171,none,0,1,1,0,1,0.000526,0,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000004149,MBR00000224,Medical_Professional,Paid,Electronic_EDI,2023-09-03,2023-09-03,2023-09-03,2023-09-20,Auto_Adjudicated,17,1505049857,1020312030,207RP1001X,Pulmonary Disease,22,In_Network,OTHER,K21.0|Z00.00|N40.0,99285,,0,Medicaid_MCO,MCO,86,F,1.3289,,,68.42,42.35,39.35,0.0,3.0,0.0,26.07,0.0,0.0,0,,0.1136,temporal_clustering,0,1,0,0,0,4e-06,0,0,,P4P
CLM0000004150,MBR00000013,Medical_Professional,Paid,Provider_Portal,2023-03-26,2023-03-26,2023-03-26,2023-04-13,Auto_Adjudicated,18,1897231867,1995553359,225100000X,Physical Therapist,23,In_Network,G47.33,Z23,90853,,0,Commercial,PPO,64,F,1.428,,,1533.01,1105.62,828.59,56.89,13.0,207.15,427.39,0.0,0.0,1,Identity Theft,1.0,outlier_billing_amount|unusual_service_frequency|high_volume_same_code|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,7.7e-05,0,0,AWV_Annual_Wellness_Visit,Bundled_Payment
CLM0000004151,MBR00000060,Medical_Institutional,Paid,Electronic_EDI,2023-06-24,2023-06-24,2023-06-27,2023-07-14,Auto_Adjudicated,20,1315569619,1554490060,208600000X,Surgery General,21,In_Network,OTHER,,revenue_code:0300,193,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,4696.51,3777.25,920.89,2242.43,0.0,613.93,919.26,0.0,0.0,0,,0.1168,none,0,1,0,0,0,8.5e-05,0,0,,FFS
CLM0000004152,MBR00000007,Medical_Professional,Paid,Electronic_EDI,2023-04-07,2023-04-07,2023-04-07,2023-04-17,Auto_Adjudicated,10,1557212800,1005335812,207RN0300X,Nephrology,11,In_Network,I10,Z23|OTHER|M54.5,99395,,0,Commercial,HDHP_HSA,72,F,0.7578,,,745.22,344.68,32.24,304.38,0.0,8.06,400.54,0.0,0.0,0,,0.0952,none,0,1,0,0,0,3e-06,0,0,,Shared_Savings
CLM0000004153,MBR00000229,Medical_Professional,Paid,Paper,2023-04-19,2023-04-19,2023-04-19,2023-04-27,Auto_Adjudicated,8,1732193518,1564691686,2084P0800X,Psychiatry,22,In_Network,N39.0,Z00.00|Z23|F32.9,81001,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,1167.8,626.31,455.98,42.34,14.0,113.99,541.49,0.0,0.0,0,,0.1193,none,0,1,0,0,0,4.2e-05,0,0,,FFS
CLM0000004154,MBR00000296,Medical_Institutional,Paid,Electronic_EDI,2023-08-22,2023-08-22,2023-08-26,2023-09-14,Auto_Adjudicated,23,1210349885,1228356980,246ZN0300X,Neuropsychology,65,In_Network,J45.20,F32.9|M54.5,revenue_code:0250,,0,Commercial,HMO,83,F,1.4969,,,10409.82,3759.01,2821.48,189.16,43.0,705.37,6650.81,0.0,0.0,0,,0.1104,none,0,1,0,1,0,0.000261,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000004155,MBR00000196,Medical_Institutional,Denied,Electronic_EDI,2023-04-23,2023-04-23,2023-04-26,2023-05-03,Manual_Review,10,1451329728,1945682535,208600000X,Surgery General,23,Out_of_Network,F41.1,,revenue_code:0450,,0,Commercial,PPO,16,F,1.6015,22,Medical_Necessity,12602.83,10506.25,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0411,none,0,1,0,0,0,0.0,1,0,,P4P
CLM0000004156,MBR00000177,Medical_Professional,Paid,Electronic_EDI,2023-09-20,2023-09-20,2023-09-20,2023-09-22,Clinical_Review,2,1642333103,1938465393,207RC0000X,Cardiovascular Disease,65,In_Network,E11.9,,99212,,0,Commercial,HMO,42,F,1.2774,,,320.0,242.82,96.72,94.93,27.0,24.18,77.18,0.0,0.0,0,,0.1276,none,0,1,0,0,0,9e-06,0,0,CDC_BP_Control,Capitation
CLM0000004157,MBR00000274,Behavioral_Health,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-15,Auto_Adjudicated,15,1923937825,1666461892,2086S0122X,Orthopedic Surgery,22,In_Network,R05.9,J20.9|OTHER,10060,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,97.46,37.84,12.51,22.2,0.0,3.13,59.62,0.0,0.0,0,,0.0661,temporal_clustering,0,1,0,1,0,1e-06,0,0,,P4P
CLM0000004158,MBR00000079,Medical_Professional,Paid,Provider_Portal,2023-12-19,2023-12-19,2023-12-19,2023-12-20,Auto_Adjudicated,1,1484613641,1865266296,207RN0300X,Nephrology,71,Out_of_Network,OTHER,,99202,,0,Medicaid_MCO,MLTSS,55,F,0.5016,,,1042.31,817.7,813.7,0.0,4.0,0.0,224.61,0.0,0.0,0,,0.0848,none,0,1,0,1,0,7.5e-05,1,0,,P4P
CLM0000004159,MBR00000020,Medical_Professional,Paid,Paper,2023-03-10,2023-03-10,2023-03-10,2023-03-27,Auto_Adjudicated,17,1208538971,1622950074,207RC0000X,Cardiovascular Disease,24,In_Network,N39.0,,99204,,0,Medicare_Advantage,MA_PPO,63,F,0.7119,,,286.3,201.47,120.94,44.29,6.0,30.24,84.83,0.0,0.0,0,,0.1839,geographic_mismatch,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000004160,MBR00000157,Dental,Paid,Electronic_EDI,2023-12-06,2023-12-06,2023-12-06,2023-12-26,Manual_Review,20,1590338573,1738617370,207RC0000X,Cardiovascular Disease,21,In_Network,E78.5,,D0150,,0,Medicare_Advantage,MA_HMO,26,F,0.9164,,,1035.89,809.41,629.46,5.59,17.0,157.36,226.48,0.0,0.0,0,,0.1841,phantom_billing_indicator,0,1,0,0,0,5.8e-05,0,0,,FFS
CLM0000004161,MBR00000081,Medical_Professional,Paid,Electronic_EDI,2023-02-17,2023-02-17,2023-02-17,2023-03-17,Auto_Adjudicated,28,1956215244,1433350836,2084P0800X,Psychiatry,22,In_Network,Z00.00,J06.9|N39.0,99396,,0,Medicare_Advantage,SNP,66,F,2.159,,,183.23,142.11,97.34,15.44,5.0,24.33,41.12,0.0,0.0,0,,0.1168,none,0,1,0,0,0,9e-06,0,0,FLU_Flu_Vaccination,Bundled_Payment
CLM0000004162,MBR00000140,Dental,Paid,Paper,2023-07-17,2023-07-17,2023-07-17,2023-08-05,Auto_Adjudicated,19,1961590405,1288028182,207Q00000X,Family Medicine,81,Out_of_Network,Z00.01,OTHER,D2140,,0,Medicare_Advantage,MA_HMO,7,M,1.3997,,,497.69,235.78,167.66,14.21,12.0,41.91,261.91,0.0,0.0,0,,0.1108,none,0,1,0,0,0,1.6e-05,1,0,,Shared_Savings
CLM0000004163,MBR00000142,Pharmacy,Paid,Electronic_EDI,2023-05-14,2023-05-14,2023-05-14,2023-05-25,Manual_Review,11,1137079475,1112696614,207R00000X,Internal Medicine,71,In_Network,OTHER,Z12.11|I10|K21.0,50458085930,,2,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,69.83,34.62,0.0,34.62,0.0,0.0,35.21,0.0,0.0,0,,0.0953,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004164,MBR00000101,Medical_Institutional,Paid,Electronic_EDI,2023-09-28,2023-09-28,2023-09-30,2023-10-18,Manual_Review,20,1263063839,1581533104,207V00000X,Obstetrics & Gynecology,21,In_Network,F41.1,M17.11|OTHER,revenue_code:0370,193,0,Commercial,PPO,83,M,0.3627,,,897.06,465.64,334.03,0.1,48.0,83.51,431.42,0.0,0.0,0,,0.0643,none,0,1,0,0,0,3.1e-05,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000004165,MBR00000151,Medical_Professional,Paid,Electronic_EDI,2023-02-16,2023-02-16,2023-02-16,2023-03-06,Manual_Review,18,1054449469,1623053477,207Q00000X,Family Medicine,31,In_Network,E11.9,OTHER|Z12.11|E11.9,99387,,0,Medicare_Advantage,MA_HMO,77,M,0.8709,,,440.08,307.05,229.06,14.72,6.0,57.27,133.03,0.0,0.0,0,,0.0637,none,0,1,0,0,0,2.1e-05,0,0,,FFS
CLM0000004166,MBR00000120,Medical_Professional,Paid,Electronic_EDI,2023-04-02,2023-04-02,2023-04-02,2023-04-25,Auto_Adjudicated,23,1886537420,1408846353,207RN0300X,Nephrology,65,Out_of_Network,OTHER,,99386,,0,Commercial,PPO,62,F,1.0823,,,308.67,209.88,0.0,196.08,13.8,0.0,98.79,0.0,0.0,0,,0.205,geographic_mismatch,0,2,0,1,0,0.0,0,0,,FFS
CLM0000004167,MBR00000035,Pharmacy,Denied,Electronic_EDI,2023-03-24,2023-03-24,2023-03-24,2023-04-21,Auto_Adjudicated,28,1618564043,1847196500,101YP2500X,Psychologist Clinical,11,In_Network,K21.0,K21.0,50458085930,,2,ACA_Marketplace,ACA_Platinum,46,M,0.6598,170,Duplicate,117.77,69.96,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.016,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004168,MBR00000262,Medical_Professional,Paid,Electronic_EDI,2023-11-27,2023-11-27,2023-11-27,2023-11-30,Auto_Adjudicated,3,1199465234,1591405274,207RC0000X,Cardiovascular Disease,22,In_Network,OTHER,M54.5|OTHER,99397,,0,Medicare_Advantage,PFFS,77,F,1.7452,,,51.79,32.22,22.13,0.56,4.0,5.53,19.57,0.0,0.0,0,,0.1402,none,0,1,0,0,0,2e-06,0,0,,Shared_Savings
CLM0000004169,MBR00000208,Pharmacy,Paid,Electronic_EDI,2023-07-12,2023-07-12,2023-07-12,2023-08-03,Auto_Adjudicated,22,1863796345,1391074619,207Q00000X,Family Medicine,24,In_Network,OTHER,Z00.01|M17.11|Z12.11,50458085930,,2,Medicare_Advantage,MA_HMO,66,M,2.1466,,,123.53,71.09,42.17,12.37,6.0,10.54,52.44,0.0,0.0,0,,0.0115,none,0,1,0,0,0,4e-06,0,1,,Shared_Savings
CLM0000004170,MBR00000013,Pharmacy,Paid,Electronic_EDI,2023-02-28,2023-02-28,2023-02-28,2023-03-25,Manual_Review,25,1918578486,1061113875,207RE0101X,Endocrinology,11,In_Network,N40.0,OTHER,59148001506,,1,Commercial,PPO,64,F,1.428,,,224.04,114.81,37.08,55.46,13.0,9.27,109.23,0.0,0.0,0,,0.056,none,0,1,0,0,0,3e-06,0,0,,FFS
CLM0000004171,MBR00000036,Pharmacy,Paid,Electronic_EDI,2023-10-11,2023-10-11,2023-10-11,2023-10-21,Manual_Review,10,1451329728,1402472115,207Q00000X,Family Medicine,24,In_Network,OTHER,J44.1,00085163102,,3,Commercial,EPO,17,M,2.0136,,,76.03,57.56,0.0,57.56,0.0,0.0,18.47,0.0,0.0,0,,0.1176,none,0,1,0,0,0,0.0,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000004172,MBR00000028,Medical_Professional,Paid,Electronic_EDI,2023-04-13,2023-04-13,2023-04-13,2023-04-26,Auto_Adjudicated,13,1881170383,1978943761,207RN0300X,Nephrology,11,In_Network,OTHER,Z00.00,83036,,0,Commercial,HMO,3,F,2.116,,,712.86,453.14,167.61,229.63,14.0,41.9,259.72,0.0,0.0,0,,0.0606,none,0,1,0,0,0,1.6e-05,0,0,MMA_Medication_Management,FFS
CLM0000004173,MBR00000018,Pharmacy,Paid,Electronic_EDI,2023-03-22,2023-03-22,2023-03-22,2023-04-04,Manual_Review,13,1097563011,1061149198,225100000X,Physical Therapist,22,In_Network,I10,I50.9|F41.1,00078043215,,1,Commercial,EPO,5,F,0.5555,,,108.33,79.39,43.62,10.87,14.0,10.9,28.94,0.0,0.0,0,,0.0646,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000004174,MBR00000017,Pharmacy,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-27,2023-07-09,Auto_Adjudicated,12,1015411732,1356856197,246ZN0300X,Neuropsychology,21,In_Network,J06.9,,00071015523,,4,Commercial,PPO,55,F,0.6174,,,68.83,29.57,0.0,29.57,0.0,0.0,39.26,0.0,0.0,0,,0.0256,none,0,1,0,1,0,0.0,0,1,,FFS
CLM0000004175,MBR00000050,Medical_Professional,Paid,Electronic_EDI,2023-10-12,2023-10-12,2023-10-12,2023-11-08,Manual_Review,27,1015096289,1847196500,101YP2500X,Psychologist Clinical,24,In_Network,OTHER,F33.0,99397,,0,Medicare_Advantage,MA_PPO,12,F,0.8486,,,260.77,123.43,92.45,7.86,0.0,23.11,137.34,0.0,0.0,0,,0.0503,none,0,1,0,0,0,9e-06,0,0,,Capitation
CLM0000004176,MBR00000255,Dental,Paid,Electronic_EDI,2023-10-29,2023-10-29,2023-10-29,2023-11-08,Manual_Review,10,1756856314,1296566243,246ZN0300X,Neuropsychology,11,In_Network,R05.9,Z00.01,D4341,,0,Medicare_Advantage,MA_HMO,21,M,0.6945,,,95.21,52.63,21.21,8.11,18.0,5.3,42.58,0.0,0.0,0,,0.1425,none,0,1,0,0,0,2e-06,0,0,,Capitation
CLM0000004177,MBR00000247,Medical_Professional,Paid,Electronic_EDI,2023-01-06,2023-01-06,2023-01-06,2023-01-20,Auto_Adjudicated,14,1321381114,1148659045,246ZN0300X,Neuropsychology,22,In_Network,K21.0,M17.11,99213,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,359.78,166.29,122.53,8.13,5.0,30.63,193.49,0.0,0.0,0,,0.1315,benford_violation,0,1,0,0,0,1.1e-05,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000004178,MBR00000232,Vision,Paid,Provider_Portal,2023-11-19,2023-11-19,2023-11-19,2023-12-07,Auto_Adjudicated,18,1590338573,1355732274,207V00000X,Obstetrics & Gynecology,11,In_Network,OTHER,,92004,,0,Medicaid_MCO,MCO,40,M,1.1083,,,294.11,192.68,190.68,0.0,2.0,0.0,101.43,0.0,0.0,0,,0.0694,high_oop_waiver,0,1,0,1,0,1.8e-05,0,0,,FFS
CLM0000004179,MBR00000184,Medical_Professional,Paid,Electronic_EDI,2023-12-24,2023-12-24,2023-12-24,2024-01-01,Auto_Adjudicated,8,1496489953,1662516615,207RC0000X,Cardiovascular Disease,11,In_Network,M79.3,N39.0,97140,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,992.68,702.02,700.02,0.0,2.0,0.0,290.66,0.0,0.0,0,,0.1077,none,0,1,0,0,0,6.5e-05,0,0,,FFS
CLM0000004180,MBR00000213,Medical_Professional,Paid,Electronic_EDI,2023-04-26,2023-04-26,2023-04-26,2023-05-17,Auto_Adjudicated,21,1321381114,1688513262,207RN0300X,Nephrology,31,In_Network,Z12.11,,97110,,0,Commercial,PPO,17,M,1.5857,,,1432.23,663.88,458.07,63.29,28.0,114.52,768.35,0.0,0.0,0,,0.0548,none,0,1,0,0,0,4.2e-05,0,0,LCS_Lung_Cancer_Screening,Shared_Savings
CLM0000004181,MBR00000216,Pharmacy,Paid,Electronic_EDI,2023-07-05,2023-07-05,2023-07-05,2023-07-21,Auto_Adjudicated,16,1388566092,1706603847,207RP1001X,Pulmonary Disease,11,In_Network,E78.5,,16590051660,,1,Medicare_Advantage,MA_HMO,71,F,0.7117,,,147.05,52.43,30.45,4.37,10.0,7.61,94.62,0.0,0.0,0,,0.0652,none,0,1,0,0,0,3e-06,0,0,,Capitation
CLM0000004182,MBR00000270,Medical_Professional,Denied,Electronic_EDI,2023-05-16,2023-05-16,2023-05-16,2023-05-22,Auto_Adjudicated,6,1550698436,1390802135,101YP2500X,Psychologist Clinical,11,In_Network,OTHER,I10,83036,,0,Commercial,POS,1,F,1.6363,18,Eligibility,99.03,64.7,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0023,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004183,MBR00000214,Medical_Professional,Paid,Electronic_EDI,2023-06-20,2023-06-20,2023-06-20,2023-06-26,Auto_Adjudicated,6,1810800968,1945682535,207RG0100X,Gastroenterology,11,In_Network,OTHER,,99205,,0,Commercial,HDHP_HSA,76,M,1.7526,,,246.27,207.01,0.0,207.01,0.0,0.0,39.26,0.0,0.0,0,,0.0313,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004184,MBR00000215,Medical_Professional,Paid,Electronic_EDI,2023-08-23,2023-08-23,2023-08-23,2023-08-24,Auto_Adjudicated,1,1309817189,1884259357,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,F33.0|OTHER,27130,,0,ACA_Marketplace,ACA_Silver,69,M,0.8895,,,8075.58,4148.07,2858.0,44.21,21.0,1224.86,3927.51,0.0,0.0,0,,0.0859,none,0,1,0,0,0,0.000265,0,0,,FFS
CLM0000004185,MBR00000238,Pharmacy,Paid,Electronic_EDI,2023-08-22,2023-08-22,2023-08-22,2023-09-09,Auto_Adjudicated,18,1976304517,1903401648,207RN0300X,Nephrology,11,In_Network,OTHER,Z00.00,00071015523,,3,Commercial,PPO,74,F,0.4382,,,566.29,377.81,269.19,16.33,25.0,67.3,188.48,0.0,0.0,0,,0.1378,diagnosis_procedure_mismatch,0,1,0,0,0,2.5e-05,0,1,,Shared_Savings
CLM0000004186,MBR00000168,Medical_Professional,Paid,Electronic_EDI,2023-06-20,2023-06-20,2023-06-20,2023-07-15,Auto_Adjudicated,25,1971354640,1847196500,207RP1001X,Pulmonary Disease,22,In_Network,I10,E78.5,99395,,0,Commercial,HMO,76,M,1.2791,,,551.13,206.11,0.0,206.11,0.0,0.0,345.02,0.0,0.0,1,Prescription Drug Diversion,0.9925,outlier_billing_amount|geographic_mismatch|benford_violation|service_date_weekend|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,1,0,0.0,0,0,,Capitation
CLM0000004187,MBR00000065,Medical_Institutional,Denied,Electronic_EDI,2023-06-20,2023-06-20,2023-06-24,2023-07-20,Auto_Adjudicated,30,1476262171,1132693989,207R00000X,Internal Medicine,23,In_Network,Z12.11,,revenue_code:0100,,0,Commercial,HDHP_HSA,63,M,0.7795,1,Coding_Error,105567.18,66971.96,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Medically Unnecessary Services,1.0,outlier_billing_amount|unusual_service_frequency|temporal_clustering|service_date_weekend|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.0,0,0,,FFS
CLM0000004188,MBR00000026,Medical_Institutional,Denied,Electronic_EDI,2023-06-25,2023-06-25,2023-06-27,2023-07-15,Auto_Adjudicated,20,1667149552,1489434038,207RP1001X,Pulmonary Disease,11,In_Network,M54.5,,revenue_code:0250,,0,Medicaid_MCO,MCO,17,M,1.0686,50,Duplicate,12843.78,8091.64,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0338,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004189,MBR00000133,Medical_Institutional,Denied,Electronic_EDI,2023-05-27,2023-05-27,2023-05-29,2023-06-26,Manual_Review,30,1590338573,1055872102,2084P0800X,Psychiatry,11,Emergency,E78.5,M54.5|J20.9,revenue_code:0300,,0,Medicaid_MCO,MCO,57,M,0.9592,18,Eligibility,12431.31,7876.93,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1042,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004190,MBR00000028,Medical_Professional,Paid,Electronic_EDI,2023-02-14,2023-02-14,2023-02-14,2023-03-16,Auto_Adjudicated,30,1639236553,1330485436,207RC0000X,Cardiovascular Disease,21,In_Network,OTHER,,99214,,0,Commercial,HMO,3,F,2.116,,,843.81,500.27,260.28,160.92,14.0,65.07,343.54,0.0,0.0,0,,0.1935,temporal_clustering|service_date_weekend,0,1,0,0,0,2.4e-05,0,0,,FFS
CLM0000004191,MBR00000053,Medical_Professional,Denied,Electronic_EDI,2023-05-14,2023-05-14,2023-05-14,2023-06-02,Manual_Review,19,1501282310,1951488764,207RN0300X,Nephrology,32,In_Network,I10,,99203,,0,Medicaid_MCO,MLTSS,74,F,0.9277,CO-45,COB,527.34,303.36,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1004,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000004192,MBR00000008,Vision,Paid,Electronic_EDI,2023-09-14,2023-09-14,2023-09-14,2023-09-26,Auto_Adjudicated,12,1176378924,1469642907,246ZN0300X,Neuropsychology,11,In_Network,F41.1,K29.70|G47.33,V2320,,0,Medicaid_MCO,MCO,74,M,0.8375,,,164.46,128.68,127.68,0.0,1.0,0.0,35.78,0.0,0.0,0,,0.0935,none,0,1,0,1,0,1.2e-05,0,0,,Shared_Savings
CLM0000004193,MBR00000095,Pharmacy,Paid,Electronic_EDI,2023-12-18,2023-12-18,2023-12-18,2024-01-14,Auto_Adjudicated,27,1496340237,1128148362,207RP1001X,Pulmonary Disease,24,Out_of_Network,OTHER,,50458085930,,1,Commercial,HMO,28,M,0.5827,,,110.43,39.38,0.0,29.86,9.52,0.0,71.05,0.0,0.0,0,,0.083,none,0,1,0,0,0,0.0,1,0,,P4P
CLM0000004194,MBR00000293,Vision,Denied,Electronic_EDI,2023-10-19,2023-10-19,2023-10-19,2023-11-07,Manual_Review,19,1485543430,1581533104,207Q00000X,Family Medicine,71,Out_of_Network,OTHER,F32.9,V2115,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,16,Duplicate,222.04,119.31,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.024,none,0,1,0,0,0,0.0,1,0,,Shared_Savings
CLM0000004195,MBR00000120,Pharmacy,Paid,Electronic_EDI,2023-11-06,2023-11-06,2023-11-06,2023-12-01,Auto_Adjudicated,25,1373899620,1040061910,2084P0800X,Psychiatry,11,In_Network,E78.5,,16590051660,,4,Commercial,PPO,62,F,1.0823,,,93.99,52.48,0.0,52.48,0.0,0.0,41.51,0.0,0.0,0,,0.0201,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000004196,MBR00000076,Pharmacy,Paid,Paper,2023-10-09,2023-10-09,2023-10-09,2023-10-16,Auto_Adjudicated,7,1485543430,1728466420,207RG0100X,Gastroenterology,21,In_Network,Z00.00,,00169751112,,1,Commercial,HMO,26,M,2.1785,,,139.74,106.82,26.07,42.23,32.0,6.52,32.92,0.0,0.0,0,,0.1381,phantom_billing_indicator,0,1,0,0,0,2e-06,0,1,SPD_Spirometry_Testing,FFS
CLM0000004197,MBR00000128,Vision,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-29,Auto_Adjudicated,29,1175252466,1209882852,2086S0122X,Orthopedic Surgery,24,In_Network,Z23,OTHER|J06.9,V2320,,0,Commercial,PPO,13,F,1.4203,,,214.82,117.04,5.43,97.26,13.0,1.36,97.78,0.0,0.0,0,,0.0329,none,0,1,0,0,0,1e-06,0,0,,Bundled_Payment
CLM0000004198,MBR00000095,Medical_Institutional,Denied,Electronic_EDI,2023-09-02,2023-09-02,2023-09-06,2023-09-15,Manual_Review,13,1170257806,1450837722,207RN0300X,Nephrology,65,Out_of_Network,J44.1,OTHER|Z00.00,revenue_code:0250,,0,Commercial,HMO,28,M,0.5827,50,Network,12398.88,4893.11,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1239,duplicate_claim_indicator,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000004199,MBR00000200,Dental,Paid,Electronic_EDI,2023-10-28,2023-10-28,2023-10-28,2023-11-24,Clinical_Review,27,1490172833,1179350099,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,,D7140,,0,Commercial,HDHP_HSA,29,M,0.8011,,,326.62,134.33,3.27,130.24,0.0,0.82,192.29,0.0,0.0,0,,0.154,unbundling_pattern,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004200,MBR00000188,Medical_Professional,Paid,Electronic_EDI,2023-03-22,2023-03-22,2023-03-22,2023-04-03,Manual_Review,12,1456447970,1300957944,207Q00000X,Family Medicine,23,In_Network,N39.0,,99284,,0,Commercial,HMO,8,F,1.5853,,,498.52,204.48,79.22,80.45,25.0,19.81,294.04,0.0,0.0,0,,0.1343,none,0,1,0,0,0,7e-06,0,0,,P4P
CLM0000004201,MBR00000009,Medical_Professional,Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-23,2023-03-22,Manual_Review,27,1464997678,1297948643,246ZN0300X,Neuropsychology,24,In_Network,E78.5,Z00.00,97110,,0,Commercial,HMO,11,F,0.5327,,,381.36,248.62,0.0,248.62,0.0,0.0,132.74,0.0,0.0,0,,0.0734,none,0,1,0,0,0,0.0,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000004202,MBR00000157,Medical_Institutional,Paid,Electronic_EDI,2023-04-06,2023-04-06,2023-04-07,2023-04-27,Auto_Adjudicated,21,1900799244,1068662623,207V00000X,Obstetrics & Gynecology,21,In_Network,E13.9,OTHER,revenue_code:0360,292,0,Medicare_Advantage,MA_HMO,26,F,0.9164,,,2671.55,1643.19,1289.67,3.1,28.0,322.42,1028.36,0.0,0.0,0,,0.0115,none,0,1,0,0,0,0.000119,0,0,,Shared_Savings
CLM0000004203,MBR00000012,Medical_Institutional,Paid,Electronic_EDI,2023-07-10,2023-07-10,2023-07-11,2023-07-17,Auto_Adjudicated,7,1732726112,1318978078,225100000X,Physical Therapist,23,In_Network,Z23,J06.9,revenue_code:0210,,0,Commercial,HMO,84,M,1.3904,,,7698.14,3654.01,2858.8,24.51,56.0,714.7,4044.13,0.0,0.0,0,,0.0972,none,0,1,0,0,0,0.000265,0,0,,P4P
CLM0000004204,MBR00000201,Medical_Institutional,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-10,2023-10-15,Auto_Adjudicated,5,1770431137,1560230600,207RE0101X,Endocrinology,22,In_Network,OTHER,,revenue_code:0370,,0,Medicare_Advantage,MA_PPO,74,M,1.1575,,,6910.14,3071.34,2410.81,11.82,46.0,602.7,3838.8,0.0,0.0,0,,0.0537,none,0,1,0,0,0,0.000223,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000004205,MBR00000283,Medical_Institutional,Paid,Electronic_EDI,2023-06-11,2023-06-11,2023-06-14,2023-06-16,Auto_Adjudicated,5,1333969109,1622950074,207RG0100X,Gastroenterology,65,In_Network,Z00.00,I50.9|Z00.00|OTHER,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,21,M,0.5294,,,122231.18,98368.53,78636.25,33.21,40.0,19659.06,23862.65,0.0,0.0,1,Upcoding,1.0,outlier_billing_amount|unusual_service_frequency|provider_specialty_mismatch|high_volume_same_code|benford_violation|impossible_service_combo|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|phantom_billing_indicator|controlled_substance_high_volume|high_oop_waiver,1,5,1,0,0,0.007279,0,0,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000004206,MBR00000274,Medical_Institutional,Paid,Provider_Portal,2023-12-19,2023-12-19,2023-12-21,2023-12-31,Auto_Adjudicated,12,1954226809,1809122260,207Q00000X,Family Medicine,22,In_Network,Z23,J06.9|I25.10,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,38589.57,24812.06,19785.38,34.33,46.0,4946.35,13777.51,0.0,0.0,0,,0.088,none,0,1,1,0,0,0.001831,0,0,,FFS
CLM0000004207,MBR00000062,Dental,Paid,Electronic_EDI,2023-04-27,2023-04-27,2023-04-27,2023-04-29,Auto_Adjudicated,2,1207676414,1301869102,207RC0000X,Cardiovascular Disease,22,In_Network,Z23,Z00.00|Z00.01,D1110,,0,Commercial,HMO,46,F,0.5516,,,623.58,481.2,364.97,3.98,21.0,91.24,142.38,0.0,0.0,0,,0.0669,none,0,1,0,1,0,3.4e-05,0,0,,Capitation
CLM0000004208,MBR00000217,Medical_Professional,Paid,Electronic_EDI,2023-06-15,2023-06-15,2023-06-15,2023-07-02,Manual_Review,17,1886549972,1029818813,225100000X,Physical Therapist,23,In_Network,J44.1,OTHER|J20.9|Z00.01,83036,,0,ACA_Marketplace,ACA_Bronze,11,F,1.1619,,,163.43,78.82,0.0,78.82,0.0,0.0,84.61,0.0,0.0,0,,0.069,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000004209,MBR00000235,Medical_Professional,Partially_Paid,Electronic_EDI,2023-11-26,2023-11-26,2023-11-26,2023-12-16,Auto_Adjudicated,20,1788188920,1352413270,225100000X,Physical Therapist,11,In_Network,J06.9,,99284,,0,Commercial,HDHP_HSA,85,F,1.4308,22,Medical_Necessity,182.82,107.38,0.0,85.52,0.0,0.0,97.3,0.0,0.0,0,,0.064,none,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000004210,MBR00000262,Pharmacy,Paid,Electronic_EDI,2023-03-03,2023-03-03,2023-03-03,2023-03-26,Manual_Review,23,1356562955,1188760037,101YP2500X,Psychologist Clinical,22,In_Network,Z23,,00069420020,,2,Medicare_Advantage,PFFS,77,F,1.7452,,,54.28,25.97,16.62,1.19,4.0,4.16,28.31,0.0,0.0,0,,0.0354,none,0,1,0,1,0,2e-06,0,0,CDC_BP_Control,FFS
CLM0000004211,MBR00000081,Medical_Institutional,Denied,Electronic_EDI,2023-10-26,2023-10-26,2023-10-29,2023-11-24,Auto_Adjudicated,29,1325430913,1867626800,207RE0101X,Endocrinology,11,In_Network,H52.4,M54.5,revenue_code:0360,,0,Medicare_Advantage,SNP,66,F,2.159,22,Authorization,49170.89,21132.98,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1959,outlier_billing_amount,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004212,MBR00000140,Pharmacy,Paid,Electronic_EDI,2023-02-24,2023-02-24,2023-02-24,2023-03-21,Auto_Adjudicated,25,1808451151,1977073565,225100000X,Physical Therapist,23,In_Network,I10,,59148001506,,1,Medicare_Advantage,MA_HMO,7,M,1.3997,,,352.47,191.95,126.58,21.72,12.0,31.65,160.52,0.0,0.0,0,,0.0344,none,0,1,0,0,0,1.2e-05,0,0,BCS_Breast_Cancer_Screening,Shared_Savings
CLM0000004213,MBR00000068,Medical_Professional,Partially_Paid,Electronic_EDI,2023-11-22,2023-11-22,2023-11-22,2023-12-22,Auto_Adjudicated,30,1310250833,1356856197,207Q00000X,Family Medicine,22,Out_of_Network,E11.9,,17000,,0,Medicare_Advantage,MA_HMO,28,F,0.8494,16,Medical_Necessity,859.01,301.99,145.24,11.26,8.0,36.31,658.19,0.0,0.0,0,,0.1431,none,0,1,0,0,0,1.3e-05,0,0,CDC_HbA1c_Poor_Control,Shared_Savings
CLM0000004214,MBR00000008,Medical_Professional,Paid,Electronic_EDI,2023-04-27,2023-04-27,2023-04-27,2023-05-16,Auto_Adjudicated,19,1232573801,1020312030,208600000X,Surgery General,31,In_Network,Z00.01,OTHER|I25.10|I50.9,99214,,0,Medicaid_MCO,MCO,74,M,0.8375,,,210.7,167.5,166.5,0.0,1.0,0.0,43.2,0.0,0.0,0,,0.1109,none,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000004215,MBR00000196,Vision,Paid,Paper,2023-08-17,2023-08-17,2023-08-17,2023-09-12,Auto_Adjudicated,26,1264953395,1513198866,208600000X,Surgery General,24,In_Network,E78.5,E11.9|E11.65,V2103,,0,Commercial,PPO,16,F,1.6015,,,222.94,128.17,0.0,128.17,0.0,0.0,94.77,0.0,0.0,0,,0.1459,unbundling_pattern,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004216,MBR00000135,Medical_Professional,Paid,Electronic_EDI,2023-09-13,2023-09-13,2023-09-13,2023-10-07,Manual_Review,24,1866366547,1114756459,207RN0300X,Nephrology,21,In_Network,M17.11,H52.4,74178,,0,Commercial,PPO,58,F,2.2702,,,355.98,146.59,86.22,1.82,37.0,21.55,209.39,0.0,0.0,0,,0.1225,none,0,1,0,0,0,8e-06,0,0,TRC_Transition_of_Care,Bundled_Payment
CLM0000004217,MBR00000077,Pharmacy,Denied,Electronic_EDI,2023-05-16,2023-05-16,2023-05-16,2023-06-10,Auto_Adjudicated,25,1264432433,1005335812,207RG0100X,Gastroenterology,23,In_Network,I10,I10|M54.5,00069420020,,3,Medicare_Advantage,MA_HMO,27,F,0.9229,PR-1,Eligibility,302.73,176.64,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1021,none,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000004218,MBR00000254,Medical_Professional,Denied,Electronic_EDI,2023-07-17,2023-07-17,2023-07-17,2023-07-30,Auto_Adjudicated,13,1519595029,1365397818,2084P0800X,Psychiatry,11,In_Network,Z00.00,,97010,,0,Commercial,PPO,22,F,0.9285,22,COB,698.93,548.84,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0563,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004219,MBR00000154,Medical_Institutional,Paid,Electronic_EDI,2023-09-29,2023-09-29,2023-09-29,2023-10-15,Manual_Review,16,1556434733,1358873132,207RC0000X,Cardiovascular Disease,21,In_Network,OTHER,,revenue_code:0100,470,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,22405.96,18567.13,14828.15,7.95,24.0,3707.04,3838.83,0.0,0.0,0,,0.1073,none,0,1,1,0,1,0.001372,0,0,,Bundled_Payment
CLM0000004220,MBR00000299,Pharmacy,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-12-09,Auto_Adjudicated,28,1706065807,1128148362,2084P0800X,Psychiatry,11,In_Network,F32.9,Z00.00,16590051660,,1,Medicaid_MCO,MCO,74,F,0.8833,,,251.6,88.28,86.28,0.0,2.0,0.0,163.32,0.0,0.0,0,,0.1059,none,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000004221,MBR00000235,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-02-08,2023-02-08,2023-02-09,2023-02-22,Auto_Adjudicated,14,1592228076,1105733833,207RN0300X,Nephrology,11,Out_of_Network,OTHER,OTHER|Z00.00,revenue_code:0210,,0,Commercial,HDHP_HSA,85,F,1.4308,3,Medical_Necessity,25226.51,21123.58,9928.65,319.56,0.0,2482.16,12496.14,0.0,0.0,0,,0.0523,none,0,1,1,0,0,0.000919,0,0,,P4P
CLM0000004222,MBR00000262,Medical_Professional,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-27,2023-07-16,Auto_Adjudicated,19,1156265220,1728466420,207RG0100X,Gastroenterology,31,Out_of_Network,K29.70,OTHER|J20.9,84443,,0,Medicare_Advantage,PFFS,77,F,1.7452,,,933.15,477.59,378.44,0.53,4.0,94.61,455.56,0.0,0.0,0,,0.0038,none,0,1,0,0,0,3.5e-05,1,0,,Bundled_Payment
CLM0000004223,MBR00000228,Pharmacy,Paid,Electronic_EDI,2023-11-03,2023-11-03,2023-11-03,2023-11-23,Auto_Adjudicated,20,1388662212,1402472115,207R00000X,Internal Medicine,81,In_Network,I10,OTHER,00006001954,,1,Commercial,PPO,55,F,0.7203,,,434.69,305.8,0.0,305.8,0.0,0.0,128.89,0.0,0.0,0,,0.0948,provider_specialty_mismatch,0,1,0,0,0,0.0,0,1,AWV_Annual_Wellness_Visit,P4P
CLM0000004224,MBR00000033,Medical_Professional,Paid,Electronic_EDI,2023-07-19,2023-07-19,2023-07-19,2023-07-25,Manual_Review,6,1793406356,1825450791,208600000X,Surgery General,22,In_Network,M17.11,M17.11|E11.9|OTHER,99386,,0,Medicare_Advantage,PFFS,31,F,0.821,,,405.31,294.41,194.38,46.43,5.0,48.6,110.9,156.87,32.19,0,,0.0667,npi_mismatch,0,1,0,0,0,1.8e-05,0,0,,Shared_Savings
CLM0000004225,MBR00000020,Medical_Professional,Paid,Electronic_EDI,2023-01-11,2023-01-11,2023-01-11,2023-01-12,Auto_Adjudicated,1,1099247356,1301833092,207RP1001X,Pulmonary Disease,11,In_Network,E11.65,,47562,,0,Medicare_Advantage,MA_PPO,63,F,0.7119,,,453.5,364.27,274.05,15.71,6.0,68.51,89.23,196.52,55.76,0,,0.0946,controlled_substance_high_volume,0,1,0,0,0,2.5e-05,0,0,,FFS
CLM0000004226,MBR00000276,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-02-15,2023-02-15,2023-02-15,2023-03-08,Auto_Adjudicated,21,1110312325,1151295616,207RP1001X,Pulmonary Disease,11,In_Network,I10,,revenue_code:0120,,0,Commercial,POS,38,M,0.8085,CO-45,Medical_Necessity,18638.66,10342.15,4572.86,201.61,47.0,1143.21,12673.98,0.0,0.0,0,,0.0602,service_date_weekend,0,1,0,1,0,0.000423,0,0,,Shared_Savings
CLM0000004227,MBR00000043,Medical_Institutional,Paid,Electronic_EDI,2023-10-21,2023-10-21,2023-10-22,2023-11-14,Auto_Adjudicated,24,1496489953,1903401648,207RG0100X,Gastroenterology,11,In_Network,Z00.01,,revenue_code:0100,,0,Commercial,PPO,68,F,0.4593,,,15851.39,11621.35,9156.63,103.57,72.0,2289.16,4230.04,0.0,0.0,0,,0.1265,high_oop_waiver,0,1,1,1,0,0.000848,0,0,,Capitation
CLM0000004228,MBR00000125,Medical_Institutional,Paid,Electronic_EDI,2023-06-01,2023-06-01,2023-06-05,2023-06-19,Auto_Adjudicated,18,1891821845,1408846353,207RN0300X,Nephrology,32,In_Network,E78.5,OTHER|N39.0|Z23,revenue_code:0450,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,10109.11,7001.78,5560.55,6.1,45.0,1390.14,3107.33,4808.93,440.33,0,,0.1064,controlled_substance_high_volume,0,1,1,0,0,0.000515,0,0,,Capitation
CLM0000004229,MBR00000184,Medical_Professional,Paid,Electronic_EDI,2023-09-10,2023-09-10,2023-09-10,2023-09-30,Auto_Adjudicated,20,1588313061,1267212691,2086S0122X,Orthopedic Surgery,22,In_Network,E78.5,OTHER,99203,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,277.59,142.32,140.32,0.0,2.0,0.0,135.27,0.0,0.0,0,,0.1299,impossible_service_combo,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000004230,MBR00000064,Medical_Professional,Paid,Electronic_EDI,2023-11-17,2023-11-17,2023-11-17,2023-11-20,Auto_Adjudicated,3,1981623199,1607833568,207R00000X,Internal Medicine,32,In_Network,E78.5,Z00.01,99231,,0,Medicare_Advantage,SNP,73,M,1.0644,,,463.22,353.47,273.59,1.48,10.0,68.4,109.75,0.0,0.0,0,,0.1306,none,0,1,0,1,0,2.5e-05,0,0,AWV_Annual_Wellness_Visit,Shared_Savings
CLM0000004231,MBR00000070,Medical_Professional,Paid,Electronic_EDI,2023-02-01,2023-02-01,2023-02-01,2023-02-07,Auto_Adjudicated,6,1059948944,1649705287,208600000X,Surgery General,21,In_Network,E78.5,OTHER|M54.5|Z00.00,99283,,0,Commercial,POS,42,F,0.8468,,,366.96,292.06,0.0,292.06,0.0,0.0,74.9,0.0,0.0,0,,0.0692,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004232,MBR00000144,Dental,Paid,Electronic_EDI,2023-06-13,2023-06-13,2023-06-13,2023-07-06,Auto_Adjudicated,23,1484613641,1318978078,101YP2500X,Psychologist Clinical,22,In_Network,J20.9,Z00.00,D0150,,0,Commercial,HDHP_HSA,56,F,2.5926,,,611.74,387.5,215.59,118.01,0.0,53.9,224.24,151.46,51.49,0,,0.1429,unbundling_pattern,0,1,0,0,0,2e-05,0,0,TRC_Transition_of_Care,FFS
CLM0000004233,MBR00000114,Medical_Professional,Paid,Electronic_EDI,2023-02-22,2023-02-22,2023-02-22,2023-03-14,Auto_Adjudicated,20,1319616460,1034732777,246ZN0300X,Neuropsychology,23,Out_of_Network,M54.5,OTHER,99212,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,285.68,216.99,130.95,34.3,19.0,32.74,68.69,0.0,0.0,0,,0.009,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000004234,MBR00000201,Vision,Paid,Electronic_EDI,2023-10-30,2023-10-30,2023-10-30,2023-11-05,Auto_Adjudicated,6,1310250833,1666461892,207RP1001X,Pulmonary Disease,11,Out_of_Network,OTHER,,V2320,,0,Medicare_Advantage,MA_PPO,74,M,1.1575,,,497.55,329.58,255.06,4.75,6.0,63.77,167.97,0.0,0.0,0,,0.2044,duplicate_claim_indicator,0,2,0,0,0,2.4e-05,0,0,CCS_Cervical_Cancer_Screening,Shared_Savings
CLM0000004235,MBR00000023,Medical_Professional,Paid,Electronic_EDI,2023-06-12,2023-06-12,2023-06-12,2023-06-30,Auto_Adjudicated,18,1864546991,1005335812,208600000X,Surgery General,23,In_Network,Z00.00,OTHER,99202,,0,Medicare_Advantage,MA_PPO,87,M,1.084,,,412.21,306.92,192.91,50.79,15.0,48.23,105.29,0.0,0.0,0,,0.1667,provider_specialty_mismatch,0,1,0,0,0,1.8e-05,0,0,,FFS
CLM0000004236,MBR00000152,Medical_Professional,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-11-13,Manual_Review,2,1804302686,1196833348,225100000X,Physical Therapist,24,In_Network,F33.0,J06.9|OTHER,90832,,0,Commercial,HMO,82,F,1.2506,,,369.67,243.64,90.15,113.96,17.0,22.54,126.03,0.0,0.0,0,,0.1606,impossible_service_combo,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000004237,MBR00000055,Pharmacy,Paid,Electronic_EDI,2023-04-18,2023-04-18,2023-04-18,2023-05-12,Manual_Review,24,1865750966,1020312030,208600000X,Surgery General,11,In_Network,OTHER,OTHER|M17.11|F33.0,00069420020,,1,Commercial,PPO,68,F,1.2896,,,135.17,94.15,0.0,94.15,0.0,0.0,41.02,0.0,0.0,0,,0.0492,none,0,1,0,0,0,0.0,0,0,KED_ESRD_Patients,Shared_Savings
CLM0000004238,MBR00000183,Medical_Professional,Partially_Paid,Provider_Portal,2023-02-22,2023-02-22,2023-02-22,2023-02-23,Auto_Adjudicated,1,1769163673,1007652766,207RN0300X,Nephrology,11,In_Network,K21.0,,17000,,0,Commercial,PPO,51,M,0.8463,3,Medical_Necessity,358.59,132.24,0.0,92.96,0.0,0.0,265.63,0.0,0.0,0,,0.071,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004239,MBR00000036,Medical_Institutional,Paid,Paper,2023-11-08,2023-11-08,2023-11-12,2023-12-04,Auto_Adjudicated,26,1617763056,1020312030,207V00000X,Obstetrics & Gynecology,22,In_Network,M54.5,Z00.00|I10,revenue_code:0210,,0,Commercial,EPO,17,M,2.0136,,,4542.06,1808.58,1382.79,40.09,40.0,345.7,2733.48,0.0,0.0,0,,0.0973,none,0,1,0,0,0,0.000128,0,0,,FFS
CLM0000004240,MBR00000061,Dental,Paid,Paper,2023-08-09,2023-08-09,2023-08-09,2023-08-16,Manual_Review,7,1542851144,1477113725,207Q00000X,Family Medicine,81,In_Network,M54.5,,D3310,,0,Commercial,PPO,66,M,2.3575,,,1747.11,972.67,762.63,6.39,13.0,190.66,774.44,0.0,0.0,0,,0.1558,unbundling_pattern,0,1,0,0,0,7.1e-05,0,0,MPT_Annual_Monitoring,Shared_Savings
CLM0000004241,MBR00000238,Pharmacy,Paid,Electronic_EDI,2023-03-11,2023-03-11,2023-03-11,2023-03-19,Manual_Review,8,1625939855,1685903362,207RG0100X,Gastroenterology,81,In_Network,M54.5,Z79.4|Z00.01,00085163102,,2,Commercial,PPO,74,F,0.4382,,,683.65,509.11,333.71,66.97,25.0,83.43,174.54,0.0,0.0,0,,0.0089,none,0,1,0,0,0,3.1e-05,0,1,POD_Persistence_of_Beta_Blocker,Shared_Savings
CLM0000004242,MBR00000074,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-09-07,2023-09-07,2023-09-09,2023-10-05,Auto_Adjudicated,28,1253087808,1746676564,225100000X,Physical Therapist,11,In_Network,Z00.01,,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,21,F,0.8719,2,Medical_Necessity,33954.22,12965.12,6345.1,16.06,47.0,1586.27,25959.79,0.0,0.0,0,,0.0179,none,0,1,1,0,0,0.000587,0,0,,FFS
CLM0000004243,MBR00000215,Pharmacy,Paid,Provider_Portal,2023-05-30,2023-05-30,2023-05-30,2023-06-24,Auto_Adjudicated,25,1617928396,1581533104,207RN0300X,Nephrology,24,Out_of_Network,I25.10,,16590051660,,3,ACA_Marketplace,ACA_Silver,69,M,0.8895,,,257.79,91.99,0.0,91.99,0.0,0.0,165.8,0.0,0.0,0,,0.0823,none,0,1,0,1,0,0.0,1,0,,Capitation
CLM0000004244,MBR00000085,Medical_Professional,Paid,Electronic_EDI,2023-01-17,2023-01-17,2023-01-17,2023-01-28,Auto_Adjudicated,11,1965682436,1951488764,207RP1001X,Pulmonary Disease,24,In_Network,F33.0,Z00.00,99204,,0,Medicare_Advantage,SNP,2,M,0.7823,,,500.68,229.83,151.99,24.84,15.0,38.0,270.85,0.0,0.0,1,Unbundling,0.9127,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|temporal_clustering|impossible_service_combo|upcoding_pattern|diagnosis_procedure_mismatch,1,5,0,0,0,1.4e-05,0,0,,FFS
CLM0000004245,MBR00000074,Pharmacy,Paid,Paper,2023-04-04,2023-04-04,2023-04-04,2023-04-10,Auto_Adjudicated,6,1137079475,1354265777,207Q00000X,Family Medicine,32,In_Network,Z12.11,Z00.01|F32.9,00071015523,,1,Medicare_Advantage,MA_PPO,21,F,0.8719,,,387.09,301.99,221.16,6.54,19.0,55.29,85.1,0.0,0.0,1,Code Substitution,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|temporal_clustering|high_volume_same_code|benford_violation|billing_spike_recent|duplicate_claim_indicator|phantom_billing_indicator|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,2e-05,0,0,,Capitation
CLM0000004246,MBR00000094,Medical_Professional,Partially_Paid,Electronic_EDI,2023-09-27,2023-09-27,2023-09-27,2023-10-01,Manual_Review,4,1122148537,1128148362,207Q00000X,Family Medicine,11,In_Network,OTHER,,73721,,0,Commercial,POS,36,F,0.3997,96,Medical_Necessity,1071.35,850.2,376.47,26.79,39.0,94.12,534.98,0.0,0.0,0,,0.0241,none,0,1,0,0,0,3.5e-05,0,0,,FFS
CLM0000004247,MBR00000266,Medical_Professional,Paid,Electronic_EDI,2023-02-15,2023-02-15,2023-02-15,2023-02-27,Auto_Adjudicated,12,1658094898,1623053477,246ZN0300X,Neuropsychology,81,In_Network,OTHER,,20610,,0,Commercial,EPO,14,M,1.075,,,723.0,359.47,122.54,173.3,33.0,30.63,363.53,0.0,0.0,0,,0.0688,none,0,1,0,1,0,1.1e-05,0,0,,Shared_Savings
CLM0000004248,MBR00000126,Medical_Institutional,Paid,Electronic_EDI,2023-05-02,2023-05-02,2023-05-02,2023-05-20,Manual_Review,18,1264953395,1452088018,2086S0122X,Orthopedic Surgery,31,In_Network,M54.5,,revenue_code:0300,,0,Medicaid_MCO,MLTSS,48,F,0.637,,,25934.42,17918.25,17912.25,0.0,6.0,0.0,8016.17,0.0,0.0,0,,0.1494,none,0,1,1,0,0,0.001658,0,0,,Bundled_Payment
CLM0000004249,MBR00000076,Medical_Professional,Paid,Provider_Portal,2023-04-04,2023-04-04,2023-04-04,2023-04-19,Auto_Adjudicated,15,1700802848,1540743888,208600000X,Surgery General,22,In_Network,L70.0,F41.1|OTHER|Z23,99233,,0,Commercial,HMO,26,M,2.1785,,,316.08,221.79,126.83,31.25,32.0,31.71,94.29,0.0,0.0,0,,0.0461,none,0,1,0,0,0,1.2e-05,0,0,,Shared_Savings
CLM0000004250,MBR00000163,Pharmacy,Paid,Electronic_EDI,2023-09-21,2023-09-21,2023-09-21,2023-10-18,Auto_Adjudicated,27,1470105939,1625992541,207RP1001X,Pulmonary Disease,11,In_Network,Z00.01,M17.11,00169751112,,1,Medicaid_MCO,MCO,21,F,0.9607,,,46.55,16.31,12.31,0.0,4.0,0.0,30.24,0.0,0.0,0,,0.0759,none,0,1,0,0,0,1e-06,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000004251,MBR00000122,Medical_Professional,Paid,Electronic_EDI,2023-11-05,2023-11-05,2023-11-05,2023-11-30,Auto_Adjudicated,25,1233824762,1804282800,225100000X,Physical Therapist,11,In_Network,OTHER,OTHER|M54.5|E11.65,85025,,0,Commercial,EPO,64,F,0.8625,,,576.11,309.41,158.5,73.29,38.0,39.62,266.7,0.0,0.0,0,,0.0474,none,0,1,0,0,0,1.5e-05,0,0,,Bundled_Payment
CLM0000004252,MBR00000235,Medical_Professional,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-10,2023-10-18,Manual_Review,8,1879212418,1538261819,208600000X,Surgery General,21,In_Network,H52.4,,90834,,0,Commercial,HDHP_HSA,85,F,1.4308,,,1741.48,740.21,515.48,95.87,0.0,128.87,1001.27,0.0,0.0,1,Provider Impersonation,1.0,unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|high_oop_waiver,1,5,0,0,0,4.8e-05,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000004253,MBR00000297,Pharmacy,Paid,Electronic_EDI,2023-09-14,2023-09-14,2023-09-14,2023-10-12,Auto_Adjudicated,28,1218947226,1197700958,207V00000X,Obstetrics & Gynecology,31,In_Network,J06.9,OTHER,00003014960,,1,Commercial,HMO,88,M,1.5311,,,379.25,198.38,130.84,7.83,27.0,32.71,180.87,0.0,0.0,0,,0.1272,npi_mismatch,0,1,0,0,0,1.2e-05,0,0,DAE_Drug_Alcohol_Dependence,FFS
CLM0000004254,MBR00000160,Medical_Institutional,Paid,Paper,2023-02-02,2023-02-02,2023-02-06,2023-02-16,Clinical_Review,14,1728728765,1912895973,207V00000X,Obstetrics & Gynecology,24,In_Network,Z12.11,OTHER,revenue_code:0200,,0,Commercial,HMO,73,M,1.9608,,,7284.43,3515.53,2690.35,112.59,40.0,672.59,3768.9,0.0,0.0,0,,0.1468,none,0,1,0,0,0,0.000249,0,0,,FFS
CLM0000004255,MBR00000140,Vision,Paid,Electronic_EDI,2023-11-25,2023-11-25,2023-11-25,2023-11-26,Auto_Adjudicated,1,1664872214,1878017518,2086S0122X,Orthopedic Surgery,71,In_Network,I25.10,,V2103,,0,Medicare_Advantage,MA_HMO,7,M,1.3997,,,219.16,85.07,54.43,5.03,12.0,13.61,134.09,0.0,0.0,0,,0.0398,none,0,1,0,1,0,5e-06,0,0,,Shared_Savings
CLM0000004256,MBR00000107,Medical_Professional,Paid,Electronic_EDI,2023-02-28,2023-02-28,2023-02-28,2023-03-26,Auto_Adjudicated,26,1375098560,1196833348,207RP1001X,Pulmonary Disease,21,In_Network,E78.5,M54.5,99397,,0,Medicare_Advantage,MA_PPO,44,M,1.0439,,,200.79,169.27,126.66,2.94,8.0,31.67,31.52,0.0,0.0,0,,0.1194,temporal_clustering,0,1,0,0,0,1.2e-05,0,0,,Bundled_Payment
CLM0000004257,MBR00000293,Medical_Professional,Paid,Provider_Portal,2023-05-26,2023-05-26,2023-05-26,2023-06-18,Auto_Adjudicated,23,1683650935,1767402068,207RC0000X,Cardiovascular Disease,65,In_Network,I25.10,K29.70,90853,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,201.94,121.28,69.11,23.9,11.0,17.28,80.66,0.0,0.0,0,,0.1208,none,0,1,0,0,0,6e-06,0,0,HBD_Hemoglobin_A1c_Testing,Shared_Savings
CLM0000004258,MBR00000149,Medical_Professional,Denied,Electronic_EDI,2023-10-25,2023-10-25,2023-10-25,2023-11-05,Auto_Adjudicated,11,1257723293,1288028182,2084P0800X,Psychiatry,32,In_Network,OTHER,,12001,,0,Commercial,PPO,42,F,0.5458,3,Medical_Necessity,636.9,269.1,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.057,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004259,MBR00000056,Medical_Institutional,Paid,Electronic_EDI,2023-03-28,2023-03-28,2023-03-28,2023-04-24,Auto_Adjudicated,27,1850379080,1007652766,2086S0122X,Orthopedic Surgery,11,In_Network,K21.0,K29.70,revenue_code:0200,,0,Commercial,EPO,74,F,1.3941,,,24194.87,11303.84,8708.83,370.81,47.0,2177.21,12891.03,0.0,0.0,0,,0.0251,none,0,1,1,0,0,0.000806,0,0,,FFS
CLM0000004260,MBR00000293,Medical_Professional,Paid,Electronic_EDI,2023-03-19,2023-03-19,2023-03-19,2023-04-16,Auto_Adjudicated,28,1059948944,1972530373,2086S0122X,Orthopedic Surgery,11,In_Network,E11.9,E11.9,99283,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,220.73,81.32,23.1,41.45,11.0,5.77,139.41,0.0,0.0,0,,0.1249,none,0,1,0,0,0,2e-06,0,0,,Bundled_Payment
CLM0000004261,MBR00000291,Pharmacy,Denied,Electronic_EDI,2023-01-10,2023-01-10,2023-01-10,2023-02-08,Clinical_Review,29,1950560596,1513198866,2086S0122X,Orthopedic Surgery,24,In_Network,E11.65,I50.9,00169751112,,4,Commercial,PPO,78,M,1.4773,CO-45,COB,66.65,33.33,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.197,high_oop_waiver,0,1,0,1,0,0.0,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000004262,MBR00000136,Medical_Professional,Paid,Electronic_EDI,2023-05-09,2023-05-09,2023-05-09,2023-06-06,Auto_Adjudicated,28,1049153238,1469881892,208600000X,Surgery General,23,In_Network,R05.9,Z00.01,97035,,0,Commercial,POS,2,F,1.2611,,,1303.79,498.32,119.53,338.9,10.0,29.88,805.47,0.0,0.0,0,,0.0477,none,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000004263,MBR00000110,Vision,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-27,2023-07-06,Auto_Adjudicated,9,1243052462,1469881892,225100000X,Physical Therapist,11,In_Network,N39.0,E78.5|Z00.00,92012,,0,Medicare_Advantage,MA_HMO,83,F,1.127,,,553.45,262.22,200.72,2.31,9.0,50.18,291.23,0.0,0.0,0,,0.1935,impossible_service_combo|unbundling_pattern,0,1,0,0,0,1.9e-05,0,0,,FFS
CLM0000004264,MBR00000202,Medical_Institutional,Paid,Electronic_EDI,2023-06-17,2023-06-17,2023-06-17,2023-07-04,Auto_Adjudicated,17,1424104563,1589482133,246ZN0300X,Neuropsychology,24,In_Network,Z00.00,I10,revenue_code:0200,,0,Commercial,PPO,87,F,0.6213,,,8072.63,4582.63,3604.4,47.14,30.0,901.1,3490.0,0.0,0.0,0,,0.1367,none,0,1,0,0,0,0.000334,0,0,,Capitation
CLM0000004265,MBR00000248,Pharmacy,Paid,Electronic_EDI,2023-01-15,2023-01-15,2023-01-15,2023-01-21,Auto_Adjudicated,6,1215358845,1867389043,225100000X,Physical Therapist,21,In_Network,I50.9,Z00.01,00006001954,,3,Commercial,PPO,40,F,0.6665,,,85.0,58.3,0.0,58.3,0.0,0.0,26.7,0.0,0.0,0,,0.1358,unbundling_pattern|npi_mismatch,0,1,0,0,0,0.0,0,1,,Shared_Savings
CLM0000004266,MBR00000154,Medical_Professional,Paid,Electronic_EDI,2023-03-15,2023-03-15,2023-03-15,2023-04-05,Auto_Adjudicated,21,1673449362,1903401648,207V00000X,Obstetrics & Gynecology,22,In_Network,Z00.00,,99391,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,260.44,199.57,152.09,9.45,0.0,38.02,60.87,0.0,0.0,0,,0.0383,none,0,1,0,1,0,1.4e-05,0,0,,Capitation
CLM0000004267,MBR00000105,Medical_Professional,Paid,Electronic_EDI,2023-01-02,2023-01-02,2023-01-02,2023-01-17,Manual_Review,15,1091271799,1447657873,2086S0122X,Orthopedic Surgery,65,Out_of_Network,Z23,OTHER|I10,27447,,0,Commercial,HMO,74,M,1.1834,,,21910.66,8272.31,6576.88,36.21,15.0,1644.22,13638.35,0.0,0.0,0,,0.0602,none,0,1,1,0,0,0.000609,1,0,,Bundled_Payment
CLM0000004268,MBR00000095,Medical_Professional,Denied,Paper,2023-03-22,2023-03-22,2023-03-22,2023-04-18,Auto_Adjudicated,27,1995916350,1938465393,208600000X,Surgery General,11,In_Network,Z23,,97110,,0,Commercial,HMO,28,M,0.5827,96,Timely_Filing,474.53,224.6,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.116,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004269,MBR00000103,Medical_Institutional,Paid,Electronic_EDI,2023-08-06,2023-08-06,2023-08-08,2023-09-03,Auto_Adjudicated,28,1958981650,1880530717,225100000X,Physical Therapist,11,In_Network,OTHER,,revenue_code:0100,,0,Medicaid_MCO,MCO,24,M,0.4785,,,2921.01,1220.46,1215.46,0.0,5.0,0.0,1700.55,0.0,0.0,0,,0.0723,none,0,1,0,0,0,0.000113,0,0,SPD_Spirometry_Testing,FFS
CLM0000004270,MBR00000036,Medical_Institutional,Paid,Electronic_EDI,2023-01-04,2023-01-04,2023-01-08,2023-01-14,Manual_Review,10,1055717021,1163639177,207RP1001X,Pulmonary Disease,23,In_Network,OTHER,Z00.00,revenue_code:0100,,0,Commercial,EPO,17,M,2.0136,,,28488.61,14929.49,11793.19,148.01,40.0,2948.3,13559.12,0.0,0.0,0,,0.1082,none,0,1,1,0,0,0.001092,0,0,,Bundled_Payment
CLM0000004271,MBR00000229,Medical_Professional,Paid,Paper,2023-03-01,2023-03-01,2023-03-01,2023-03-11,Manual_Review,10,1433357203,1527857018,246ZN0300X,Neuropsychology,23,In_Network,OTHER,M25.511|R05.9,99385,,0,Medicare_Advantage,PFFS,63,M,1.1626,,,316.04,138.48,84.33,19.07,14.0,21.08,177.56,0.0,0.0,0,,0.2522,provider_specialty_mismatch|npi_mismatch,0,2,0,0,0,8e-06,0,0,,FFS
CLM0000004272,MBR00000032,Medical_Professional,Paid,Electronic_EDI,2023-07-15,2023-07-15,2023-07-15,2023-07-16,Clinical_Review,1,1170257806,1878874025,246ZN0300X,Neuropsychology,21,In_Network,OTHER,,43239,,0,Medicaid_MCO,FFS_Medicaid,87,M,0.4839,,,1922.08,898.76,896.76,0.0,2.0,0.0,1023.32,0.0,0.0,0,,0.0136,none,0,1,0,0,0,8.3e-05,0,0,,FFS
CLM0000004273,MBR00000127,Behavioral_Health,Denied,Electronic_EDI,2023-07-20,2023-07-20,2023-07-20,2023-08-05,Auto_Adjudicated,16,1207676414,1452088018,101YP2500X,Psychologist Clinical,22,Emergency,E11.9,Z79.4,99396,,0,Commercial,HMO,31,F,0.3336,97,Timely_Filing,224.71,181.73,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.124,none,0,1,0,0,0,0.0,0,0,SPD_Spirometry_Testing,FFS
CLM0000004274,MBR00000249,Medical_Professional,Paid,Electronic_EDI,2023-11-18,2023-11-18,2023-11-18,2023-11-30,Auto_Adjudicated,12,1034110592,1650774392,207V00000X,Obstetrics & Gynecology,22,In_Network,N40.0,,17000,,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,1821.81,1221.9,762.39,102.77,30.0,326.74,599.91,0.0,0.0,0,,0.1214,none,0,1,0,0,0,7.1e-05,0,0,PPC_Prenatal_Care,Capitation
CLM0000004275,MBR00000129,Medical_Professional,Paid,Provider_Portal,2023-07-25,2023-07-25,2023-07-25,2023-08-24,Auto_Adjudicated,30,1594587354,1415734567,2084P0800X,Psychiatry,31,In_Network,I48.91,,99232,,0,Medicare_Advantage,MA_PPO,9,F,0.8196,,,250.03,195.84,134.69,10.48,17.0,33.67,54.19,0.0,0.0,0,,0.0944,phantom_billing_indicator,0,1,0,1,0,1.2e-05,0,0,,FFS
CLM0000004276,MBR00000092,Medical_Professional,Paid,Electronic_EDI,2023-11-29,2023-11-29,2023-11-29,2023-12-24,Clinical_Review,25,1078576574,1880530717,225100000X,Physical Therapist,23,In_Network,OTHER,OTHER,90837,,0,Medicaid_MCO,MLTSS,68,F,1.3217,,,425.8,264.74,261.74,0.0,3.0,0.0,161.06,0.0,0.0,0,,0.0951,controlled_substance_high_volume,0,1,0,0,0,2.4e-05,0,0,,Capitation
CLM0000004277,MBR00000287,Medical_Professional,Paid,Electronic_EDI,2023-09-17,2023-09-17,2023-09-17,2023-10-01,Clinical_Review,14,1688560518,1433350836,207RE0101X,Endocrinology,11,Emergency,OTHER,,99283,,0,Commercial,PPO,4,M,0.7685,,,218.04,165.69,0.0,148.25,17.44,0.0,52.35,0.0,0.0,0,,0.1292,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004278,MBR00000038,Medical_Institutional,Paid,Electronic_EDI,2023-07-17,2023-07-17,2023-07-20,2023-08-04,Auto_Adjudicated,18,1046058495,1339359594,207RN0300X,Nephrology,11,In_Network,I10,G47.33|I50.9,revenue_code:0210,,0,Commercial,EPO,46,M,1.1295,,,61975.7,32527.56,25907.49,72.2,71.0,6476.87,29448.14,0.0,0.0,0,,0.1697,outlier_billing_amount|provider_specialty_mismatch,0,1,1,0,0,0.002398,0,0,,FFS
CLM0000004279,MBR00000268,Medical_Institutional,Paid,Electronic_EDI,2023-05-18,2023-05-18,2023-05-19,2023-06-06,Auto_Adjudicated,19,1508520529,1887266184,101YP2500X,Psychologist Clinical,21,In_Network,E78.5,,revenue_code:0250,682,0,Medicaid_MCO,MCO,13,M,0.3526,,,10135.78,4786.4,4782.4,0.0,4.0,0.0,5349.38,0.0,0.0,0,,0.1126,none,0,1,0,1,0,0.000443,0,0,SPC_Statin_Therapy,Shared_Savings
CLM0000004280,MBR00000018,Medical_Institutional,Paid,Electronic_EDI,2023-02-09,2023-02-09,2023-02-11,2023-03-09,Auto_Adjudicated,28,1326896487,1433350836,207RG0100X,Gastroenterology,11,In_Network,OTHER,F32.9,revenue_code:0370,,0,Commercial,EPO,5,F,0.5555,,,49816.08,31105.15,24809.76,25.95,67.0,6202.44,18710.93,0.0,0.0,0,,0.2664,outlier_billing_amount|high_volume_same_code|unbundling_pattern,0,2,1,0,0,0.002296,0,0,,FFS
CLM0000004281,MBR00000131,Pharmacy,Partially_Paid,Electronic_EDI,2023-09-11,2023-09-11,2023-09-11,2023-10-11,Manual_Review,30,1617763056,1789540567,207V00000X,Obstetrics & Gynecology,11,In_Network,I10,,00169751112,,4,Commercial,EPO,15,F,0.9228,3,Medical_Necessity,124.44,102.17,5.95,22.21,26.0,1.49,68.79,0.0,0.0,0,,0.0945,none,0,1,0,0,0,1e-06,0,0,TRC_Transition_of_Care,Capitation
CLM0000004282,MBR00000187,Medical_Professional,Paid,Paper,2023-12-03,2023-12-03,2023-12-03,2023-12-16,Auto_Adjudicated,13,1159640414,1114756459,2086S0122X,Orthopedic Surgery,31,In_Network,I10,,99214,,0,Medicaid_MCO,MCO,36,F,1.191,,,140.12,107.55,104.55,0.0,3.0,0.0,32.57,0.0,0.0,0,,0.1015,service_date_weekend,0,1,0,0,0,1e-05,0,0,,Shared_Savings
CLM0000004283,MBR00000117,Medical_Professional,Paid,Paper,2023-05-12,2023-05-12,2023-05-12,2023-05-24,Manual_Review,12,1713741288,1746676564,208600000X,Surgery General,31,In_Network,OTHER,E11.65,99212,,0,Medicaid_MCO,MLTSS,72,F,0.8628,,,397.13,187.28,183.28,0.0,4.0,0.0,209.85,0.0,0.0,0,,0.0356,none,0,1,0,0,0,1.7e-05,0,0,AMR_Asthma_Medication_Ratio,Capitation
CLM0000004284,MBR00000162,Pharmacy,Paid,Electronic_EDI,2023-05-08,2023-05-08,2023-05-08,2023-05-30,Auto_Adjudicated,22,1874109311,1809122260,225100000X,Physical Therapist,11,In_Network,OTHER,OTHER,00078043215,,2,Medicaid_MCO,MLTSS,84,F,1.324,,,107.75,89.15,88.15,0.0,1.0,0.0,18.6,0.0,0.0,0,,0.038,none,0,1,0,0,0,8e-06,0,0,,Capitation
CLM0000004285,MBR00000061,Medical_Professional,Paid,Electronic_EDI,2023-02-05,2023-02-05,2023-02-05,2023-02-14,Auto_Adjudicated,9,1774425033,1027261156,208600000X,Surgery General,31,In_Network,J06.9,,99203,,0,Commercial,PPO,66,M,2.3575,,,325.91,199.62,130.82,23.1,13.0,32.7,126.29,0.0,0.0,0,,0.1088,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000004286,MBR00000170,Medical_Professional,Paid,Electronic_EDI,2023-08-03,2023-08-03,2023-08-03,2023-08-08,Auto_Adjudicated,5,1602370875,1396850418,2086S0122X,Orthopedic Surgery,22,In_Network,Z00.00,,99282,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,309.6,173.52,109.61,33.51,3.0,27.4,136.08,0.0,0.0,0,,0.0668,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000004287,MBR00000042,Medical_Institutional,Denied,Electronic_EDI,2023-04-22,2023-04-22,2023-04-22,2023-05-01,Auto_Adjudicated,9,1826043246,1867626800,207R00000X,Internal Medicine,23,In_Network,Z12.11,,revenue_code:0120,,0,Commercial,HMO,78,F,1.1448,22,Timely_Filing,14189.53,7010.84,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1994,unbundling_pattern,0,1,0,0,0,0.0,0,0,,P4P
CLM0000004288,MBR00000236,Pharmacy,Paid,Electronic_EDI,2023-01-04,2023-01-04,2023-01-04,2023-01-14,Manual_Review,10,1532359759,1267212691,207R00000X,Internal Medicine,32,In_Network,Z00.00,J06.9|Z00.00,00078043215,,1,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,673.05,446.61,443.61,0.0,3.0,0.0,226.44,0.0,0.0,0,,0.1208,none,0,1,0,1,0,4.1e-05,0,0,COA_Care_Transitions,Shared_Savings
CLM0000004289,MBR00000176,Medical_Professional,Paid,Electronic_EDI,2023-01-03,2023-01-03,2023-01-03,2023-01-22,Auto_Adjudicated,19,1629674542,1391074619,207RE0101X,Endocrinology,11,In_Network,I10,Z23|Z12.11,99285,,0,Commercial,POS,4,M,0.8792,,,317.64,203.11,76.8,86.12,21.0,19.2,114.53,49.92,23.82,0,,0.0655,none,0,1,0,0,0,7e-06,0,0,,Shared_Savings
CLM0000004290,MBR00000148,Dental,Denied,Electronic_EDI,2023-05-01,2023-05-01,2023-05-01,2023-05-24,Auto_Adjudicated,23,1015096289,1694343357,207RN0300X,Nephrology,23,In_Network,E11.9,,D2140,,0,Commercial,EPO,51,F,0.6534,96,COB,376.03,286.73,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1493,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004291,MBR00000014,Medical_Professional,Denied,Electronic_EDI,2023-06-16,2023-06-16,2023-06-16,2023-06-21,Auto_Adjudicated,5,1957378066,1829216053,207RN0300X,Nephrology,11,In_Network,OTHER,,97140,,0,Commercial,HMO,77,M,2.8513,5,Medical_Necessity,507.06,409.39,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0612,benford_violation,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004292,MBR00000154,Behavioral_Health,Partially_Paid,Electronic_EDI,2023-06-14,2023-06-14,2023-06-14,2023-06-16,Manual_Review,2,1853233709,1123879500,207RG0100X,Gastroenterology,65,In_Network,Z12.11,I10,17000,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,3,Medical_Necessity,287.89,208.21,76.58,12.74,0.0,19.15,179.42,0.0,0.0,0,,0.1144,none,0,1,0,0,0,7e-06,0,0,POD_Persistence_of_Beta_Blocker,FFS
CLM0000004293,MBR00000169,Medical_Professional,Paid,Electronic_EDI,2023-09-23,2023-09-23,2023-09-23,2023-09-28,Auto_Adjudicated,5,1853233709,1579331190,207V00000X,Obstetrics & Gynecology,11,In_Network,Z00.00,C50.911|OTHER,90837,,0,Commercial,EPO,30,M,1.4348,,,888.19,393.02,261.34,44.35,22.0,65.33,495.17,0.0,0.0,0,,0.0888,none,0,1,0,0,0,2.4e-05,0,0,,FFS
CLM0000004294,MBR00000081,Pharmacy,Paid,Electronic_EDI,2023-07-09,2023-07-09,2023-07-09,2023-08-06,Auto_Adjudicated,28,1990849102,1972530373,207Q00000X,Family Medicine,23,In_Network,Z79.4,,00006001954,,1,Medicare_Advantage,SNP,66,F,2.159,,,130.56,54.34,35.07,5.5,5.0,8.77,76.22,0.0,0.0,0,,0.118,none,0,1,0,0,0,3e-06,0,0,MMA_Medication_Management,Shared_Savings
CLM0000004295,MBR00000201,Medical_Professional,Paid,Provider_Portal,2023-10-09,2023-10-09,2023-10-09,2023-10-17,Auto_Adjudicated,8,1853233709,1574982369,2086S0122X,Orthopedic Surgery,11,In_Network,Z00.00,,99285,,0,Medicare_Advantage,MA_PPO,74,M,1.1575,,,448.49,277.18,207.62,11.65,6.0,51.91,171.31,0.0,0.0,0,,0.1036,none,0,1,0,0,0,1.9e-05,0,0,,P4P
CLM0000004296,MBR00000024,Pharmacy,Paid,Electronic_EDI,2023-04-17,2023-04-17,2023-04-17,2023-05-03,Manual_Review,16,1543927384,1296566243,207R00000X,Internal Medicine,21,In_Network,OTHER,I10,16590051660,,3,Medicaid_MCO,FFS_Medicaid,82,M,1.315,,,152.82,65.22,62.22,0.0,3.0,0.0,87.6,0.0,0.0,0,,0.1373,none,0,1,0,1,0,6e-06,0,1,,Capitation
CLM0000004297,MBR00000063,Medical_Institutional,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-26,2023-04-11,Auto_Adjudicated,17,1642333103,1029818813,207V00000X,Obstetrics & Gynecology,21,In_Network,E11.9,F41.1|M54.5,revenue_code:0200,248,0,ACA_Marketplace,ACA_Silver,56,M,0.8198,,,20227.63,13320.96,9097.29,262.83,62.0,3898.84,6906.67,0.0,0.0,0,,0.0724,none,0,1,1,0,0,0.000842,0,0,,Bundled_Payment
CLM0000004298,MBR00000216,Dental,Paid,Electronic_EDI,2023-07-13,2023-07-13,2023-07-13,2023-07-22,Clinical_Review,9,1727787144,1300957944,207Q00000X,Family Medicine,24,In_Network,E11.9,E11.65,D4341,,0,Medicare_Advantage,MA_HMO,71,F,0.7117,,,157.94,68.04,31.71,18.4,10.0,7.93,89.9,19.42,9.08,0,,0.0971,none,0,1,0,0,0,3e-06,0,0,,Bundled_Payment
CLM0000004299,MBR00000046,Pharmacy,Partially_Paid,Electronic_EDI,2023-02-07,2023-02-07,2023-02-07,2023-03-05,Auto_Adjudicated,26,1826567270,1287935251,207R00000X,Internal Medicine,11,In_Network,Z12.11,Z00.01|OTHER,00169751112,,1,Commercial,HMO,76,F,0.9613,3,Medical_Necessity,373.84,174.26,0.0,104.27,10.06,0.0,259.5,0.0,0.0,0,,0.2023,impossible_service_combo|service_date_weekend,0,2,0,0,0,0.0,0,1,TRC_Transition_of_Care,Capitation
CLM0000004300,MBR00000076,Medical_Institutional,Paid,Paper,2023-10-02,2023-10-02,2023-10-05,2023-10-04,Auto_Adjudicated,2,1490172833,1157814306,246ZN0300X,Neuropsychology,21,In_Network,Z00.01,,revenue_code:0300,470,0,Commercial,HMO,26,M,2.1785,,,6288.08,2464.04,1908.83,38.0,40.0,477.21,3824.04,0.0,0.0,0,,0.113,none,0,1,0,0,0,0.000177,0,0,,FFS
CLM0000004301,MBR00000194,Medical_Professional,Denied,Electronic_EDI,2023-03-08,2023-03-08,2023-03-08,2023-03-24,Auto_Adjudicated,16,1218947226,1951488764,207Q00000X,Family Medicine,11,In_Network,Z00.00,Z00.00,27130,,0,Commercial,PPO,77,M,0.9783,1,Duplicate,28880.39,22195.98,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0085,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004302,MBR00000214,Medical_Professional,Denied,Electronic_EDI,2023-11-25,2023-11-25,2023-11-25,2023-12-08,Auto_Adjudicated,13,1879212418,1469697158,101YP2500X,Psychologist Clinical,21,In_Network,OTHER,OTHER,99394,,0,Commercial,HDHP_HSA,76,M,1.7526,96,Medical_Necessity,531.24,342.53,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0428,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004303,MBR00000014,Behavioral_Health,Paid,Electronic_EDI,2023-12-20,2023-12-20,2023-12-20,2024-01-13,Auto_Adjudicated,24,1886549972,1388050552,208600000X,Surgery General,11,In_Network,OTHER,E11.9|OTHER,99203,,0,Commercial,HMO,77,M,2.8513,,,270.06,141.31,0.0,141.31,0.0,0.0,128.75,0.0,0.0,0,,0.0869,impossible_service_combo,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004304,MBR00000038,Vision,Paid,Electronic_EDI,2023-07-12,2023-07-12,2023-07-12,2023-07-18,Auto_Adjudicated,6,1015411732,1402472115,246ZN0300X,Neuropsychology,22,In_Network,OTHER,,V2100,,0,Commercial,EPO,46,M,1.1295,,,498.24,273.21,101.0,108.96,38.0,25.25,225.03,0.0,0.0,0,,0.1291,npi_mismatch,0,1,0,0,0,9e-06,0,0,CBP_Controlling_BP,Capitation
CLM0000004305,MBR00000139,Medical_Professional,Paid,Electronic_EDI,2023-04-23,2023-04-23,2023-04-23,2023-05-22,Auto_Adjudicated,29,1264953395,1576271272,207RC0000X,Cardiovascular Disease,21,Out_of_Network,K57.30,E78.5,33510,,0,Commercial,PPO,74,M,1.7701,,,305.54,127.51,0.0,127.51,0.0,0.0,178.03,0.0,0.0,0,,0.1199,service_date_weekend,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004306,MBR00000178,Medical_Professional,Paid,Electronic_EDI,2023-05-02,2023-05-02,2023-05-02,2023-05-26,Clinical_Review,24,1732193518,1489434038,2086S0122X,Orthopedic Surgery,81,In_Network,Z00.00,,97140,,0,Medicaid_MCO,MCO,89,M,0.7057,,,613.44,474.79,471.79,0.0,3.0,0.0,138.65,314.17,136.33,0,,0.0619,temporal_clustering,0,1,0,0,0,4.4e-05,0,0,,FFS
CLM0000004307,MBR00000141,Medical_Professional,Paid,Provider_Portal,2023-06-04,2023-06-04,2023-06-04,2023-06-27,Manual_Review,23,1836409547,1354265777,225100000X,Physical Therapist,22,In_Network,OTHER,OTHER|C50.911,99203,,0,Commercial,HMO,47,F,0.6724,,,202.53,101.78,29.54,38.85,26.0,7.39,100.75,0.0,0.0,0,,0.0783,geographic_mismatch,0,1,0,0,0,3e-06,0,0,,FFS
CLM0000004308,MBR00000192,Medical_Professional,Paid,Electronic_EDI,2023-06-22,2023-06-22,2023-06-22,2023-07-07,Auto_Adjudicated,15,1175448241,1105733833,207R00000X,Internal Medicine,11,Emergency,C50.911,,27130,,0,Medicaid_MCO,MCO,22,F,1.1739,,,11334.01,4370.72,4370.72,0.0,0.0,0.0,6963.29,0.0,0.0,0,,0.031,none,0,1,0,0,0,0.000405,0,0,BPD_BP_Declined,Shared_Savings
CLM0000004309,MBR00000221,Medical_Professional,Paid,Electronic_EDI,2023-01-28,2023-01-28,2023-01-28,2023-02-17,Auto_Adjudicated,20,1629674542,1469642907,208600000X,Surgery General,24,In_Network,Z23,OTHER|Z23,97140,,0,Commercial,HDHP_HSA,28,M,1.6683,,,215.36,114.05,0.0,114.05,0.0,0.0,101.31,0.0,0.0,0,,0.0534,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004310,MBR00000288,Pharmacy,Paid,Provider_Portal,2023-03-12,2023-03-12,2023-03-12,2023-03-19,Auto_Adjudicated,7,1243349799,1163639177,207R00000X,Internal Medicine,11,In_Network,L70.0,K21.0|OTHER,00085163102,,4,Commercial,HMO,36,M,0.8408,,,191.98,90.52,0.0,90.52,0.0,0.0,101.46,0.0,0.0,0,,0.038,none,0,1,0,0,0,0.0,0,0,CBP_Controlling_BP,Bundled_Payment
CLM0000004311,MBR00000110,Medical_Professional,Paid,Electronic_EDI,2023-10-11,2023-10-11,2023-10-11,2023-10-12,Clinical_Review,1,1487261286,1930040953,2084P0800X,Psychiatry,31,In_Network,E11.65,OTHER,33510,,0,Medicare_Advantage,MA_HMO,83,F,1.127,,,1255.72,695.41,541.82,9.13,9.0,135.46,560.31,0.0,0.0,0,,0.0271,none,0,1,0,0,0,5e-05,0,0,AMR_Asthma_Medication_Ratio,Bundled_Payment
CLM0000004312,MBR00000052,Dental,Paid,Electronic_EDI,2023-01-19,2023-01-19,2023-01-19,2023-02-11,Auto_Adjudicated,23,1193571728,1296566243,101YP2500X,Psychologist Clinical,21,In_Network,I50.9,F41.1|Z12.11,D0150,,0,Commercial,PPO,0,F,1.325,,,748.21,583.71,257.85,229.4,32.0,64.46,164.5,0.0,0.0,0,,0.0219,none,0,1,0,0,0,2.4e-05,0,0,,FFS
CLM0000004313,MBR00000081,Behavioral_Health,Paid,Paper,2023-06-11,2023-06-11,2023-06-11,2023-06-25,Manual_Review,14,1470105939,1704466150,207V00000X,Obstetrics & Gynecology,11,Emergency,OTHER,,74178,,0,Medicare_Advantage,SNP,66,F,2.159,,,129.72,93.72,58.31,15.83,5.0,14.58,36.0,0.0,0.0,0,,0.095,none,0,1,0,0,0,5e-06,0,0,AMR_Asthma_Medication_Ratio,Capitation
CLM0000004314,MBR00000046,Medical_Professional,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-11-22,Auto_Adjudicated,11,1262622669,1747935894,2084P0800X,Psychiatry,81,In_Network,OTHER,,90837,,0,Commercial,HMO,76,F,0.9613,,,464.59,219.21,119.52,34.81,35.0,29.88,245.38,0.0,0.0,0,,0.0028,none,0,1,0,0,0,1.1e-05,0,0,,Shared_Savings
CLM0000004315,MBR00000125,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-02-01,2023-02-01,2023-02-03,2023-02-10,Auto_Adjudicated,9,1075661656,1319611206,207RP1001X,Pulmonary Disease,22,In_Network,OTHER,Z00.01,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,96,Medical_Necessity,6161.07,3146.43,1306.91,0.81,45.0,326.73,4481.63,0.0,0.0,0,,0.1888,unbundling_pattern|high_oop_waiver,0,1,0,0,0,0.000121,0,0,,FFS
CLM0000004316,MBR00000263,Medical_Institutional,Paid,Electronic_EDI,2023-11-29,2023-11-29,2023-12-03,2023-12-18,Manual_Review,19,1505049857,1942423230,207RN0300X,Nephrology,31,Out_of_Network,OTHER,J06.9|F32.9,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,,,5793.33,3282.17,2573.86,30.84,34.0,643.47,2511.16,0.0,0.0,0,,0.0584,none,0,1,0,0,0,0.000238,1,0,,Shared_Savings
CLM0000004317,MBR00000110,Medical_Professional,Paid,Paper,2023-06-19,2023-06-19,2023-06-19,2023-07-05,Auto_Adjudicated,16,1346717076,1177602659,207R00000X,Internal Medicine,21,Emergency,E11.65,OTHER|M54.5|Z00.00,99223,,0,Medicare_Advantage,MA_HMO,83,F,1.127,,,241.41,103.98,72.39,4.49,9.0,18.1,137.43,0.0,0.0,0,,0.1012,none,0,1,0,0,0,7e-06,0,0,HBD_Hemoglobin_A1c_Testing,Shared_Savings
CLM0000004318,MBR00000047,Pharmacy,Partially_Paid,Electronic_EDI,2023-06-01,2023-06-01,2023-06-01,2023-06-22,Auto_Adjudicated,21,1542851144,1880530717,207V00000X,Obstetrics & Gynecology,22,In_Network,J06.9,Z00.00,00006001954,,1,Commercial,PPO,37,M,0.565,170,Medical_Necessity,182.86,90.06,0.0,55.31,0.0,0.0,127.55,0.0,0.0,0,,0.1102,none,0,1,0,1,0,0.0,0,1,,FFS
CLM0000004319,MBR00000160,Medical_Institutional,Paid,Electronic_EDI,2023-09-14,2023-09-14,2023-09-16,2023-10-13,Clinical_Review,29,1484613641,1622950074,207RN0300X,Nephrology,21,In_Network,I50.9,,revenue_code:0110,682,0,Commercial,HMO,73,M,1.9608,,,9242.36,4660.18,3669.13,33.77,40.0,917.28,4582.18,0.0,0.0,0,,0.0769,none,0,1,0,0,0,0.00034,0,0,,Shared_Savings
CLM0000004320,MBR00000298,Medical_Professional,Paid,Electronic_EDI,2023-10-07,2023-10-07,2023-10-07,2023-11-02,Manual_Review,26,1808451151,1419347445,207RC0000X,Cardiovascular Disease,21,In_Network,E11.65,,83036,,0,Medicaid_MCO,MCO,75,M,0.8324,,,245.22,108.98,108.98,0.0,0.0,0.0,136.24,0.0,0.0,0,,0.0718,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000004321,MBR00000059,Dental,Paid,Provider_Portal,2023-06-19,2023-06-19,2023-06-19,2023-06-29,Auto_Adjudicated,10,1514646292,1704466150,207RC0000X,Cardiovascular Disease,24,In_Network,Z00.00,OTHER,D3310,,0,Medicare_Advantage,SNP,12,F,1.266,,,626.01,304.68,214.86,20.1,16.0,53.72,321.33,135.77,53.57,0,,0.0025,none,0,1,0,0,0,2e-05,0,0,COL_Colorectal_Cancer_Screening,Capitation
CLM0000004322,MBR00000229,Medical_Professional,Denied,Paper,2023-01-30,2023-01-30,2023-01-30,2023-02-07,Auto_Adjudicated,8,1034110592,1049766043,207V00000X,Obstetrics & Gynecology,11,In_Network,I25.10,I10|OTHER,99204,,0,Medicare_Advantage,PFFS,63,M,1.1626,1,Coding_Error,306.06,172.11,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1411,temporal_clustering,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004323,MBR00000246,Medical_Professional,Paid,Electronic_EDI,2023-12-14,2023-12-14,2023-12-14,2023-12-19,Auto_Adjudicated,5,1083045036,1574982369,2084P0800X,Psychiatry,22,In_Network,Z23,Z00.00,99232,,0,Commercial,PPO,80,F,0.7925,,,604.03,467.46,242.33,134.55,30.0,60.58,136.57,0.0,0.0,1,Identity Theft,1.0,outlier_billing_amount|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|impossible_service_combo|service_date_weekend|billing_spike_recent|upcoding_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,2.2e-05,0,0,,FFS
CLM0000004324,MBR00000128,Behavioral_Health,Paid,Electronic_EDI,2023-01-04,2023-01-04,2023-01-04,2023-01-22,Auto_Adjudicated,18,1175252466,1188760037,101YP2500X,Psychologist Clinical,11,In_Network,Z12.11,OTHER|Z00.01,99285,,0,Commercial,PPO,13,F,1.4203,,,299.42,206.6,146.37,10.63,13.0,36.59,92.82,0.0,0.0,0,,0.1288,none,0,1,0,0,0,1.4e-05,0,0,,Shared_Savings
CLM0000004325,MBR00000185,Medical_Professional,Paid,Electronic_EDI,2023-11-09,2023-11-09,2023-11-09,2023-12-04,Auto_Adjudicated,25,1830816512,1581533104,2084P0800X,Psychiatry,22,In_Network,G43.909,,99202,,0,Medicaid_MCO,MCO,73,M,1.5417,,,302.34,115.94,112.94,0.0,3.0,0.0,186.4,0.0,0.0,0,,0.1342,none,0,1,0,0,0,1e-05,0,0,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000004326,MBR00000135,Medical_Professional,Paid,Electronic_EDI,2023-06-05,2023-06-05,2023-06-05,2023-06-13,Manual_Review,8,1560886857,1878874025,2084P0800X,Psychiatry,11,In_Network,OTHER,Z79.4,20610,,0,Commercial,PPO,58,F,2.2702,,,362.74,219.16,143.8,2.41,37.0,35.95,143.58,0.0,0.0,0,,0.1789,benford_violation,0,1,0,0,0,1.3e-05,0,0,,Capitation
CLM0000004327,MBR00000081,Medical_Professional,Denied,Paper,2023-07-04,2023-07-04,2023-07-04,2023-08-03,Auto_Adjudicated,30,1411619682,1133410177,207V00000X,Obstetrics & Gynecology,21,In_Network,E11.9,,11200,,0,Medicare_Advantage,SNP,66,F,2.159,22,Medical_Necessity,1877.46,877.56,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0419,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004328,MBR00000135,Medical_Professional,Paid,Provider_Portal,2023-10-02,2023-10-02,2023-10-02,2023-10-15,Auto_Adjudicated,13,1049153238,1493836023,101YP2500X,Psychologist Clinical,22,Out_of_Network,OTHER,Z00.121,97140,,0,Commercial,PPO,58,F,2.2702,,,1016.27,356.34,252.44,3.79,37.0,63.11,659.93,0.0,0.0,0,,0.0824,none,0,1,0,0,0,2.3e-05,1,0,,Bundled_Payment
CLM0000004329,MBR00000028,Medical_Institutional,Denied,Electronic_EDI,2023-12-04,2023-12-04,2023-12-08,2023-12-28,Auto_Adjudicated,24,1220235547,1867626800,207RG0100X,Gastroenterology,24,Emergency,I10,E11.9|E11.65,revenue_code:0450,,0,Commercial,HMO,3,F,2.116,CO-45,Medical_Necessity,5349.32,3384.7,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0674,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004330,MBR00000209,Pharmacy,Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-23,2023-03-04,Auto_Adjudicated,9,1373899620,1447186817,207RP1001X,Pulmonary Disease,71,In_Network,I25.10,OTHER,00085163102,,2,Medicare_Advantage,MA_HMO,10,F,0.5199,,,88.79,39.92,19.01,14.16,2.0,4.75,48.87,0.0,0.0,0,,0.0145,none,0,1,0,0,0,2e-06,0,1,SPC_Statin_Therapy,Shared_Savings
CLM0000004331,MBR00000248,Medical_Professional,Paid,Electronic_EDI,2023-10-19,2023-10-19,2023-10-19,2023-10-24,Auto_Adjudicated,5,1433357203,1650774392,246ZN0300X,Neuropsychology,11,In_Network,OTHER,I10,90834,,0,Commercial,PPO,40,F,0.6665,,,2617.36,1762.76,1147.52,312.36,16.0,286.88,854.6,0.0,0.0,0,,0.2021,npi_mismatch,0,2,0,0,0,0.000106,0,0,COL_Colorectal_Cancer_Screening,Bundled_Payment
CLM0000004332,MBR00000097,Medical_Institutional,Paid,Electronic_EDI,2023-08-26,2023-08-26,2023-08-29,2023-09-11,Clinical_Review,16,1298243993,1690197969,246ZN0300X,Neuropsychology,22,In_Network,OTHER,,revenue_code:0120,,0,Commercial,EPO,34,M,1.3765,,,10367.86,4980.22,3839.33,124.06,57.0,959.83,5387.64,0.0,0.0,0,,0.1433,none,0,1,0,0,0,0.000355,0,0,,Bundled_Payment
CLM0000004333,MBR00000170,Medical_Professional,Paid,Electronic_EDI,2023-05-13,2023-05-13,2023-05-13,2023-05-30,Auto_Adjudicated,17,1006962798,1321680994,2086S0122X,Orthopedic Surgery,21,In_Network,M54.5,N39.0|OTHER|E78.5,99214,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,199.54,93.99,60.19,15.75,3.0,15.05,105.55,0.0,0.0,0,,0.0902,none,0,1,0,0,0,6e-06,0,0,PCR_Plan_All_Cause_Readmission,Bundled_Payment
CLM0000004334,MBR00000073,Medical_Professional,Paid,Electronic_EDI,2023-06-02,2023-06-02,2023-06-02,2023-06-17,Auto_Adjudicated,15,1528602428,1560230600,207RN0300X,Nephrology,22,In_Network,OTHER,M79.3,84443,,0,Commercial,POS,79,M,1.1768,,,448.41,289.41,138.5,83.29,33.0,34.62,159.0,0.0,0.0,0,,0.1599,unbundling_pattern,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000004335,MBR00000039,Vision,Partially_Paid,Electronic_EDI,2023-10-04,2023-10-04,2023-10-04,2023-10-17,Clinical_Review,13,1295273693,1767402068,207RC0000X,Cardiovascular Disease,21,In_Network,OTHER,OTHER|C50.911,V2100,,0,Medicaid_MCO,MCO,20,F,0.5358,96,Medical_Necessity,350.83,226.4,179.18,0.0,0.0,0.0,171.65,0.0,0.0,0,,0.1624,unbundling_pattern,0,1,0,1,0,1.7e-05,0,0,,Shared_Savings
CLM0000004336,MBR00000197,Pharmacy,Paid,Provider_Portal,2023-02-20,2023-02-20,2023-02-20,2023-03-12,Clinical_Review,20,1971354640,1867389043,207V00000X,Obstetrics & Gynecology,11,In_Network,I10,,16590051660,,1,Medicare_Advantage,MA_HMO,59,M,1.1414,,,123.04,95.28,56.4,11.78,13.0,14.1,27.76,0.0,0.0,0,,0.068,none,0,1,0,0,0,5e-06,0,0,POD_Persistence_of_Beta_Blocker,FFS
CLM0000004337,MBR00000042,Pharmacy,Paid,Electronic_EDI,2023-07-01,2023-07-01,2023-07-01,2023-07-21,Manual_Review,20,1995916350,1406199453,207RG0100X,Gastroenterology,22,In_Network,Z12.11,,00085163102,,3,Commercial,HMO,78,F,1.1448,,,200.26,89.95,36.76,24.0,20.0,9.19,110.31,0.0,0.0,0,,0.0485,none,0,1,0,1,0,3e-06,0,1,,P4P
CLM0000004338,MBR00000231,Medical_Professional,Paid,Electronic_EDI,2023-09-17,2023-09-17,2023-09-17,2023-09-22,Auto_Adjudicated,5,1994365754,1282319940,2084P0800X,Psychiatry,11,In_Network,OTHER,Z00.00,83036,,0,ACA_Marketplace,ACA_Silver,12,M,0.6456,,,3273.12,2760.78,1903.31,0.77,41.0,815.7,512.34,1444.42,411.07,0,,0.2955,impossible_service_combo|billing_spike_recent|unbundling_pattern,0,2,0,1,0,0.000176,0,0,,Capitation
CLM0000004339,MBR00000084,Medical_Institutional,Denied,Electronic_EDI,2023-07-13,2023-07-13,2023-07-15,2023-08-03,Auto_Adjudicated,21,1369267360,1133410177,2086S0122X,Orthopedic Surgery,11,Out_of_Network,Z00.00,I10,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,15,F,0.8004,5,Medical_Necessity,2917.87,1559.99,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.088,none,0,1,0,1,0,0.0,1,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000004340,MBR00000244,Pharmacy,Denied,Electronic_EDI,2023-06-10,2023-06-10,2023-06-10,2023-06-20,Auto_Adjudicated,10,1567711165,1728466420,208600000X,Surgery General,32,In_Network,F33.0,Z12.11,16590051660,,1,Commercial,PPO,52,M,0.6677,256,Duplicate,130.08,108.62,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0588,none,0,1,0,1,0,0.0,0,1,,FFS
CLM0000004341,MBR00000117,Dental,Paid,Electronic_EDI,2023-07-06,2023-07-06,2023-07-06,2023-07-31,Auto_Adjudicated,25,1478458171,1004714954,207V00000X,Obstetrics & Gynecology,32,In_Network,Z23,Z23,D3310,,0,Medicaid_MCO,MLTSS,72,F,0.8628,,,363.12,155.3,151.3,0.0,4.0,0.0,207.82,0.0,0.0,0,,0.0207,none,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000004342,MBR00000117,Pharmacy,Paid,Paper,2023-07-03,2023-07-03,2023-07-03,2023-07-18,Auto_Adjudicated,15,1368580443,1574982369,246ZN0300X,Neuropsychology,22,In_Network,M17.11,M54.5,16590051660,,1,Medicaid_MCO,MLTSS,72,F,0.8628,,,43.89,36.27,32.27,0.0,4.0,0.0,7.62,0.0,0.0,0,,0.0484,none,0,1,0,0,0,3e-06,0,1,,FFS
CLM0000004343,MBR00000220,Medical_Institutional,Paid,Electronic_EDI,2023-10-16,2023-10-16,2023-10-20,2023-10-24,Auto_Adjudicated,8,1550698436,1144950506,208600000X,Surgery General,11,In_Network,Z23,K21.0,revenue_code:0200,,0,Commercial,HMO,38,M,0.7736,,,19110.97,15901.23,12598.98,97.51,55.0,3149.74,3209.74,0.0,0.0,0,,0.084,phantom_billing_indicator,0,1,1,0,0,0.001166,0,0,,FFS
CLM0000004344,MBR00000157,Medical_Professional,Paid,Paper,2023-10-22,2023-10-22,2023-10-22,2023-10-28,Manual_Review,6,1310400164,1789540567,2086S0122X,Orthopedic Surgery,21,In_Network,E11.9,,17000,,0,Medicare_Advantage,MA_HMO,26,F,0.9164,,,1216.43,602.38,463.02,6.61,17.0,115.75,614.05,0.0,0.0,0,,0.0485,none,0,1,0,0,0,4.3e-05,0,0,DAE_Drug_Alcohol_Dependence,Capitation
CLM0000004345,MBR00000061,Medical_Professional,Paid,Provider_Portal,2023-11-26,2023-11-26,2023-11-26,2023-12-25,Manual_Review,29,1478458171,1498781755,208600000X,Surgery General,21,In_Network,J06.9,OTHER|Z00.01,70553,,0,Commercial,PPO,66,M,2.3575,,,245.94,111.06,0.0,111.06,0.0,0.0,134.88,0.0,0.0,0,,0.1873,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,FFS
CLM0000004346,MBR00000256,Medical_Professional,Paid,Electronic_EDI,2023-01-26,2023-01-26,2023-01-26,2023-02-17,Auto_Adjudicated,22,1377412382,1289435414,207RN0300X,Nephrology,23,In_Network,OTHER,K21.0|K57.30,99394,,0,Commercial,HDHP_HSA,71,F,0.3642,,,268.83,175.14,0.0,175.14,0.0,0.0,93.69,0.0,0.0,0,,0.1742,high_volume_same_code,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004347,MBR00000106,Medical_Professional,Paid,Provider_Portal,2023-04-25,2023-04-25,2023-04-25,2023-05-02,Auto_Adjudicated,7,1388566092,1469642907,207RG0100X,Gastroenterology,24,In_Network,N18.3,I10,99231,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,306.85,128.46,77.96,25.01,6.0,19.49,178.39,0.0,0.0,0,,0.0556,none,0,1,0,0,0,7e-06,0,0,,Capitation
CLM0000004348,MBR00000031,Medical_Professional,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-11-27,Auto_Adjudicated,16,1950560596,1055872102,207RP1001X,Pulmonary Disease,21,In_Network,F41.1,Z00.00|OTHER|K57.30,33510,,0,Commercial,PPO,71,M,0.6746,,,971.92,483.59,359.95,17.65,16.0,89.99,488.33,0.0,0.0,0,,0.078,none,0,1,0,0,0,3.3e-05,0,0,,Shared_Savings
CLM0000004349,MBR00000132,Medical_Institutional,Paid,Electronic_EDI,2023-08-19,2023-08-19,2023-08-23,2023-08-23,Auto_Adjudicated,4,1059948944,1391074619,2086S0122X,Orthopedic Surgery,21,In_Network,Z87.891,OTHER|K57.30|Z12.11,revenue_code:0200,871,0,Medicare_Advantage,MA_PPO,84,F,1.3018,,,132550.33,111536.42,89209.53,0.5,24.0,22302.38,21013.91,0.0,0.0,0,,0.1139,outlier_billing_amount,0,1,1,0,0,0.008257,0,0,,Bundled_Payment
CLM0000004350,MBR00000173,Medical_Institutional,Paid,Electronic_EDI,2023-05-16,2023-05-16,2023-05-17,2023-06-11,Manual_Review,26,1556072255,1274911960,207RN0300X,Nephrology,11,In_Network,I10,E78.5,revenue_code:0200,,0,Medicare_Advantage,PFFS,23,F,1.0279,,,6157.91,4510.52,3562.07,17.94,40.0,890.52,1647.39,0.0,0.0,0,,0.0655,none,0,1,0,0,0,0.00033,0,0,,Bundled_Payment
CLM0000004351,MBR00000184,Medical_Institutional,Paid,Electronic_EDI,2023-08-14,2023-08-14,2023-08-15,2023-09-08,Auto_Adjudicated,25,1042080259,1498781755,225100000X,Physical Therapist,23,In_Network,Z00.01,Z00.01|J44.1,revenue_code:0120,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,19463.83,14558.96,14558.96,0.0,0.0,0.0,4904.87,0.0,0.0,0,,0.133,none,0,1,1,0,0,0.001348,0,0,,Shared_Savings
CLM0000004352,MBR00000250,Medical_Institutional,Paid,Electronic_EDI,2023-06-16,2023-06-16,2023-06-19,2023-07-11,Auto_Adjudicated,25,1901547390,1847196500,246ZN0300X,Neuropsychology,21,In_Network,J20.9,E11.9,revenue_code:0250,439,0,Commercial,PPO,41,M,0.9245,,,10699.25,8417.36,6646.26,62.54,47.0,1661.56,2281.89,4602.66,1372.09,0,,0.0241,none,0,1,1,0,0,0.000615,0,0,,FFS
CLM0000004353,MBR00000165,Medical_Professional,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-11-29,Auto_Adjudicated,14,1046207613,1831337866,207RN0300X,Nephrology,23,In_Network,Z00.00,,27447,,0,ACA_Marketplace,ACA_Bronze,55,M,0.9775,,,14609.26,10148.89,5250.21,1398.54,0.0,3500.14,4460.37,0.0,0.0,0,,0.0371,none,0,1,1,0,0,0.000486,0,0,SPC_Statin_Therapy,Shared_Savings
CLM0000004354,MBR00000070,Medical_Institutional,Paid,Electronic_EDI,2023-07-20,2023-07-20,2023-07-20,2023-07-25,Manual_Review,5,1263063839,1148659045,246ZN0300X,Neuropsychology,23,Out_of_Network,I10,,revenue_code:0360,,0,Commercial,POS,42,F,0.8468,,,12176.37,8624.74,6614.43,303.7,53.0,1653.61,3551.63,0.0,0.0,0,,0.1269,none,0,1,1,0,0,0.000612,1,0,,Shared_Savings
CLM0000004355,MBR00000081,Behavioral_Health,Denied,Provider_Portal,2023-06-10,2023-06-10,2023-06-10,2023-06-25,Auto_Adjudicated,15,1317654726,1408846353,2086S0122X,Orthopedic Surgery,11,In_Network,N40.0,OTHER,99393,,0,Medicare_Advantage,SNP,66,F,2.159,3,Coding_Error,270.16,193.51,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1666,temporal_clustering,0,1,0,0,0,0.0,0,0,MMA_Medication_Management,Capitation
CLM0000004356,MBR00000030,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-08-12,2023-08-12,2023-08-15,2023-08-28,Auto_Adjudicated,16,1866366547,1774401124,207RP1001X,Pulmonary Disease,32,In_Network,OTHER,,revenue_code:0250,,0,Medicaid_MCO,MCO,67,M,0.4581,4,Medical_Necessity,12104.44,6605.68,3524.12,0.0,4.0,0.0,8576.32,2536.65,580.98,0,,0.1867,diagnosis_procedure_mismatch,0,1,0,1,0,0.000326,0,0,,Shared_Savings
CLM0000004357,MBR00000215,Dental,Paid,Electronic_EDI,2023-03-10,2023-03-10,2023-03-10,2023-03-20,Manual_Review,10,1863796345,1811797489,207RE0101X,Endocrinology,31,Out_of_Network,E78.5,N39.0|OTHER|Z12.11,D2391,,0,ACA_Marketplace,ACA_Silver,69,M,0.8895,,,412.88,165.18,0.0,165.18,0.0,0.0,247.7,0.0,0.0,0,,0.1599,provider_specialty_mismatch,0,1,0,0,0,0.0,1,0,,FFS
CLM0000004358,MBR00000033,Medical_Professional,Denied,Electronic_EDI,2023-10-04,2023-10-04,2023-10-04,2023-10-16,Manual_Review,12,1292994726,1005335812,207RN0300X,Nephrology,22,In_Network,Z12.11,Z23|E78.5|M17.11,99213,,0,Medicare_Advantage,PFFS,31,F,0.821,5,Eligibility,268.97,176.18,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1542,npi_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004359,MBR00000183,Medical_Institutional,Partially_Paid,Provider_Portal,2023-03-14,2023-03-14,2023-03-16,2023-03-16,Auto_Adjudicated,2,1231954359,1560230600,207Q00000X,Family Medicine,11,In_Network,K57.30,Z00.00,revenue_code:0360,,0,Commercial,PPO,51,M,0.8463,97,Medical_Necessity,5163.47,3872.35,1849.89,208.87,57.0,462.47,2585.23,0.0,0.0,0,,0.0749,none,0,1,0,0,0,0.000171,0,0,,FFS
CLM0000004360,MBR00000180,Medical_Institutional,Paid,Electronic_EDI,2023-01-09,2023-01-09,2023-01-12,2023-01-25,Auto_Adjudicated,16,1976304517,1774401124,2086S0122X,Orthopedic Surgery,11,In_Network,OTHER,OTHER,revenue_code:0100,,0,Medicare_Advantage,MA_PPO,72,F,1.1909,,,25226.28,11786.27,9387.03,1.49,51.0,2346.76,13440.01,6941.24,1730.27,0,,0.0506,none,0,1,1,0,0,0.000869,0,0,,Shared_Savings
CLM0000004361,MBR00000232,Pharmacy,Paid,Electronic_EDI,2023-01-19,2023-01-19,2023-01-19,2023-01-25,Auto_Adjudicated,6,1915327071,1140170394,207RE0101X,Endocrinology,11,In_Network,E78.5,Z00.01|OTHER|Z23,00310075090,,2,Medicaid_MCO,MCO,40,M,1.1083,,,409.26,180.56,178.56,0.0,2.0,0.0,228.7,0.0,0.0,0,,0.1438,none,0,1,0,0,0,1.7e-05,0,0,PPC_Prenatal_Care,Bundled_Payment
CLM0000004362,MBR00000023,Dental,Paid,Electronic_EDI,2023-01-24,2023-01-24,2023-01-24,2023-02-19,Auto_Adjudicated,26,1727787144,1098360555,207V00000X,Obstetrics & Gynecology,22,In_Network,OTHER,F32.9|OTHER,D0150,,0,Medicare_Advantage,MA_PPO,87,M,1.084,,,630.61,522.46,362.72,54.06,15.0,90.68,108.15,0.0,0.0,0,,0.0897,temporal_clustering,0,1,0,0,0,3.4e-05,0,0,,FFS
CLM0000004363,MBR00000061,Medical_Institutional,Paid,Electronic_EDI,2023-02-06,2023-02-06,2023-02-06,2023-03-01,Auto_Adjudicated,23,1295273693,1509799493,207RN0300X,Nephrology,11,In_Network,OTHER,,revenue_code:0450,,0,Commercial,PPO,66,M,2.3575,,,22017.28,9230.12,7315.94,51.2,34.0,1828.98,12787.16,0.0,0.0,0,,0.0588,none,0,1,1,0,0,0.000677,0,0,,FFS
CLM0000004364,MBR00000274,Pharmacy,Paid,Electronic_EDI,2023-01-19,2023-01-19,2023-01-19,2023-02-07,Auto_Adjudicated,19,1954226809,1827839595,101YP2500X,Psychologist Clinical,31,In_Network,Z00.01,K29.70|E78.5|M54.5,00003014960,,1,Medicare_Advantage,MA_HMO,58,F,2.1025,,,96.76,60.42,21.16,33.97,0.0,5.29,36.34,0.0,0.0,0,,0.1484,none,0,1,0,0,0,2e-06,0,0,,Shared_Savings
CLM0000004365,MBR00000171,Dental,Paid,Paper,2023-04-19,2023-04-19,2023-04-19,2023-04-26,Auto_Adjudicated,7,1026612378,1825450791,207R00000X,Internal Medicine,21,In_Network,E11.9,I10,D0120,,0,Commercial,PPO,27,F,0.819,,,197.52,142.33,0.0,142.33,0.0,0.0,55.19,0.0,0.0,0,,0.0643,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004366,MBR00000142,Pharmacy,Paid,Electronic_EDI,2023-12-11,2023-12-11,2023-12-11,2024-01-01,Auto_Adjudicated,21,1633089013,1746676564,246ZN0300X,Neuropsychology,22,In_Network,G43.909,,16590051660,,2,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,374.54,148.88,0.0,148.88,0.0,0.0,225.66,0.0,0.0,0,,0.1505,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004367,MBR00000219,Medical_Professional,Paid,Electronic_EDI,2023-02-06,2023-02-06,2023-02-06,2023-03-08,Auto_Adjudicated,30,1214787184,1791502603,207RG0100X,Gastroenterology,65,In_Network,Z00.00,,17000,,0,Medicare_Advantage,MA_HMO,84,M,0.9513,,,279.79,176.35,104.86,45.27,0.0,26.22,103.44,0.0,0.0,0,,0.127,none,0,1,0,0,0,1e-05,0,0,HBD_Hemoglobin_A1c_Testing,Bundled_Payment
CLM0000004368,MBR00000273,Medical_Professional,Denied,Electronic_EDI,2023-08-31,2023-08-31,2023-08-31,2023-09-19,Auto_Adjudicated,19,1216417633,1619587398,101YP2500X,Psychologist Clinical,22,In_Network,E78.5,M79.3|G47.33,99205,,0,ACA_Marketplace,ACA_Bronze,4,M,1.3569,3,COB,198.76,137.16,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0228,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004369,MBR00000081,Dental,Paid,Electronic_EDI,2023-11-09,2023-11-09,2023-11-09,2023-12-03,Manual_Review,24,1732726112,1542515060,207RN0300X,Nephrology,21,In_Network,OTHER,,D7140,,0,Medicare_Advantage,SNP,66,F,2.159,,,1268.53,471.7,357.83,19.41,5.0,89.46,796.83,0.0,0.0,0,,0.064,provider_specialty_mismatch,0,1,0,0,0,3.3e-05,0,0,,P4P
CLM0000004370,MBR00000273,Pharmacy,Denied,Electronic_EDI,2023-10-18,2023-10-18,2023-10-18,2023-11-15,Manual_Review,28,1117755591,1616762819,207RG0100X,Gastroenterology,81,In_Network,K57.30,OTHER|E78.5,00169751112,,1,ACA_Marketplace,ACA_Bronze,4,M,1.3569,CO-45,Duplicate,270.22,151.3,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0764,upcoding_pattern,0,1,0,1,0,0.0,0,0,,FFS
CLM0000004371,MBR00000034,Vision,Paid,Electronic_EDI,2023-05-10,2023-05-10,2023-05-10,2023-06-05,Auto_Adjudicated,26,1958171947,1764064254,207Q00000X,Family Medicine,22,In_Network,M79.3,Z00.00|E11.9,92004,,0,Medicare_Advantage,MA_HMO,35,M,0.7712,,,303.24,178.05,105.71,38.91,7.0,26.43,125.19,0.0,0.0,0,,0.1372,none,0,1,0,1,0,1e-05,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000004372,MBR00000294,Medical_Professional,Paid,Electronic_EDI,2023-01-19,2023-01-19,2023-01-19,2023-01-24,Auto_Adjudicated,5,1388566092,1489993356,207RG0100X,Gastroenterology,22,Emergency,N18.3,,80053,,0,Medicare_Advantage,MA_HMO,8,M,0.6878,,,177.79,111.64,63.68,14.05,18.0,15.92,66.15,0.0,0.0,0,,0.1285,none,0,1,0,0,0,6e-06,0,0,,Bundled_Payment
CLM0000004373,MBR00000052,Pharmacy,Partially_Paid,Electronic_EDI,2023-05-13,2023-05-13,2023-05-13,2023-06-09,Auto_Adjudicated,27,1326896487,1388050552,208600000X,Surgery General,21,Out_of_Network,M17.11,OTHER,59148001506,,2,Commercial,PPO,0,F,1.325,50,Medical_Necessity,105.22,38.92,0.0,28.79,0.0,0.0,76.43,0.0,0.0,0,,0.0598,none,0,1,0,1,0,0.0,1,0,,FFS
CLM0000004374,MBR00000082,Pharmacy,Paid,Electronic_EDI,2023-08-04,2023-08-04,2023-08-04,2023-08-27,Auto_Adjudicated,23,1012271279,1368666316,207RG0100X,Gastroenterology,23,In_Network,OTHER,OTHER,00078043215,,2,Medicare_Advantage,MA_HMO,39,F,0.5376,,,351.35,279.94,205.13,20.53,3.0,51.28,71.41,0.0,0.0,0,,0.1168,none,0,1,0,0,0,1.9e-05,0,0,,FFS
CLM0000004375,MBR00000028,Dental,Paid,Electronic_EDI,2023-09-29,2023-09-29,2023-09-29,2023-10-21,Auto_Adjudicated,22,1375098560,1012893364,207RN0300X,Nephrology,24,In_Network,OTHER,,D2391,,0,Commercial,HMO,3,F,2.116,,,143.73,112.15,0.0,112.15,0.0,0.0,31.58,0.0,0.0,0,,0.0289,none,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000004376,MBR00000238,Pharmacy,Paid,Electronic_EDI,2023-02-20,2023-02-20,2023-02-20,2023-02-27,Auto_Adjudicated,7,1918160357,1804282800,2086S0122X,Orthopedic Surgery,23,In_Network,OTHER,J06.9,00071012831,,1,Commercial,PPO,74,F,0.4382,,,248.41,192.92,59.6,93.42,25.0,14.9,55.49,0.0,0.0,0,,0.0517,none,0,1,0,0,0,6e-06,0,0,CDC_BP_Control,Bundled_Payment
CLM0000004377,MBR00000296,Medical_Professional,Paid,Electronic_EDI,2023-04-19,2023-04-19,2023-04-19,2023-05-03,Manual_Review,14,1069440570,1985590322,2084P0800X,Psychiatry,11,In_Network,F41.1,F41.1|OTHER|G43.909,99213,,0,Commercial,HMO,83,F,1.4969,,,140.29,85.55,0.0,85.55,0.0,0.0,54.74,0.0,0.0,0,,0.167,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004378,MBR00000093,Pharmacy,Paid,Electronic_EDI,2023-08-04,2023-08-04,2023-08-04,2023-09-01,Auto_Adjudicated,28,1718336220,1352413270,207RG0100X,Gastroenterology,71,In_Network,OTHER,OTHER,00003014960,,2,Medicare_Advantage,MA_HMO,43,F,0.6162,,,109.27,81.3,35.84,17.5,19.0,8.96,27.97,0.0,0.0,0,,0.0969,controlled_substance_high_volume,0,1,0,0,0,3e-06,0,0,,FFS
CLM0000004379,MBR00000103,Medical_Institutional,Denied,Electronic_EDI,2023-09-14,2023-09-14,2023-09-16,2023-10-12,Auto_Adjudicated,28,1923332120,1945682535,225100000X,Physical Therapist,22,In_Network,Z00.121,J45.20,revenue_code:0360,,0,Medicaid_MCO,MCO,24,M,0.4785,4,Authorization,2911.93,2185.75,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0908,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004380,MBR00000087,Medical_Professional,Paid,Electronic_EDI,2023-04-22,2023-04-22,2023-04-22,2023-04-26,Auto_Adjudicated,4,1630305772,1510751265,2084P0800X,Psychiatry,31,In_Network,F32.9,Z79.4|E11.9,73721,,0,Medicaid_MCO,MCO,70,F,0.9232,,,694.75,577.74,576.74,0.0,1.0,0.0,117.01,0.0,0.0,0,,0.2362,upcoding_pattern|npi_mismatch,0,2,0,0,0,5.3e-05,0,0,POD_Persistence_of_Beta_Blocker,Shared_Savings
CLM0000004381,MBR00000049,Medical_Professional,Paid,Electronic_EDI,2023-10-23,2023-10-23,2023-10-23,2023-11-05,Manual_Review,13,1793406356,1985590322,246ZN0300X,Neuropsychology,11,In_Network,J06.9,I10|OTHER|E11.9,90837,,0,Medicare_Advantage,PFFS,67,M,0.978,,,197.66,149.85,84.63,40.07,4.0,21.16,47.81,0.0,0.0,0,,0.0731,none,0,1,0,0,0,8e-06,0,0,,Shared_Savings
CLM0000004382,MBR00000233,Dental,Paid,Paper,2023-10-15,2023-10-15,2023-10-15,2023-11-03,Auto_Adjudicated,19,1484613641,1027261156,208600000X,Surgery General,22,In_Network,Z23,E11.9|OTHER|Z00.00,D2140,,0,Medicare_Advantage,MA_PPO,87,M,0.8034,,,332.84,136.36,71.13,44.45,3.0,17.78,196.48,0.0,0.0,0,,0.1375,unusual_service_frequency|high_volume_same_code,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000004383,MBR00000018,Medical_Professional,Paid,Electronic_EDI,2023-05-10,2023-05-10,2023-05-10,2023-05-13,Auto_Adjudicated,3,1484438840,1355732274,225100000X,Physical Therapist,65,In_Network,F41.1,,47562,,0,Commercial,EPO,5,F,0.5555,,,1016.49,428.29,317.27,17.71,14.0,79.32,588.2,0.0,0.0,0,,0.0186,none,0,1,0,0,0,2.9e-05,0,0,DAE_Drug_Alcohol_Dependence,Capitation
CLM0000004384,MBR00000293,Medical_Institutional,Paid,Provider_Portal,2023-07-12,2023-07-12,2023-07-14,2023-07-20,Auto_Adjudicated,8,1115589144,1128148362,207RP1001X,Pulmonary Disease,23,In_Network,I10,,revenue_code:0200,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,14364.8,8680.39,6912.49,7.78,32.0,1728.12,5684.41,0.0,0.0,0,,0.0856,phantom_billing_indicator,0,1,1,0,0,0.00064,0,0,SPC_Statin_Therapy,FFS
CLM0000004385,MBR00000279,Medical_Institutional,Paid,Electronic_EDI,2023-06-21,2023-06-21,2023-06-21,2023-07-09,Manual_Review,18,1402833352,1874728994,207RG0100X,Gastroenterology,11,In_Network,E11.9,N40.0,revenue_code:0370,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,,,18233.2,12849.33,10246.84,10.78,30.0,2561.71,5383.87,0.0,0.0,0,,0.0522,none,0,1,1,0,0,0.000948,0,0,,FFS
CLM0000004386,MBR00000036,Behavioral_Health,Paid,Electronic_EDI,2023-08-29,2023-08-29,2023-08-29,2023-09-18,Auto_Adjudicated,20,1388662212,1694343357,207RG0100X,Gastroenterology,23,In_Network,Z00.01,,99212,,0,Commercial,EPO,17,M,2.0136,,,246.3,189.07,56.84,85.02,33.0,14.21,57.23,0.0,0.0,0,,0.1151,temporal_clustering,0,1,0,0,0,5e-06,0,0,TRC_Transition_of_Care,P4P
CLM0000004387,MBR00000161,Pharmacy,Denied,Electronic_EDI,2023-04-26,2023-04-26,2023-04-26,2023-04-30,Auto_Adjudicated,4,1067329999,1842149518,246ZN0300X,Neuropsychology,11,In_Network,Z00.00,F33.0,16590051660,,2,Medicaid_MCO,MLTSS,9,F,0.8354,97,Coding_Error,167.37,59.57,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0537,none,0,1,0,0,0,0.0,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000004388,MBR00000298,Medical_Professional,Paid,Electronic_EDI,2023-04-29,2023-04-29,2023-04-29,2023-05-12,Clinical_Review,13,1597649716,1510751265,246ZN0300X,Neuropsychology,21,In_Network,E11.65,Z00.00|I10,99284,,0,Medicaid_MCO,MCO,75,M,0.8324,,,270.58,153.37,153.37,0.0,0.0,0.0,117.21,0.0,0.0,0,,0.0597,none,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000004389,MBR00000257,Medical_Professional,Paid,Electronic_EDI,2023-06-01,2023-06-01,2023-06-01,2023-06-21,Auto_Adjudicated,20,1882720848,1983760474,2084P0800X,Psychiatry,11,In_Network,M47.816,M54.5|E11.9|I10,71250,,0,Medicaid_MCO,MCO,76,F,0.8322,,,797.99,448.27,447.27,0.0,1.0,0.0,349.72,0.0,0.0,0,,0.1867,provider_specialty_mismatch,0,1,0,0,0,4.1e-05,0,0,DAE_Drug_Alcohol_Dependence,Bundled_Payment
CLM0000004390,MBR00000212,Medical_Professional,Paid,Electronic_EDI,2023-03-19,2023-03-19,2023-03-19,2023-04-18,Auto_Adjudicated,30,1625939855,1415734567,207RN0300X,Nephrology,11,In_Network,N18.3,OTHER,99221,,0,Commercial,HMO,57,F,2.5456,,,162.21,113.1,0.0,113.1,0.0,0.0,49.11,0.0,0.0,0,,0.0586,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004391,MBR00000007,Medical_Professional,Paid,Electronic_EDI,2023-07-28,2023-07-28,2023-07-28,2023-08-27,Auto_Adjudicated,30,1017424540,1391074619,207RG0100X,Gastroenterology,11,In_Network,G43.909,OTHER|I10,99212,,0,Commercial,HDHP_HSA,72,F,0.7578,,,229.71,144.06,0.0,144.06,0.0,0.0,85.65,0.0,0.0,0,,0.1456,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004392,MBR00000021,Pharmacy,Paid,Electronic_EDI,2023-12-10,2023-12-10,2023-12-10,2023-12-20,Auto_Adjudicated,10,1677021292,1419347445,207V00000X,Obstetrics & Gynecology,22,In_Network,Z23,I25.10,00003014960,,5,Commercial,POS,72,M,0.6126,,,916.15,688.37,418.88,139.77,25.0,104.72,227.78,0.0,0.0,0,,0.1912,phantom_billing_indicator,0,1,0,0,0,3.9e-05,0,1,,Bundled_Payment
CLM0000004393,MBR00000235,Medical_Professional,Paid,Electronic_EDI,2023-05-06,2023-05-06,2023-05-06,2023-05-27,Auto_Adjudicated,21,1706065807,1055872102,207RE0101X,Endocrinology,24,Emergency,OTHER,K21.0|Z12.11,11200,,0,Commercial,HDHP_HSA,85,F,1.4308,,,912.59,638.84,409.0,127.59,0.0,102.25,273.75,0.0,0.0,0,,0.1909,provider_specialty_mismatch,0,1,0,0,0,3.8e-05,0,0,,FFS
CLM0000004394,MBR00000119,Medical_Professional,Paid,Electronic_EDI,2023-11-06,2023-11-06,2023-11-06,2023-11-23,Auto_Adjudicated,17,1164721841,1804282800,208600000X,Surgery General,11,In_Network,I48.91,,99387,,0,Commercial,POS,42,M,0.4987,,,1007.14,594.5,170.23,365.72,16.0,42.56,412.64,0.0,0.0,1,Upcoding,0.8724,outlier_billing_amount|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|service_date_weekend|billing_spike_recent|phantom_billing_indicator|npi_mismatch,1,5,0,1,0,1.6e-05,0,0,,FFS
CLM0000004395,MBR00000198,Dental,Paid,Electronic_EDI,2023-06-16,2023-06-16,2023-06-16,2023-06-23,Auto_Adjudicated,7,1542851144,1027261156,207RE0101X,Endocrinology,22,Out_of_Network,C50.911,,D0120,,0,Medicaid_MCO,MCO,81,F,1.4199,,,225.61,105.79,103.79,0.0,2.0,0.0,119.82,67.76,28.56,0,,0.0902,npi_mismatch,0,1,0,1,0,1e-05,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000004396,MBR00000216,Medical_Professional,Paid,Electronic_EDI,2023-03-01,2023-03-01,2023-03-01,2023-03-17,Manual_Review,16,1069440570,1390802135,207RC0000X,Cardiovascular Disease,22,Out_of_Network,OTHER,OTHER|Z00.00,99214,,0,Medicare_Advantage,MA_HMO,71,F,0.7117,,,240.44,161.61,119.52,2.22,10.0,29.88,78.83,0.0,0.0,0,,0.1454,none,0,1,0,0,0,1.1e-05,1,0,,FFS
CLM0000004397,MBR00000134,Medical_Professional,Paid,Electronic_EDI,2023-06-28,2023-06-28,2023-06-28,2023-07-03,Auto_Adjudicated,5,1886549972,1489993356,101YP2500X,Psychologist Clinical,81,In_Network,E11.9,OTHER,27447,,0,Medicare_Advantage,MA_PPO,33,M,1.115,,,5316.25,2463.75,1948.38,15.27,13.0,487.1,2852.5,0.0,0.0,0,,0.0971,none,0,1,0,0,0,0.00018,0,0,,Capitation
CLM0000004398,MBR00000045,Medical_Institutional,Denied,Electronic_EDI,2023-06-29,2023-06-29,2023-07-01,2023-07-03,Auto_Adjudicated,4,1164721841,1209882852,207RG0100X,Gastroenterology,24,In_Network,E11.65,M54.5|E11.65,revenue_code:0250,,0,Commercial,HMO,78,F,1.0658,3,Coding_Error,41342.24,27855.35,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1128,none,0,1,0,1,0,0.0,0,0,,Bundled_Payment
CLM0000004399,MBR00000122,Medical_Professional,Paid,Electronic_EDI,2023-01-09,2023-01-09,2023-01-09,2023-01-20,Manual_Review,11,1232573801,1587454801,207V00000X,Obstetrics & Gynecology,71,In_Network,OTHER,,99284,,0,Commercial,EPO,64,F,0.8625,,,438.13,186.48,106.54,15.31,38.0,26.63,251.65,0.0,0.0,0,,0.0957,none,0,1,0,0,0,1e-05,0,0,,Bundled_Payment
CLM0000004400,MBR00000263,Medical_Professional,Denied,Electronic_EDI,2023-06-22,2023-06-22,2023-06-22,2023-06-30,Manual_Review,8,1688560518,1666461892,208600000X,Surgery General,31,In_Network,Z00.01,,71250,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,18,Coding_Error,361.94,165.05,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1155,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004401,MBR00000105,Behavioral_Health,Partially_Paid,Electronic_EDI,2023-02-28,2023-02-28,2023-02-28,2023-03-05,Auto_Adjudicated,5,1923332120,1432077493,207R00000X,Internal Medicine,23,Out_of_Network,E11.9,,99205,,0,Commercial,HMO,74,M,1.1834,96,Medical_Necessity,322.39,182.09,0.0,104.92,0.0,0.0,217.47,0.0,0.0,0,,0.0175,none,0,1,0,0,0,0.0,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000004402,MBR00000019,Pharmacy,Paid,Electronic_EDI,2023-10-13,2023-10-13,2023-10-13,2023-10-15,Auto_Adjudicated,2,1209940651,1148612764,2084P0800X,Psychiatry,11,In_Network,F41.1,OTHER|M79.3,00310075090,,1,Commercial,PPO,77,M,0.6521,,,308.78,188.17,0.0,188.17,0.0,0.0,120.61,0.0,0.0,0,,0.0004,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000004403,MBR00000291,Pharmacy,Paid,Electronic_EDI,2023-07-14,2023-07-14,2023-07-14,2023-08-01,Manual_Review,18,1424104563,1105871325,207RC0000X,Cardiovascular Disease,31,In_Network,Z23,OTHER,00078043215,,1,Commercial,PPO,78,M,1.4773,,,191.47,158.32,86.94,35.65,14.0,21.73,33.15,0.0,0.0,0,,0.1887,phantom_billing_indicator,0,1,0,0,0,8e-06,0,0,,FFS
CLM0000004404,MBR00000202,Pharmacy,Denied,Electronic_EDI,2023-04-20,2023-04-20,2023-04-20,2023-04-21,Auto_Adjudicated,1,1495592428,1301833092,207V00000X,Obstetrics & Gynecology,24,In_Network,OTHER,Z00.01,00310075090,,1,Commercial,PPO,87,F,0.6213,CO-45,Authorization,263.45,172.24,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0798,service_date_weekend,0,1,0,0,0,0.0,0,0,KED_ESRD_Patients,FFS
CLM0000004405,MBR00000164,Medical_Professional,Paid,Electronic_EDI,2023-01-01,2023-01-01,2023-01-01,2023-01-25,Auto_Adjudicated,24,1299958874,1027261156,208600000X,Surgery General,11,In_Network,M25.511,,90853,,0,ACA_Marketplace,ACA_Silver,3,F,0.7155,,,968.74,544.79,227.54,180.73,39.0,97.52,423.95,0.0,0.0,0,,0.138,phantom_billing_indicator,0,1,0,0,0,2.1e-05,0,0,,Shared_Savings
CLM0000004406,MBR00000248,Pharmacy,Paid,Electronic_EDI,2023-07-24,2023-07-24,2023-07-24,2023-07-27,Auto_Adjudicated,3,1326896487,1452088018,101YP2500X,Psychologist Clinical,11,In_Network,Z00.00,,00069420020,,1,Commercial,PPO,40,F,0.6665,,,244.84,187.06,21.58,144.09,16.0,5.39,57.78,0.0,0.0,0,,0.1183,none,0,1,0,0,0,2e-06,0,0,FLU_Flu_Vaccination,Shared_Savings
CLM0000004407,MBR00000131,Medical_Institutional,Paid,Provider_Portal,2023-09-10,2023-09-10,2023-09-13,2023-09-30,Manual_Review,20,1034110592,1865266296,246ZN0300X,Neuropsychology,22,Out_of_Network,F32.9,,revenue_code:0300,,0,Commercial,EPO,15,F,0.9228,,,13748.62,5769.43,4288.77,370.47,38.0,1072.19,7979.19,0.0,0.0,0,,0.0744,none,0,1,0,0,0,0.000397,1,0,,Capitation
CLM0000004408,MBR00000296,Medical_Professional,Paid,Electronic_EDI,2023-06-02,2023-06-02,2023-06-02,2023-06-07,Manual_Review,5,1633089013,1747596016,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,,27447,,0,Commercial,HMO,83,F,1.4969,,,19113.67,6830.97,5413.45,33.16,31.0,1353.36,12282.7,0.0,0.0,0,,0.0396,none,0,1,1,1,0,0.000501,0,0,,Shared_Savings
CLM0000004409,MBR00000259,Medical_Professional,Paid,Electronic_EDI,2023-11-22,2023-11-22,2023-11-22,2023-12-11,Manual_Review,19,1638309014,1765164601,225100000X,Physical Therapist,81,In_Network,I50.9,E11.65|M54.5|Z23,99213,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,210.85,100.74,66.87,10.15,7.0,16.72,110.11,0.0,0.0,0,,0.0788,none,0,1,0,0,0,6e-06,0,0,,P4P
CLM0000004410,MBR00000088,Medical_Institutional,Paid,Electronic_EDI,2023-03-12,2023-03-12,2023-03-14,2023-03-17,Clinical_Review,5,1994365754,1312595355,207RN0300X,Nephrology,11,Out_of_Network,J20.9,,revenue_code:0450,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,,,27178.55,16752.97,11249.14,592.76,90.0,4821.06,10425.58,0.0,0.0,0,,0.107,none,0,1,1,0,0,0.001041,0,0,,FFS
CLM0000004411,MBR00000118,Medical_Professional,Paid,Electronic_EDI,2023-09-28,2023-09-28,2023-09-28,2023-10-12,Manual_Review,14,1556434733,1576271272,207R00000X,Internal Medicine,11,In_Network,Z00.01,,47562,,0,Medicaid_MCO,MCO,69,M,1.2773,,,2601.84,1738.55,1737.55,0.0,1.0,0.0,863.29,0.0,0.0,0,,0.0014,none,0,1,0,0,0,0.000161,0,0,,Capitation
CLM0000004412,MBR00000086,Medical_Professional,Paid,Electronic_EDI,2023-06-27,2023-06-27,2023-06-27,2023-07-17,Auto_Adjudicated,20,1177281088,1396850418,207V00000X,Obstetrics & Gynecology,11,In_Network,OTHER,E11.9|F33.0,99204,,0,Medicare_Advantage,MA_PPO,8,M,0.5427,,,159.94,120.08,87.69,2.47,8.0,21.92,39.86,0.0,0.0,0,,0.1145,high_volume_same_code,0,1,0,1,0,8e-06,0,0,,FFS
CLM0000004413,MBR00000196,Medical_Professional,Paid,Provider_Portal,2023-04-23,2023-04-23,2023-04-23,2023-04-29,Auto_Adjudicated,6,1007414142,1055872102,207Q00000X,Family Medicine,22,In_Network,Z23,N39.0|I10|L70.0,27130,,0,Commercial,PPO,16,F,1.6015,,,18438.48,12015.4,9536.13,72.24,23.0,2384.03,6423.08,0.0,0.0,0,,0.1134,none,0,1,1,0,0,0.000883,0,0,,FFS
CLM0000004414,MBR00000189,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-04-14,2023-04-14,2023-04-17,2023-04-18,Manual_Review,4,1380824221,1312595355,101YP2500X,Psychologist Clinical,24,In_Network,I10,E78.5,revenue_code:0100,,0,Medicaid_MCO,MCO,71,F,0.9722,1,Medical_Necessity,6664.04,2719.38,1698.9,0.0,7.0,0.0,4958.14,0.0,0.0,0,,0.0247,none,0,1,0,1,0,0.000157,0,0,,Shared_Savings
CLM0000004415,MBR00000160,Medical_Professional,Denied,Electronic_EDI,2023-06-11,2023-06-11,2023-06-11,2023-07-01,Auto_Adjudicated,20,1997577166,1291071007,207R00000X,Internal Medicine,22,Out_of_Network,Z00.01,,99284,,0,Commercial,HMO,73,M,1.9608,5,Eligibility,368.71,274.96,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1651,high_volume_same_code|controlled_substance_high_volume,0,1,0,0,0,0.0,1,0,,FFS
CLM0000004416,MBR00000292,Medical_Institutional,Paid,Electronic_EDI,2023-01-29,2023-01-29,2023-01-30,2023-02-18,Auto_Adjudicated,20,1292994726,1912895973,246ZN0300X,Neuropsychology,11,In_Network,OTHER,I25.10,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,4,M,1.1779,,,17615.23,6275.11,4979.5,21.74,29.0,1244.87,11340.12,0.0,0.0,0,,0.0938,none,0,1,0,0,0,0.000461,0,0,,FFS
CLM0000004417,MBR00000144,Medical_Professional,Paid,Electronic_EDI,2023-08-22,2023-08-22,2023-08-22,2023-09-04,Auto_Adjudicated,13,1424416273,1842149518,207RG0100X,Gastroenterology,65,In_Network,N18.3,,99204,,0,Commercial,HDHP_HSA,56,F,2.5926,,,299.51,210.46,60.78,134.48,0.0,15.2,89.05,0.0,0.0,0,,0.0886,npi_mismatch,0,1,0,0,0,6e-06,0,0,FLU_Flu_Vaccination,FFS
CLM0000004418,MBR00000232,Medical_Institutional,Paid,Electronic_EDI,2023-05-27,2023-05-27,2023-05-30,2023-05-31,Auto_Adjudicated,4,1475070784,1287472731,207RE0101X,Endocrinology,21,In_Network,E78.5,,revenue_code:0300,871,0,Medicaid_MCO,MCO,40,M,1.1083,,,7047.19,4303.59,4294.59,0.0,9.0,0.0,2743.6,0.0,0.0,0,,0.0576,none,0,1,0,0,0,0.000398,0,0,CBP_Controlling_BP,Capitation
CLM0000004419,MBR00000196,Medical_Professional,Paid,Electronic_EDI,2023-09-02,2023-09-02,2023-09-02,2023-09-12,Auto_Adjudicated,10,1630305772,1894215172,2086S0122X,Orthopedic Surgery,11,In_Network,N39.0,OTHER|Z12.11,99394,,0,Commercial,PPO,16,F,1.6015,,,221.03,132.08,86.42,1.05,23.0,21.61,88.95,0.0,0.0,0,,0.2136,high_volume_same_code|upcoding_pattern,0,2,0,0,0,8e-06,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000004420,MBR00000159,Medical_Institutional,Paid,Electronic_EDI,2023-07-04,2023-07-04,2023-07-05,2023-07-11,Auto_Adjudicated,7,1735391772,1690197969,207V00000X,Obstetrics & Gynecology,11,In_Network,OTHER,M79.3|OTHER,revenue_code:0250,,0,Commercial,PPO,70,F,1.2009,,,13491.57,9749.11,7716.61,32.35,71.0,1929.15,3742.46,0.0,0.0,1,Prescription Drug Diversion,1.0,geographic_mismatch|temporal_clustering|high_volume_same_code|benford_violation|impossible_service_combo|billing_spike_recent|duplicate_claim_indicator|unbundling_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,1,0,0,0.000714,0,0,,P4P
CLM0000004421,MBR00000013,Medical_Institutional,Denied,Electronic_EDI,2023-12-17,2023-12-17,2023-12-18,2024-01-06,Manual_Review,20,1888245409,1622950074,207RN0300X,Nephrology,22,Out_of_Network,F41.1,,revenue_code:0300,,0,Commercial,PPO,64,F,1.428,4,Authorization,36275.34,13496.74,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1616,benford_violation,0,1,0,0,0,0.0,0,0,,P4P
CLM0000004422,MBR00000196,Pharmacy,Paid,Paper,2023-01-30,2023-01-30,2023-01-30,2023-02-09,Auto_Adjudicated,10,1871417879,1765164601,208600000X,Surgery General,22,In_Network,Z12.11,F33.0|OTHER,00003014960,,1,Commercial,PPO,16,F,1.6015,,,307.32,170.66,0.0,170.66,0.0,0.0,136.66,0.0,0.0,0,,0.1402,diagnosis_procedure_mismatch,0,1,0,0,0,0.0,0,1,,Capitation
CLM0000004423,MBR00000191,Medical_Professional,Denied,Electronic_EDI,2023-06-26,2023-06-26,2023-06-26,2023-07-08,Manual_Review,12,1451464799,1662516615,207V00000X,Obstetrics & Gynecology,22,In_Network,M54.5,Z00.01,99204,,0,Commercial,POS,85,F,0.9729,97,Coding_Error,533.75,438.08,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0846,none,0,1,0,0,0,0.0,0,0,PPC_Prenatal_Care,Shared_Savings
CLM0000004424,MBR00000038,Medical_Institutional,Denied,Electronic_EDI,2023-07-12,2023-07-12,2023-07-12,2023-07-20,Auto_Adjudicated,8,1641660170,1356856197,208600000X,Surgery General,11,In_Network,I10,J06.9,revenue_code:0370,,0,Commercial,EPO,46,M,1.1295,16,Authorization,8766.8,3128.74,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0467,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000004425,MBR00000236,Pharmacy,Denied,Paper,2023-03-31,2023-03-31,2023-03-31,2023-04-06,Manual_Review,6,1542851144,1040061910,207R00000X,Internal Medicine,32,In_Network,OTHER,,00078043215,,1,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,50,Medical_Necessity,266.4,210.11,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0956,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000004426,MBR00000144,Medical_Professional,Paid,Electronic_EDI,2023-08-30,2023-08-30,2023-08-30,2023-09-24,Auto_Adjudicated,25,1260336577,1288028182,207RG0100X,Gastroenterology,21,Emergency,I10,Z87.891|F41.1|E78.5,97110,,0,Commercial,HDHP_HSA,56,F,2.5926,,,359.11,242.14,0.0,242.14,0.0,0.0,116.97,0.0,0.0,0,,0.1354,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004427,MBR00000102,Medical_Institutional,Paid,Provider_Portal,2023-05-11,2023-05-11,2023-05-11,2023-05-26,Auto_Adjudicated,15,1932483309,1027261156,207RE0101X,Endocrinology,11,In_Network,Z00.00,,revenue_code:0210,,0,Commercial,POS,68,M,1.6864,,,7186.84,5778.52,4294.35,345.58,65.0,1073.59,1408.32,0.0,0.0,0,,0.1251,none,0,1,0,0,0,0.000397,0,0,IET_Initiation_Substance_Use,FFS
CLM0000004428,MBR00000246,Medical_Institutional,Paid,Electronic_EDI,2023-10-02,2023-10-02,2023-10-02,2023-10-20,Clinical_Review,18,1929402739,1396850418,207RN0300X,Nephrology,23,Out_of_Network,I10,,revenue_code:0100,,0,Commercial,PPO,80,F,0.7925,,,75894.82,28306.0,22287.13,380.09,67.0,5571.78,47588.82,0.0,0.0,0,,0.1866,outlier_billing_amount|provider_specialty_mismatch,0,1,1,0,0,0.002063,1,0,POD_Persistence_of_Beta_Blocker,Shared_Savings
CLM0000004429,MBR00000107,Pharmacy,Paid,Electronic_EDI,2023-11-28,2023-11-28,2023-11-28,2023-12-07,Auto_Adjudicated,9,1042080259,1187669363,207RN0300X,Nephrology,22,In_Network,I10,,16590051660,,3,Medicare_Advantage,MA_PPO,44,M,1.0439,,,133.54,100.64,70.71,4.25,8.0,17.68,32.9,0.0,0.0,0,,0.1866,service_date_weekend,0,1,0,0,0,7e-06,0,1,,Shared_Savings
CLM0000004430,MBR00000185,Medical_Institutional,Paid,Electronic_EDI,2023-11-03,2023-11-03,2023-11-03,2023-11-06,Auto_Adjudicated,3,1893886964,1878874025,207V00000X,Obstetrics & Gynecology,81,In_Network,Z23,J06.9|G43.909,revenue_code:0300,,0,Medicaid_MCO,MCO,73,M,1.5417,,,28149.02,17331.01,17323.01,0.0,8.0,0.0,10818.01,0.0,0.0,0,,0.1242,none,0,1,1,0,0,0.001603,0,0,COA_Care_Transitions,Shared_Savings
CLM0000004431,MBR00000185,Vision,Paid,Electronic_EDI,2023-08-16,2023-08-16,2023-08-16,2023-09-08,Auto_Adjudicated,23,1051254008,1133410177,207RG0100X,Gastroenterology,21,In_Network,OTHER,OTHER|Z79.4|Z12.11,V2100,,0,Medicaid_MCO,MCO,73,M,1.5417,,,317.47,150.56,147.56,0.0,3.0,0.0,166.91,0.0,0.0,0,,0.1159,geographic_mismatch,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000004432,MBR00000014,Pharmacy,Denied,Electronic_EDI,2023-09-15,2023-09-15,2023-09-15,2023-10-07,Auto_Adjudicated,22,1661091022,1391074619,246ZN0300X,Neuropsychology,11,In_Network,I10,,00169751112,,1,Commercial,HMO,77,M,2.8513,4,Duplicate,58.97,34.53,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1229,upcoding_pattern,0,1,0,0,0,0.0,0,1,TRC_Transition_of_Care,Bundled_Payment
CLM0000004433,MBR00000134,Medical_Institutional,Paid,Electronic_EDI,2023-11-07,2023-11-07,2023-11-10,2023-11-09,Manual_Review,2,1871417879,1977073565,207V00000X,Obstetrics & Gynecology,81,In_Network,I10,,revenue_code:0120,,0,Medicare_Advantage,MA_PPO,33,M,1.115,,,10631.34,8627.91,6879.44,6.6,22.0,1719.86,2003.43,0.0,0.0,0,,0.0497,none,0,1,1,0,0,0.000637,0,0,,FFS
CLM0000004434,MBR00000069,Medical_Professional,Paid,Electronic_EDI,2023-12-19,2023-12-19,2023-12-19,2024-01-15,Auto_Adjudicated,27,1207676414,1576271272,2084P0800X,Psychiatry,22,In_Network,K21.0,OTHER|Z00.01|I50.9,99232,,0,Medicare_Advantage,MA_PPO,2,M,0.5765,,,338.22,192.68,103.67,55.1,8.0,25.92,145.54,0.0,0.0,0,,0.1256,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000004435,MBR00000061,Medical_Institutional,Denied,Electronic_EDI,2023-09-17,2023-09-17,2023-09-18,2023-10-13,Auto_Adjudicated,26,1597649716,1164525386,101YP2500X,Psychologist Clinical,23,In_Network,OTHER,OTHER|M79.3,revenue_code:0450,,0,Commercial,PPO,66,M,2.3575,5,Eligibility,22729.55,9510.75,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0582,service_date_weekend,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004436,MBR00000195,Medical_Professional,Paid,Electronic_EDI,2023-11-24,2023-11-24,2023-11-24,2023-12-20,Manual_Review,26,1699014308,1098360555,2086S0122X,Orthopedic Surgery,11,In_Network,OTHER,Z00.01|OTHER|I10,99204,,0,Commercial,PPO,13,F,0.5967,,,114.58,43.86,0.0,43.86,0.0,0.0,70.72,0.0,0.0,0,,0.0409,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004437,MBR00000004,Medical_Institutional,Paid,Electronic_EDI,2023-12-13,2023-12-13,2023-12-14,2023-12-27,Auto_Adjudicated,14,1513278494,1589482133,207RC0000X,Cardiovascular Disease,21,In_Network,OTHER,OTHER|E11.65,revenue_code:0370,292,0,Medicare_Advantage,MA_PPO,68,M,1.23,,,5033.34,1797.73,1353.34,53.06,53.0,338.33,3235.61,0.0,0.0,0,,0.2002,temporal_clustering,0,2,0,1,0,0.000125,0,0,,FFS
CLM0000004438,MBR00000293,Medical_Professional,Paid,Electronic_EDI,2023-03-05,2023-03-05,2023-03-05,2023-03-26,Auto_Adjudicated,21,1101385540,1831337866,246ZN0300X,Neuropsychology,81,In_Network,I10,E78.5|M54.5,99284,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,327.02,149.0,77.34,41.33,11.0,19.33,178.02,0.0,0.0,0,,0.0559,none,0,1,0,0,0,7e-06,0,0,,Capitation
CLM0000004439,MBR00000125,Pharmacy,Paid,Electronic_EDI,2023-06-29,2023-06-29,2023-06-29,2023-06-30,Auto_Adjudicated,1,1034110592,1574982369,101YP2500X,Psychologist Clinical,81,Out_of_Network,Z87.891,E78.5,00069420020,,1,Medicare_Advantage,MA_HMO,3,F,1.9037,,,84.8,52.97,25.47,10.13,11.0,6.37,31.83,0.0,0.0,0,,0.2228,temporal_clustering|upcoding_pattern|high_oop_waiver,0,2,0,0,0,2e-06,1,1,,Capitation
CLM0000004440,MBR00000094,Pharmacy,Paid,Paper,2023-05-09,2023-05-09,2023-05-09,2023-05-27,Manual_Review,18,1267286378,1650774392,207RN0300X,Nephrology,81,Out_of_Network,M79.3,,59148001506,,1,Commercial,POS,36,F,0.3997,,,477.28,250.64,97.45,89.83,39.0,24.36,226.64,0.0,0.0,0,,0.1132,none,0,1,0,0,0,9e-06,1,1,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000004441,MBR00000277,Vision,Paid,Electronic_EDI,2023-12-08,2023-12-08,2023-12-08,2023-12-13,Manual_Review,5,1918359820,1912895973,207RE0101X,Endocrinology,31,In_Network,Z00.00,G43.909,V2103,,0,Medicaid_MCO,MCO,30,M,1.8495,,,271.42,213.75,210.75,0.0,3.0,0.0,57.67,0.0,0.0,0,,0.0531,none,0,1,0,0,0,2e-05,0,0,,Bundled_Payment
CLM0000004442,MBR00000151,Medical_Professional,Paid,Electronic_EDI,2023-09-25,2023-09-25,2023-09-25,2023-10-23,Auto_Adjudicated,28,1061181028,1473869105,2084P0800X,Psychiatry,22,In_Network,I50.9,H52.4,99396,,0,Medicare_Advantage,MA_HMO,77,M,0.8709,,,357.12,265.35,201.83,7.07,6.0,50.46,91.77,0.0,0.0,0,,0.0944,provider_specialty_mismatch,0,1,0,0,0,1.9e-05,0,0,,Shared_Savings
CLM0000004443,MBR00000184,Dental,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-12-14,Auto_Adjudicated,29,1084831484,1587454801,2084P0800X,Psychiatry,22,In_Network,M47.816,K21.0,D2391,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,761.61,443.56,441.56,0.0,2.0,0.0,318.05,0.0,0.0,0,,0.2033,upcoding_pattern|phantom_billing_indicator,0,2,0,0,0,4.1e-05,0,0,,FFS
CLM0000004444,MBR00000207,Pharmacy,Paid,Electronic_EDI,2023-05-06,2023-05-06,2023-05-06,2023-05-11,Manual_Review,5,1485543430,1368666316,207RC0000X,Cardiovascular Disease,11,In_Network,R05.9,K21.0,00310075090,,1,Medicaid_MCO,MLTSS,11,F,1.6522,,,68.12,31.69,31.69,0.0,0.0,0.0,36.43,0.0,0.0,0,,0.1953,provider_specialty_mismatch|service_date_weekend,0,1,0,1,0,3e-06,0,0,,Shared_Savings
CLM0000004445,MBR00000263,Dental,Denied,Electronic_EDI,2023-10-30,2023-10-30,2023-10-30,2023-11-16,Auto_Adjudicated,17,1929402739,1576271272,207Q00000X,Family Medicine,24,In_Network,E11.9,,D2391,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,1,Eligibility,461.92,257.46,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1626,unusual_service_frequency,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,Capitation
CLM0000004446,MBR00000040,Pharmacy,Paid,Electronic_EDI,2023-01-30,2023-01-30,2023-01-30,2023-02-17,Auto_Adjudicated,18,1673449362,1140170394,207RC0000X,Cardiovascular Disease,24,In_Network,M54.5,E11.9,50458085930,,3,Medicare_Advantage,MA_HMO,66,F,0.6755,,,200.49,134.12,86.6,11.87,14.0,21.65,66.37,0.0,0.0,0,,0.1058,none,0,1,0,0,0,8e-06,0,0,IET_Initiation_Substance_Use,FFS
CLM0000004447,MBR00000025,Medical_Professional,Denied,Electronic_EDI,2023-12-04,2023-12-04,2023-12-04,2023-12-28,Auto_Adjudicated,24,1451464799,1133410177,207RN0300X,Nephrology,23,Out_of_Network,J20.9,Z12.11,82947,,0,Commercial,POS,74,M,1.3309,1,COB,1929.77,697.82,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Code Substitution,1.0,outlier_billing_amount|unusual_service_frequency|temporal_clustering|benford_violation|impossible_service_combo|billing_spike_recent|upcoding_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.0,0,0,DAE_Drug_Alcohol_Dependence,FFS
CLM0000004448,MBR00000299,Dental,Paid,Electronic_EDI,2023-03-24,2023-03-24,2023-03-24,2023-04-08,Manual_Review,15,1046207613,1020312030,207RC0000X,Cardiovascular Disease,21,Out_of_Network,I10,G47.33|F33.0,D3310,,0,Medicaid_MCO,MCO,74,F,0.8833,,,385.1,306.01,304.01,0.0,2.0,0.0,79.09,192.28,88.24,0,,0.0733,diagnosis_procedure_mismatch,0,1,0,0,0,2.8e-05,0,0,,FFS
CLM0000004449,MBR00000003,Medical_Institutional,Paid,Electronic_EDI,2023-07-08,2023-07-08,2023-07-08,2023-08-04,Auto_Adjudicated,27,1232573801,1689327034,207RC0000X,Cardiovascular Disease,11,In_Network,I10,,revenue_code:0100,,0,Commercial,PPO,79,F,1.3879,,,862.19,584.02,417.62,11.99,50.0,104.41,278.17,0.0,0.0,0,,0.1299,none,0,1,0,0,0,3.9e-05,0,0,,FFS
CLM0000004450,MBR00000210,Pharmacy,Paid,Electronic_EDI,2023-09-15,2023-09-15,2023-09-15,2023-09-26,Auto_Adjudicated,11,1564110057,1163639177,101YP2500X,Psychologist Clinical,24,In_Network,M47.816,I10,00003014960,,2,Medicare_Advantage,SNP,49,M,0.6952,,,487.01,404.84,283.67,32.26,18.0,70.92,82.17,0.0,0.0,0,,0.047,none,0,1,0,0,0,2.6e-05,0,0,MMA_Medication_Management,P4P
CLM0000004451,MBR00000184,Medical_Professional,Paid,Electronic_EDI,2023-09-24,2023-09-24,2023-09-24,2023-10-04,Auto_Adjudicated,10,1788188920,1650774392,207RE0101X,Endocrinology,81,In_Network,I10,L70.0,83036,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,255.09,174.0,172.0,0.0,2.0,0.0,81.09,0.0,0.0,0,,0.0842,npi_mismatch,0,1,0,1,0,1.6e-05,0,0,,FFS
CLM0000004452,MBR00000167,Medical_Professional,Paid,Paper,2023-03-18,2023-03-18,2023-03-18,2023-04-09,Auto_Adjudicated,22,1048378959,1289435414,246ZN0300X,Neuropsychology,21,In_Network,Z00.00,,27447,,0,Commercial,PPO,77,F,0.9377,,,62336.03,33122.58,26410.75,97.15,12.0,6602.69,29213.45,0.0,0.0,0,,0.1323,outlier_billing_amount,0,1,1,0,0,0.002445,0,0,,FFS
CLM0000004453,MBR00000232,Medical_Professional,Denied,Electronic_EDI,2023-07-19,2023-07-19,2023-07-19,2023-08-05,Auto_Adjudicated,17,1971354640,1320546364,207V00000X,Obstetrics & Gynecology,11,In_Network,I10,OTHER,71250,,0,Medicaid_MCO,MCO,40,M,1.1083,170,Coding_Error,671.49,382.1,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Provider Impersonation,0.9442,unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|benford_violation|impossible_service_combo|upcoding_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch,1,5,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004454,MBR00000298,Medical_Institutional,Paid,Electronic_EDI,2023-07-10,2023-07-10,2023-07-12,2023-07-13,Manual_Review,3,1067329999,1896197144,208600000X,Surgery General,65,Out_of_Network,Z00.00,OTHER,revenue_code:0300,,0,Medicaid_MCO,MCO,75,M,0.8324,,,17279.19,6107.85,6107.85,0.0,0.0,0.0,11171.34,0.0,0.0,0,,0.1419,none,0,1,1,0,0,0.000565,0,0,,FFS
CLM0000004455,MBR00000014,Medical_Institutional,Paid,Electronic_EDI,2023-10-06,2023-10-06,2023-10-07,2023-10-26,Auto_Adjudicated,20,1331903993,1287935251,207RN0300X,Nephrology,23,In_Network,E78.5,Z00.00|OTHER,revenue_code:0370,,0,Commercial,HMO,77,M,2.8513,,,15320.39,5800.52,4439.03,216.73,35.0,1109.76,9519.87,0.0,0.0,0,,0.0839,none,0,1,0,0,0,0.000411,0,0,,FFS
CLM0000004456,MBR00000184,Dental,Paid,Electronic_EDI,2023-04-26,2023-04-26,2023-04-26,2023-05-05,Auto_Adjudicated,9,1866366547,1493836023,207Q00000X,Family Medicine,23,In_Network,OTHER,,D2140,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,458.7,184.16,182.16,0.0,2.0,0.0,274.54,0.0,0.0,0,,0.0343,none,0,1,0,0,0,1.7e-05,0,0,,Bundled_Payment
CLM0000004457,MBR00000212,Medical_Professional,Paid,Electronic_EDI,2023-10-02,2023-10-02,2023-10-02,2023-10-28,Auto_Adjudicated,26,1557212800,1123879500,207RN0300X,Nephrology,71,In_Network,OTHER,Z00.00|I10,99205,,0,Commercial,HMO,57,F,2.5456,,,335.53,183.45,15.56,146.0,18.0,3.89,152.08,0.0,0.0,0,,0.0942,high_oop_waiver,0,1,0,0,0,1e-06,0,0,,Capitation
CLM0000004458,MBR00000097,Medical_Professional,Paid,Electronic_EDI,2023-08-10,2023-08-10,2023-08-10,2023-09-05,Auto_Adjudicated,26,1855186422,1025886739,208600000X,Surgery General,23,In_Network,Z00.00,,99232,,0,Commercial,EPO,34,M,1.3765,,,261.0,128.79,0.0,128.79,0.0,0.0,132.21,0.0,0.0,0,,0.0953,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000004459,MBR00000270,Medical_Professional,Paid,Electronic_EDI,2023-09-30,2023-09-30,2023-09-30,2023-10-13,Manual_Review,13,1269720844,1867626800,246ZN0300X,Neuropsychology,22,In_Network,E11.65,E11.9,97140,,0,Commercial,POS,1,F,1.6363,,,502.52,276.57,138.17,91.85,12.0,34.54,225.95,0.0,0.0,0,,0.1178,none,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000004460,MBR00000142,Medical_Professional,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-12-07,Auto_Adjudicated,26,1147452455,1995553359,101YP2500X,Psychologist Clinical,23,In_Network,Z00.01,F41.1,71046,,0,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,977.08,540.37,135.37,318.98,28.0,58.02,436.71,0.0,0.0,0,,0.021,none,0,1,0,0,0,1.3e-05,0,0,,FFS
CLM0000004461,MBR00000052,Medical_Institutional,Paid,Electronic_EDI,2023-06-03,2023-06-03,2023-06-04,2023-07-02,Auto_Adjudicated,29,1253087808,1055872102,207RG0100X,Gastroenterology,22,In_Network,I10,,revenue_code:0300,,0,Commercial,PPO,0,F,1.325,,,6439.33,3383.62,2439.21,258.61,76.0,609.8,3055.71,0.0,0.0,0,,0.0145,none,0,1,0,1,0,0.000226,0,0,,Shared_Savings
CLM0000004462,MBR00000258,Pharmacy,Paid,Electronic_EDI,2023-06-05,2023-06-05,2023-06-05,2023-06-27,Auto_Adjudicated,22,1375098560,1827839595,207R00000X,Internal Medicine,11,Out_of_Network,OTHER,,59148001506,,3,Commercial,EPO,9,F,0.5431,,,198.02,120.18,73.35,10.49,18.0,18.34,77.84,0.0,0.0,0,,0.1174,none,0,1,0,0,0,7e-06,1,0,,Shared_Savings
CLM0000004463,MBR00000286,Behavioral_Health,Paid,Paper,2023-10-13,2023-10-13,2023-10-13,2023-11-01,Auto_Adjudicated,19,1426424205,1447186817,101YP2500X,Psychologist Clinical,11,In_Network,OTHER,,99212,,0,Medicare_Advantage,PFFS,40,F,1.2751,,,94.28,77.1,38.8,25.6,3.0,9.7,17.18,33.6,4.4,0,,0.0806,benford_violation,0,1,0,0,0,4e-06,0,0,,Bundled_Payment
CLM0000004464,MBR00000029,Medical_Professional,Paid,Electronic_EDI,2023-10-08,2023-10-08,2023-10-08,2023-11-05,Auto_Adjudicated,28,1426424205,1489993356,207RN0300X,Nephrology,23,In_Network,E78.5,OTHER,99203,,0,Medicaid_MCO,MCO,13,F,0.9053,,,317.92,194.38,193.38,0.0,1.0,0.0,123.54,0.0,0.0,0,,0.0845,none,0,1,0,1,0,1.8e-05,0,0,,FFS
CLM0000004465,MBR00000221,Medical_Professional,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-12-08,Auto_Adjudicated,27,1637260822,1157814306,207Q00000X,Family Medicine,11,Emergency,OTHER,OTHER,99391,,0,Commercial,HDHP_HSA,28,M,1.6683,,,294.13,223.57,0.0,223.57,0.0,0.0,70.56,0.0,0.0,0,,0.0158,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000004466,MBR00000065,Pharmacy,Denied,Electronic_EDI,2023-07-17,2023-07-17,2023-07-17,2023-08-01,Auto_Adjudicated,15,1183801932,1827839595,207RC0000X,Cardiovascular Disease,65,Emergency,J06.9,Z12.11|F32.9|I10,00310075090,,2,Commercial,HDHP_HSA,63,M,0.7795,170,COB,174.2,128.86,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1408,controlled_substance_high_volume,0,1,0,0,0,0.0,0,1,,P4P
CLM0000004467,MBR00000003,Medical_Professional,Paid,Electronic_EDI,2023-08-17,2023-08-17,2023-08-17,2023-08-20,Auto_Adjudicated,3,1718336220,1339359594,101YP2500X,Psychologist Clinical,21,In_Network,OTHER,,73721,,0,Commercial,PPO,79,F,1.3879,,,2145.88,1198.96,930.82,10.43,25.0,232.71,946.92,0.0,0.0,0,,0.0938,none,0,1,0,0,0,8.6e-05,0,0,,Capitation
CLM0000004468,MBR00000081,Pharmacy,Paid,Electronic_EDI,2023-01-22,2023-01-22,2023-01-22,2023-02-10,Clinical_Review,19,1981623199,1368666316,246ZN0300X,Neuropsychology,23,In_Network,E11.65,OTHER|E78.5,00085163102,,2,Medicare_Advantage,SNP,66,F,2.159,,,595.17,279.63,215.6,5.13,5.0,53.9,315.54,0.0,0.0,0,,0.1144,none,0,1,0,0,0,2e-05,0,1,,P4P
CLM0000004469,MBR00000258,Medical_Institutional,Paid,Electronic_EDI,2023-06-13,2023-06-13,2023-06-13,2023-06-27,Auto_Adjudicated,14,1462532026,1461075342,208600000X,Surgery General,11,In_Network,J20.9,E11.9|OTHER|I10,revenue_code:0110,,0,Commercial,EPO,9,F,0.5431,,,27327.66,9997.45,7960.23,4.16,43.0,1990.06,17330.21,0.0,0.0,0,,0.1031,none,0,1,1,0,0,0.000737,0,0,,FFS
CLM0000004470,MBR00000044,Dental,Denied,Provider_Portal,2023-03-30,2023-03-30,2023-03-30,2023-04-10,Manual_Review,11,1274357072,1252125670,101YP2500X,Psychologist Clinical,22,In_Network,OTHER,,D3310,,0,Commercial,PPO,29,M,0.7512,170,Network,597.9,225.91,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0856,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000004471,MBR00000040,Medical_Professional,Partially_Paid,Electronic_EDI,2023-11-03,2023-11-03,2023-11-03,2023-11-09,Auto_Adjudicated,6,1484438840,1390802135,2086S0122X,Orthopedic Surgery,21,In_Network,M47.816,OTHER|Z00.00,12001,,0,Medicare_Advantage,MA_HMO,66,F,0.6755,CO-45,Medical_Necessity,699.91,321.63,159.33,4.87,14.0,39.83,481.87,0.0,0.0,0,,0.2045,diagnosis_procedure_mismatch,0,2,0,0,0,1.5e-05,0,0,PCR_Plan_All_Cause_Readmission,Bundled_Payment
CLM0000004472,MBR00000216,Behavioral_Health,Paid,Electronic_EDI,2023-02-13,2023-02-13,2023-02-13,2023-03-07,Auto_Adjudicated,22,1980039511,1301869102,225100000X,Physical Therapist,24,In_Network,OTHER,Z00.00|F32.9|M54.5,99283,,0,Medicare_Advantage,MA_HMO,71,F,0.7117,,,256.55,202.31,132.9,26.18,10.0,33.23,54.24,0.0,0.0,0,,0.0764,high_oop_waiver,0,1,0,0,0,1.2e-05,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000004473,MBR00000129,Vision,Denied,Electronic_EDI,2023-10-07,2023-10-07,2023-10-07,2023-11-04,Auto_Adjudicated,28,1137079475,1289435414,207V00000X,Obstetrics & Gynecology,11,In_Network,J06.9,,V2100,,0,Medicare_Advantage,MA_PPO,9,F,0.8196,5,Authorization,347.63,139.99,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1105,geographic_mismatch,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000004474,MBR00000046,Medical_Professional,Paid,Provider_Portal,2023-10-28,2023-10-28,2023-10-28,2023-11-15,Auto_Adjudicated,18,1943769986,1741177636,207RP1001X,Pulmonary Disease,21,Out_of_Network,OTHER,OTHER,80053,,0,Commercial,HMO,76,F,0.9613,,,991.02,755.86,456.33,150.45,35.0,114.08,235.16,0.0,0.0,0,,0.008,none,0,1,0,0,0,4.2e-05,0,0,,FFS
CLM0000004475,MBR00000073,Medical_Institutional,Paid,Electronic_EDI,2023-06-18,2023-06-18,2023-06-20,2023-06-26,Manual_Review,8,1051254008,1493836023,207Q00000X,Family Medicine,31,In_Network,OTHER,H52.4|J20.9,revenue_code:0360,,0,Commercial,POS,79,M,1.1768,,,12796.4,7404.15,5794.65,88.83,72.0,1448.66,5392.25,0.0,0.0,0,,0.1445,none,0,1,1,0,0,0.000536,0,0,,Shared_Savings
CLM0000004476,MBR00000235,Medical_Institutional,Paid,Electronic_EDI,2023-08-28,2023-08-28,2023-08-29,2023-08-29,Auto_Adjudicated,1,1918359820,1622950074,101YP2500X,Psychologist Clinical,23,Out_of_Network,F41.1,Z00.00|E78.5,revenue_code:0250,,0,Commercial,HDHP_HSA,85,F,1.4308,,,19546.17,13150.24,10051.07,586.4,0.0,2512.77,6395.93,0.0,0.0,0,,0.0952,none,0,1,1,1,0,0.00093,1,0,PCR_Plan_All_Cause_Readmission,Bundled_Payment
CLM0000004477,MBR00000186,Medical_Professional,Paid,Electronic_EDI,2023-07-28,2023-07-28,2023-07-28,2023-08-19,Auto_Adjudicated,22,1981853293,1983760474,207RC0000X,Cardiovascular Disease,24,In_Network,M17.11,OTHER|E78.5,99395,,0,Commercial,PPO,65,M,1.6983,,,289.19,122.01,54.04,42.45,12.0,13.51,167.18,0.0,0.0,0,,0.1329,none,0,1,0,1,0,5e-06,0,0,,FFS
CLM0000004478,MBR00000224,Behavioral_Health,Denied,Electronic_EDI,2023-09-05,2023-09-05,2023-09-05,2023-09-10,Auto_Adjudicated,5,1682685390,1747935894,207RE0101X,Endocrinology,24,In_Network,OTHER,Z00.00,99222,,0,Medicaid_MCO,MCO,86,F,1.3289,4,COB,271.63,202.91,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0317,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004479,MBR00000029,Medical_Professional,Paid,Electronic_EDI,2023-09-04,2023-09-04,2023-09-04,2023-09-06,Auto_Adjudicated,2,1875632885,1133410177,208600000X,Surgery General,23,Out_of_Network,J44.1,,27130,,0,Medicaid_MCO,MCO,13,F,0.9053,,,34216.51,13510.84,13509.84,0.0,1.0,0.0,20705.67,0.0,0.0,0,,0.1128,benford_violation|diagnosis_procedure_mismatch,0,1,1,0,0,0.00125,0,0,,FFS
CLM0000004480,MBR00000142,Medical_Professional,Paid,Provider_Portal,2023-04-01,2023-04-01,2023-04-01,2023-04-07,Auto_Adjudicated,6,1159640414,1874728994,207RN0300X,Nephrology,21,In_Network,J06.9,E11.9|Z00.121,99284,,0,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,201.69,123.33,0.0,123.33,0.0,0.0,78.36,0.0,0.0,0,,0.0524,none,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000004481,MBR00000236,Medical_Professional,Paid,Electronic_EDI,2023-09-05,2023-09-05,2023-09-05,2023-09-12,Auto_Adjudicated,7,1856989511,1522426351,207RN0300X,Nephrology,21,In_Network,Z00.00,OTHER,99214,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,299.15,120.12,117.12,0.0,3.0,0.0,179.03,0.0,0.0,0,,0.0848,impossible_service_combo,0,1,0,1,0,1.1e-05,0,0,CBP_Controlling_BP,Shared_Savings
CLM0000004482,MBR00000082,Medical_Institutional,Denied,Provider_Portal,2023-11-20,2023-11-20,2023-11-23,2023-12-01,Auto_Adjudicated,11,1886537420,1887266184,207RP1001X,Pulmonary Disease,11,In_Network,M54.5,E78.5,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,39,F,0.5376,3,Coding_Error,12848.4,9990.14,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1389,service_date_weekend,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004483,MBR00000053,Dental,Paid,Electronic_EDI,2023-04-22,2023-04-22,2023-04-22,2023-05-02,Auto_Adjudicated,10,1319616460,1148659045,225100000X,Physical Therapist,11,In_Network,E11.9,E11.9,D2140,,0,Medicaid_MCO,MLTSS,74,F,0.9277,,,189.99,122.39,122.39,0.0,0.0,0.0,67.6,0.0,0.0,0,,0.0702,none,0,1,0,0,0,1.1e-05,0,0,CDC_HbA1c_Poor_Control,Capitation
CLM0000004484,MBR00000121,Medical_Institutional,Paid,Electronic_EDI,2023-04-21,2023-04-21,2023-04-25,2023-04-27,Auto_Adjudicated,6,1176378924,1513198866,207RG0100X,Gastroenterology,22,In_Network,I10,OTHER,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,58,M,1.226,,,41967.46,26138.4,20858.53,9.24,56.0,5214.63,15829.06,0.0,0.0,0,,0.074,geographic_mismatch,0,1,1,0,0,0.001931,0,0,,FFS
CLM0000004485,MBR00000105,Pharmacy,Paid,Electronic_EDI,2023-04-16,2023-04-16,2023-04-16,2023-05-10,Clinical_Review,24,1190558906,1747935894,207RC0000X,Cardiovascular Disease,32,In_Network,I50.9,E11.9|J06.9,50458085930,,1,Commercial,HMO,74,M,1.1834,,,92.99,45.22,0.0,45.22,0.0,0.0,47.77,0.0,0.0,0,,0.0911,none,0,1,0,0,0,0.0,0,1,,P4P
CLM0000004486,MBR00000058,Medical_Professional,Paid,Electronic_EDI,2023-11-24,2023-11-24,2023-11-24,2023-12-19,Auto_Adjudicated,25,1396168768,1356856197,207RN0300X,Nephrology,22,In_Network,Z12.11,Z12.11,70553,,0,Commercial,PPO,56,F,1.1626,,,1771.89,1072.91,842.49,4.8,15.0,210.62,698.98,0.0,0.0,0,,0.2341,service_date_weekend|billing_spike_recent,0,2,0,0,0,7.8e-05,0,0,,Shared_Savings
CLM0000004487,MBR00000289,Pharmacy,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-11-23,Auto_Adjudicated,8,1012271279,1144950506,207RE0101X,Endocrinology,21,In_Network,Z00.01,Z12.11,00071015523,,3,Commercial,POS,51,M,1.0534,,,61.5,22.16,0.0,22.16,0.0,0.0,39.34,0.0,0.0,0,,0.0873,none,0,1,0,0,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,P4P
CLM0000004488,MBR00000149,Medical_Institutional,Paid,Electronic_EDI,2023-05-05,2023-05-05,2023-05-07,2023-05-17,Manual_Review,12,1299958874,1538261819,2086S0122X,Orthopedic Surgery,31,In_Network,M54.5,Z00.00|OTHER|E11.9,revenue_code:0300,,0,Commercial,PPO,42,F,0.5458,,,3120.52,1842.43,1374.97,91.71,32.0,343.74,1278.09,0.0,0.0,0,,0.147,unbundling_pattern,0,1,0,0,0,0.000127,0,0,,FFS
CLM0000004489,MBR00000184,Medical_Institutional,Denied,Electronic_EDI,2023-12-03,2023-12-03,2023-12-05,2023-12-28,Auto_Adjudicated,25,1338575285,1994275960,207RP1001X,Pulmonary Disease,22,In_Network,I10,,revenue_code:0370,,0,Medicaid_MCO,MLTSS,30,M,2.8302,22,Duplicate,8867.69,4054.1,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0161,none,0,1,0,0,0,0.0,0,0,CBP_Controlling_BP,Capitation
CLM0000004490,MBR00000037,Medical_Institutional,Denied,Electronic_EDI,2023-10-01,2023-10-01,2023-10-05,2023-10-30,Manual_Review,29,1896279539,1690197969,2084P0800X,Psychiatry,11,In_Network,J44.1,J06.9|Z79.4,revenue_code:0300,,0,Medicaid_MCO,MLTSS,11,M,1.043,170,COB,17165.9,13664.84,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0406,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004491,MBR00000184,Behavioral_Health,Paid,Electronic_EDI,2023-05-25,2023-05-25,2023-05-25,2023-06-18,Auto_Adjudicated,24,1617763056,1388050552,2084P0800X,Psychiatry,11,In_Network,Z23,OTHER,99213,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,267.67,130.13,128.13,0.0,2.0,0.0,137.54,0.0,0.0,0,,0.1932,diagnosis_procedure_mismatch,0,1,0,0,0,1.2e-05,0,0,FUM_Follow_Up_ED_Mental_Health,Capitation
CLM0000004492,MBR00000168,Pharmacy,Paid,Electronic_EDI,2023-10-24,2023-10-24,2023-10-24,2023-11-10,Manual_Review,17,1046207613,1054984734,207RN0300X,Nephrology,31,In_Network,OTHER,J44.1,50458085930,,1,Commercial,HMO,76,M,1.2791,,,506.41,306.7,0.0,284.41,22.29,0.0,199.71,0.0,0.0,0,,0.1138,none,0,1,0,0,0,0.0,0,1,,Capitation
CLM0000004493,MBR00000281,Pharmacy,Paid,Provider_Portal,2023-11-24,2023-11-24,2023-11-24,2023-12-24,Auto_Adjudicated,30,1580443769,1296566243,207RN0300X,Nephrology,22,Out_of_Network,N18.3,J06.9|Z00.00,00006001954,,4,Medicare_Advantage,MA_HMO,3,M,0.8531,,,97.22,34.18,24.22,0.91,3.0,6.05,63.04,0.0,0.0,0,,0.1312,none,0,1,0,0,0,2e-06,1,1,,Shared_Savings
CLM0000004494,MBR00000131,Medical_Institutional,Paid,Electronic_EDI,2023-11-08,2023-11-08,2023-11-09,2023-11-30,Manual_Review,22,1435110996,1175334579,101YP2500X,Psychologist Clinical,22,In_Network,OTHER,F41.1|E11.65|J06.9,revenue_code:0370,,0,Commercial,EPO,15,F,0.9228,,,27614.52,19922.1,15810.13,121.44,38.0,3952.53,7692.42,0.0,0.0,0,,0.0928,none,0,1,1,0,0,0.001463,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000004495,MBR00000231,Medical_Professional,Denied,Electronic_EDI,2023-06-18,2023-06-18,2023-06-18,2023-07-09,Auto_Adjudicated,21,1718336220,1356856197,2084P0800X,Psychiatry,23,In_Network,J06.9,Z79.4,27130,,0,ACA_Marketplace,ACA_Silver,12,M,0.6456,2,Medical_Necessity,5637.78,2426.19,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1322,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004496,MBR00000096,Medical_Institutional,Paid,Paper,2023-03-19,2023-03-19,2023-03-19,2023-03-20,Manual_Review,1,1484438840,1972530373,2086S0122X,Orthopedic Surgery,22,In_Network,Z00.121,OTHER|Z00.00,revenue_code:0210,,0,Medicaid_MCO,MCO,62,M,0.7948,,,5026.29,4269.27,4264.27,0.0,5.0,0.0,757.02,0.0,0.0,0,,0.1113,none,0,1,0,1,0,0.000395,0,0,COA_Care_Transitions,Capitation
CLM0000004497,MBR00000175,Pharmacy,Paid,Electronic_EDI,2023-03-02,2023-03-02,2023-03-02,2023-03-22,Manual_Review,20,1064567615,1560230600,207RG0100X,Gastroenterology,21,In_Network,H52.4,OTHER,00085163102,,3,Commercial,PPO,14,F,1.5785,,,145.82,72.39,44.98,6.16,10.0,11.25,73.43,0.0,0.0,0,,0.0104,none,0,1,0,0,0,4e-06,0,1,,P4P
CLM0000004498,MBR00000279,Pharmacy,Paid,Electronic_EDI,2023-10-25,2023-10-25,2023-10-25,2023-11-03,Auto_Adjudicated,9,1457568950,1433350836,207RE0101X,Endocrinology,22,In_Network,OTHER,J44.1|M54.5,00310075090,,1,Medicare_Advantage,MA_PPO,81,M,1.6817,,,74.64,50.96,12.47,26.38,9.0,3.12,23.68,0.0,0.0,0,,0.1215,none,0,1,0,0,0,1e-06,0,1,,Capitation
CLM0000004499,MBR00000186,Medical_Institutional,Paid,Electronic_EDI,2023-09-21,2023-09-21,2023-09-24,2023-10-10,Auto_Adjudicated,19,1629674542,1865266296,207RC0000X,Cardiovascular Disease,11,In_Network,G47.33,M47.816|Z87.891,revenue_code:0110,,0,Commercial,PPO,65,M,1.6983,,,19634.88,16296.41,12875.19,152.42,50.0,3218.8,3338.47,0.0,0.0,0,,0.0524,none,0,1,1,1,0,0.001192,0,0,COA_Care_Transitions,Capitation
CLM0000004500,MBR00000211,Medical_Professional,Paid,Electronic_EDI,2023-09-12,2023-09-12,2023-09-12,2023-09-30,Auto_Adjudicated,18,1080383191,1325999602,207RE0101X,Endocrinology,11,In_Network,OTHER,OTHER|Z23,70553,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,,,412.1,300.07,229.62,1.05,12.0,57.4,112.03,0.0,0.0,0,,0.14,billing_spike_recent,0,1,0,0,0,2.1e-05,0,0,,P4P
CLM0000004501,MBR00000264,Medical_Professional,Denied,Electronic_EDI,2023-01-17,2023-01-17,2023-01-17,2023-01-21,Auto_Adjudicated,4,1042080259,1649705287,207Q00000X,Family Medicine,22,In_Network,OTHER,I25.10|F32.9,43239,,0,ACA_Marketplace,ACA_Bronze,12,F,0.5826,22,Duplicate,1311.75,688.49,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0347,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004502,MBR00000279,Medical_Professional,Paid,Electronic_EDI,2023-12-13,2023-12-13,2023-12-13,2023-12-27,Manual_Review,14,1603037534,1187669363,208600000X,Surgery General,11,In_Network,OTHER,J06.9|I10,99383,,0,Medicare_Advantage,MA_PPO,81,M,1.6817,,,432.28,350.31,256.51,20.67,9.0,64.13,81.97,0.0,0.0,0,,0.0409,none,0,1,0,0,0,2.4e-05,0,0,,Capitation
CLM0000004503,MBR00000063,Pharmacy,Denied,Electronic_EDI,2023-02-10,2023-02-10,2023-02-10,2023-02-26,Auto_Adjudicated,16,1981623199,1903401648,207Q00000X,Family Medicine,31,In_Network,I25.10,,00003014960,,2,ACA_Marketplace,ACA_Silver,56,M,0.8198,50,Eligibility,104.88,47.86,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0123,none,0,1,0,1,0,0.0,0,0,DDE_Diabetes_Short_Term_Complications,Bundled_Payment
CLM0000004504,MBR00000060,Behavioral_Health,Paid,Electronic_EDI,2023-07-28,2023-07-28,2023-07-28,2023-07-30,Auto_Adjudicated,2,1997577166,1040061910,2084P0800X,Psychiatry,11,In_Network,E11.9,OTHER|I10,43239,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,184.48,123.09,0.0,123.09,0.0,0.0,61.39,0.0,0.0,0,,0.041,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004505,MBR00000166,Medical_Institutional,Paid,Electronic_EDI,2023-12-04,2023-12-04,2023-12-07,2023-12-30,Manual_Review,26,1886549972,1994275960,2086S0122X,Orthopedic Surgery,21,In_Network,I25.10,R05.9,revenue_code:0110,193,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,11072.89,8000.37,5110.41,632.78,67.0,2190.18,3072.52,0.0,0.0,0,,0.142,high_oop_waiver,0,1,1,0,0,0.000473,0,0,,FFS
CLM0000004506,MBR00000299,Pharmacy,Paid,Provider_Portal,2023-03-28,2023-03-28,2023-03-28,2023-04-26,Auto_Adjudicated,29,1469009511,1581533104,207RE0101X,Endocrinology,22,In_Network,OTHER,Z23,00071015523,,2,Medicaid_MCO,MCO,74,F,0.8833,,,986.16,521.14,519.14,0.0,2.0,0.0,465.02,0.0,0.0,1,Provider Impersonation,1.0,unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|high_volume_same_code|benford_violation|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|unbundling_pattern|phantom_billing_indicator|npi_mismatch|controlled_substance_high_volume,1,5,0,0,0,4.8e-05,0,1,,Capitation
CLM0000004507,MBR00000152,Pharmacy,Paid,Paper,2023-07-05,2023-07-05,2023-07-05,2023-07-06,Auto_Adjudicated,1,1618546650,1068662623,207RE0101X,Endocrinology,23,In_Network,OTHER,OTHER|F32.9|I10,00169751112,,4,Commercial,HMO,82,F,1.2506,,,26.95,20.63,0.0,20.63,0.0,0.0,6.32,0.0,0.0,0,,0.0517,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004508,MBR00000105,Medical_Professional,Paid,Electronic_EDI,2023-10-29,2023-10-29,2023-10-29,2023-11-02,Auto_Adjudicated,4,1108756266,1575884274,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,I10,99386,,0,Commercial,HMO,74,M,1.1834,,,226.57,132.83,0.0,132.83,0.0,0.0,93.74,0.0,0.0,0,,0.1238,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004509,MBR00000163,Medical_Professional,Paid,Electronic_EDI,2023-04-06,2023-04-06,2023-04-06,2023-04-10,Manual_Review,4,1310400164,1358873132,207V00000X,Obstetrics & Gynecology,31,In_Network,K21.0,,99283,,0,Medicaid_MCO,MCO,21,F,0.9607,,,176.8,138.04,134.04,0.0,4.0,0.0,38.76,94.23,31.37,0,,0.0386,none,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000004510,MBR00000020,Medical_Professional,Paid,Electronic_EDI,2023-02-06,2023-02-06,2023-02-06,2023-02-20,Auto_Adjudicated,14,1654042271,1325999602,207RN0300X,Nephrology,21,In_Network,OTHER,Z12.11|N39.0,99203,,0,Medicare_Advantage,MA_PPO,63,F,0.7119,,,130.19,59.53,0.96,52.33,6.0,0.24,70.66,0.0,0.0,0,,0.0995,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004511,MBR00000056,Vision,Paid,Electronic_EDI,2023-06-22,2023-06-22,2023-06-22,2023-07-11,Auto_Adjudicated,19,1670125610,1132693989,225100000X,Physical Therapist,11,In_Network,F41.1,,V2103,,0,Commercial,EPO,74,F,1.3941,,,274.89,219.31,80.71,107.43,11.0,20.18,55.58,0.0,0.0,0,,0.0685,none,0,1,0,0,0,7e-06,0,0,,Shared_Savings
CLM0000004512,MBR00000047,Medical_Professional,Paid,Electronic_EDI,2023-10-13,2023-10-13,2023-10-13,2023-10-21,Manual_Review,8,1453331651,1133410177,207RE0101X,Endocrinology,11,Out_of_Network,E13.9,Z79.4|OTHER,43239,,0,Commercial,PPO,37,M,0.565,,,285.9,176.27,0.0,176.27,0.0,0.0,109.63,0.0,0.0,0,,0.2897,temporal_clustering|high_volume_same_code|service_date_weekend,0,2,0,1,0,0.0,1,0,,P4P
CLM0000004513,MBR00000010,Medical_Institutional,Denied,Electronic_EDI,2023-07-27,2023-07-27,2023-07-29,2023-08-22,Manual_Review,26,1334227781,1588993671,207RN0300X,Nephrology,65,In_Network,K21.0,Z12.11|OTHER|E11.9,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,44,F,1.4631,170,Duplicate,44225.07,24958.48,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Identity Theft,1.0,unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|benford_violation|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,0.0,0,0,PPC_Prenatal_Care,FFS
CLM0000004514,MBR00000212,Medical_Professional,Paid,Electronic_EDI,2023-06-08,2023-06-08,2023-06-08,2023-06-18,Auto_Adjudicated,10,1981853293,1450837722,2086S0122X,Orthopedic Surgery,21,In_Network,M54.5,OTHER|Z00.01,99284,,0,Commercial,HMO,57,F,2.5456,,,1225.89,573.32,322.65,152.01,18.0,80.66,652.57,0.0,0.0,0,,0.1986,controlled_substance_high_volume,0,1,0,0,0,3e-05,0,0,,Capitation
CLM0000004515,MBR00000103,Pharmacy,Denied,Paper,2023-08-18,2023-08-18,2023-08-18,2023-08-28,Auto_Adjudicated,10,1997933026,1477113725,207RC0000X,Cardiovascular Disease,21,In_Network,K21.0,OTHER,00071015523,,1,Medicaid_MCO,MCO,24,M,0.4785,18,Network,420.03,168.66,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1239,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004516,MBR00000053,Medical_Professional,Paid,Electronic_EDI,2023-01-19,2023-01-19,2023-01-19,2023-02-06,Auto_Adjudicated,18,1611521069,1930040953,207RG0100X,Gastroenterology,11,In_Network,M54.5,E78.5|R05.9|J20.9,74177,,0,Medicaid_MCO,MLTSS,74,F,0.9277,,,389.12,192.85,192.85,0.0,0.0,0.0,196.27,0.0,0.0,0,,0.124,provider_specialty_mismatch,0,1,0,0,0,1.8e-05,0,0,,Shared_Savings
CLM0000004517,MBR00000157,Vision,Paid,Electronic_EDI,2023-05-06,2023-05-06,2023-05-06,2023-06-02,Manual_Review,27,1965682436,1847196500,207Q00000X,Family Medicine,22,In_Network,Z23,I25.10,V2100,,0,Medicare_Advantage,MA_HMO,26,F,0.9164,,,190.41,104.5,64.7,6.62,17.0,16.18,85.91,0.0,0.0,0,,0.1016,none,0,1,0,0,0,6e-06,0,0,,P4P
CLM0000004518,MBR00000102,Medical_Professional,Paid,Provider_Portal,2023-11-12,2023-11-12,2023-11-12,2023-11-20,Auto_Adjudicated,8,1592228076,1994275960,2084P0800X,Psychiatry,21,In_Network,K57.30,,99215,,0,Commercial,POS,68,M,1.6864,,,254.62,165.39,69.87,46.05,32.0,17.47,89.23,0.0,0.0,0,,0.0864,none,0,1,0,0,0,6e-06,0,0,,Bundled_Payment
CLM0000004519,MBR00000125,Vision,Denied,Electronic_EDI,2023-05-20,2023-05-20,2023-05-20,2023-05-31,Auto_Adjudicated,11,1344162462,1747935894,101YP2500X,Psychologist Clinical,11,In_Network,E11.9,OTHER|J44.1,V2100,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,170,Medical_Necessity,404.57,287.92,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1496,none,0,1,0,0,0,0.0,0,0,FLU_Flu_Vaccination,Capitation
CLM0000004520,MBR00000100,Medical_Institutional,Paid,Electronic_EDI,2023-12-13,2023-12-13,2023-12-14,2023-12-24,Auto_Adjudicated,11,1932483309,1527857018,207RN0300X,Nephrology,24,In_Network,K57.30,E11.9|Z23,revenue_code:0450,,0,ACA_Marketplace,ACA_Gold,87,M,1.435,,,8019.3,2978.21,2232.97,127.99,59.0,558.24,5041.09,1902.85,282.41,0,,0.0259,none,0,1,0,0,0,0.000207,0,0,,FFS
CLM0000004521,MBR00000002,Medical_Institutional,Denied,Electronic_EDI,2023-07-17,2023-07-17,2023-07-17,2023-07-31,Auto_Adjudicated,14,1288855406,1339359594,2086S0122X,Orthopedic Surgery,65,In_Network,Z00.00,Z00.01|J06.9,revenue_code:0100,,0,Commercial,PPO,42,F,0.9012,PR-1,Medical_Necessity,4218.3,3483.14,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1523,unusual_service_frequency,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004522,MBR00000205,Pharmacy,Denied,Electronic_EDI,2023-12-02,2023-12-02,2023-12-02,2023-12-15,Clinical_Review,13,1886549972,1662516615,207Q00000X,Family Medicine,21,In_Network,Z00.00,M54.5,00071015523,,5,Medicaid_MCO,MCO,1,F,0.9425,2,Medical_Necessity,56.38,26.74,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.093,none,0,1,0,0,0,0.0,0,1,POD_Persistence_of_Beta_Blocker,FFS
CLM0000004523,MBR00000034,Medical_Institutional,Paid,Electronic_EDI,2023-08-13,2023-08-13,2023-08-15,2023-09-11,Auto_Adjudicated,29,1928139578,1764064254,246ZN0300X,Neuropsychology,11,Out_of_Network,E11.9,,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,35,M,0.7712,,,11799.15,8133.23,6440.78,38.26,44.0,1610.19,3665.92,0.0,0.0,0,,0.1118,none,0,1,1,0,0,0.000596,0,0,,FFS
CLM0000004524,MBR00000068,Medical_Professional,Denied,Electronic_EDI,2023-05-31,2023-05-31,2023-05-31,2023-06-05,Clinical_Review,5,1898658234,1884259357,208600000X,Surgery General,21,In_Network,E11.9,,99386,,0,Medicare_Advantage,MA_HMO,28,F,0.8494,5,Timely_Filing,194.9,146.83,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0181,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004525,MBR00000059,Pharmacy,Paid,Provider_Portal,2023-11-27,2023-11-27,2023-11-27,2023-12-10,Auto_Adjudicated,13,1728728765,1356856197,246ZN0300X,Neuropsychology,65,In_Network,OTHER,M79.3,00085163102,,5,Medicare_Advantage,SNP,12,F,1.266,,,225.76,126.12,56.84,39.07,16.0,14.21,99.64,0.0,0.0,0,,0.022,none,0,1,0,1,0,5e-06,0,0,,FFS
CLM0000004526,MBR00000105,Medical_Institutional,Paid,Electronic_EDI,2023-04-07,2023-04-07,2023-04-09,2023-04-15,Auto_Adjudicated,8,1475070784,1810068286,207RN0300X,Nephrology,22,In_Network,Z00.121,OTHER|E78.5,revenue_code:0100,,0,Commercial,HMO,74,M,1.1834,,,1770.42,1007.12,574.33,239.21,50.0,143.58,763.3,0.0,0.0,0,,0.1923,temporal_clustering,0,1,0,0,0,5.3e-05,0,0,,FFS
CLM0000004527,MBR00000051,Medical_Institutional,Denied,Electronic_EDI,2023-05-21,2023-05-21,2023-05-23,2023-06-08,Auto_Adjudicated,18,1732193518,1300957944,101YP2500X,Psychologist Clinical,11,In_Network,G47.33,OTHER,revenue_code:0370,,0,Medicare_Advantage,MA_PPO,17,F,1.0695,3,Timely_Filing,18359.96,6864.96,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0548,none,0,1,0,0,0,0.0,0,0,COA_Care_Transitions,P4P
CLM0000004528,MBR00000110,Pharmacy,Paid,Electronic_EDI,2023-09-17,2023-09-17,2023-09-17,2023-10-11,Auto_Adjudicated,24,1898865801,1643323506,207R00000X,Internal Medicine,23,In_Network,C50.911,,59148001506,,4,Medicare_Advantage,MA_HMO,83,F,1.127,,,139.24,77.15,50.61,4.89,9.0,12.65,62.09,0.0,0.0,0,,0.1272,none,0,1,0,0,0,5e-06,0,0,AWV_Annual_Wellness_Visit,Shared_Savings
CLM0000004529,MBR00000076,Pharmacy,Paid,Electronic_EDI,2023-11-11,2023-11-11,2023-11-11,2023-12-10,Auto_Adjudicated,29,1882720848,1297948643,246ZN0300X,Neuropsychology,21,In_Network,G47.33,,00169751112,,1,Commercial,HMO,26,M,2.1785,,,44.23,36.21,0.0,36.21,0.0,0.0,8.02,0.0,0.0,0,,0.0317,none,0,1,0,0,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,Bundled_Payment
CLM0000004530,MBR00000018,Medical_Professional,Denied,Paper,2023-03-11,2023-03-11,2023-03-11,2023-03-25,Auto_Adjudicated,14,1139362508,1616762819,207RG0100X,Gastroenterology,11,In_Network,OTHER,OTHER,90847,,0,Commercial,EPO,5,F,0.5555,96,Medical_Necessity,837.58,447.78,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0643,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004531,MBR00000263,Medical_Professional,Paid,Electronic_EDI,2023-12-23,2023-12-23,2023-12-23,2023-12-31,Auto_Adjudicated,8,1375098560,1432077493,207RN0300X,Nephrology,81,Emergency,N39.0,Z79.4,99222,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,,,359.27,286.93,182.67,39.59,19.0,45.67,72.34,0.0,0.0,0,,0.0599,none,0,1,0,0,0,1.7e-05,0,0,,P4P
CLM0000004532,MBR00000097,Medical_Professional,Paid,Electronic_EDI,2023-06-04,2023-06-04,2023-06-04,2023-07-03,Auto_Adjudicated,29,1560886857,1650774392,246ZN0300X,Neuropsychology,11,In_Network,Z00.00,M47.816|OTHER,99383,,0,Commercial,EPO,34,M,1.3765,,,187.06,131.03,0.0,131.03,0.0,0.0,56.03,0.0,0.0,0,,0.022,none,0,1,0,0,0,0.0,0,0,AWV_Annual_Wellness_Visit,Bundled_Payment
CLM0000004533,MBR00000028,Medical_Institutional,Paid,Electronic_EDI,2023-05-02,2023-05-02,2023-05-03,2023-05-05,Auto_Adjudicated,3,1971354640,1187669363,207V00000X,Obstetrics & Gynecology,21,In_Network,OTHER,Z12.11|OTHER|Z00.00,revenue_code:0100,248,0,Commercial,HMO,3,F,2.116,,,21470.07,17013.67,13297.18,313.2,79.0,3324.29,4456.4,0.0,0.0,0,,0.1455,none,0,1,1,0,0,0.001231,0,0,,Bundled_Payment
CLM0000004534,MBR00000159,Medical_Professional,Paid,Electronic_EDI,2023-02-16,2023-02-16,2023-02-16,2023-02-20,Auto_Adjudicated,4,1597245892,1986847322,207RP1001X,Pulmonary Disease,23,In_Network,F32.9,L70.0,99284,,0,Commercial,PPO,70,F,1.2009,,,141.43,63.35,1.78,47.13,14.0,0.44,78.08,0.0,0.0,0,,0.0497,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004535,MBR00000037,Medical_Professional,Paid,Electronic_EDI,2023-01-10,2023-01-10,2023-01-10,2023-02-08,Auto_Adjudicated,29,1871348663,1356856197,101YP2500X,Psychologist Clinical,22,In_Network,OTHER,J06.9,90834,,0,Medicaid_MCO,MLTSS,11,M,1.043,,,130.38,89.23,88.23,0.0,1.0,0.0,41.15,0.0,0.0,0,,0.0662,none,0,1,0,0,0,8e-06,0,0,,Shared_Savings
CLM0000004536,MBR00000228,Pharmacy,Paid,Electronic_EDI,2023-07-20,2023-07-20,2023-07-20,2023-08-16,Manual_Review,27,1428403730,1274911960,207V00000X,Obstetrics & Gynecology,11,Out_of_Network,OTHER,,00078043215,,5,Commercial,PPO,55,F,0.7203,,,157.13,62.81,0.0,62.81,0.0,0.0,94.32,0.0,0.0,0,,0.1094,none,0,1,0,1,0,0.0,1,1,DDE_Diabetes_Short_Term_Complications,Bundled_Payment
CLM0000004537,MBR00000018,Medical_Professional,Denied,Electronic_EDI,2023-08-05,2023-08-05,2023-08-05,2023-08-22,Manual_Review,17,1788188920,1847196500,207RP1001X,Pulmonary Disease,22,In_Network,Z23,Z00.00,99285,,0,Commercial,EPO,5,F,0.5555,96,Authorization,179.71,106.69,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.039,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000004538,MBR00000143,Medical_Professional,Paid,Electronic_EDI,2023-02-03,2023-02-03,2023-02-03,2023-02-13,Auto_Adjudicated,10,1061181028,1473869105,246ZN0300X,Neuropsychology,23,In_Network,OTHER,I10,11200,,0,Commercial,POS,85,M,1.6078,,,271.73,193.51,121.21,6.0,36.0,30.3,78.22,0.0,0.0,0,,0.0162,none,0,1,0,0,0,1.1e-05,0,0,COL_Colorectal_Cancer_Screening,Bundled_Payment
CLM0000004539,MBR00000286,Pharmacy,Paid,Electronic_EDI,2023-11-21,2023-11-21,2023-11-21,2023-12-20,Auto_Adjudicated,29,1736809698,1296566243,207RN0300X,Nephrology,31,In_Network,Z00.00,Z12.11,00169751112,,2,Medicare_Advantage,PFFS,40,F,1.2751,,,284.14,122.43,83.8,14.68,3.0,20.95,161.71,0.0,0.0,0,,0.0724,none,0,1,0,0,0,8e-06,0,0,,Capitation
CLM0000004540,MBR00000051,Pharmacy,Paid,Electronic_EDI,2023-07-15,2023-07-15,2023-07-15,2023-08-13,Auto_Adjudicated,29,1906448800,1804282800,207RP1001X,Pulmonary Disease,11,In_Network,G47.33,E11.9,00085163102,,3,Medicare_Advantage,MA_PPO,17,F,1.0695,,,213.74,177.27,118.79,14.79,14.0,29.7,36.47,0.0,0.0,0,,0.092,none,0,1,0,0,0,1.1e-05,0,1,,Shared_Savings
CLM0000004541,MBR00000061,Pharmacy,Paid,Electronic_EDI,2023-01-20,2023-01-20,2023-01-20,2023-02-16,Auto_Adjudicated,27,1557212800,1874728994,225100000X,Physical Therapist,11,In_Network,K57.30,I10|R05.9,59148001506,,1,Commercial,PPO,66,M,2.3575,,,668.56,391.05,292.31,12.67,13.0,73.08,277.51,0.0,0.0,0,,0.014,none,0,1,0,0,0,2.7e-05,0,0,,Shared_Savings
CLM0000004542,MBR00000181,Medical_Professional,Paid,Electronic_EDI,2023-10-30,2023-10-30,2023-10-30,2023-11-23,Auto_Adjudicated,24,1901054209,1027261156,225100000X,Physical Therapist,71,In_Network,OTHER,I10|OTHER,74177,,0,Commercial,PPO,82,F,1.0432,,,870.33,499.37,291.43,107.08,28.0,72.86,370.96,0.0,0.0,0,,0.0683,none,0,1,0,0,0,2.7e-05,0,0,,FFS
CLM0000004543,MBR00000295,Medical_Institutional,Paid,Electronic_EDI,2023-03-12,2023-03-12,2023-03-12,2023-03-30,Manual_Review,18,1618564043,1509799493,207RP1001X,Pulmonary Disease,23,In_Network,F32.9,OTHER,revenue_code:0250,,0,Commercial,HDHP_HSA,78,F,0.8618,,,19734.94,15649.59,12451.68,84.99,0.0,3112.92,4085.35,0.0,0.0,0,,0.0559,none,0,1,1,0,0,0.001153,0,0,,Shared_Savings
CLM0000004544,MBR00000122,Vision,Paid,Electronic_EDI,2023-08-30,2023-08-30,2023-08-30,2023-09-11,Auto_Adjudicated,12,1747318937,1607833568,207R00000X,Internal Medicine,22,In_Network,E11.9,G43.909,92002,,0,Commercial,EPO,64,F,0.8625,,,180.94,141.15,0.0,141.15,0.0,0.0,39.79,0.0,0.0,0,,0.0671,none,0,1,0,0,0,0.0,0,0,ACR_Urine_Protein,Shared_Savings
CLM0000004545,MBR00000192,Medical_Professional,Paid,Electronic_EDI,2023-08-31,2023-08-31,2023-08-31,2023-09-15,Auto_Adjudicated,15,1424643153,1498781755,207RG0100X,Gastroenterology,23,In_Network,Z00.00,E11.9,84443,,0,Medicaid_MCO,MCO,22,F,1.1739,,,145.31,117.47,117.47,0.0,0.0,0.0,27.84,0.0,0.0,0,,0.1035,controlled_substance_high_volume,0,1,0,0,0,1.1e-05,0,0,PPC_Prenatal_Care,Capitation
CLM0000004546,MBR00000048,Medical_Professional,Paid,Electronic_EDI,2023-10-18,2023-10-18,2023-10-18,2023-11-04,Auto_Adjudicated,17,1399379863,1140170394,207RN0300X,Nephrology,11,Emergency,F32.9,,97010,,0,Commercial,POS,27,F,0.639,,,2595.45,1777.62,1318.93,103.96,25.0,329.73,817.83,1092.25,168.56,0,,0.0081,none,0,1,0,0,0,0.000122,0,0,,FFS
CLM0000004547,MBR00000190,Medical_Professional,Paid,Electronic_EDI,2023-10-18,2023-10-18,2023-10-18,2023-11-02,Auto_Adjudicated,15,1580443769,1365397818,207V00000X,Obstetrics & Gynecology,81,Emergency,F32.9,I25.10|Z00.00,99284,,0,Commercial,PPO,24,F,0.3232,,,358.22,243.94,7.71,199.3,35.0,1.93,114.28,0.0,0.0,0,,0.0689,none,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000004548,MBR00000078,Dental,Paid,Electronic_EDI,2023-12-20,2023-12-20,2023-12-20,2024-01-15,Auto_Adjudicated,26,1567711165,1978943761,2084P0800X,Psychiatry,23,In_Network,J06.9,,D0150,,0,Commercial,EPO,65,F,1.3174,,,916.2,425.91,237.37,92.2,37.0,59.34,490.29,0.0,0.0,0,,0.0127,none,0,1,0,1,0,2.2e-05,0,0,,Capitation
CLM0000004549,MBR00000184,Medical_Professional,Paid,Electronic_EDI,2023-02-01,2023-02-01,2023-02-01,2023-02-06,Auto_Adjudicated,5,1231954359,1587454801,2084P0800X,Psychiatry,32,In_Network,Z79.4,,99396,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,155.08,111.83,109.83,0.0,2.0,0.0,43.25,0.0,0.0,0,,0.0973,duplicate_claim_indicator,0,1,0,0,0,1e-05,0,0,,Capitation
CLM0000004550,MBR00000027,Medical_Institutional,Denied,Paper,2023-05-12,2023-05-12,2023-05-14,2023-05-15,Manual_Review,3,1871417879,1625992541,101YP2500X,Psychologist Clinical,22,In_Network,N39.0,OTHER,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,45,M,0.6886,256,Coding_Error,29688.44,19616.89,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0193,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004551,MBR00000160,Medical_Institutional,Denied,Electronic_EDI,2023-05-11,2023-05-11,2023-05-14,2023-05-25,Auto_Adjudicated,14,1881358103,1809122260,207RE0101X,Endocrinology,24,In_Network,Z00.01,Z00.00,revenue_code:0450,,0,Commercial,HMO,73,M,1.9608,PR-1,Timely_Filing,15562.83,8116.59,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0045,none,0,1,0,0,0,0.0,0,0,SPC_Statin_Therapy,FFS
CLM0000004552,MBR00000075,Vision,Paid,Electronic_EDI,2023-05-16,2023-05-16,2023-05-16,2023-05-23,Auto_Adjudicated,7,1292994726,1012893364,207RC0000X,Cardiovascular Disease,21,In_Network,Z00.00,E11.9,V2115,,0,Medicaid_MCO,MCO,5,M,1.0573,,,476.25,396.86,392.86,0.0,4.0,0.0,79.39,0.0,0.0,0,,0.0242,none,0,1,0,0,0,3.6e-05,0,0,,FFS
CLM0000004553,MBR00000202,Medical_Professional,Paid,Electronic_EDI,2023-03-27,2023-03-27,2023-03-27,2023-04-21,Auto_Adjudicated,25,1560886857,1619587398,207RP1001X,Pulmonary Disease,11,In_Network,OTHER,Z00.01|OTHER|Z00.00,82947,,0,Commercial,PPO,87,F,0.6213,,,975.81,578.76,99.87,431.92,22.0,24.97,397.05,0.0,0.0,0,,0.2539,high_volume_same_code|upcoding_pattern,0,2,0,0,0,9e-06,0,0,IET_Initiation_Substance_Use,Capitation
CLM0000004554,MBR00000219,Medical_Institutional,Paid,Provider_Portal,2023-03-25,2023-03-25,2023-03-25,2023-04-20,Manual_Review,26,1175978429,1509799493,207RP1001X,Pulmonary Disease,21,In_Network,J45.20,,revenue_code:0210,683,0,Medicare_Advantage,MA_HMO,84,M,0.9513,,,9765.48,6949.94,5520.77,25.98,23.0,1380.19,2815.54,0.0,0.0,0,,0.0039,none,0,1,1,0,1,0.000511,0,0,FUH_Follow_Up_Hospitalization,Bundled_Payment
CLM0000004555,MBR00000255,Vision,Paid,Electronic_EDI,2023-12-13,2023-12-13,2023-12-13,2024-01-12,Auto_Adjudicated,30,1484438840,1860951128,101YP2500X,Psychologist Clinical,65,In_Network,F32.9,,V2103,,0,Medicare_Advantage,MA_HMO,21,M,0.6945,,,322.22,220.07,161.56,0.12,18.0,40.39,102.15,0.0,0.0,0,,0.1416,none,0,1,0,0,0,1.5e-05,0,0,MPT_Annual_Monitoring,Shared_Savings
CLM0000004556,MBR00000298,Medical_Professional,Paid,Electronic_EDI,2023-11-19,2023-11-19,2023-11-19,2023-12-01,Auto_Adjudicated,12,1451464799,1477113725,207Q00000X,Family Medicine,23,In_Network,F41.1,,97110,,0,Medicaid_MCO,MCO,75,M,0.8324,,,507.66,180.35,180.35,0.0,0.0,0.0,327.31,0.0,0.0,0,,0.053,none,0,1,0,0,0,1.7e-05,0,0,,FFS
CLM0000004557,MBR00000142,Medical_Institutional,Denied,Electronic_EDI,2023-09-03,2023-09-03,2023-09-03,2023-10-02,Auto_Adjudicated,29,1214787184,1148612764,225100000X,Physical Therapist,22,Emergency,Z00.01,,revenue_code:0100,,0,ACA_Marketplace,ACA_Silver,48,M,1.3761,18,COB,25491.11,14743.21,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0242,none,0,1,0,0,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,Shared_Savings
CLM0000004558,MBR00000199,Medical_Professional,Paid,Electronic_EDI,2023-07-19,2023-07-19,2023-07-19,2023-07-23,Auto_Adjudicated,4,1555292468,1509799493,246ZN0300X,Neuropsychology,11,In_Network,E78.5,Z00.00|Z00.01,97110,,0,Medicaid_MCO,MLTSS,17,F,1.0776,,,372.36,243.33,241.33,0.0,2.0,0.0,129.03,0.0,0.0,0,,0.0272,none,0,1,0,0,0,2.2e-05,0,0,LCS_Lung_Cancer_Screening,Capitation
CLM0000004559,MBR00000006,Medical_Professional,Denied,Electronic_EDI,2023-06-20,2023-06-20,2023-06-20,2023-07-19,Auto_Adjudicated,29,1068197532,1880530717,207RE0101X,Endocrinology,22,In_Network,OTHER,OTHER,84443,,0,Commercial,EPO,88,M,1.4365,PR-1,COB,397.51,337.87,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0358,none,0,1,0,0,0,0.0,0,0,W30_Well_Child_Visit,FFS
CLM0000004560,MBR00000274,Medical_Professional,Paid,Provider_Portal,2023-09-02,2023-09-02,2023-09-02,2023-09-10,Manual_Review,8,1324084461,1469642907,246ZN0300X,Neuropsychology,22,In_Network,I10,,17000,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,580.82,248.11,170.19,35.38,0.0,42.55,332.71,0.0,0.0,0,,0.0686,none,0,1,0,0,0,1.6e-05,0,0,,Bundled_Payment
CLM0000004561,MBR00000184,Medical_Professional,Paid,Electronic_EDI,2023-11-06,2023-11-06,2023-11-06,2023-11-07,Auto_Adjudicated,1,1083045036,1576271272,246ZN0300X,Neuropsychology,22,In_Network,Z00.01,Z23|OTHER,99214,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,380.82,263.14,261.14,0.0,2.0,0.0,117.68,0.0,0.0,0,,0.0282,none,0,1,0,0,0,2.4e-05,0,0,,P4P
CLM0000004562,MBR00000133,Medical_Professional,Partially_Paid,Electronic_EDI,2023-06-03,2023-06-03,2023-06-03,2023-06-28,Auto_Adjudicated,25,1177281088,1252125670,207R00000X,Internal Medicine,24,Emergency,E11.65,OTHER|G43.909,90832,,0,Medicaid_MCO,MCO,57,M,0.9592,256,Medical_Necessity,674.69,383.43,286.68,0.0,1.0,0.0,387.01,0.0,0.0,0,,0.0716,none,0,1,0,0,0,2.7e-05,0,0,,FFS
CLM0000004563,MBR00000136,Pharmacy,Paid,Provider_Portal,2023-07-13,2023-07-13,2023-07-13,2023-07-29,Auto_Adjudicated,16,1972755666,1579331190,207Q00000X,Family Medicine,11,In_Network,OTHER,I10|OTHER|K21.0,00071015523,,3,Commercial,POS,2,F,1.2611,,,138.54,81.08,1.44,69.28,10.0,0.36,57.46,0.0,0.0,0,,0.0881,geographic_mismatch,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004564,MBR00000222,Medical_Institutional,Paid,Paper,2023-11-24,2023-11-24,2023-11-26,2023-12-07,Manual_Review,13,1476262171,1588993671,207RP1001X,Pulmonary Disease,22,In_Network,Z12.11,F32.9,revenue_code:0110,,0,Commercial,PPO,48,F,0.6945,,,31049.06,13325.36,10525.74,124.19,44.0,2631.43,17723.7,0.0,0.0,0,,0.1783,diagnosis_procedure_mismatch,0,1,1,0,0,0.000974,0,0,,FFS
CLM0000004565,MBR00000249,Medical_Institutional,Paid,Electronic_EDI,2023-11-24,2023-11-24,2023-11-24,2023-12-01,Auto_Adjudicated,7,1267286378,1576271272,207V00000X,Obstetrics & Gynecology,11,In_Network,M79.3,Z79.4|N40.0,revenue_code:0300,,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,20380.87,12535.49,8402.36,444.11,88.0,3601.01,7845.38,0.0,0.0,0,,0.1411,none,0,1,1,0,0,0.000778,0,0,,Shared_Savings
CLM0000004566,MBR00000239,Pharmacy,Paid,Electronic_EDI,2023-03-24,2023-03-24,2023-03-24,2023-04-06,Manual_Review,13,1631060535,1553094822,246ZN0300X,Neuropsychology,11,In_Network,OTHER,,59148001506,,1,Commercial,HMO,1,F,1.1193,,,174.79,65.18,0.0,65.18,0.0,0.0,109.61,0.0,0.0,1,Prescription Drug Diversion,1.0,geographic_mismatch|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|impossible_service_combo|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.0,0,0,,Capitation
CLM0000004567,MBR00000157,Vision,Paid,Electronic_EDI,2023-03-27,2023-03-27,2023-03-27,2023-04-15,Auto_Adjudicated,19,1568777164,1312595355,225100000X,Physical Therapist,21,In_Network,OTHER,OTHER|M54.5,V2115,,0,Medicare_Advantage,MA_HMO,26,F,0.9164,,,256.46,142.86,93.24,9.31,17.0,23.31,113.6,0.0,0.0,0,,0.1414,high_volume_same_code,0,1,0,1,0,9e-06,0,0,,P4P
CLM0000004568,MBR00000118,Medical_Professional,Paid,Electronic_EDI,2023-03-15,2023-03-15,2023-03-15,2023-03-20,Auto_Adjudicated,5,1963647323,1643673796,207R00000X,Internal Medicine,24,Out_of_Network,F32.9,I10|OTHER|Z00.01,97110,,0,Medicaid_MCO,MCO,69,M,1.2773,,,420.1,232.21,231.21,0.0,1.0,0.0,187.89,0.0,0.0,0,,0.106,none,0,1,0,0,0,2.1e-05,0,0,W30_Well_Child_Visit,Bundled_Payment
CLM0000004569,MBR00000286,Medical_Professional,Paid,Electronic_EDI,2023-01-10,2023-01-10,2023-01-10,2023-02-08,Auto_Adjudicated,29,1732193518,1576271272,101YP2500X,Psychologist Clinical,11,Out_of_Network,M54.5,J20.9,99213,,0,Medicare_Advantage,PFFS,40,F,1.2751,,,190.32,83.12,48.36,19.67,3.0,12.09,107.2,0.0,0.0,0,,0.1248,npi_mismatch|high_oop_waiver,0,1,0,0,0,4e-06,1,0,,Shared_Savings
CLM0000004570,MBR00000188,Medical_Professional,Paid,Electronic_EDI,2023-09-07,2023-09-07,2023-09-07,2023-09-29,Auto_Adjudicated,22,1485543430,1564636990,246ZN0300X,Neuropsychology,11,In_Network,I25.10,I10|J06.9,90837,,0,Commercial,HMO,8,F,1.5853,,,1098.48,932.42,692.26,42.1,25.0,173.06,166.06,0.0,0.0,0,,0.1352,billing_spike_recent,0,1,0,0,0,6.4e-05,0,0,BPD_BP_Declined,FFS
CLM0000004571,MBR00000165,Dental,Paid,Provider_Portal,2023-06-03,2023-06-03,2023-06-03,2023-06-30,Auto_Adjudicated,27,1603037534,1811797489,207RP1001X,Pulmonary Disease,22,Emergency,OTHER,N39.0|Z87.891,D0150,,0,ACA_Marketplace,ACA_Bronze,55,M,0.9775,,,688.35,486.12,0.0,486.12,0.0,0.0,202.23,0.0,0.0,0,,0.0805,temporal_clustering,0,1,0,1,0,0.0,0,0,,P4P
CLM0000004572,MBR00000180,Pharmacy,Paid,Electronic_EDI,2023-01-12,2023-01-12,2023-01-12,2023-01-14,Auto_Adjudicated,2,1243349799,1469697158,2084P0800X,Psychiatry,21,In_Network,K57.30,OTHER,00071015523,,1,Medicare_Advantage,MA_PPO,72,F,1.1909,,,287.66,238.13,171.76,6.43,17.0,42.94,49.53,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|high_volume_same_code|impossible_service_combo|service_date_weekend|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch,1,5,0,0,0,1.6e-05,0,0,,Bundled_Payment
CLM0000004573,MBR00000187,Medical_Institutional,Paid,Electronic_EDI,2023-03-15,2023-03-15,2023-03-15,2023-04-10,Auto_Adjudicated,26,1929402739,1355732274,207RP1001X,Pulmonary Disease,31,In_Network,OTHER,OTHER,revenue_code:0210,,0,Medicaid_MCO,MCO,36,F,1.191,,,6165.97,4447.18,4440.18,0.0,7.0,0.0,1718.79,0.0,0.0,0,,0.1763,provider_specialty_mismatch,0,1,0,0,0,0.000411,0,0,,P4P
CLM0000004574,MBR00000211,Medical_Professional,Denied,Electronic_EDI,2023-07-11,2023-07-11,2023-07-11,2023-08-06,Manual_Review,26,1099247356,1788579687,207V00000X,Obstetrics & Gynecology,24,In_Network,I25.10,N39.0|M54.5,99386,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,CO-45,Network,164.54,98.22,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1012,high_volume_same_code,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004575,MBR00000167,Medical_Institutional,Paid,Electronic_EDI,2023-10-28,2023-10-28,2023-10-31,2023-11-08,Auto_Adjudicated,11,1183801932,1860951128,2084P0800X,Psychiatry,23,In_Network,Z00.00,N39.0|J06.9|F32.9,revenue_code:0250,,0,Commercial,PPO,77,F,0.9377,,,24559.14,16119.96,12865.92,4.56,33.0,3216.48,8439.18,0.0,0.0,0,,0.1482,none,0,1,1,0,0,0.001191,0,0,,FFS
CLM0000004576,MBR00000264,Pharmacy,Paid,Electronic_EDI,2023-08-26,2023-08-26,2023-08-26,2023-09-13,Auto_Adjudicated,18,1292920374,1951488764,207R00000X,Internal Medicine,11,In_Network,K21.0,OTHER|M17.11,00069420020,,1,ACA_Marketplace,ACA_Bronze,12,F,0.5826,,,65.14,28.27,0.0,28.27,0.0,0.0,36.87,0.0,0.0,0,,0.1711,service_date_weekend,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004577,MBR00000259,Medical_Professional,Paid,Electronic_EDI,2023-07-11,2023-07-11,2023-07-11,2023-07-27,Auto_Adjudicated,16,1813729693,1625992541,207RG0100X,Gastroenterology,11,In_Network,OTHER,Z00.00,99213,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,205.42,87.6,63.02,1.82,7.0,15.76,117.82,0.0,0.0,0,,0.0535,none,0,1,0,0,0,6e-06,0,0,PCR_Plan_All_Cause_Readmission,Capitation
CLM0000004578,MBR00000139,Medical_Professional,Paid,Electronic_EDI,2023-03-08,2023-03-08,2023-03-08,2023-04-02,Manual_Review,25,1995916350,1994275960,207RN0300X,Nephrology,21,In_Network,Z00.00,E13.9,10060,,0,Commercial,PPO,74,M,1.7701,,,411.97,244.37,0.0,244.37,0.0,0.0,167.6,0.0,0.0,0,,0.1261,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004579,MBR00000053,Medical_Professional,Paid,Electronic_EDI,2023-04-14,2023-04-14,2023-04-14,2023-04-23,Auto_Adjudicated,9,1624242487,1098360555,207RE0101X,Endocrinology,22,In_Network,F33.0,E78.5,82947,,0,Medicaid_MCO,MLTSS,74,F,0.9277,,,874.64,394.92,394.92,0.0,0.0,0.0,479.72,245.52,100.1,0,,0.0898,duplicate_claim_indicator,0,1,0,0,0,3.7e-05,0,0,,FFS
CLM0000004580,MBR00000173,Pharmacy,Paid,Electronic_EDI,2023-10-08,2023-10-08,2023-10-08,2023-11-05,Clinical_Review,28,1390393668,1408846353,2084P0800X,Psychiatry,11,In_Network,Z12.11,,50458085930,,4,Medicare_Advantage,PFFS,23,F,1.0279,,,153.7,112.97,70.59,10.73,14.0,17.65,40.73,0.0,0.0,0,,0.1857,geographic_mismatch,0,1,0,0,0,7e-06,0,0,,Capitation
CLM0000004581,MBR00000185,Behavioral_Health,Paid,Electronic_EDI,2023-10-05,2023-10-05,2023-10-05,2023-10-22,Manual_Review,17,1898865801,1287935251,207Q00000X,Family Medicine,31,In_Network,Z23,E11.9,85025,,0,Medicaid_MCO,MCO,73,M,1.5417,,,165.48,82.49,79.49,0.0,3.0,0.0,82.99,0.0,0.0,0,,0.1134,none,0,1,0,0,0,7e-06,0,0,,Capitation
CLM0000004582,MBR00000160,Medical_Professional,Paid,Electronic_EDI,2023-11-08,2023-11-08,2023-11-08,2023-11-09,Auto_Adjudicated,1,1641779816,1252125670,2084P0800X,Psychiatry,81,In_Network,E11.65,,47562,,0,Commercial,HMO,73,M,1.9608,,,1683.19,662.63,275.61,295.11,23.0,68.9,1020.56,0.0,0.0,0,,0.1592,impossible_service_combo,0,1,0,0,0,2.6e-05,0,0,,FFS
CLM0000004583,MBR00000270,Dental,Paid,Electronic_EDI,2023-07-09,2023-07-09,2023-07-09,2023-07-19,Auto_Adjudicated,10,1256824549,1461075342,246ZN0300X,Neuropsychology,24,In_Network,Z23,OTHER,D7140,,0,Commercial,POS,1,F,1.6363,,,930.82,598.24,295.4,216.99,12.0,73.85,332.58,0.0,0.0,0,,0.1832,high_volume_same_code|service_date_weekend,0,1,0,1,0,2.7e-05,0,0,,FFS
CLM0000004584,MBR00000028,Medical_Institutional,Paid,Electronic_EDI,2023-04-09,2023-04-09,2023-04-10,2023-04-14,Auto_Adjudicated,5,1055095309,1791502603,207RG0100X,Gastroenterology,21,Out_of_Network,OTHER,,revenue_code:0200,439,0,Commercial,HMO,3,F,2.116,,,25645.51,16098.31,12559.37,320.09,79.0,3139.84,9547.2,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|geographic_mismatch|temporal_clustering|high_volume_same_code|benford_violation|impossible_service_combo|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|phantom_billing_indicator|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,1,1,0,0.001162,0,0,,P4P
CLM0000004585,MBR00000090,Pharmacy,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-25,Auto_Adjudicated,25,1039678579,1354265777,207Q00000X,Family Medicine,24,In_Network,M54.5,I10,59148001506,,1,Medicare_Advantage,MA_HMO,49,F,0.4351,,,120.33,57.83,19.72,18.18,15.0,4.93,62.5,0.0,0.0,0,,0.1735,benford_violation,0,1,0,0,0,2e-06,0,1,SPC_Statin_Therapy,FFS
CLM0000004586,MBR00000262,Dental,Paid,Electronic_EDI,2023-11-18,2023-11-18,2023-11-18,2023-12-01,Manual_Review,13,1886537420,1365397818,207RN0300X,Nephrology,11,In_Network,OTHER,N18.3|OTHER|M54.5,D0120,,0,Medicare_Advantage,PFFS,77,F,1.7452,,,346.16,143.44,111.05,0.63,4.0,27.76,202.72,0.0,0.0,0,,0.0365,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000004587,MBR00000285,Medical_Institutional,Paid,Electronic_EDI,2023-03-06,2023-03-06,2023-03-08,2023-03-20,Auto_Adjudicated,14,1907932706,1878874025,207RP1001X,Pulmonary Disease,71,In_Network,Z00.01,,revenue_code:0110,,0,Commercial,HDHP_HSA,56,M,0.9226,,,4057.15,2695.06,2004.89,188.95,0.0,501.22,1362.09,0.0,0.0,0,,0.1422,unusual_service_frequency,0,1,0,0,0,0.000186,0,0,,Bundled_Payment
CLM0000004588,MBR00000135,Medical_Professional,Paid,Electronic_EDI,2023-11-01,2023-11-01,2023-11-01,2023-11-12,Manual_Review,11,1526973051,1880530717,225100000X,Physical Therapist,21,In_Network,M54.5,,47562,,0,Commercial,PPO,58,F,2.2702,,,1298.66,935.26,715.52,3.86,37.0,178.88,363.4,0.0,0.0,0,,0.0845,none,0,1,0,1,0,6.6e-05,0,0,,Shared_Savings
CLM0000004589,MBR00000060,Medical_Professional,Paid,Electronic_EDI,2023-12-24,2023-12-24,2023-12-24,2024-01-15,Auto_Adjudicated,22,1543927384,1666461892,208600000X,Surgery General,23,In_Network,I10,F32.9,90853,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,592.78,263.52,0.0,263.52,0.0,0.0,329.26,0.0,0.0,0,,0.134,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000004590,MBR00000133,Pharmacy,Paid,Electronic_EDI,2023-10-22,2023-10-22,2023-10-22,2023-11-21,Auto_Adjudicated,30,1995916350,1747596016,101YP2500X,Psychologist Clinical,11,In_Network,E11.9,I25.10,00069420020,,1,Medicaid_MCO,MCO,57,M,0.9592,,,103.85,75.08,74.08,0.0,1.0,0.0,28.77,0.0,0.0,0,,0.1902,impossible_service_combo,0,1,0,0,0,7e-06,0,0,,FFS
CLM0000004591,MBR00000142,Medical_Institutional,Partially_Paid,Provider_Portal,2023-08-25,2023-08-25,2023-08-28,2023-09-21,Auto_Adjudicated,27,1706476585,1513198866,207Q00000X,Family Medicine,23,In_Network,E11.65,M79.3|OTHER|I10,revenue_code:0250,,0,ACA_Marketplace,ACA_Silver,48,M,1.3761,50,Medical_Necessity,8904.24,6035.01,2685.47,339.44,81.0,1150.92,4647.42,2241.23,289.34,0,,0.0304,none,0,1,0,0,0,0.000249,0,0,,Shared_Savings
CLM0000004592,MBR00000159,Medical_Professional,Denied,Electronic_EDI,2023-05-27,2023-05-27,2023-05-27,2023-06-26,Auto_Adjudicated,30,1055717021,1978943761,225100000X,Physical Therapist,11,In_Network,J06.9,J20.9,85025,,0,Commercial,PPO,70,F,1.2009,170,Authorization,1607.91,1185.45,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|unusual_service_frequency|temporal_clustering|high_volume_same_code|duplicate_claim_indicator|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.0,0,0,W30_Well_Child_Visit,FFS
CLM0000004593,MBR00000085,Medical_Institutional,Denied,Electronic_EDI,2023-11-03,2023-11-03,2023-11-03,2023-11-12,Manual_Review,9,1706046899,1576271272,207RC0000X,Cardiovascular Disease,11,In_Network,Z00.00,I10|Z00.00,revenue_code:0450,,0,Medicare_Advantage,SNP,2,M,0.7823,1,COB,5907.84,2256.51,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1083,none,0,1,0,0,0,0.0,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000004594,MBR00000099,Medical_Professional,Denied,Electronic_EDI,2023-02-27,2023-02-27,2023-02-27,2023-03-19,Auto_Adjudicated,20,1159640414,1972530373,207RG0100X,Gastroenterology,21,Out_of_Network,OTHER,,99391,,0,Commercial,HMO,10,F,0.7843,PR-1,Medical_Necessity,98.5,82.05,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1558,service_date_weekend,0,1,0,0,0,0.0,0,0,AMR_Asthma_Medication_Ratio,Shared_Savings
CLM0000004595,MBR00000195,Medical_Professional,Paid,Electronic_EDI,2023-09-30,2023-09-30,2023-09-30,2023-10-19,Auto_Adjudicated,19,1750232347,1788579687,207R00000X,Internal Medicine,11,In_Network,I50.9,,82947,,0,Commercial,PPO,13,F,0.5967,,,615.49,418.4,238.52,107.24,13.0,59.63,197.09,0.0,0.0,0,,0.1394,none,0,1,0,0,0,2.2e-05,0,0,,Bundled_Payment
CLM0000004596,MBR00000185,Pharmacy,Partially_Paid,Electronic_EDI,2023-05-25,2023-05-25,2023-05-25,2023-06-04,Auto_Adjudicated,10,1374458552,1538261819,101YP2500X,Psychologist Clinical,11,In_Network,OTHER,J06.9|M54.5,00003014960,,1,Medicaid_MCO,MCO,73,M,1.5417,2,Medical_Necessity,243.09,116.53,73.03,0.0,3.0,0.0,167.06,0.0,0.0,0,,0.1554,diagnosis_procedure_mismatch,0,1,0,1,0,7e-06,0,0,,FFS
CLM0000004597,MBR00000197,Medical_Institutional,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-07-01,2023-07-26,Manual_Review,26,1513278494,1829216053,207RE0101X,Endocrinology,32,Emergency,OTHER,,revenue_code:0200,,0,Medicare_Advantage,MA_HMO,59,M,1.1414,,,7717.95,6086.19,4837.93,2.78,36.0,1209.48,1631.76,0.0,0.0,0,,0.0825,billing_spike_recent,0,1,0,0,0,0.000448,0,0,,FFS
CLM0000004598,MBR00000120,Medical_Professional,Paid,Electronic_EDI,2023-06-16,2023-06-16,2023-06-16,2023-07-14,Auto_Adjudicated,28,1887322427,1884259357,2084P0800X,Psychiatry,11,Out_of_Network,E11.65,E11.65,74177,,0,Commercial,PPO,62,F,1.0823,,,372.84,238.76,0.0,238.76,0.0,0.0,134.08,0.0,0.0,0,,0.0545,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000004599,MBR00000106,Medical_Institutional,Paid,Electronic_EDI,2023-01-04,2023-01-04,2023-01-05,2023-02-02,Auto_Adjudicated,29,1468401280,1765164601,207RP1001X,Pulmonary Disease,22,In_Network,F32.9,M79.3,revenue_code:0370,,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,4358.45,1875.3,1464.64,9.5,35.0,366.16,2483.15,0.0,0.0,0,,0.0544,none,0,1,0,0,0,0.000136,0,0,LCS_Lung_Cancer_Screening,Capitation
CLM0000004600,MBR00000111,Vision,Paid,Electronic_EDI,2023-12-21,2023-12-21,2023-12-21,2024-01-20,Auto_Adjudicated,30,1035707913,1132693989,207Q00000X,Family Medicine,11,In_Network,OTHER,Z12.11|OTHER|J20.9,V2103,,0,Medicare_Advantage,MA_PPO,44,M,0.7462,,,232.0,180.1,115.82,19.32,16.0,28.96,51.9,89.42,21.6,0,,0.1373,none,0,1,0,0,0,1.1e-05,0,0,,Shared_Savings
CLM0000004601,MBR00000288,Medical_Professional,Paid,Paper,2023-08-28,2023-08-28,2023-08-28,2023-09-02,Auto_Adjudicated,5,1881358103,1688513262,207V00000X,Obstetrics & Gynecology,23,In_Network,Z23,J06.9,71250,,0,Commercial,HMO,36,M,0.8408,,,297.98,211.89,133.11,11.5,34.0,33.28,86.09,0.0,0.0,0,,0.1918,service_date_weekend|high_oop_waiver,0,1,0,0,0,1.2e-05,0,0,AWV_Annual_Wellness_Visit,Bundled_Payment
CLM0000004602,MBR00000125,Medical_Professional,Paid,Electronic_EDI,2023-08-04,2023-08-04,2023-08-04,2023-08-09,Manual_Review,5,1750232347,1689327034,207RN0300X,Nephrology,81,In_Network,J20.9,E11.9|Z00.01|E78.5,99215,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,159.88,78.37,51.13,3.46,11.0,12.78,81.51,0.0,0.0,0,,0.0248,none,0,1,0,0,0,5e-06,0,0,,P4P
CLM0000004603,MBR00000183,Medical_Professional,Paid,Electronic_EDI,2023-02-06,2023-02-06,2023-02-06,2023-02-27,Manual_Review,21,1898865801,1942423230,208600000X,Surgery General,21,In_Network,J06.9,OTHER,97012,,0,Commercial,PPO,51,M,0.8463,,,464.82,289.07,0.0,289.07,0.0,0.0,175.75,0.0,0.0,0,,0.0262,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004604,MBR00000160,Medical_Professional,Paid,Paper,2023-10-07,2023-10-07,2023-10-07,2023-10-29,Auto_Adjudicated,22,1232573801,1898471307,207RN0300X,Nephrology,81,In_Network,E78.5,,99203,,0,Commercial,HMO,73,M,1.9608,,,718.13,394.68,189.85,134.36,23.0,47.46,323.45,0.0,0.0,0,,0.0707,none,0,1,0,1,0,1.8e-05,0,0,,Bundled_Payment
CLM0000004605,MBR00000264,Medical_Professional,Denied,Electronic_EDI,2023-12-12,2023-12-12,2023-12-12,2023-12-26,Manual_Review,14,1176378924,1509799493,246ZN0300X,Neuropsychology,23,In_Network,OTHER,,97140,,0,ACA_Marketplace,ACA_Bronze,12,F,0.5826,170,Eligibility,3332.78,1177.82,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0085,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004606,MBR00000117,Medical_Professional,Denied,Electronic_EDI,2023-10-20,2023-10-20,2023-10-20,2023-10-25,Auto_Adjudicated,5,1756856314,1390802135,208600000X,Surgery General,22,In_Network,E11.9,Z23,99231,,0,Medicaid_MCO,MLTSS,72,F,0.8628,256,Medical_Necessity,504.52,297.1,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1108,none,0,1,0,0,0,0.0,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000004607,MBR00000136,Medical_Professional,Paid,Electronic_EDI,2023-03-31,2023-03-31,2023-03-31,2023-04-09,Auto_Adjudicated,9,1171387771,1040061910,207RN0300X,Nephrology,11,In_Network,I10,,73721,,0,Commercial,POS,2,F,1.2611,,,1020.43,477.36,149.73,280.2,10.0,37.43,543.07,0.0,0.0,0,,0.0049,none,0,1,0,0,0,1.4e-05,0,0,,Capitation
CLM0000004608,MBR00000252,Medical_Institutional,Paid,Electronic_EDI,2023-03-07,2023-03-07,2023-03-09,2023-03-11,Auto_Adjudicated,4,1243349799,1554490060,207Q00000X,Family Medicine,71,In_Network,G43.909,Z23,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,80,M,0.7173,,,2097.83,896.21,690.13,6.55,27.0,172.53,1201.62,0.0,0.0,0,,0.133,none,0,1,0,0,0,6.4e-05,0,0,DAE_Drug_Alcohol_Dependence,FFS
CLM0000004609,MBR00000051,Medical_Professional,Paid,Electronic_EDI,2023-05-12,2023-05-12,2023-05-12,2023-05-17,Auto_Adjudicated,5,1976612978,1689327034,207RG0100X,Gastroenterology,31,Emergency,OTHER,F32.9,99231,,0,Medicare_Advantage,MA_PPO,17,F,1.0695,,,2028.03,803.75,615.94,19.83,14.0,153.98,1224.28,0.0,0.0,1,Unbundling,1.0,outlier_billing_amount|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|benford_violation|impossible_service_combo|upcoding_pattern,1,5,0,0,0,5.7e-05,0,0,,Capitation
CLM0000004610,MBR00000179,Medical_Professional,Paid,Electronic_EDI,2023-01-09,2023-01-09,2023-01-09,2023-01-15,Auto_Adjudicated,6,1201027197,1884259357,2084P0800X,Psychiatry,11,In_Network,OTHER,R05.9,90837,,0,Medicare_Advantage,SNP,82,F,0.5266,,,301.08,139.01,94.7,3.63,17.0,23.68,162.07,0.0,0.0,0,,0.0331,none,0,1,0,0,0,9e-06,0,0,FUM_Follow_Up_ED_Mental_Health,Shared_Savings
CLM0000004611,MBR00000128,Pharmacy,Paid,Electronic_EDI,2023-07-18,2023-07-18,2023-07-18,2023-08-05,Manual_Review,18,1411619682,1489993356,207V00000X,Obstetrics & Gynecology,11,Out_of_Network,I50.9,OTHER,00310075090,,2,Commercial,PPO,13,F,1.4203,,,1543.82,1126.61,781.29,137.0,13.0,195.32,417.21,0.0,0.0,0,,0.0605,none,0,1,0,1,0,7.2e-05,0,1,IET_Initiation_Substance_Use,FFS
CLM0000004612,MBR00000297,Medical_Professional,Paid,Electronic_EDI,2023-06-14,2023-06-14,2023-06-14,2023-06-30,Auto_Adjudicated,16,1550698436,1282319940,246ZN0300X,Neuropsychology,21,In_Network,J06.9,Z00.01|OTHER|K21.0,99393,,0,Commercial,HMO,88,M,1.5311,,,266.55,141.1,72.31,23.72,27.0,18.08,125.45,0.0,0.0,0,,0.0622,billing_spike_recent,0,1,0,0,0,7e-06,0,0,,P4P
CLM0000004613,MBR00000212,Medical_Professional,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-11,Auto_Adjudicated,11,1464997678,1810068286,207RG0100X,Gastroenterology,11,In_Network,M17.11,,99203,,0,Commercial,HMO,57,F,2.5456,,,424.93,178.27,0.0,178.27,0.0,0.0,246.66,0.0,0.0,0,,0.1947,impossible_service_combo,0,1,0,1,0,0.0,0,0,,FFS
CLM0000004614,MBR00000004,Behavioral_Health,Paid,Electronic_EDI,2023-12-22,2023-12-22,2023-12-22,2024-01-08,Manual_Review,17,1641779816,1187669363,2084P0800X,Psychiatry,21,In_Network,I10,E78.5|J20.9|I10,10060,,0,Medicare_Advantage,MA_PPO,68,M,1.23,,,187.99,81.74,46.0,16.24,8.0,11.5,106.25,0.0,0.0,0,,0.0339,none,0,1,0,0,0,4e-06,0,0,CBP_Controlling_BP,FFS
CLM0000004615,MBR00000251,Medical_Institutional,Paid,Electronic_EDI,2023-08-24,2023-08-24,2023-08-26,2023-09-14,Auto_Adjudicated,21,1909649019,1690197969,207RE0101X,Endocrinology,81,In_Network,E11.9,Z00.01|Z79.4,revenue_code:0110,,0,Commercial,PPO,65,M,0.7737,,,20000.63,13523.68,10636.29,173.31,55.0,2659.07,6476.95,0.0,0.0,0,,0.095,none,0,1,1,0,0,0.000984,0,0,,FFS
CLM0000004616,MBR00000208,Pharmacy,Paid,Electronic_EDI,2023-05-30,2023-05-30,2023-05-30,2023-06-02,Auto_Adjudicated,3,1958981650,1540743888,225100000X,Physical Therapist,31,In_Network,OTHER,H52.4|F33.0,16590051660,,4,Medicare_Advantage,MA_HMO,66,M,2.1466,,,311.68,171.95,121.22,14.42,6.0,30.31,139.73,0.0,0.0,0,,0.1171,none,0,1,0,0,0,1.1e-05,0,0,,Shared_Savings
CLM0000004617,MBR00000169,Medical_Institutional,Paid,Electronic_EDI,2023-10-09,2023-10-09,2023-10-09,2023-10-18,Auto_Adjudicated,9,1231231881,1643323506,207RE0101X,Endocrinology,22,Emergency,OTHER,J06.9,revenue_code:0360,,0,Commercial,EPO,30,M,1.4348,,,26022.94,17201.04,13631.76,100.34,61.0,3407.94,8821.9,0.0,0.0,0,,0.0895,none,0,1,1,1,0,0.001262,0,0,MPT_Annual_Monitoring,Shared_Savings
CLM0000004618,MBR00000074,Vision,Denied,Electronic_EDI,2023-05-13,2023-05-13,2023-05-13,2023-05-20,Auto_Adjudicated,7,1631060535,1643673796,207Q00000X,Family Medicine,11,In_Network,E78.5,,92012,,0,Medicare_Advantage,MA_PPO,21,F,0.8719,96,Authorization,701.07,263.67,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Medically Unnecessary Services,1.0,outlier_billing_amount|geographic_mismatch|provider_specialty_mismatch|high_volume_same_code|impossible_service_combo|service_date_weekend|billing_spike_recent|upcoding_pattern|unbundling_pattern|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.0,0,0,AMR_Asthma_Medication_Ratio,Bundled_Payment
CLM0000004619,MBR00000047,Medical_Professional,Paid,Provider_Portal,2023-09-29,2023-09-29,2023-09-29,2023-09-30,Auto_Adjudicated,1,1048378959,1112696614,207RN0300X,Nephrology,22,In_Network,Z12.11,E11.65|OTHER,99394,,0,Commercial,PPO,37,M,0.565,,,310.97,222.11,0.0,222.11,0.0,0.0,88.86,0.0,0.0,0,,0.1257,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000004620,MBR00000187,Medical_Professional,Paid,Electronic_EDI,2023-12-01,2023-12-01,2023-12-01,2023-12-05,Auto_Adjudicated,4,1981623199,1291071007,207Q00000X,Family Medicine,65,In_Network,OTHER,OTHER|E11.9,70553,,0,Medicaid_MCO,MCO,36,F,1.191,,,628.58,522.58,519.58,0.0,3.0,0.0,106.0,0.0,0.0,0,,0.0595,none,0,1,0,1,0,4.8e-05,0,0,,P4P
CLM0000004621,MBR00000138,Pharmacy,Denied,Electronic_EDI,2023-11-23,2023-11-23,2023-11-23,2023-12-17,Clinical_Review,24,1631060535,1252125670,207RN0300X,Nephrology,24,In_Network,Z12.11,Z00.01|R05.9,16590051660,,1,Commercial,HDHP_HSA,47,M,0.996,5,COB,78.08,58.03,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2409,unusual_service_frequency|duplicate_claim_indicator,0,2,0,0,0,0.0,0,1,,FFS
CLM0000004622,MBR00000260,Medical_Professional,Paid,Electronic_EDI,2023-07-06,2023-07-06,2023-07-06,2023-08-02,Auto_Adjudicated,27,1568777164,1477113725,225100000X,Physical Therapist,32,In_Network,M54.5,I10|OTHER,33510,,0,Medicare_Advantage,SNP,59,M,0.3786,,,345.05,245.28,187.27,5.19,6.0,46.82,99.77,0.0,0.0,0,,0.0726,none,0,1,0,0,0,1.7e-05,0,0,FUH_Follow_Up_Hospitalization,P4P
CLM0000004623,MBR00000081,Medical_Institutional,Denied,Electronic_EDI,2023-06-18,2023-06-18,2023-06-20,2023-06-23,Auto_Adjudicated,5,1484438840,1810068286,208600000X,Surgery General,24,In_Network,E11.9,,revenue_code:0120,,0,Medicare_Advantage,SNP,66,F,2.159,18,Medical_Necessity,9093.47,4085.77,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.2037,unusual_service_frequency,0,2,0,0,0,0.0,0,0,,Capitation
CLM0000004624,MBR00000189,Medical_Professional,Partially_Paid,Electronic_EDI,2023-05-23,2023-05-23,2023-05-23,2023-06-16,Manual_Review,24,1151127621,1767402068,207RP1001X,Pulmonary Disease,22,Out_of_Network,Z23,E78.5|I10|OTHER,71046,,0,Medicaid_MCO,MCO,71,F,0.9722,5,Medical_Necessity,1572.68,869.39,647.01,0.0,4.0,0.0,921.67,0.0,0.0,0,,0.1434,none,0,1,0,0,0,6e-05,1,0,CBP_Controlling_BP,Bundled_Payment
CLM0000004625,MBR00000077,Medical_Professional,Paid,Electronic_EDI,2023-07-11,2023-07-11,2023-07-11,2023-07-19,Auto_Adjudicated,8,1468401280,1039962073,101YP2500X,Psychologist Clinical,11,In_Network,J06.9,E11.9|Z00.00|OTHER,20610,,0,Medicare_Advantage,MA_HMO,27,F,0.9229,,,903.7,386.64,295.47,13.31,4.0,73.87,517.06,265.41,19.94,0,,0.0766,service_date_weekend,0,1,0,0,0,2.7e-05,0,0,,FFS
CLM0000004626,MBR00000188,Pharmacy,Paid,Electronic_EDI,2023-12-03,2023-12-03,2023-12-03,2023-12-08,Auto_Adjudicated,5,1360102160,1672803287,225100000X,Physical Therapist,31,In_Network,H52.4,Z00.01|Z23,00085163102,,1,Commercial,HMO,8,F,1.5853,,,167.07,122.14,59.18,23.17,25.0,14.79,44.93,0.0,0.0,0,,0.075,none,0,1,0,0,0,5e-06,0,0,COA_Care_Transitions,FFS
CLM0000004627,MBR00000014,Medical_Institutional,Paid,Electronic_EDI,2023-11-10,2023-11-10,2023-11-13,2023-11-18,Auto_Adjudicated,8,1897146144,1415734567,207Q00000X,Family Medicine,23,In_Network,J06.9,Z12.11,revenue_code:0250,,0,Commercial,HMO,77,M,2.8513,,,9464.88,6825.09,5277.64,193.04,35.0,1319.41,2639.79,0.0,0.0,0,,0.0109,none,0,1,1,0,0,0.000488,0,0,KED_ESRD_Patients,FFS
CLM0000004628,MBR00000125,Medical_Institutional,Paid,Electronic_EDI,2023-08-06,2023-08-06,2023-08-10,2023-09-03,Clinical_Review,28,1484613641,1447657873,207R00000X,Internal Medicine,24,In_Network,F32.9,I10|Z00.00,revenue_code:0300,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,4198.05,1727.91,1345.37,1.19,45.0,336.34,2470.14,0.0,0.0,0,,0.0872,none,0,1,0,0,0,0.000125,0,0,,Capitation
CLM0000004629,MBR00000055,Medical_Professional,Paid,Electronic_EDI,2023-04-12,2023-04-12,2023-04-12,2023-04-23,Auto_Adjudicated,11,1641779816,1220755708,2084P0800X,Psychiatry,24,In_Network,M54.5,Z00.01,97035,,0,Commercial,PPO,68,F,1.2896,,,346.47,250.36,62.37,162.4,10.0,15.59,96.11,0.0,0.0,0,,0.0792,none,0,1,0,0,0,6e-06,0,0,CDC_BP_Control,Capitation
CLM0000004630,MBR00000183,Medical_Professional,Paid,Electronic_EDI,2023-05-16,2023-05-16,2023-05-16,2023-06-08,Auto_Adjudicated,23,1375680589,1542515060,207RN0300X,Nephrology,11,In_Network,M54.5,K21.0,82947,,0,Commercial,PPO,51,M,0.8463,,,724.4,460.4,47.79,361.66,39.0,11.95,264.0,0.0,0.0,0,,0.1285,none,0,1,0,1,0,4e-06,0,0,FUM_Follow_Up_ED_Mental_Health,Capitation
CLM0000004631,MBR00000100,Pharmacy,Paid,Electronic_EDI,2023-03-30,2023-03-30,2023-03-30,2023-04-14,Auto_Adjudicated,15,1051254008,1406199453,207RC0000X,Cardiovascular Disease,11,In_Network,E78.5,OTHER|G43.909|N40.0,00169751112,,2,ACA_Marketplace,ACA_Gold,87,M,1.435,,,181.2,152.27,17.04,118.97,12.0,4.26,28.93,0.0,0.0,0,,0.1673,impossible_service_combo,0,1,0,0,0,2e-06,0,1,,Capitation
CLM0000004632,MBR00000227,Medical_Professional,Denied,Paper,2023-03-08,2023-03-08,2023-03-08,2023-03-22,Auto_Adjudicated,14,1843445592,1061113875,207RC0000X,Cardiovascular Disease,31,In_Network,F41.1,,90847,,0,Medicare_Advantage,MA_PPO,2,F,0.7835,22,Timely_Filing,1120.77,946.82,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1402,none,0,1,0,0,0,0.0,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000004633,MBR00000036,Medical_Institutional,Paid,Electronic_EDI,2023-01-04,2023-01-04,2023-01-06,2023-01-29,Auto_Adjudicated,25,1443292773,1339359594,246ZN0300X,Neuropsychology,21,In_Network,K21.0,I50.9|OTHER,revenue_code:0120,248,0,Commercial,EPO,17,M,2.0136,,,9875.68,3855.18,2972.28,99.82,40.0,743.07,6020.5,0.0,0.0,0,,0.0641,geographic_mismatch,0,1,0,0,1,0.000275,0,0,,P4P
CLM0000004634,MBR00000168,Medical_Institutional,Paid,Electronic_EDI,2023-10-05,2023-10-05,2023-10-08,2023-11-04,Auto_Adjudicated,30,1683994149,1903401648,207RC0000X,Cardiovascular Disease,11,In_Network,Z00.00,N39.0,revenue_code:0110,,0,Commercial,HMO,76,M,1.2791,,,19997.41,15366.2,12135.02,121.43,76.0,3033.75,4631.21,0.0,0.0,0,,0.1364,provider_specialty_mismatch,0,1,1,0,0,0.001123,0,0,FUH_Follow_Up_Hospitalization,Shared_Savings
CLM0000004635,MBR00000179,Medical_Professional,Paid,Provider_Portal,2023-09-23,2023-09-23,2023-09-23,2023-10-13,Manual_Review,20,1466922283,1289435414,2086S0122X,Orthopedic Surgery,23,In_Network,OTHER,,33510,,0,Medicare_Advantage,SNP,82,F,0.5266,,,222.53,95.75,62.15,1.06,17.0,15.54,126.78,0.0,0.0,0,,0.11,none,0,1,0,0,0,6e-06,0,0,,Capitation
CLM0000004636,MBR00000007,Medical_Professional,Denied,Electronic_EDI,2023-03-06,2023-03-06,2023-03-06,2023-04-01,Auto_Adjudicated,26,1727787144,1012893364,207Q00000X,Family Medicine,11,Out_of_Network,J06.9,OTHER,97012,,0,Commercial,HDHP_HSA,72,F,0.7578,1,Eligibility,334.4,208.98,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0345,none,0,1,0,0,0,0.0,1,0,,Shared_Savings
CLM0000004637,MBR00000011,Pharmacy,Paid,Electronic_EDI,2023-09-04,2023-09-04,2023-09-04,2023-09-09,Auto_Adjudicated,5,1891821845,1252125670,207RP1001X,Pulmonary Disease,23,In_Network,Z00.121,N18.3,50458085930,,2,Medicare_Advantage,SNP,35,F,1.0833,,,222.26,133.93,91.38,2.7,17.0,22.85,88.33,0.0,0.0,0,,0.0265,none,0,1,0,0,0,8e-06,0,1,,P4P
CLM0000004638,MBR00000097,Medical_Professional,Paid,Electronic_EDI,2023-03-01,2023-03-01,2023-03-01,2023-03-29,Manual_Review,28,1338575285,1930040953,207RN0300X,Nephrology,22,In_Network,OTHER,,99384,,0,Commercial,EPO,34,M,1.3765,,,389.15,189.49,12.95,149.3,24.0,3.24,199.66,0.0,0.0,1,Duplicate Billing,0.8845,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|service_date_weekend|billing_spike_recent|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,1e-06,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000004639,MBR00000184,Medical_Professional,Paid,Electronic_EDI,2023-04-10,2023-04-10,2023-04-10,2023-04-16,Auto_Adjudicated,6,1700802848,1564691686,207V00000X,Obstetrics & Gynecology,23,In_Network,Z00.00,Z79.4|Z00.00,20610,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,1480.17,1052.48,1050.48,0.0,2.0,0.0,427.69,0.0,0.0,0,,0.0084,none,0,1,0,0,0,9.7e-05,0,0,,Shared_Savings
CLM0000004640,MBR00000292,Vision,Paid,Electronic_EDI,2023-04-03,2023-04-03,2023-04-03,2023-04-09,Manual_Review,6,1648123576,1408846353,207RN0300X,Nephrology,81,In_Network,I10,Z00.121,92002,,0,Medicare_Advantage,MA_HMO,4,M,1.1779,,,515.66,318.64,234.79,22.16,3.0,58.7,197.02,0.0,0.0,0,,0.16,impossible_service_combo,0,1,0,0,0,2.2e-05,0,0,,FFS
CLM0000004641,MBR00000028,Medical_Professional,Paid,Provider_Portal,2023-02-16,2023-02-16,2023-02-16,2023-03-14,Auto_Adjudicated,26,1901547390,1728466420,207R00000X,Internal Medicine,11,In_Network,I10,J06.9|OTHER,71250,,0,Commercial,HMO,3,F,2.116,,,1972.71,1304.06,931.83,125.27,14.0,232.96,668.65,0.0,0.0,0,,0.0397,none,0,1,0,0,0,8.6e-05,0,0,,P4P
CLM0000004642,MBR00000208,Pharmacy,Paid,Electronic_EDI,2023-09-19,2023-09-19,2023-09-19,2023-10-04,Auto_Adjudicated,15,1702283246,1390802135,208600000X,Surgery General,81,In_Network,OTHER,,16590051660,,3,Medicare_Advantage,MA_HMO,66,M,2.1466,,,772.51,537.33,417.25,9.77,6.0,104.31,235.18,0.0,0.0,0,,0.0019,none,0,1,0,1,0,3.9e-05,0,1,,FFS
CLM0000004643,MBR00000206,Medical_Professional,Paid,Electronic_EDI,2023-01-16,2023-01-16,2023-01-16,2023-01-24,Auto_Adjudicated,8,1403662694,1469642907,207RN0300X,Nephrology,24,In_Network,J20.9,,99223,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,234.32,129.4,128.4,0.0,1.0,0.0,104.92,0.0,0.0,0,,0.1028,none,0,1,0,0,0,1.2e-05,0,0,,Bundled_Payment
CLM0000004644,MBR00000198,Medical_Professional,Denied,Electronic_EDI,2023-05-26,2023-05-26,2023-05-26,2023-05-27,Auto_Adjudicated,1,1603037534,1643673796,207R00000X,Internal Medicine,31,In_Network,M54.5,,97110,,0,Medicaid_MCO,MCO,81,F,1.4199,256,Network,3250.92,1205.2,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.091,none,0,1,0,0,0,0.0,0,0,FLU_Flu_Vaccination,FFS
CLM0000004645,MBR00000158,Medical_Institutional,Paid,Electronic_EDI,2023-06-25,2023-06-25,2023-06-29,2023-07-02,Auto_Adjudicated,7,1731980913,1619587398,246ZN0300X,Neuropsychology,24,In_Network,Z00.00,,revenue_code:0360,,0,Commercial,HMO,65,M,1.5361,,,161629.51,77396.27,61677.96,248.82,50.0,15419.49,84233.24,0.0,0.0,0,,0.0858,outlier_billing_amount,0,1,1,0,0,0.005709,0,0,,Shared_Savings
CLM0000004646,MBR00000293,Medical_Professional,Denied,Electronic_EDI,2023-07-27,2023-07-27,2023-07-27,2023-08-21,Auto_Adjudicated,25,1683994149,1450837722,225100000X,Physical Therapist,11,In_Network,Z00.00,OTHER|Z00.00,99204,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,4,Coding_Error,146.0,63.92,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.187,upcoding_pattern,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004647,MBR00000155,Pharmacy,Paid,Electronic_EDI,2023-03-11,2023-03-11,2023-03-11,2023-03-12,Manual_Review,1,1260336577,1619587398,207RP1001X,Pulmonary Disease,22,In_Network,I25.10,Z12.11,00310075090,,1,ACA_Marketplace,ACA_Bronze,9,F,0.8196,,,112.39,81.67,0.0,81.67,0.0,0.0,30.72,0.0,0.0,0,,0.0263,none,0,1,0,0,0,0.0,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000004648,MBR00000250,Medical_Professional,Paid,Electronic_EDI,2023-06-19,2023-06-19,2023-06-19,2023-07-17,Auto_Adjudicated,28,1913217838,1810068286,246ZN0300X,Neuropsychology,11,In_Network,Z87.891,OTHER|I10,47562,,0,Commercial,PPO,41,M,0.9245,,,836.4,397.14,179.29,149.03,24.0,44.82,439.26,0.0,0.0,0,,0.1404,none,0,1,0,0,0,1.7e-05,0,0,,FFS
CLM0000004649,MBR00000081,Medical_Institutional,Denied,Electronic_EDI,2023-10-12,2023-10-12,2023-10-15,2023-11-05,Auto_Adjudicated,24,1145860509,1577226132,207RN0300X,Nephrology,23,In_Network,Z12.11,J45.20|M54.5,revenue_code:0110,,0,Medicare_Advantage,SNP,66,F,2.159,16,Timely_Filing,14787.07,7875.85,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.001,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004650,MBR00000239,Pharmacy,Paid,Electronic_EDI,2023-05-15,2023-05-15,2023-05-15,2023-05-22,Auto_Adjudicated,7,1119083414,1098360555,207RP1001X,Pulmonary Disease,11,In_Network,E78.5,,00310075090,,2,Commercial,HMO,1,F,1.1193,,,46.7,26.76,0.0,20.19,6.57,0.0,19.94,0.0,0.0,0,,0.0725,none,0,1,0,0,0,0.0,0,0,LCS_Lung_Cancer_Screening,FFS
CLM0000004651,MBR00000300,Medical_Institutional,Paid,Electronic_EDI,2023-12-08,2023-12-08,2023-12-10,2023-12-31,Auto_Adjudicated,23,1231954359,1894215172,207RG0100X,Gastroenterology,11,Out_of_Network,OTHER,M17.11|OTHER|Z79.4,revenue_code:0370,,0,Commercial,PPO,64,F,1.0393,,,5104.98,3918.73,3041.35,69.04,48.0,760.34,1186.25,0.0,0.0,0,,0.117,none,0,1,0,1,0,0.000282,0,0,,Capitation
CLM0000004652,MBR00000275,Medical_Institutional,Paid,Electronic_EDI,2023-06-04,2023-06-04,2023-06-06,2023-06-20,Auto_Adjudicated,16,1793630905,1972530373,207RG0100X,Gastroenterology,65,In_Network,OTHER,K21.0|M47.816,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,67,M,0.8169,,,14585.03,11263.18,8937.6,39.17,52.0,2234.4,3321.85,0.0,0.0,0,,0.1098,none,0,1,1,0,0,0.000827,0,0,POD_Persistence_of_Beta_Blocker,FFS
CLM0000004653,MBR00000096,Medical_Professional,Paid,Electronic_EDI,2023-10-06,2023-10-06,2023-10-06,2023-10-17,Auto_Adjudicated,11,1770738194,1809122260,207RG0100X,Gastroenterology,65,In_Network,Z12.11,,83036,,0,Medicaid_MCO,MCO,62,M,0.7948,,,558.13,256.72,254.72,0.0,2.0,0.0,301.41,0.0,0.0,0,,0.1239,none,0,1,0,1,0,2.4e-05,0,0,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000004654,MBR00000254,Medical_Professional,Paid,Paper,2023-02-10,2023-02-10,2023-02-10,2023-02-26,Auto_Adjudicated,16,1006539337,1986847322,207RC0000X,Cardiovascular Disease,22,In_Network,I48.91,E11.9,99203,,0,Commercial,PPO,22,F,0.9285,,,381.94,211.66,119.89,33.79,28.0,29.97,170.28,0.0,0.0,0,,0.1647,npi_mismatch,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000004655,MBR00000028,Dental,Paid,Electronic_EDI,2023-11-02,2023-11-02,2023-11-02,2023-11-03,Auto_Adjudicated,1,1061181028,1896197144,225100000X,Physical Therapist,22,In_Network,OTHER,Z00.00,D0150,,0,Commercial,HMO,3,F,2.116,,,1131.59,534.36,288.01,160.35,14.0,72.0,597.23,0.0,0.0,0,,0.1648,high_volume_same_code,0,1,0,0,0,2.7e-05,0,0,,Shared_Savings
CLM0000004656,MBR00000201,Medical_Institutional,Denied,Electronic_EDI,2023-06-22,2023-06-22,2023-06-26,2023-07-19,Auto_Adjudicated,27,1514646292,1352413270,207RG0100X,Gastroenterology,31,In_Network,Z12.11,F33.0,revenue_code:0250,,0,Medicare_Advantage,MA_PPO,74,M,1.1575,170,Timely_Filing,3914.95,3280.78,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1881,temporal_clustering|high_oop_waiver,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004657,MBR00000107,Medical_Institutional,Paid,Electronic_EDI,2023-12-22,2023-12-22,2023-12-25,2024-01-15,Auto_Adjudicated,24,1218947226,1029818813,207R00000X,Internal Medicine,81,In_Network,I10,OTHER,revenue_code:0100,,0,Medicare_Advantage,MA_PPO,44,M,1.0439,,,96320.21,59388.31,47456.47,36.73,31.0,11864.12,36931.9,0.0,0.0,0,,0.1699,outlier_billing_amount,0,1,1,0,0,0.004393,0,0,,P4P
CLM0000004658,MBR00000196,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-09-09,2023-09-09,2023-09-10,2023-09-15,Clinical_Review,6,1257723293,1574982369,207RP1001X,Pulmonary Disease,11,In_Network,J06.9,Z87.891,revenue_code:0110,,0,Commercial,PPO,16,F,1.6015,3,Medical_Necessity,65232.92,22857.74,13090.77,86.54,36.0,3272.69,48746.92,0.0,0.0,0,,0.2158,outlier_billing_amount|benford_violation,0,2,1,0,0,0.001212,0,0,,Bundled_Payment
CLM0000004659,MBR00000131,Medical_Professional,Denied,Electronic_EDI,2023-09-23,2023-09-23,2023-09-23,2023-09-26,Auto_Adjudicated,3,1476262171,1297948643,225100000X,Physical Therapist,11,In_Network,Z00.00,N39.0,27447,,0,Commercial,EPO,15,F,0.9228,16,COB,5377.82,2125.92,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0378,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004660,MBR00000003,Medical_Professional,Paid,Electronic_EDI,2023-02-23,2023-02-23,2023-02-23,2023-03-08,Auto_Adjudicated,13,1866366547,1898471307,207Q00000X,Family Medicine,65,In_Network,Z00.00,I10,99395,,0,Commercial,PPO,79,F,1.3879,,,154.15,119.93,67.09,11.06,25.0,16.77,34.22,0.0,0.0,0,,0.1399,high_oop_waiver,0,1,0,0,0,6e-06,0,0,COA_Care_Transitions,FFS
CLM0000004661,MBR00000073,Medical_Professional,Paid,Electronic_EDI,2023-07-23,2023-07-23,2023-07-23,2023-08-06,Auto_Adjudicated,14,1771383741,1576271272,225100000X,Physical Therapist,11,In_Network,OTHER,Z00.01,97140,,0,Commercial,POS,79,M,1.1768,,,489.94,268.99,176.39,15.5,33.0,44.1,220.95,0.0,0.0,0,,0.0768,impossible_service_combo,0,1,0,0,0,1.6e-05,0,0,,FFS
CLM0000004662,MBR00000013,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-09-22,2023-09-22,2023-09-24,2023-10-16,Auto_Adjudicated,24,1026612378,1894215172,207RN0300X,Nephrology,23,In_Network,OTHER,E78.5|OTHER,revenue_code:0120,,0,Commercial,PPO,64,F,1.428,PR-1,Medical_Necessity,5087.71,4083.77,1509.58,382.86,36.0,377.39,2781.88,0.0,0.0,0,,0.077,none,0,1,0,0,0,0.00014,0,0,,P4P
CLM0000004663,MBR00000135,Medical_Professional,Paid,Electronic_EDI,2023-10-18,2023-10-18,2023-10-18,2023-11-13,Auto_Adjudicated,26,1853233709,1509799493,207RN0300X,Nephrology,22,In_Network,M79.3,,99214,,0,Commercial,PPO,58,F,2.2702,,,374.57,255.32,169.96,5.87,37.0,42.49,119.25,0.0,0.0,0,,0.031,none,0,1,0,0,0,1.6e-05,0,0,,Shared_Savings
CLM0000004664,MBR00000251,Medical_Professional,Paid,Electronic_EDI,2023-05-16,2023-05-16,2023-05-16,2023-05-18,Clinical_Review,2,1990244466,1587454801,2086S0122X,Orthopedic Surgery,22,In_Network,OTHER,,99385,,0,Commercial,PPO,65,M,0.7737,,,384.63,237.17,88.88,113.07,13.0,22.22,147.46,0.0,0.0,0,,0.2382,benford_violation|billing_spike_recent,0,2,0,1,0,8e-06,0,0,,Capitation
CLM0000004665,MBR00000216,Medical_Institutional,Denied,Electronic_EDI,2023-07-22,2023-07-22,2023-07-25,2023-07-30,Auto_Adjudicated,8,1594322174,1978943761,207RG0100X,Gastroenterology,11,In_Network,OTHER,F32.9,revenue_code:0370,,0,Medicare_Advantage,MA_HMO,71,F,0.7117,16,Coding_Error,13630.09,10324.52,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1341,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004666,MBR00000234,Medical_Institutional,Paid,Electronic_EDI,2023-03-04,2023-03-04,2023-03-06,2023-03-22,Manual_Review,18,1110312325,1105733833,207R00000X,Internal Medicine,23,In_Network,E13.9,OTHER,revenue_code:0360,,0,Medicare_Advantage,MA_HMO,59,M,0.395,,,16802.23,12016.61,9575.22,11.59,36.0,2393.8,4785.62,0.0,0.0,0,,0.0386,none,0,1,1,0,0,0.000886,0,0,,Bundled_Payment
CLM0000004667,MBR00000239,Medical_Institutional,Paid,Electronic_EDI,2023-06-05,2023-06-05,2023-06-07,2023-06-17,Manual_Review,12,1639236553,1942423230,207RE0101X,Endocrinology,22,In_Network,OTHER,Z00.00,revenue_code:0450,,0,Commercial,HMO,1,F,1.1193,,,10637.91,6818.04,5374.88,34.43,65.0,1343.72,3819.87,0.0,0.0,0,,0.187,billing_spike_recent,0,1,1,1,0,0.000497,0,0,,Capitation
CLM0000004668,MBR00000118,Pharmacy,Paid,Paper,2023-06-20,2023-06-20,2023-06-20,2023-07-20,Auto_Adjudicated,30,1803277343,1791502603,246ZN0300X,Neuropsychology,65,In_Network,OTHER,F32.9,00169751112,,1,Medicaid_MCO,MCO,69,M,1.2773,,,247.22,97.03,96.03,0.0,1.0,0.0,150.19,68.26,18.59,0,,0.2083,service_date_weekend|duplicate_claim_indicator,0,2,0,0,0,9e-06,0,1,,FFS
CLM0000004669,MBR00000156,Medical_Institutional,Paid,Paper,2023-01-12,2023-01-12,2023-01-15,2023-02-01,Auto_Adjudicated,20,1117755591,1878874025,207RE0101X,Endocrinology,22,In_Network,E78.5,,revenue_code:0120,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,67117.44,50421.27,40313.36,0.57,29.0,10078.34,16696.17,0.0,0.0,0,,0.1685,outlier_billing_amount|phantom_billing_indicator,0,1,1,0,0,0.003731,0,0,,FFS
CLM0000004670,MBR00000156,Medical_Professional,Paid,Electronic_EDI,2023-11-26,2023-11-26,2023-11-26,2023-12-06,Manual_Review,10,1145860509,1829216053,2084P0800X,Psychiatry,65,Out_of_Network,OTHER,E11.9,99285,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,84.89,65.0,16.61,31.24,13.0,4.15,19.89,12.04,3.42,0,,0.2095,unusual_service_frequency|high_volume_same_code,0,2,0,0,0,2e-06,0,0,PPC_Prenatal_Care,FFS
CLM0000004671,MBR00000036,Pharmacy,Paid,Electronic_EDI,2023-08-19,2023-08-19,2023-08-19,2023-09-09,Auto_Adjudicated,21,1098094939,1128148362,207RP1001X,Pulmonary Disease,11,Out_of_Network,OTHER,OTHER,00310075090,,3,Commercial,EPO,17,M,2.0136,,,182.6,145.51,0.0,145.51,0.0,0.0,37.09,0.0,0.0,0,,0.036,none,0,1,0,0,0,0.0,0,1,CCS_Cervical_Cancer_Screening,FFS
CLM0000004672,MBR00000180,Medical_Institutional,Paid,Electronic_EDI,2023-03-07,2023-03-07,2023-03-08,2023-03-20,Auto_Adjudicated,13,1424104563,1527857018,207RE0101X,Endocrinology,11,In_Network,E78.5,E11.9,revenue_code:0200,,0,Medicare_Advantage,MA_PPO,72,F,1.1909,,,18232.29,7308.07,5792.33,16.66,51.0,1448.08,10924.22,0.0,0.0,0,,0.0853,none,0,1,1,0,0,0.000536,0,0,COL_Colorectal_Cancer_Screening,P4P
CLM0000004673,MBR00000212,Medical_Institutional,Denied,Paper,2023-11-19,2023-11-19,2023-11-22,2023-12-03,Auto_Adjudicated,14,1326896487,1301833092,207Q00000X,Family Medicine,71,In_Network,Z79.4,Z00.00,revenue_code:0120,,0,Commercial,HMO,57,F,2.5456,50,Duplicate,10979.51,9179.69,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1259,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004674,MBR00000184,Dental,Paid,Paper,2023-09-06,2023-09-06,2023-09-06,2023-09-28,Manual_Review,22,1356562955,1012893364,2086S0122X,Orthopedic Surgery,11,In_Network,E11.9,I10,D7140,,0,Medicaid_MCO,MLTSS,30,M,2.8302,,,422.27,240.17,238.17,0.0,2.0,0.0,182.1,199.45,20.54,0,,0.0329,none,0,1,0,0,0,2.2e-05,0,0,,FFS
CLM0000004675,MBR00000219,Medical_Professional,Paid,Electronic_EDI,2023-09-06,2023-09-06,2023-09-06,2023-09-20,Auto_Adjudicated,14,1008470017,1560230600,207R00000X,Internal Medicine,11,In_Network,Z12.11,Z00.00,99203,,0,Medicare_Advantage,MA_HMO,84,M,0.9513,,,509.88,234.0,183.69,4.39,0.0,45.92,275.88,113.02,54.83,0,,0.1471,none,0,1,0,0,0,1.7e-05,0,0,,Capitation
CLM0000004676,MBR00000036,Medical_Institutional,Denied,Electronic_EDI,2023-12-01,2023-12-01,2023-12-04,2023-12-22,Manual_Review,21,1986485249,1811797489,2084P0800X,Psychiatry,11,In_Network,F33.0,M54.5|OTHER,revenue_code:0450,,0,Commercial,EPO,17,M,2.0136,18,Coding_Error,7540.61,5319.02,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1701,duplicate_claim_indicator,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004677,MBR00000224,Medical_Professional,Paid,Electronic_EDI,2023-05-26,2023-05-26,2023-05-26,2023-06-08,Manual_Review,13,1369267360,1510751265,207RP1001X,Pulmonary Disease,23,In_Network,Z00.00,OTHER,90847,,0,Medicaid_MCO,MCO,86,F,1.3289,,,3051.07,2249.41,2246.41,0.0,3.0,0.0,801.66,0.0,0.0,0,,0.1127,none,0,1,0,0,0,0.000208,0,0,,FFS
CLM0000004678,MBR00000063,Medical_Professional,Paid,Provider_Portal,2023-05-08,2023-05-08,2023-05-08,2023-05-26,Auto_Adjudicated,18,1147937670,1390802135,207RN0300X,Nephrology,24,In_Network,M79.3,I25.10|OTHER|Z23,99203,,0,ACA_Marketplace,ACA_Silver,56,M,0.8198,,,133.27,46.68,0.0,46.68,0.0,0.0,86.59,0.0,0.0,0,,0.0361,none,0,1,0,0,0,0.0,0,0,POD_Persistence_of_Beta_Blocker,Bundled_Payment
CLM0000004679,MBR00000264,Medical_Institutional,Paid,Electronic_EDI,2023-08-10,2023-08-10,2023-08-14,2023-08-25,Auto_Adjudicated,15,1746688640,1587454801,101YP2500X,Psychologist Clinical,65,In_Network,F41.1,OTHER|E11.9|Z23,revenue_code:0100,,0,ACA_Marketplace,ACA_Bronze,12,F,0.5826,,,20975.98,10751.05,5888.88,936.25,0.0,3925.92,10224.93,0.0,0.0,0,,0.1347,none,0,1,1,1,0,0.000545,0,0,SPD_Spirometry_Testing,Shared_Savings
CLM0000004680,MBR00000076,Medical_Professional,Partially_Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-12-03,Manual_Review,18,1505049857,1287935251,225100000X,Physical Therapist,11,In_Network,I10,Z00.01,99214,,0,Commercial,HMO,26,M,2.1785,16,Medical_Necessity,278.11,162.47,38.66,14.31,32.0,9.66,183.48,0.0,0.0,0,,0.1096,npi_mismatch,0,1,0,1,0,4e-06,0,0,,Bundled_Payment
CLM0000004681,MBR00000153,Medical_Professional,Paid,Electronic_EDI,2023-10-19,2023-10-19,2023-10-19,2023-10-30,Manual_Review,11,1214787184,1040061910,207Q00000X,Family Medicine,21,In_Network,E13.9,OTHER|J06.9,71046,,0,Commercial,POS,12,F,0.6525,,,779.69,603.9,339.93,153.99,25.0,84.98,175.79,0.0,0.0,0,,0.0693,none,0,1,0,0,0,3.1e-05,0,0,,FFS
CLM0000004682,MBR00000151,Medical_Institutional,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-14,2023-10-14,Auto_Adjudicated,4,1584745499,1296566243,2086S0122X,Orthopedic Surgery,21,In_Network,OTHER,E11.9,revenue_code:0360,291,0,Medicare_Advantage,MA_HMO,77,M,0.8709,,,23811.47,8571.19,6814.91,15.55,37.0,1703.73,15240.28,0.0,0.0,0,,0.0919,diagnosis_procedure_mismatch,0,1,1,1,0,0.000631,0,0,,FFS
CLM0000004683,MBR00000083,Medical_Professional,Denied,Electronic_EDI,2023-10-02,2023-10-02,2023-10-02,2023-10-10,Auto_Adjudicated,8,1330688043,1005335812,207Q00000X,Family Medicine,81,In_Network,Z00.00,E11.9|F32.9|M17.11,99214,,0,Commercial,PPO,76,M,0.6621,97,Duplicate,205.55,149.2,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0856,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004684,MBR00000114,Medical_Institutional,Paid,Electronic_EDI,2023-01-13,2023-01-13,2023-01-16,2023-01-24,Manual_Review,11,1804302686,1013600387,246ZN0300X,Neuropsychology,22,In_Network,K21.0,I50.9|OTHER|Z87.891,revenue_code:0110,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,32362.57,26398.03,21099.56,3.57,20.0,5274.89,5964.54,0.0,0.0,0,,0.1449,npi_mismatch,0,1,1,0,0,0.001953,0,0,,Bundled_Payment
CLM0000004685,MBR00000058,Medical_Professional,Paid,Electronic_EDI,2023-06-26,2023-06-26,2023-06-26,2023-07-06,Auto_Adjudicated,10,1091271799,1175334579,207R00000X,Internal Medicine,21,In_Network,I10,F41.1,99204,,0,Commercial,PPO,56,F,1.1626,,,751.68,616.98,382.59,123.74,15.0,95.65,134.7,0.0,0.0,0,,0.0552,none,0,1,0,0,0,3.5e-05,0,0,,FFS
CLM0000004686,MBR00000171,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-05-08,2023-05-08,2023-05-11,2023-05-21,Auto_Adjudicated,13,1321381114,1452088018,207RN0300X,Nephrology,11,In_Network,E11.9,N39.0,revenue_code:0360,,0,Commercial,PPO,27,F,0.819,16,Medical_Necessity,9243.64,4275.93,1718.93,237.65,65.0,429.73,6792.33,0.0,0.0,0,,0.173,unusual_service_frequency,0,1,0,0,0,0.000159,0,0,,FFS
CLM0000004687,MBR00000276,Medical_Institutional,Paid,Electronic_EDI,2023-05-10,2023-05-10,2023-05-13,2023-05-25,Manual_Review,15,1192302048,1304018750,207Q00000X,Family Medicine,21,In_Network,F41.1,OTHER|K21.0,revenue_code:0360,872,0,Commercial,POS,38,M,0.8085,,,7530.41,4960.43,3910.13,25.77,47.0,977.53,2569.98,0.0,0.0,0,,0.0659,high_oop_waiver,0,1,0,0,0,0.000362,0,0,,Bundled_Payment
CLM0000004688,MBR00000100,Medical_Institutional,Paid,Electronic_EDI,2023-11-04,2023-11-04,2023-11-05,2023-11-12,Auto_Adjudicated,8,1243349799,1564691686,207R00000X,Internal Medicine,23,In_Network,E78.5,M54.5,revenue_code:0370,,0,ACA_Marketplace,ACA_Gold,87,M,1.435,,,37476.96,22049.64,17531.8,75.89,59.0,4382.95,15427.32,0.0,0.0,0,,0.007,none,0,1,1,0,0,0.001623,0,0,,Capitation
CLM0000004689,MBR00000156,Pharmacy,Denied,Electronic_EDI,2023-05-23,2023-05-23,2023-05-23,2023-06-04,Auto_Adjudicated,12,1683994149,1287472731,225100000X,Physical Therapist,22,In_Network,R05.9,M79.3|I50.9,00169751112,,3,Medicare_Advantage,MA_PPO,66,F,1.8933,PR-1,Medical_Necessity,395.0,259.94,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0473,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004690,MBR00000260,Behavioral_Health,Paid,Paper,2023-10-28,2023-10-28,2023-10-28,2023-11-06,Manual_Review,9,1666911728,1884259357,207RC0000X,Cardiovascular Disease,22,In_Network,E78.5,OTHER,17000,,0,Medicare_Advantage,SNP,59,M,0.3786,,,100.57,62.68,37.13,10.27,6.0,9.28,37.89,0.0,0.0,0,,0.0561,none,0,1,0,0,0,3e-06,0,0,,Shared_Savings
CLM0000004691,MBR00000140,Medical_Professional,Partially_Paid,Electronic_EDI,2023-11-22,2023-11-22,2023-11-22,2023-12-10,Auto_Adjudicated,18,1909649019,1867389043,2086S0122X,Orthopedic Surgery,22,In_Network,OTHER,J06.9,74178,,0,Medicare_Advantage,MA_HMO,7,M,1.3997,1,Medical_Necessity,957.0,767.82,350.56,6.71,12.0,87.64,500.1,0.0,0.0,0,,0.0244,none,0,1,0,0,0,3.2e-05,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000004692,MBR00000249,Medical_Professional,Paid,Electronic_EDI,2023-06-13,2023-06-13,2023-06-13,2023-06-28,Auto_Adjudicated,15,1750232347,1473869105,2086S0122X,Orthopedic Surgery,11,In_Network,I10,M17.11,99284,,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,412.61,295.56,0.0,295.56,0.0,0.0,117.05,0.0,0.0,0,,0.1452,none,0,1,0,0,0,0.0,0,0,W30_Well_Child_Visit,FFS
CLM0000004693,MBR00000139,Dental,Denied,Provider_Portal,2023-03-02,2023-03-02,2023-03-02,2023-03-21,Auto_Adjudicated,19,1263063839,1004714954,207RG0100X,Gastroenterology,23,Emergency,OTHER,F33.0|C50.911,D4341,,0,Commercial,PPO,74,M,1.7701,256,Medical_Necessity,338.68,211.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0559,none,0,1,0,0,0,0.0,0,0,FUH_Follow_Up_Hospitalization,Bundled_Payment
CLM0000004694,MBR00000138,Medical_Institutional,Paid,Paper,2023-09-08,2023-09-08,2023-09-12,2023-09-21,Auto_Adjudicated,13,1175978429,1880530717,101YP2500X,Psychologist Clinical,23,In_Network,Z23,Z00.00,revenue_code:0110,,0,Commercial,HDHP_HSA,47,M,0.996,,,46311.95,39304.0,31220.67,278.16,0.0,7805.17,7007.95,0.0,0.0,0,,0.0074,none,0,1,1,0,0,0.00289,0,0,,FFS
CLM0000004695,MBR00000050,Behavioral_Health,Paid,Electronic_EDI,2023-11-06,2023-11-06,2023-11-06,2023-12-06,Auto_Adjudicated,30,1419204214,1804282800,208600000X,Surgery General,11,In_Network,Z00.00,OTHER|I10,99395,,0,Medicare_Advantage,MA_PPO,12,F,0.8486,,,98.65,80.83,54.89,12.22,0.0,13.72,17.82,0.0,0.0,0,,0.0794,none,0,1,0,0,0,5e-06,0,0,,Shared_Savings
CLM0000004696,MBR00000038,Pharmacy,Denied,Electronic_EDI,2023-05-26,2023-05-26,2023-05-26,2023-06-10,Manual_Review,15,1190787795,1912895973,207RP1001X,Pulmonary Disease,23,In_Network,Z00.01,E11.9|M47.816,00069420020,,2,Commercial,EPO,46,M,1.1295,22,Timely_Filing,32.23,13.69,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1311,upcoding_pattern,0,1,0,0,0,0.0,0,0,FUH_Follow_Up_Hospitalization,Bundled_Payment
CLM0000004697,MBR00000184,Pharmacy,Paid,Electronic_EDI,2023-03-12,2023-03-12,2023-03-12,2023-03-31,Auto_Adjudicated,19,1319616460,1825450791,101YP2500X,Psychologist Clinical,32,In_Network,N39.0,E11.9|I10,00085163102,,4,Medicaid_MCO,MLTSS,30,M,2.8302,,,421.95,281.82,279.82,0.0,2.0,0.0,140.13,0.0,0.0,0,,0.0572,none,0,1,0,0,0,2.6e-05,0,1,,P4P
CLM0000004698,MBR00000247,Medical_Professional,Paid,Electronic_EDI,2023-07-06,2023-07-06,2023-07-06,2023-07-20,Manual_Review,14,1918578486,1469697158,207R00000X,Internal Medicine,22,In_Network,OTHER,OTHER,90837,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,367.93,300.94,234.83,2.41,5.0,58.71,66.99,0.0,0.0,0,,0.0061,none,0,1,0,0,0,2.2e-05,0,0,,FFS
CLM0000004699,MBR00000042,Medical_Professional,Paid,Electronic_EDI,2023-12-19,2023-12-19,2023-12-19,2024-01-11,Auto_Adjudicated,23,1592228076,1898471307,2086S0122X,Orthopedic Surgery,23,In_Network,M17.11,,99233,,0,Commercial,HMO,78,F,1.1448,,,275.19,212.59,140.61,16.82,20.0,35.15,62.6,0.0,0.0,0,,0.0187,none,0,1,0,0,0,1.3e-05,0,0,,Capitation
CLM0000004700,MBR00000275,Medical_Institutional,Paid,Electronic_EDI,2023-07-05,2023-07-05,2023-07-07,2023-07-22,Manual_Review,17,1078527460,1450837722,207RN0300X,Nephrology,23,In_Network,K21.0,M79.3,revenue_code:0370,,0,Medicare_Advantage,MA_PPO,67,M,0.8169,,,4328.45,3449.86,2713.68,5.76,52.0,678.42,878.59,0.0,0.0,0,,0.0329,none,0,1,0,0,0,0.000251,0,0,MMA_Medication_Management,FFS
CLM0000004701,MBR00000113,Medical_Institutional,Paid,Electronic_EDI,2023-06-10,2023-06-10,2023-06-14,2023-06-13,Manual_Review,3,1496489953,1527857018,101YP2500X,Psychologist Clinical,21,In_Network,OTHER,OTHER,revenue_code:0250,872,0,Medicaid_MCO,MLTSS,29,F,1.1621,,,25841.56,17012.9,17006.9,0.0,6.0,0.0,8828.66,0.0,0.0,0,,0.1842,high_volume_same_code|diagnosis_procedure_mismatch,0,1,1,0,0,0.001574,0,0,,P4P
CLM0000004702,MBR00000134,Pharmacy,Paid,Electronic_EDI,2023-06-07,2023-06-07,2023-06-07,2023-06-29,Auto_Adjudicated,22,1825861601,1588993671,207RP1001X,Pulmonary Disease,11,In_Network,E11.9,,00085163102,,1,Medicare_Advantage,MA_PPO,33,M,1.115,,,310.58,120.83,77.81,10.57,13.0,19.45,189.75,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|geographic_mismatch|temporal_clustering|benford_violation|impossible_service_combo|service_date_weekend|duplicate_claim_indicator|phantom_billing_indicator|npi_mismatch|controlled_substance_high_volume,1,5,0,0,0,7e-06,0,0,,FFS
CLM0000004703,MBR00000271,Behavioral_Health,Paid,Electronic_EDI,2023-09-21,2023-09-21,2023-09-21,2023-10-14,Auto_Adjudicated,23,1172766349,1365397818,207RP1001X,Pulmonary Disease,22,In_Network,K57.30,Z00.00|J06.9,17000,,0,Medicaid_MCO,MCO,4,F,0.6696,,,118.66,42.54,42.54,0.0,0.0,0.0,76.12,0.0,0.0,0,,0.1214,none,0,1,0,0,0,4e-06,0,0,MMA_Medication_Management,P4P
CLM0000004704,MBR00000272,Medical_Professional,Paid,Electronic_EDI,2023-05-03,2023-05-03,2023-05-03,2023-05-16,Auto_Adjudicated,13,1373899620,1450837722,207RC0000X,Cardiovascular Disease,11,Out_of_Network,E11.9,,99284,,0,Medicare_Advantage,MA_HMO,15,M,0.8525,,,258.44,129.43,69.14,28.0,15.0,17.29,129.01,0.0,0.0,0,,0.0469,none,0,1,0,0,0,6e-06,1,0,,FFS
CLM0000004705,MBR00000160,Medical_Institutional,Paid,Electronic_EDI,2023-09-19,2023-09-19,2023-09-20,2023-10-05,Clinical_Review,16,1317654726,1994275960,101YP2500X,Psychologist Clinical,23,In_Network,OTHER,Z00.00,revenue_code:0210,,0,Commercial,HMO,73,M,1.9608,,,16203.57,10664.55,8286.6,266.3,40.0,2071.65,5539.02,0.0,0.0,0,,0.0769,controlled_substance_high_volume,0,1,1,0,0,0.000767,0,0,,Capitation
CLM0000004706,MBR00000086,Dental,Paid,Electronic_EDI,2023-12-21,2023-12-21,2023-12-21,2023-12-22,Auto_Adjudicated,1,1881170383,1164525386,207R00000X,Internal Medicine,23,In_Network,OTHER,K21.0,D1110,,0,Medicare_Advantage,MA_PPO,8,M,0.5427,,,254.39,206.75,156.95,2.56,8.0,39.24,47.64,0.0,0.0,0,,0.1019,none,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000004707,MBR00000054,Pharmacy,Paid,Electronic_EDI,2023-10-05,2023-10-05,2023-10-05,2023-10-31,Auto_Adjudicated,26,1506426842,1355732274,2086S0122X,Orthopedic Surgery,11,In_Network,E11.9,OTHER|J06.9,00003014960,,1,Medicare_Advantage,MA_HMO,66,F,0.8625,,,120.89,66.14,48.8,4.14,1.0,12.2,54.75,0.0,0.0,0,,0.0932,none,0,1,0,0,0,5e-06,0,0,,Capitation
CLM0000004708,MBR00000084,Pharmacy,Paid,Provider_Portal,2023-11-30,2023-11-30,2023-11-30,2023-12-24,Auto_Adjudicated,24,1115589144,1811797489,207RG0100X,Gastroenterology,71,Emergency,I10,L70.0,00006001954,,2,Medicare_Advantage,MA_HMO,15,F,0.8004,,,181.5,120.41,66.38,26.44,11.0,16.59,61.09,0.0,0.0,0,,0.0075,none,0,1,0,0,0,6e-06,0,1,,Capitation
CLM0000004709,MBR00000231,Medical_Institutional,Denied,Electronic_EDI,2023-10-11,2023-10-11,2023-10-12,2023-11-10,Auto_Adjudicated,30,1735391772,1461075342,225100000X,Physical Therapist,65,In_Network,G43.909,M79.3|Z00.00,revenue_code:0100,,0,ACA_Marketplace,ACA_Silver,12,M,0.6456,5,Network,22005.99,13573.41,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0171,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004710,MBR00000102,Behavioral_Health,Paid,Electronic_EDI,2023-10-30,2023-10-30,2023-10-30,2023-11-17,Auto_Adjudicated,18,1699074676,1554490060,207RN0300X,Nephrology,11,In_Network,R05.9,E11.9|Z79.4|Z00.01,97035,,0,Commercial,POS,68,M,1.6864,,,271.94,127.27,69.44,8.47,32.0,17.36,144.67,0.0,0.0,0,,0.0061,none,0,1,0,0,0,6e-06,0,0,ACR_Urine_Protein,FFS
CLM0000004711,MBR00000207,Medical_Professional,Denied,Electronic_EDI,2023-01-15,2023-01-15,2023-01-15,2023-01-22,Auto_Adjudicated,7,1273835569,1509799493,2084P0800X,Psychiatry,22,In_Network,F33.0,,97110,,0,Medicaid_MCO,MLTSS,11,F,1.6522,5,Duplicate,1480.64,750.43,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1065,none,0,1,0,0,0,0.0,0,0,DDE_Diabetes_Short_Term_Complications,Bundled_Payment
CLM0000004712,MBR00000060,Medical_Professional,Paid,Electronic_EDI,2023-05-07,2023-05-07,2023-05-07,2023-05-16,Manual_Review,9,1428403730,1175334579,207Q00000X,Family Medicine,11,In_Network,M17.11,F32.9|K57.30|J06.9,99282,,0,ACA_Marketplace,ACA_Bronze,10,M,1.4568,,,267.72,143.65,33.11,88.47,0.0,22.07,124.07,0.0,0.0,0,,0.1313,none,0,1,0,0,0,3e-06,0,0,,P4P
CLM0000004713,MBR00000147,Medical_Professional,Paid,Electronic_EDI,2023-04-09,2023-04-09,2023-04-09,2023-05-07,Auto_Adjudicated,28,1688560518,1945682535,207RP1001X,Pulmonary Disease,81,In_Network,I10,M54.5,99391,,0,Commercial,PPO,31,F,0.7098,,,464.63,340.24,197.61,67.23,26.0,49.4,124.39,0.0,0.0,0,,0.113,temporal_clustering|upcoding_pattern,0,1,0,0,0,1.8e-05,0,0,IET_Initiation_Substance_Use,FFS
CLM0000004714,MBR00000111,Medical_Institutional,Paid,Electronic_EDI,2023-11-06,2023-11-06,2023-11-09,2023-11-08,Manual_Review,2,1856989511,1741177636,207RC0000X,Cardiovascular Disease,22,In_Network,F10.10,G43.909,revenue_code:0370,,0,Medicare_Advantage,MA_PPO,44,M,0.7462,,,4202.22,2875.47,2268.62,11.69,28.0,567.16,1326.75,0.0,0.0,0,,0.0002,none,0,1,0,0,0,0.00021,0,0,,Shared_Savings
CLM0000004715,MBR00000156,Pharmacy,Paid,Electronic_EDI,2023-03-24,2023-03-24,2023-03-24,2023-04-14,Auto_Adjudicated,21,1137079475,1765164601,207RP1001X,Pulmonary Disease,23,In_Network,I10,Z23|N39.0,59148001506,,1,Medicare_Advantage,MA_PPO,66,F,1.8933,,,247.53,145.36,101.44,5.57,13.0,25.36,102.17,0.0,0.0,0,,0.1399,impossible_service_combo,0,1,0,1,0,9e-06,0,0,,Shared_Savings
CLM0000004716,MBR00000171,Medical_Institutional,Paid,Electronic_EDI,2023-12-14,2023-12-14,2023-12-16,2023-12-17,Manual_Review,3,1557212800,1179350099,207R00000X,Internal Medicine,81,In_Network,J20.9,E11.9|OTHER,revenue_code:0200,,0,Commercial,PPO,27,F,0.819,,,16369.6,13843.26,10713.99,385.77,65.0,2678.5,2526.34,8294.92,1959.01,0,,0.1436,controlled_substance_high_volume,0,1,1,0,0,0.000992,0,0,,P4P
CLM0000004717,MBR00000298,Medical_Institutional,Paid,Electronic_EDI,2023-09-08,2023-09-08,2023-09-10,2023-10-01,Manual_Review,23,1550698436,1287935251,2086S0122X,Orthopedic Surgery,23,In_Network,J06.9,J44.1|OTHER,revenue_code:0200,,0,Medicaid_MCO,MCO,75,M,0.8324,,,100155.51,50001.01,50001.01,0.0,0.0,0.0,50154.5,0.0,0.0,0,,0.2583,outlier_billing_amount|impossible_service_combo,0,2,1,0,0,0.004628,0,0,FLU_Flu_Vaccination,FFS
CLM0000004718,MBR00000273,Medical_Professional,Paid,Electronic_EDI,2023-02-14,2023-02-14,2023-02-14,2023-03-04,Manual_Review,18,1550698436,1767402068,2086S0122X,Orthopedic Surgery,32,In_Network,M54.5,Z00.121,27447,,0,ACA_Marketplace,ACA_Bronze,4,M,1.3569,,,11260.08,8068.83,4777.03,107.12,0.0,3184.69,3191.25,0.0,0.0,0,,0.1379,high_volume_same_code,0,1,0,0,0,0.000442,0,0,,Shared_Savings
CLM0000004719,MBR00000207,Pharmacy,Paid,Electronic_EDI,2023-09-03,2023-09-03,2023-09-03,2023-09-18,Auto_Adjudicated,15,1881358103,1878874025,2086S0122X,Orthopedic Surgery,11,In_Network,OTHER,,16590051660,,2,Medicaid_MCO,MLTSS,11,F,1.6522,,,68.86,27.91,27.91,0.0,0.0,0.0,40.95,0.0,0.0,0,,0.0147,none,0,1,0,1,0,3e-06,0,0,,FFS
CLM0000004720,MBR00000049,Medical_Professional,Paid,Electronic_EDI,2023-05-03,2023-05-03,2023-05-03,2023-05-25,Auto_Adjudicated,22,1451329728,1061113875,207RN0300X,Nephrology,11,Out_of_Network,F32.9,J44.1,70553,,0,Medicare_Advantage,PFFS,67,M,0.978,,,379.09,218.29,162.55,11.1,4.0,40.64,160.8,0.0,0.0,0,,0.1366,none,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000004721,MBR00000277,Medical_Institutional,Denied,Electronic_EDI,2023-04-17,2023-04-17,2023-04-18,2023-04-28,Manual_Review,11,1208538971,1105871325,207RC0000X,Cardiovascular Disease,22,In_Network,F41.1,F33.0,revenue_code:0100,,0,Medicaid_MCO,MCO,30,M,1.8495,256,COB,6793.71,5021.14,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1099,none,0,1,0,1,0,0.0,0,0,IET_Initiation_Substance_Use,Capitation
CLM0000004722,MBR00000270,Medical_Professional,Paid,Electronic_EDI,2023-12-23,2023-12-23,2023-12-23,2024-01-10,Auto_Adjudicated,18,1464997678,1300957944,207RN0300X,Nephrology,32,In_Network,OTHER,M54.5,99394,,0,Commercial,POS,1,F,1.6363,,,343.69,202.46,0.0,202.46,0.0,0.0,141.23,0.0,0.0,0,,0.0071,none,0,1,0,0,0,0.0,0,0,SPD_Spirometry_Testing,Capitation
CLM0000004723,MBR00000269,Medical_Institutional,Denied,Electronic_EDI,2023-10-12,2023-10-12,2023-10-13,2023-11-06,Auto_Adjudicated,25,1428403730,1068662623,225100000X,Physical Therapist,11,In_Network,E11.65,K21.0|I50.9|M17.11,revenue_code:0370,,0,Commercial,EPO,10,F,0.718,3,COB,3859.02,2481.01,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0639,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,CCS_Cervical_Cancer_Screening,Shared_Savings
CLM0000004724,MBR00000147,Medical_Institutional,Denied,Provider_Portal,2023-10-02,2023-10-02,2023-10-05,2023-10-16,Manual_Review,14,1218294278,1461075342,207RN0300X,Nephrology,22,In_Network,OTHER,OTHER,revenue_code:0250,,0,Commercial,PPO,31,F,0.7098,4,Eligibility,16375.82,9643.63,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0226,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004725,MBR00000054,Medical_Institutional,Paid,Electronic_EDI,2023-04-22,2023-04-22,2023-04-22,2023-04-23,Manual_Review,1,1415701059,1564636990,208600000X,Surgery General,31,In_Network,OTHER,J20.9|Z00.00,revenue_code:0210,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,,,12375.57,5728.2,4546.28,0.34,45.0,1136.57,6647.37,0.0,0.0,0,,0.0381,none,0,1,0,1,0,0.000421,0,0,,FFS
CLM0000004726,MBR00000221,Medical_Institutional,Paid,Electronic_EDI,2023-08-26,2023-08-26,2023-08-26,2023-09-25,Manual_Review,30,1034130209,1867389043,207R00000X,Internal Medicine,11,In_Network,M47.816,I10|Z00.00,revenue_code:0300,,0,Commercial,HDHP_HSA,28,M,1.6683,,,27328.06,21468.02,17147.98,33.05,0.0,4286.99,5860.04,0.0,0.0,0,,0.1284,temporal_clustering|high_oop_waiver,0,1,1,0,0,0.001587,0,0,,FFS
CLM0000004727,MBR00000124,Behavioral_Health,Paid,Electronic_EDI,2023-05-04,2023-05-04,2023-05-04,2023-05-21,Auto_Adjudicated,17,1257723293,1054984734,207RC0000X,Cardiovascular Disease,22,In_Network,I10,OTHER|M54.5,80053,,0,Commercial,EPO,40,F,0.4583,,,299.84,204.46,0.0,204.46,0.0,0.0,95.38,0.0,0.0,0,,0.2036,temporal_clustering,0,2,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004728,MBR00000108,Dental,Paid,Electronic_EDI,2023-08-05,2023-08-05,2023-08-05,2023-08-18,Manual_Review,13,1426424205,1995553359,2084P0800X,Psychiatry,11,Out_of_Network,Z00.01,OTHER|K21.0|J06.9,D0120,,0,Medicaid_MCO,MCO,25,F,0.2795,,,575.3,415.14,415.14,0.0,0.0,0.0,160.16,0.0,0.0,0,,0.0655,none,0,1,0,0,0,3.8e-05,1,0,,Capitation
CLM0000004729,MBR00000125,Medical_Professional,Paid,Electronic_EDI,2023-05-24,2023-05-24,2023-05-24,2023-05-27,Auto_Adjudicated,3,1089569577,1175334579,207RG0100X,Gastroenterology,11,In_Network,K21.0,OTHER|I50.9,99385,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,357.94,295.14,222.51,6.0,11.0,55.63,62.8,0.0,0.0,0,,0.0041,none,0,1,0,0,0,2.1e-05,0,0,,FFS
CLM0000004730,MBR00000168,Medical_Professional,Paid,Electronic_EDI,2023-08-07,2023-08-07,2023-08-07,2023-08-10,Auto_Adjudicated,3,1269185915,1321680994,207RG0100X,Gastroenterology,21,In_Network,Z00.00,,99387,,0,Commercial,HMO,76,M,1.2791,,,502.04,349.52,0.0,349.52,0.0,0.0,152.52,0.0,0.0,0,,0.0292,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004731,MBR00000105,Medical_Professional,Paid,Electronic_EDI,2023-09-25,2023-09-25,2023-09-25,2023-10-03,Manual_Review,8,1310250833,1274911960,207RG0100X,Gastroenterology,24,In_Network,M54.5,E78.5|I25.10,83036,,0,Commercial,HMO,74,M,1.1834,,,228.96,87.57,0.0,87.57,0.0,0.0,141.39,0.0,0.0,0,,0.0952,unusual_service_frequency,0,1,0,0,0,0.0,0,0,MMA_Medication_Management,FFS
CLM0000004732,MBR00000206,Medical_Professional,Partially_Paid,Electronic_EDI,2023-04-24,2023-04-24,2023-04-24,2023-05-22,Manual_Review,28,1838794554,1098360555,207R00000X,Internal Medicine,11,In_Network,E11.9,E78.5|E11.9|M54.5,33510,,0,Medicaid_MCO,MLTSS,21,M,1.4038,4,Medical_Necessity,234.64,155.96,105.11,0.0,1.0,0.0,128.53,0.0,0.0,0,,0.0082,none,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000004733,MBR00000192,Medical_Professional,Partially_Paid,Paper,2023-01-05,2023-01-05,2023-01-05,2023-01-27,Manual_Review,22,1631060535,1564636990,207Q00000X,Family Medicine,21,In_Network,Z00.00,,99282,,0,Medicaid_MCO,MCO,22,F,1.1739,97,Medical_Necessity,277.13,166.98,121.81,0.0,0.0,0.0,155.32,0.0,0.0,0,,0.1841,unbundling_pattern,0,1,0,0,0,1.1e-05,0,0,CDC_BP_Control,FFS
CLM0000004734,MBR00000156,Dental,Paid,Electronic_EDI,2023-02-04,2023-02-04,2023-02-04,2023-02-17,Auto_Adjudicated,13,1402424417,1029818813,207RN0300X,Nephrology,23,In_Network,Z23,M54.5,D2391,,0,Medicare_Advantage,MA_PPO,66,F,1.8933,,,368.16,169.63,123.62,2.11,13.0,30.9,198.53,0.0,0.0,0,,0.0939,none,0,1,0,0,0,1.1e-05,0,0,,P4P
CLM0000004735,MBR00000014,Vision,Denied,Electronic_EDI,2023-11-22,2023-11-22,2023-11-22,2023-12-15,Auto_Adjudicated,23,1478783612,1291071007,207RN0300X,Nephrology,21,In_Network,E78.5,F41.1,92002,,0,Commercial,HMO,77,M,2.8513,22,Coding_Error,167.8,108.51,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0209,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004736,MBR00000283,Medical_Professional,Paid,Electronic_EDI,2023-12-11,2023-12-11,2023-12-11,2023-12-23,Auto_Adjudicated,12,1901547390,1406199453,2086S0122X,Orthopedic Surgery,22,Emergency,Z00.01,Z79.4,99282,,0,Medicare_Advantage,MA_HMO,21,M,0.5294,,,370.52,254.37,162.93,36.7,14.0,40.73,116.15,0.0,0.0,0,,0.0406,none,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000004737,MBR00000131,Pharmacy,Paid,Electronic_EDI,2023-09-06,2023-09-06,2023-09-06,2023-10-03,Auto_Adjudicated,27,1139362508,1765164601,207V00000X,Obstetrics & Gynecology,22,In_Network,L70.0,OTHER|F32.9,00006001954,,1,Commercial,EPO,15,F,0.9228,,,63.4,39.91,0.0,39.91,0.0,0.0,23.49,0.0,0.0,0,,0.06,none,0,1,0,0,0,0.0,0,0,KED_ESRD_Patients,Capitation
CLM0000004738,MBR00000140,Pharmacy,Paid,Electronic_EDI,2023-02-08,2023-02-08,2023-02-08,2023-02-18,Auto_Adjudicated,10,1231954359,1978943761,207RC0000X,Cardiovascular Disease,65,Out_of_Network,OTHER,OTHER|F41.1,50458085930,,1,Medicare_Advantage,MA_HMO,7,M,1.3997,,,145.26,61.97,25.24,18.42,12.0,6.31,83.29,0.0,0.0,0,,0.0228,none,0,1,0,0,0,2e-06,0,0,,P4P
CLM0000004739,MBR00000142,Medical_Professional,Paid,Electronic_EDI,2023-07-30,2023-07-30,2023-07-30,2023-08-21,Auto_Adjudicated,22,1288855406,1228356980,246ZN0300X,Neuropsychology,32,Out_of_Network,F33.0,,99394,,0,ACA_Marketplace,ACA_Silver,48,M,1.3761,,,277.49,185.23,0.0,182.13,3.1,0.0,92.26,0.0,0.0,0,,0.1486,high_oop_waiver,0,1,0,0,0,0.0,0,0,IET_Initiation_Substance_Use,FFS
CLM0000004740,MBR00000115,Dental,Paid,Paper,2023-06-05,2023-06-05,2023-06-05,2023-06-19,Auto_Adjudicated,14,1374361443,1811797489,207RN0300X,Nephrology,11,In_Network,OTHER,,D2391,,0,Commercial,PPO,15,F,0.7398,,,493.33,178.79,62.9,75.16,25.0,15.73,314.54,0.0,0.0,0,,0.0343,none,0,1,0,0,0,6e-06,0,0,,Shared_Savings
CLM0000004741,MBR00000200,Behavioral_Health,Paid,Electronic_EDI,2023-03-27,2023-03-27,2023-03-27,2023-04-17,Auto_Adjudicated,21,1878453830,1694343357,207RN0300X,Nephrology,23,In_Network,I10,,97012,,0,Commercial,HDHP_HSA,29,M,0.8011,,,170.99,73.48,0.0,73.48,0.0,0.0,97.51,0.0,0.0,0,,0.1334,upcoding_pattern,0,1,0,0,0,0.0,0,0,,P4P
CLM0000004742,MBR00000005,Vision,Paid,Electronic_EDI,2023-05-17,2023-05-17,2023-05-17,2023-05-23,Auto_Adjudicated,6,1183801932,1522426351,207RP1001X,Pulmonary Disease,22,In_Network,OTHER,K21.0|Z23,92014,,0,Medicare_Advantage,MA_PPO,8,M,0.566,,,514.18,385.17,294.49,12.06,5.0,73.62,129.01,0.0,0.0,0,,0.0128,none,0,1,0,0,0,2.7e-05,0,0,,FFS
CLM0000004743,MBR00000263,Pharmacy,Paid,Electronic_EDI,2023-10-09,2023-10-09,2023-10-09,2023-11-07,Auto_Adjudicated,29,1089569577,1542515060,207RN0300X,Nephrology,21,In_Network,Z23,,00169751112,,3,Medicare_Advantage,MA_HMO,29,F,1.5001,,,690.29,410.67,298.15,18.99,19.0,74.54,279.62,0.0,0.0,0,,0.0887,duplicate_claim_indicator,0,1,0,0,0,2.8e-05,0,1,ACR_Urine_Protein,Shared_Savings
CLM0000004744,MBR00000031,Medical_Professional,Paid,Electronic_EDI,2023-12-24,2023-12-24,2023-12-24,2024-01-02,Auto_Adjudicated,9,1374361443,1588993671,207Q00000X,Family Medicine,22,In_Network,F41.1,OTHER,99215,,0,Commercial,PPO,71,M,0.6746,,,604.13,389.83,274.64,30.53,16.0,68.66,214.3,0.0,0.0,0,,0.131,none,0,1,0,0,0,2.5e-05,0,0,,Capitation
CLM0000004745,MBR00000300,Medical_Professional,Paid,Electronic_EDI,2023-11-10,2023-11-10,2023-11-10,2023-11-27,Manual_Review,17,1083045036,1842149518,207RN0300X,Nephrology,32,In_Network,G47.33,I10|E78.5,82947,,0,Commercial,PPO,64,F,1.0393,,,2304.12,1197.22,830.62,129.94,29.0,207.66,1106.9,0.0,0.0,0,,0.2042,geographic_mismatch,0,2,0,0,0,7.7e-05,0,0,,Bundled_Payment
CLM0000004746,MBR00000186,Behavioral_Health,Paid,Electronic_EDI,2023-03-15,2023-03-15,2023-03-15,2023-04-05,Auto_Adjudicated,21,1707022770,1301869102,207R00000X,Internal Medicine,24,In_Network,OTHER,,12001,,0,Commercial,PPO,65,M,1.6983,,,374.91,237.33,117.94,77.9,12.0,29.49,137.58,0.0,0.0,0,,0.1083,none,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000004747,MBR00000020,Medical_Professional,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-20,Auto_Adjudicated,20,1477762002,1452088018,207RE0101X,Endocrinology,22,In_Network,Z00.00,,27447,,0,Medicare_Advantage,MA_PPO,63,F,0.7119,,,27688.03,10215.25,8143.48,29.89,6.0,2035.87,17472.78,0.0,0.0,0,,0.0853,geographic_mismatch,0,1,1,0,0,0.000754,0,0,CDC_HbA1c_Poor_Control,Bundled_Payment
CLM0000004748,MBR00000169,Medical_Institutional,Paid,Electronic_EDI,2023-07-09,2023-07-09,2023-07-13,2023-07-26,Auto_Adjudicated,17,1026612378,1672803287,207RN0300X,Nephrology,11,In_Network,Z12.11,F10.10|M54.5,revenue_code:0210,,0,Commercial,EPO,30,M,1.4348,,,6114.22,2212.97,1655.93,82.06,61.0,413.98,3901.25,0.0,0.0,0,,0.0658,none,0,1,0,0,0,0.000153,0,0,CDC_BP_Control,P4P
CLM0000004749,MBR00000105,Medical_Professional,Paid,Paper,2023-04-15,2023-04-15,2023-04-15,2023-05-12,Auto_Adjudicated,27,1426424205,1368666316,225100000X,Physical Therapist,22,In_Network,OTHER,Z00.00,99386,,0,Commercial,HMO,74,M,1.1834,,,494.97,396.94,0.0,396.94,0.0,0.0,98.03,0.0,0.0,1,Kickback Arrangement,1.0,outlier_billing_amount|provider_specialty_mismatch|temporal_clustering|high_volume_same_code|benford_violation|service_date_weekend|billing_spike_recent|upcoding_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,0.0,0,0,,Capitation
CLM0000004750,MBR00000289,Medical_Institutional,Denied,Electronic_EDI,2023-06-06,2023-06-06,2023-06-10,2023-07-06,Auto_Adjudicated,30,1310400164,1105733833,207V00000X,Obstetrics & Gynecology,22,In_Network,N39.0,E11.9,revenue_code:0450,,0,Commercial,POS,51,M,1.0534,96,Timely_Filing,2415.92,1191.44,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1089,unbundling_pattern,0,1,0,1,0,0.0,0,0,,FFS
CLM0000004751,MBR00000221,Medical_Professional,Paid,Electronic_EDI,2023-05-17,2023-05-17,2023-05-17,2023-06-09,Auto_Adjudicated,23,1706476585,1860951128,207RN0300X,Nephrology,22,In_Network,J06.9,Z00.00,99282,,0,Commercial,HDHP_HSA,28,M,1.6683,,,542.71,408.01,0.0,408.01,0.0,0.0,134.7,0.0,0.0,0,,0.0413,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004752,MBR00000156,Pharmacy,Paid,Electronic_EDI,2023-01-25,2023-01-25,2023-01-25,2023-01-31,Auto_Adjudicated,6,1313587359,1013600387,225100000X,Physical Therapist,71,In_Network,Z00.00,,00085163102,,1,Medicare_Advantage,MA_PPO,66,F,1.8933,,,110.83,67.4,42.29,1.54,13.0,10.57,43.43,0.0,0.0,0,,0.0877,none,0,1,0,0,0,4e-06,0,1,,Capitation
CLM0000004753,MBR00000135,Medical_Institutional,Denied,Electronic_EDI,2023-05-30,2023-05-30,2023-05-30,2023-06-23,Auto_Adjudicated,24,1756856314,1493836023,225100000X,Physical Therapist,81,In_Network,Z00.00,E78.5,revenue_code:0110,,0,Commercial,PPO,58,F,2.2702,256,Authorization,7420.28,2876.33,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1887,service_date_weekend|npi_mismatch,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004754,MBR00000299,Medical_Institutional,Denied,Electronic_EDI,2023-05-11,2023-05-11,2023-05-11,2023-05-27,Manual_Review,16,1654042271,1061149198,207RP1001X,Pulmonary Disease,71,In_Network,Z23,,revenue_code:0450,,0,Medicaid_MCO,MCO,74,F,0.8833,18,Network,24123.8,9200.12,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0938,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004755,MBR00000198,Medical_Professional,Paid,Provider_Portal,2023-04-20,2023-04-20,2023-04-20,2023-05-07,Auto_Adjudicated,17,1896279539,1297948643,2084P0800X,Psychiatry,24,In_Network,F41.1,M54.5,73721,,0,Medicaid_MCO,MCO,81,F,1.4199,,,790.98,301.38,299.38,0.0,2.0,0.0,489.6,0.0,0.0,0,,0.03,none,0,1,0,0,0,2.8e-05,0,0,,FFS
CLM0000004756,MBR00000158,Medical_Institutional,Paid,Electronic_EDI,2023-08-09,2023-08-09,2023-08-10,2023-09-07,Manual_Review,29,1220235547,1894215172,208600000X,Surgery General,22,In_Network,E11.9,,revenue_code:0360,,0,Commercial,HMO,65,M,1.5361,,,8226.27,4945.71,3858.32,72.8,50.0,964.58,3280.56,0.0,0.0,0,,0.0666,none,0,1,0,0,0,0.000357,0,0,,FFS
CLM0000004757,MBR00000126,Pharmacy,Paid,Electronic_EDI,2023-09-13,2023-09-13,2023-09-13,2023-09-29,Auto_Adjudicated,16,1231954359,1004714954,207RC0000X,Cardiovascular Disease,21,In_Network,OTHER,OTHER,00071012831,,2,Medicaid_MCO,MLTSS,48,F,0.637,,,86.87,44.9,42.9,0.0,2.0,0.0,41.97,0.0,0.0,0,,0.1439,none,0,1,0,0,0,4e-06,0,1,,FFS
CLM0000004758,MBR00000102,Dental,Paid,Electronic_EDI,2023-01-17,2023-01-17,2023-01-17,2023-02-12,Manual_Review,26,1470105939,1288028182,207V00000X,Obstetrics & Gynecology,71,In_Network,G43.909,,D3310,,0,Commercial,POS,68,M,1.6864,,,142.19,119.3,0.0,119.3,0.0,0.0,22.89,0.0,0.0,0,,0.0175,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004759,MBR00000208,Pharmacy,Paid,Electronic_EDI,2023-05-03,2023-05-03,2023-05-03,2023-05-23,Auto_Adjudicated,20,1373899620,1685903362,207V00000X,Obstetrics & Gynecology,22,In_Network,I10,,00071015523,,5,Medicare_Advantage,MA_HMO,66,M,2.1466,,,31.89,12.88,0.0,12.88,0.0,0.0,19.01,0.0,0.0,0,,0.214,high_volume_same_code|npi_mismatch,0,2,0,0,0,0.0,0,0,,Capitation
CLM0000004760,MBR00000177,Medical_Institutional,Paid,Electronic_EDI,2023-01-12,2023-01-12,2023-01-14,2023-01-15,Auto_Adjudicated,3,1903785749,1509799493,101YP2500X,Psychologist Clinical,11,In_Network,I10,OTHER|I10,revenue_code:0450,,0,Commercial,HMO,42,F,1.2774,,,44779.45,24556.27,19480.9,128.15,77.0,4870.22,20223.18,0.0,0.0,0,,0.1411,none,0,1,1,0,0,0.001803,0,0,,P4P
CLM0000004761,MBR00000255,Pharmacy,Paid,Electronic_EDI,2023-10-22,2023-10-22,2023-10-22,2023-11-13,Auto_Adjudicated,22,1042080259,1469642907,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,I10,59148001506,,1,Medicare_Advantage,MA_HMO,21,M,0.6945,,,151.37,54.03,24.16,5.83,18.0,6.04,97.34,0.0,0.0,0,,0.0296,none,0,1,0,0,0,2e-06,0,0,,FFS
CLM0000004762,MBR00000167,Medical_Institutional,Paid,Paper,2023-11-29,2023-11-29,2023-11-29,2023-12-14,Manual_Review,15,1670125610,1179350099,207RN0300X,Nephrology,31,In_Network,OTHER,OTHER|I50.9,revenue_code:0210,,0,Commercial,PPO,77,F,0.9377,,,5392.55,3542.47,2605.79,252.23,33.0,651.45,1850.08,0.0,0.0,0,,0.0439,none,0,1,0,0,0,0.000241,0,0,,FFS
CLM0000004763,MBR00000175,Medical_Institutional,Paid,Electronic_EDI,2023-06-16,2023-06-16,2023-06-20,2023-07-03,Auto_Adjudicated,17,1617763056,1358873132,207RE0101X,Endocrinology,21,Out_of_Network,OTHER,F33.0|J44.1,revenue_code:0450,291,0,Commercial,PPO,14,F,1.5785,,,23600.65,9375.3,7442.65,23.99,48.0,1860.66,14225.35,0.0,0.0,0,,0.1666,unbundling_pattern,0,1,1,0,0,0.000689,0,0,,FFS
CLM0000004764,MBR00000146,Pharmacy,Paid,Electronic_EDI,2023-12-06,2023-12-06,2023-12-06,2023-12-16,Auto_Adjudicated,10,1330688043,1672803287,207R00000X,Internal Medicine,24,In_Network,E13.9,I10,00169751112,,2,Medicaid_MCO,MCO,24,M,0.6484,,,96.5,66.62,62.62,0.0,4.0,0.0,29.88,0.0,0.0,0,,0.0474,none,0,1,0,0,0,6e-06,0,1,,Capitation
CLM0000004765,MBR00000224,Medical_Professional,Paid,Electronic_EDI,2023-08-14,2023-08-14,2023-08-14,2023-08-20,Manual_Review,6,1855186422,1391074619,208600000X,Surgery General,23,In_Network,OTHER,E78.5,99203,,0,Medicaid_MCO,MCO,86,F,1.3289,,,191.51,135.86,132.86,0.0,3.0,0.0,55.65,0.0,0.0,0,,0.1772,service_date_weekend,0,1,0,1,0,1.2e-05,0,0,DDE_Diabetes_Short_Term_Complications,FFS
CLM0000004766,MBR00000132,Medical_Institutional,Paid,Electronic_EDI,2023-11-08,2023-11-08,2023-11-10,2023-12-01,Auto_Adjudicated,23,1012271279,1012893364,101YP2500X,Psychologist Clinical,11,In_Network,I10,K21.0|OTHER|Z00.00,revenue_code:0370,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,,,35009.53,29514.1,23592.07,0.01,24.0,5898.02,5495.43,0.0,0.0,0,,0.1574,temporal_clustering,0,1,1,0,0,0.002184,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000004767,MBR00000257,Pharmacy,Paid,Electronic_EDI,2023-12-07,2023-12-07,2023-12-07,2023-12-15,Auto_Adjudicated,8,1267286378,1788579687,208600000X,Surgery General,31,In_Network,I10,Z00.00,00003014960,,1,Medicaid_MCO,MCO,76,F,0.8322,,,325.77,150.04,149.04,0.0,1.0,0.0,175.73,0.0,0.0,0,,0.0157,none,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000004768,MBR00000104,Medical_Professional,Paid,Electronic_EDI,2023-07-30,2023-07-30,2023-07-30,2023-08-02,Auto_Adjudicated,3,1994365754,1542515060,207RC0000X,Cardiovascular Disease,31,In_Network,Z00.00,,99393,,0,Medicaid_MCO,MCO,87,F,1.2297,,,306.85,208.12,208.12,0.0,0.0,0.0,98.73,0.0,0.0,0,,0.12,none,0,1,0,0,0,1.9e-05,0,0,POD_Persistence_of_Beta_Blocker,Shared_Savings
CLM0000004769,MBR00000206,Pharmacy,Denied,Electronic_EDI,2023-06-10,2023-06-10,2023-06-10,2023-06-25,Auto_Adjudicated,15,1954226809,1179350099,207RN0300X,Nephrology,11,In_Network,J20.9,,50458085930,,4,Medicaid_MCO,MLTSS,21,M,1.4038,50,Network,115.54,58.1,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0563,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004770,MBR00000270,Medical_Professional,Paid,Electronic_EDI,2023-09-24,2023-09-24,2023-09-24,2023-10-16,Auto_Adjudicated,22,1205744244,1368666316,207RG0100X,Gastroenterology,11,In_Network,E11.9,OTHER|E78.5|E11.9,90832,,0,Commercial,POS,1,F,1.6363,,,765.47,384.43,68.56,286.74,12.0,17.14,381.04,0.0,0.0,0,,0.1149,geographic_mismatch,0,1,0,0,0,6e-06,0,0,LCS_Lung_Cancer_Screening,Bundled_Payment
CLM0000004771,MBR00000226,Medical_Institutional,Paid,Electronic_EDI,2023-03-03,2023-03-03,2023-03-05,2023-03-10,Auto_Adjudicated,7,1918578486,1887266184,207RN0300X,Nephrology,22,In_Network,E11.65,,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,84,M,1.0796,,,20233.6,15748.02,12569.56,0.07,36.0,3142.39,4485.58,0.0,0.0,0,,0.0256,none,0,1,1,0,0,0.001163,0,0,,Capitation
CLM0000004772,MBR00000107,Pharmacy,Paid,Electronic_EDI,2023-04-17,2023-04-17,2023-04-17,2023-04-28,Auto_Adjudicated,11,1039678579,1493836023,207RE0101X,Endocrinology,11,In_Network,Z00.00,J44.1|E11.9|OTHER,00069420020,,3,Medicare_Advantage,MA_PPO,44,M,1.0439,,,221.27,175.96,110.45,29.9,8.0,27.61,45.31,0.0,0.0,0,,0.0674,none,0,1,0,0,0,1e-05,0,1,,FFS
CLM0000004773,MBR00000208,Medical_Professional,Paid,Electronic_EDI,2023-07-17,2023-07-17,2023-07-17,2023-07-30,Auto_Adjudicated,13,1921056264,1650774392,207RE0101X,Endocrinology,21,In_Network,N39.0,E78.5,99391,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,513.88,248.97,175.54,23.55,6.0,43.88,264.91,0.0,0.0,0,,0.0756,phantom_billing_indicator,0,1,0,0,0,1.6e-05,0,0,,Capitation
CLM0000004774,MBR00000063,Medical_Professional,Paid,Provider_Portal,2023-03-14,2023-03-14,2023-03-14,2023-04-11,Clinical_Review,28,1175252466,1402472115,207R00000X,Internal Medicine,65,In_Network,OTHER,Z00.00,99213,,0,ACA_Marketplace,ACA_Silver,56,M,0.8198,,,169.72,110.17,0.0,110.17,0.0,0.0,59.55,0.0,0.0,0,,0.0685,none,0,1,0,0,0,0.0,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000004775,MBR00000016,Medical_Institutional,Paid,Electronic_EDI,2023-06-28,2023-06-28,2023-06-28,2023-07-03,Auto_Adjudicated,5,1469822310,1810068286,207RG0100X,Gastroenterology,11,In_Network,G43.909,N39.0,revenue_code:0360,,0,Commercial,HDHP_HSA,20,F,0.5843,,,9512.62,6850.01,5326.11,192.37,0.0,1331.53,2662.61,0.0,0.0,0,,0.0926,impossible_service_combo,0,1,1,0,0,0.000493,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000004776,MBR00000235,Medical_Professional,Paid,Electronic_EDI,2023-11-04,2023-11-04,2023-11-04,2023-12-02,Auto_Adjudicated,28,1048378959,1765164601,207RN0300X,Nephrology,22,In_Network,J06.9,H52.4,71250,,0,Commercial,HDHP_HSA,85,F,1.4308,,,959.9,498.83,214.68,230.48,0.0,53.67,461.07,0.0,0.0,0,,0.0146,none,0,1,0,0,0,2e-05,0,0,MPT_Annual_Monitoring,FFS
CLM0000004777,MBR00000239,Medical_Professional,Paid,Electronic_EDI,2023-10-08,2023-10-08,2023-10-08,2023-10-13,Auto_Adjudicated,5,1368580443,1170002937,207RN0300X,Nephrology,11,Out_of_Network,Z00.00,OTHER,90847,,0,Commercial,HMO,1,F,1.1193,,,435.33,185.88,79.65,67.32,19.0,19.91,249.45,0.0,0.0,0,,0.0899,none,0,1,0,1,0,7e-06,1,0,CCS_Cervical_Cancer_Screening,Shared_Savings
CLM0000004778,MBR00000007,Pharmacy,Paid,Electronic_EDI,2023-11-16,2023-11-16,2023-11-16,2023-12-04,Auto_Adjudicated,18,1267286378,1282319940,207RN0300X,Nephrology,21,In_Network,E11.9,F33.0|Z00.01,00071015523,,3,Commercial,HDHP_HSA,72,F,0.7578,,,385.76,292.48,0.0,292.48,0.0,0.0,93.28,0.0,0.0,0,,0.0772,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004779,MBR00000287,Medical_Professional,Paid,Electronic_EDI,2023-11-05,2023-11-05,2023-11-05,2023-12-01,Auto_Adjudicated,26,1008470017,1301833092,207RG0100X,Gastroenterology,21,In_Network,M17.11,G47.33|Z00.01,99282,,0,Commercial,PPO,4,M,0.7685,,,547.94,335.05,230.47,20.96,26.0,57.62,212.89,0.0,0.0,0,,0.0778,none,0,1,0,0,0,2.1e-05,0,0,,FFS
CLM0000004780,MBR00000139,Medical_Institutional,Paid,Electronic_EDI,2023-04-30,2023-04-30,2023-05-01,2023-05-28,Auto_Adjudicated,28,1647029816,1450837722,225100000X,Physical Therapist,11,In_Network,E78.5,E11.9,revenue_code:0300,,0,Commercial,PPO,74,M,1.7701,,,12658.17,6188.6,4693.13,289.19,33.0,1173.28,6469.57,0.0,0.0,0,,0.0359,none,0,1,0,0,0,0.000434,0,0,,P4P
CLM0000004781,MBR00000274,Medical_Professional,Paid,Electronic_EDI,2023-09-13,2023-09-13,2023-09-13,2023-09-30,Clinical_Review,17,1119160702,1746676564,207RN0300X,Nephrology,24,Out_of_Network,OTHER,M54.5,99214,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,339.07,123.35,69.15,36.91,0.0,17.29,215.72,58.05,5.66,0,,0.0779,none,0,1,0,0,0,6e-06,1,0,,FFS
CLM0000004782,MBR00000233,Medical_Professional,Paid,Electronic_EDI,2023-05-14,2023-05-14,2023-05-14,2023-05-29,Manual_Review,15,1145860509,1196833348,207V00000X,Obstetrics & Gynecology,24,In_Network,OTHER,Z00.00,11200,,0,Medicare_Advantage,MA_PPO,87,M,0.8034,,,561.64,437.47,317.77,37.25,3.0,79.44,124.17,0.0,0.0,0,,0.0327,none,0,1,0,1,0,2.9e-05,0,0,CDC_BP_Control,Shared_Savings
CLM0000004783,MBR00000273,Medical_Professional,Denied,Electronic_EDI,2023-12-15,2023-12-15,2023-12-15,2024-01-08,Auto_Adjudicated,24,1950560596,1027261156,207RG0100X,Gastroenterology,22,Out_of_Network,I10,J06.9,99212,,0,ACA_Marketplace,ACA_Bronze,4,M,1.3569,2,Duplicate,241.88,138.46,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0769,none,0,1,0,0,0,0.0,1,0,,Bundled_Payment
CLM0000004784,MBR00000249,Vision,Paid,Electronic_EDI,2023-03-05,2023-03-05,2023-03-05,2023-04-02,Auto_Adjudicated,28,1739169232,1320546364,207RE0101X,Endocrinology,65,In_Network,Z00.00,OTHER|Z00.00,92014,,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,531.9,333.68,0.0,333.68,0.0,0.0,198.22,0.0,0.0,0,,0.0639,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004785,MBR00000293,Medical_Institutional,Paid,Electronic_EDI,2023-04-07,2023-04-07,2023-04-10,2023-04-08,Auto_Adjudicated,1,1466922283,1220755708,225100000X,Physical Therapist,11,In_Network,Z00.01,,revenue_code:0100,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,5653.95,2358.1,1827.3,41.97,32.0,456.83,3295.85,0.0,0.0,0,,0.0819,none,0,1,0,0,0,0.000169,0,0,,Capitation
CLM0000004786,MBR00000187,Medical_Professional,Paid,Electronic_EDI,2023-12-05,2023-12-05,2023-12-05,2023-12-13,Auto_Adjudicated,8,1780111559,1007652766,207RP1001X,Pulmonary Disease,22,In_Network,OTHER,F41.1|E11.9|E11.65,99213,,0,Medicaid_MCO,MCO,36,F,1.191,,,423.33,165.67,162.67,0.0,3.0,0.0,257.66,0.0,0.0,0,,0.1172,service_date_weekend|duplicate_claim_indicator,0,1,0,0,0,1.5e-05,0,0,W30_Well_Child_Visit,FFS
CLM0000004787,MBR00000071,Medical_Institutional,Paid,Paper,2023-03-27,2023-03-27,2023-03-30,2023-04-05,Auto_Adjudicated,9,1274357072,1650774392,101YP2500X,Psychologist Clinical,31,In_Network,Z00.00,F41.1,revenue_code:0200,,0,Commercial,EPO,19,F,0.5699,,,7700.72,4065.94,3173.44,30.14,69.0,793.36,3634.78,0.0,0.0,0,,0.0952,unusual_service_frequency,0,1,0,0,0,0.000294,0,0,BPD_BP_Declined,FFS
CLM0000004788,MBR00000125,Medical_Institutional,Denied,Electronic_EDI,2023-08-11,2023-08-11,2023-08-12,2023-09-06,Auto_Adjudicated,26,1944105498,1029818813,207RN0300X,Nephrology,22,In_Network,I48.91,I10,revenue_code:0360,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,CO-45,Eligibility,15097.56,7013.75,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Upcoding,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|temporal_clustering|high_volume_same_code|benford_violation|service_date_weekend|billing_spike_recent|upcoding_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,0.0,0,0,FUH_Follow_Up_Hospitalization,Bundled_Payment
CLM0000004789,MBR00000221,Medical_Institutional,Denied,Electronic_EDI,2023-04-15,2023-04-15,2023-04-17,2023-04-16,Auto_Adjudicated,1,1156265220,1388050552,207RC0000X,Cardiovascular Disease,81,In_Network,Z23,OTHER,revenue_code:0110,,0,Commercial,HDHP_HSA,28,M,1.6683,96,COB,22458.53,8245.86,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0347,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000004790,MBR00000050,Medical_Professional,Paid,Electronic_EDI,2023-04-13,2023-04-13,2023-04-13,2023-04-17,Auto_Adjudicated,4,1490172833,1791502603,207RG0100X,Gastroenterology,22,In_Network,Z23,M17.11,99214,,0,Medicare_Advantage,MA_PPO,12,F,0.8486,,,201.97,88.48,60.15,13.3,0.0,15.04,113.49,0.0,0.0,0,,0.1252,none,0,1,0,1,0,6e-06,0,0,,Shared_Savings
CLM0000004791,MBR00000280,Medical_Professional,Paid,Electronic_EDI,2023-08-29,2023-08-29,2023-08-29,2023-08-30,Auto_Adjudicated,1,1593056613,1012893364,207RN0300X,Nephrology,81,In_Network,L70.0,,90837,,0,Commercial,PPO,79,F,0.6697,,,577.77,391.09,281.72,3.94,35.0,70.43,186.68,0.0,0.0,0,,0.0744,none,0,1,0,0,0,2.6e-05,0,0,,Shared_Savings
CLM0000004792,MBR00000062,Medical_Institutional,Paid,Electronic_EDI,2023-10-13,2023-10-13,2023-10-13,2023-11-11,Auto_Adjudicated,29,1741980770,1287472731,207RE0101X,Endocrinology,11,In_Network,M54.5,OTHER,revenue_code:0100,,0,Commercial,HMO,46,F,0.5516,,,10727.85,5100.59,4041.63,15.55,33.0,1010.41,5627.26,0.0,0.0,0,,0.0297,none,0,1,0,0,0,0.000374,0,0,,Capitation
CLM0000004793,MBR00000264,Medical_Institutional,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-27,2023-03-26,Auto_Adjudicated,1,1012271279,1887266184,207RN0300X,Nephrology,11,In_Network,OTHER,OTHER,revenue_code:0370,,0,ACA_Marketplace,ACA_Bronze,12,F,0.5826,,,14827.63,12350.17,6139.5,2117.68,0.0,4093.0,2477.46,4599.81,1374.65,0,,0.1066,none,0,1,1,1,0,0.000568,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000004794,MBR00000149,Pharmacy,Paid,Electronic_EDI,2023-12-19,2023-12-19,2023-12-19,2023-12-27,Auto_Adjudicated,8,1117755591,1513198866,2086S0122X,Orthopedic Surgery,21,In_Network,Z00.01,,00169751112,,3,Commercial,PPO,42,F,0.5458,,,121.68,97.4,0.0,97.4,0.0,0.0,24.28,0.0,0.0,0,,0.1026,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000004795,MBR00000251,Medical_Institutional,Paid,Electronic_EDI,2023-02-01,2023-02-01,2023-02-02,2023-02-17,Auto_Adjudicated,16,1145498455,1542515060,207RN0300X,Nephrology,31,In_Network,F10.10,,revenue_code:0250,,0,Commercial,PPO,65,M,0.7737,,,57271.76,29945.18,23733.93,222.77,55.0,5933.48,27326.58,0.0,0.0,0,,0.114,outlier_billing_amount,0,1,1,0,0,0.002197,0,0,FLU_Flu_Vaccination,Shared_Savings
CLM0000004796,MBR00000291,Pharmacy,Paid,Electronic_EDI,2023-02-05,2023-02-05,2023-02-05,2023-02-16,Auto_Adjudicated,11,1145860509,1330485436,207RE0101X,Endocrinology,11,In_Network,OTHER,E78.5|OTHER,50458085930,,5,Commercial,PPO,78,M,1.4773,,,74.14,55.28,0.0,55.28,0.0,0.0,18.86,0.0,0.0,0,,0.0179,none,0,1,0,0,0,0.0,0,1,COL_Colorectal_Cancer_Screening,FFS
CLM0000004797,MBR00000134,Medical_Institutional,Paid,Electronic_EDI,2023-12-18,2023-12-18,2023-12-22,2023-12-21,Auto_Adjudicated,3,1699074676,1867389043,207R00000X,Internal Medicine,11,In_Network,I10,F10.10|K21.0,revenue_code:0210,,0,Medicare_Advantage,MA_PPO,33,M,1.115,,,3066.39,1348.78,1030.44,38.73,22.0,257.61,1717.61,0.0,0.0,0,,0.0759,none,0,1,0,0,0,9.5e-05,0,0,,P4P
CLM0000004798,MBR00000207,Medical_Institutional,Paid,Provider_Portal,2023-01-20,2023-01-20,2023-01-21,2023-02-02,Auto_Adjudicated,13,1624242487,1522426351,208600000X,Surgery General,81,In_Network,J20.9,OTHER,revenue_code:0100,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,10799.96,6292.32,6286.32,0.0,6.0,0.0,4507.64,0.0,0.0,0,,0.1499,none,0,1,1,0,0,0.000582,0,0,,FFS
CLM0000004799,MBR00000071,Medical_Institutional,Denied,Electronic_EDI,2023-04-23,2023-04-23,2023-04-25,2023-05-17,Auto_Adjudicated,24,1556072255,1300957944,101YP2500X,Psychologist Clinical,23,In_Network,M79.3,,revenue_code:0360,,0,Commercial,EPO,19,F,0.5699,CO-45,Timely_Filing,2006.06,1132.53,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0913,none,0,1,0,0,0,0.0,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000004800,MBR00000236,Medical_Professional,Paid,Electronic_EDI,2023-02-13,2023-02-13,2023-02-13,2023-02-22,Auto_Adjudicated,9,1882720848,1068662623,207V00000X,Obstetrics & Gynecology,21,In_Network,I10,Z23,27130,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,10450.28,8218.91,8215.91,0.0,3.0,0.0,2231.37,0.0,0.0,0,,0.1285,none,0,1,1,0,0,0.00076,0,0,W30_Well_Child_Visit,Capitation
CLM0000004801,MBR00000244,Vision,Paid,Electronic_EDI,2023-03-21,2023-03-21,2023-03-21,2023-04-06,Auto_Adjudicated,16,1484613641,1140170394,246ZN0300X,Neuropsychology,11,In_Network,J20.9,F41.1|Z12.11|OTHER,92012,,0,Commercial,PPO,52,M,0.6677,,,204.05,112.75,49.16,40.3,11.0,12.29,91.3,0.0,0.0,0,,0.0314,none,0,1,0,0,0,5e-06,0,0,,FFS
CLM0000004802,MBR00000092,Medical_Professional,Paid,Electronic_EDI,2023-01-27,2023-01-27,2023-01-27,2023-02-11,Auto_Adjudicated,15,1137079475,1986847322,246ZN0300X,Neuropsychology,24,In_Network,E78.5,OTHER|I10,99203,,0,Medicaid_MCO,MLTSS,68,F,1.3217,,,282.13,121.68,118.68,0.0,3.0,0.0,160.45,0.0,0.0,0,,0.019,none,0,1,0,0,0,1.1e-05,0,0,,Bundled_Payment
CLM0000004803,MBR00000008,Medical_Institutional,Paid,Electronic_EDI,2023-05-09,2023-05-09,2023-05-12,2023-05-17,Auto_Adjudicated,8,1159640414,1179350099,225100000X,Physical Therapist,65,In_Network,Z00.121,J44.1|Z00.01,revenue_code:0100,,0,Medicaid_MCO,MCO,74,M,0.8375,,,10047.18,7026.73,7023.73,0.0,3.0,0.0,3020.45,0.0,0.0,0,,0.1082,billing_spike_recent,0,1,1,0,0,0.00065,0,0,,FFS
CLM0000004804,MBR00000135,Medical_Institutional,Paid,Electronic_EDI,2023-04-17,2023-04-17,2023-04-17,2023-04-18,Manual_Review,1,1102040918,1666461892,208600000X,Surgery General,24,In_Network,E11.65,OTHER|E11.9,revenue_code:0360,,0,Commercial,PPO,58,F,2.2702,,,14839.83,9945.88,7907.99,1.9,59.0,1977.0,4893.95,0.0,0.0,0,,0.1565,benford_violation,0,1,1,0,0,0.000732,0,0,BPD_BP_Declined,FFS
CLM0000004805,MBR00000054,Dental,Paid,Electronic_EDI,2023-02-26,2023-02-26,2023-02-26,2023-03-24,Auto_Adjudicated,26,1873731689,1289435414,207RE0101X,Endocrinology,11,In_Network,Z23,Z00.00|I48.91,D2391,,0,Medicare_Advantage,MA_HMO,66,F,0.8625,,,219.18,112.0,88.47,0.42,1.0,22.12,107.18,0.0,0.0,0,,0.006,none,0,1,0,0,0,8e-06,0,0,,Capitation
CLM0000004806,MBR00000244,Medical_Professional,Paid,Electronic_EDI,2023-09-16,2023-09-16,2023-09-16,2023-10-16,Manual_Review,30,1374361443,1469697158,225100000X,Physical Therapist,22,In_Network,J45.20,,90837,,0,Commercial,PPO,52,M,0.6677,,,498.73,359.53,214.19,80.79,11.0,53.55,139.2,0.0,0.0,0,,0.0622,none,0,1,0,0,0,2e-05,0,0,MPT_Annual_Monitoring,FFS
CLM0000004807,MBR00000081,Dental,Paid,Electronic_EDI,2023-01-13,2023-01-13,2023-01-13,2023-01-29,Auto_Adjudicated,16,1415701059,1589482133,2086S0122X,Orthopedic Surgery,21,In_Network,L70.0,G47.33,D4341,,0,Medicare_Advantage,SNP,66,F,2.159,,,495.31,331.91,246.3,19.04,5.0,61.57,163.4,0.0,0.0,0,,0.0127,none,0,1,0,0,0,2.3e-05,0,0,,FFS
CLM0000004808,MBR00000286,Medical_Professional,Denied,Provider_Portal,2023-06-20,2023-06-20,2023-06-20,2023-07-15,Auto_Adjudicated,25,1089569577,1320546364,207RN0300X,Nephrology,65,In_Network,E11.9,Z23|F33.0,99213,,0,Medicare_Advantage,PFFS,40,F,1.2751,96,Network,90.03,38.47,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0302,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004809,MBR00000293,Medical_Professional,Denied,Electronic_EDI,2023-04-20,2023-04-20,2023-04-20,2023-05-01,Auto_Adjudicated,11,1661091022,1013600387,208600000X,Surgery General,24,In_Network,Z00.00,,90853,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,97,Eligibility,872.6,393.59,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.126,provider_specialty_mismatch,0,1,0,0,0,0.0,0,0,,P4P
CLM0000004810,MBR00000274,Dental,Paid,Electronic_EDI,2023-08-22,2023-08-22,2023-08-22,2023-09-20,Auto_Adjudicated,29,1901547390,1643673796,207RN0300X,Nephrology,24,In_Network,E78.5,,D1110,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,96.65,65.83,43.02,12.06,0.0,10.75,30.82,0.0,0.0,0,,0.0501,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000004811,MBR00000181,Medical_Professional,Paid,Electronic_EDI,2023-05-02,2023-05-02,2023-05-02,2023-05-20,Auto_Adjudicated,18,1961590405,1880530717,2084P0800X,Psychiatry,21,In_Network,OTHER,OTHER|I10,99212,,0,Commercial,PPO,82,F,1.0432,,,281.49,182.99,54.03,87.45,28.0,13.51,98.5,0.0,0.0,0,,0.0376,none,0,1,0,1,0,5e-06,0,0,,FFS
CLM0000004812,MBR00000082,Medical_Institutional,Paid,Electronic_EDI,2023-06-19,2023-06-19,2023-06-20,2023-07-14,Auto_Adjudicated,25,1470105939,1581533104,246ZN0300X,Neuropsychology,11,In_Network,Z12.11,M54.5|F41.1,revenue_code:0110,,0,Medicare_Advantage,MA_HMO,39,F,0.5376,,,19160.18,7039.93,5583.75,16.25,44.0,1395.94,12120.25,0.0,0.0,0,,0.1076,none,0,1,1,0,0,0.000517,0,0,,FFS
CLM0000004813,MBR00000239,Medical_Institutional,Denied,Electronic_EDI,2023-10-19,2023-10-19,2023-10-23,2023-11-09,Auto_Adjudicated,21,1181941909,1450837722,207RE0101X,Endocrinology,24,In_Network,E11.9,,revenue_code:0210,,0,Commercial,HMO,1,F,1.1193,1,Network,33809.06,16156.34,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Medically Unnecessary Services,1.0,unusual_service_frequency|provider_specialty_mismatch|temporal_clustering|benford_violation|impossible_service_combo|service_date_weekend|billing_spike_recent|duplicate_claim_indicator|upcoding_pattern|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,0.0,0,0,,Capitation
CLM0000004814,MBR00000208,Vision,Paid,Provider_Portal,2023-02-21,2023-02-21,2023-02-21,2023-03-21,Auto_Adjudicated,28,1325430913,1741177636,207RN0300X,Nephrology,23,In_Network,Z12.11,Z79.4,92014,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,443.85,175.92,134.52,1.77,6.0,33.63,267.93,0.0,0.0,1,Kickback Arrangement,0.9747,unusual_service_frequency|geographic_mismatch|temporal_clustering|benford_violation|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|diagnosis_procedure_mismatch|controlled_substance_high_volume,1,5,0,0,0,1.2e-05,0,0,,FFS
CLM0000004815,MBR00000294,Pharmacy,Denied,Provider_Portal,2023-06-06,2023-06-06,2023-06-06,2023-06-23,Auto_Adjudicated,17,1443292773,1408846353,207RC0000X,Cardiovascular Disease,11,Emergency,Z12.11,,00003014960,,2,Medicare_Advantage,MA_HMO,8,M,0.6878,256,Duplicate,543.8,455.17,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0765,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000004816,MBR00000120,Medical_Professional,Paid,Electronic_EDI,2023-07-21,2023-07-21,2023-07-21,2023-08-16,Auto_Adjudicated,26,1231231881,1013600387,225100000X,Physical Therapist,24,In_Network,F32.9,,97110,,0,Commercial,PPO,62,F,1.0823,,,1163.13,688.08,339.88,246.22,17.0,84.97,475.05,0.0,0.0,0,,0.0546,none,0,1,0,0,0,3.1e-05,0,0,,Bundled_Payment
CLM0000004817,MBR00000017,Pharmacy,Denied,Electronic_EDI,2023-09-22,2023-09-22,2023-09-22,2023-10-20,Auto_Adjudicated,28,1591624417,1827839595,225100000X,Physical Therapist,11,In_Network,K21.0,,00069420020,,1,Commercial,PPO,55,F,0.6174,2,COB,84.25,50.84,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1019,none,0,1,0,0,0,0.0,0,1,,Capitation
CLM0000004818,MBR00000300,Medical_Professional,Paid,Provider_Portal,2023-07-12,2023-07-12,2023-07-12,2023-08-04,Clinical_Review,23,1292920374,1300957944,207RE0101X,Endocrinology,24,In_Network,M54.5,N18.3|F41.1,99285,,0,Commercial,PPO,64,F,1.0393,,,557.37,235.9,150.1,19.27,29.0,37.53,321.47,0.0,0.0,0,,0.1135,none,0,1,0,0,0,1.4e-05,0,0,,FFS
CLM0000004819,MBR00000250,Medical_Institutional,Paid,Electronic_EDI,2023-09-22,2023-09-22,2023-09-25,2023-10-03,Auto_Adjudicated,11,1825861601,1296566243,2086S0122X,Orthopedic Surgery,23,In_Network,M54.5,G47.33,revenue_code:0210,,0,Commercial,PPO,41,M,0.9245,,,14297.13,8353.34,6583.89,76.48,47.0,1645.97,5943.79,0.0,0.0,0,,0.034,none,0,1,1,0,0,0.000609,0,0,BCS_Breast_Cancer_Screening,Shared_Savings
CLM0000004820,MBR00000068,Pharmacy,Paid,Paper,2023-10-13,2023-10-13,2023-10-13,2023-10-16,Auto_Adjudicated,3,1068197532,1274911960,207RN0300X,Nephrology,11,In_Network,OTHER,Z00.00|M54.5,00169751112,,2,Medicare_Advantage,MA_HMO,28,F,0.8494,,,72.91,60.65,41.25,1.09,8.0,10.31,12.26,0.0,0.0,0,,0.1032,none,0,1,0,0,0,4e-06,0,1,,FFS
CLM0000004821,MBR00000213,Pharmacy,Paid,Provider_Portal,2023-10-11,2023-10-11,2023-10-11,2023-10-24,Auto_Adjudicated,13,1042080259,1951488764,207RP1001X,Pulmonary Disease,24,In_Network,G47.33,,59148001506,,2,Commercial,PPO,17,M,1.5857,,,458.07,358.42,57.08,259.07,28.0,14.27,99.65,47.31,6.78,0,,0.0764,none,0,1,0,0,0,5e-06,0,0,,Capitation
CLM0000004822,MBR00000001,Pharmacy,Paid,Paper,2023-08-09,2023-08-09,2023-08-09,2023-08-30,Auto_Adjudicated,21,1137079475,1977073565,207RP1001X,Pulmonary Disease,21,In_Network,K57.30,,00069420020,,2,Commercial,EPO,73,M,0.6527,,,670.36,396.07,184.74,137.15,28.0,46.18,274.29,0.0,0.0,0,,0.0176,none,0,1,0,0,0,1.7e-05,0,1,POD_Persistence_of_Beta_Blocker,FFS
CLM0000004823,MBR00000168,Pharmacy,Partially_Paid,Electronic_EDI,2023-11-26,2023-11-26,2023-11-26,2023-12-22,Auto_Adjudicated,26,1981853293,1274911960,207RE0101X,Endocrinology,22,In_Network,I10,,59148001506,,2,Commercial,HMO,76,M,1.2791,18,Medical_Necessity,146.7,115.94,0.0,65.74,0.0,0.0,80.96,0.0,0.0,0,,0.0338,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004824,MBR00000114,Medical_Institutional,Paid,Electronic_EDI,2023-01-09,2023-01-09,2023-01-10,2023-02-02,Auto_Adjudicated,24,1210349885,1493836023,207Q00000X,Family Medicine,81,In_Network,OTHER,I25.10|M54.5,revenue_code:0370,,0,Medicare_Advantage,MA_PPO,57,F,1.0712,,,16681.37,9355.67,7462.44,7.62,20.0,1865.61,7325.7,0.0,0.0,0,,0.0687,unusual_service_frequency,0,1,1,0,0,0.000691,0,0,COL_Colorectal_Cancer_Screening,FFS
CLM0000004825,MBR00000121,Vision,Denied,Paper,2023-06-29,2023-06-29,2023-06-29,2023-07-19,Auto_Adjudicated,20,1617763056,1354959095,101YP2500X,Psychologist Clinical,65,In_Network,Z00.01,OTHER|Z12.11|I10,V2100,,0,Medicare_Advantage,MA_PPO,58,M,1.226,PR-1,Timely_Filing,278.17,182.55,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1495,none,0,1,0,1,0,0.0,0,0,,Shared_Savings
CLM0000004826,MBR00000076,Medical_Professional,Paid,Electronic_EDI,2023-10-15,2023-10-15,2023-10-15,2023-11-01,Auto_Adjudicated,17,1555292468,1012893364,225100000X,Physical Therapist,21,In_Network,K57.30,E11.9,81001,,0,Commercial,HMO,26,M,2.1785,,,975.09,527.7,373.7,28.58,32.0,93.42,447.39,0.0,0.0,0,,0.1071,temporal_clustering,0,1,0,0,0,3.5e-05,0,0,,Shared_Savings
CLM0000004827,MBR00000085,Medical_Professional,Denied,Electronic_EDI,2023-02-07,2023-02-07,2023-02-07,2023-03-08,Auto_Adjudicated,29,1901547390,1133410177,101YP2500X,Psychologist Clinical,23,In_Network,J45.20,K21.0,99283,,0,Medicare_Advantage,SNP,2,M,0.7823,PR-1,Authorization,416.63,287.62,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0812,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004828,MBR00000141,Pharmacy,Paid,Electronic_EDI,2023-10-21,2023-10-21,2023-10-21,2023-10-29,Auto_Adjudicated,8,1881358103,1763260577,207Q00000X,Family Medicine,22,Out_of_Network,E78.5,,00078043215,,3,Commercial,HMO,47,F,0.6724,,,396.15,277.69,198.79,3.21,26.0,49.7,118.46,0.0,0.0,0,,0.1324,none,0,1,0,0,0,1.8e-05,1,0,,FFS
CLM0000004829,MBR00000077,Medical_Professional,Paid,Electronic_EDI,2023-01-14,2023-01-14,2023-01-14,2023-02-07,Auto_Adjudicated,24,1269185915,1788579687,207RG0100X,Gastroenterology,31,In_Network,Z00.00,,99386,,0,Medicare_Advantage,MA_HMO,27,F,0.9229,,,111.15,44.67,30.49,2.56,4.0,7.62,66.48,21.47,7.66,0,,0.1375,unusual_service_frequency,0,1,0,0,0,3e-06,0,0,,Capitation
CLM0000004830,MBR00000144,Medical_Institutional,Partially_Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-12,2023-10-27,Auto_Adjudicated,17,1813729693,1616762819,207RE0101X,Endocrinology,21,In_Network,K29.70,,revenue_code:0210,683,0,Commercial,HDHP_HSA,56,F,2.5926,4,Medical_Necessity,7527.1,6016.28,3425.57,157.38,0.0,856.39,3087.76,2191.49,818.55,0,,0.1869,upcoding_pattern,0,1,0,0,0,0.000317,0,0,,Shared_Savings
CLM0000004831,MBR00000174,Pharmacy,Paid,Electronic_EDI,2023-03-09,2023-03-09,2023-03-09,2023-03-25,Auto_Adjudicated,16,1190558906,1356856197,207RN0300X,Nephrology,22,In_Network,E11.65,,00071015523,,1,Medicare_Advantage,MA_HMO,85,M,0.3901,,,891.67,423.83,302.31,27.94,18.0,75.58,467.84,0.0,0.0,1,Duplicate Billing,1.0,outlier_billing_amount|unusual_service_frequency|temporal_clustering|high_volume_same_code|benford_violation|impossible_service_combo|duplicate_claim_indicator|npi_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,2.8e-05,0,1,,Shared_Savings
CLM0000004832,MBR00000211,Medical_Institutional,Denied,Electronic_EDI,2023-08-28,2023-08-28,2023-09-01,2023-09-09,Manual_Review,12,1112402001,1187669363,208600000X,Surgery General,11,Emergency,OTHER,OTHER|E11.9,revenue_code:0450,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,50,Eligibility,16401.6,11989.23,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0172,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004833,MBR00000201,Medical_Professional,Denied,Electronic_EDI,2023-10-25,2023-10-25,2023-10-25,2023-11-14,Auto_Adjudicated,20,1110312325,1622950074,207RE0101X,Endocrinology,65,In_Network,G43.909,M54.5,99212,,0,Medicare_Advantage,MA_PPO,74,M,1.1575,5,Duplicate,177.08,145.4,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0232,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004834,MBR00000076,Medical_Professional,Paid,Paper,2023-10-20,2023-10-20,2023-10-20,2023-11-19,Auto_Adjudicated,30,1683650935,1589482133,207V00000X,Obstetrics & Gynecology,65,Out_of_Network,OTHER,E11.65|I50.9,99202,,0,Commercial,HMO,26,M,2.1785,,,392.97,195.15,124.01,8.14,32.0,31.0,197.82,0.0,0.0,0,,0.0352,none,0,1,0,0,0,1.1e-05,1,0,SPC_Statin_Therapy,FFS
CLM0000004835,MBR00000012,Medical_Professional,Paid,Electronic_EDI,2023-07-26,2023-07-26,2023-07-26,2023-08-08,Manual_Review,13,1971354640,1945682535,207V00000X,Obstetrics & Gynecology,11,In_Network,Z79.4,G43.909|OTHER,99203,,0,Commercial,HMO,84,M,1.3904,,,285.3,238.96,78.12,113.31,28.0,19.53,46.34,0.0,0.0,0,,0.1302,none,0,1,0,0,0,7e-06,0,0,SPC_Statin_Therapy,FFS
CLM0000004836,MBR00000249,Medical_Professional,Paid,Electronic_EDI,2023-11-23,2023-11-23,2023-11-23,2023-11-27,Auto_Adjudicated,4,1519736600,1187669363,225100000X,Physical Therapist,22,In_Network,F41.1,F41.1|Z00.00,99232,,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,,,378.72,279.17,0.0,279.17,0.0,0.0,99.55,0.0,0.0,0,,0.1084,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004837,MBR00000263,Medical_Professional,Paid,Electronic_EDI,2023-02-20,2023-02-20,2023-02-20,2023-02-24,Auto_Adjudicated,4,1464997678,1312595355,246ZN0300X,Neuropsychology,21,Out_of_Network,OTHER,K57.30,90834,,0,Medicare_Advantage,MA_HMO,29,F,1.5001,,,857.01,614.24,450.17,32.53,19.0,112.54,242.77,0.0,0.0,0,,0.0114,none,0,1,0,0,0,4.2e-05,1,0,,FFS
CLM0000004838,MBR00000295,Pharmacy,Denied,Electronic_EDI,2023-03-26,2023-03-26,2023-03-26,2023-04-01,Auto_Adjudicated,6,1661091022,1013600387,207RG0100X,Gastroenterology,11,In_Network,OTHER,,00071015523,,3,Commercial,HDHP_HSA,78,F,0.8618,96,Network,58.48,23.57,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0401,none,0,1,0,0,0,0.0,0,1,CCS_Cervical_Cancer_Screening,Shared_Savings
CLM0000004839,MBR00000291,Medical_Professional,Paid,Electronic_EDI,2023-02-17,2023-02-17,2023-02-17,2023-03-02,Auto_Adjudicated,13,1921056264,1649705287,101YP2500X,Psychologist Clinical,11,Out_of_Network,Z00.00,,99215,,0,Commercial,PPO,78,M,1.4773,,,1771.93,1030.73,719.47,117.39,14.0,179.87,741.2,0.0,0.0,1,Date of Service Falsification,1.0,outlier_billing_amount|geographic_mismatch|temporal_clustering|high_volume_same_code|impossible_service_combo|service_date_weekend|duplicate_claim_indicator|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,1,0,6.7e-05,1,0,,FFS
CLM0000004840,MBR00000188,Pharmacy,Paid,Electronic_EDI,2023-09-16,2023-09-16,2023-09-16,2023-09-17,Auto_Adjudicated,1,1769163673,1132693989,208600000X,Surgery General,31,In_Network,I25.10,,00003014960,,5,Commercial,HMO,8,F,1.5853,,,1314.57,771.28,553.88,53.93,25.0,138.47,543.29,0.0,0.0,0,,0.0091,none,0,1,0,0,0,5.1e-05,0,0,,FFS
CLM0000004841,MBR00000271,Behavioral_Health,Denied,Electronic_EDI,2023-11-17,2023-11-17,2023-11-17,2023-11-26,Auto_Adjudicated,9,1054449469,1616762819,207R00000X,Internal Medicine,11,In_Network,I10,,12001,,0,Medicaid_MCO,MCO,4,F,0.6696,3,Coding_Error,74.7,59.58,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0569,unbundling_pattern,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004842,MBR00000139,Medical_Professional,Paid,Electronic_EDI,2023-12-01,2023-12-01,2023-12-01,2023-12-22,Auto_Adjudicated,21,1901054209,1013600387,225100000X,Physical Therapist,22,In_Network,OTHER,,99215,,0,Commercial,PPO,74,M,1.7701,,,289.7,172.42,92.94,35.24,21.0,23.24,117.28,0.0,0.0,0,,0.0766,none,0,1,0,0,0,9e-06,0,0,,P4P
CLM0000004843,MBR00000233,Behavioral_Health,Paid,Electronic_EDI,2023-07-06,2023-07-06,2023-07-06,2023-07-27,Auto_Adjudicated,21,1231231881,1391074619,2084P0800X,Psychiatry,65,In_Network,K57.30,J44.1|E11.9,90834,,0,Medicare_Advantage,MA_PPO,87,M,0.8034,,,108.84,59.09,34.1,13.47,3.0,8.52,49.75,0.0,0.0,0,,0.1163,none,0,1,0,0,0,3e-06,0,0,,Capitation
CLM0000004844,MBR00000289,Medical_Professional,Paid,Provider_Portal,2023-02-17,2023-02-17,2023-02-17,2023-03-10,Auto_Adjudicated,21,1853403237,1789540567,208600000X,Surgery General,11,In_Network,K21.0,OTHER,70553,,0,Commercial,POS,51,M,1.0534,,,2014.24,1132.38,779.18,119.4,39.0,194.8,881.86,0.0,0.0,0,,0.0305,none,0,1,0,1,0,7.2e-05,0,0,,FFS
CLM0000004845,MBR00000236,Medical_Institutional,Paid,Electronic_EDI,2023-03-03,2023-03-03,2023-03-03,2023-03-24,Auto_Adjudicated,21,1292920374,1831337866,2084P0800X,Psychiatry,22,In_Network,OTHER,J45.20,revenue_code:0300,,0,Medicaid_MCO,FFS_Medicaid,76,M,1.7555,,,4815.93,4006.15,4000.15,0.0,6.0,0.0,809.78,0.0,0.0,0,,0.1233,none,0,1,0,0,0,0.00037,0,0,,FFS
CLM0000004846,MBR00000132,Behavioral_Health,Paid,Electronic_EDI,2023-08-13,2023-08-13,2023-08-13,2023-08-16,Auto_Adjudicated,3,1007266616,1477113725,225100000X,Physical Therapist,71,In_Network,J06.9,Z23,99395,,0,Medicare_Advantage,MA_PPO,84,F,1.3018,,,127.25,83.59,61.38,0.87,6.0,15.34,43.66,0.0,0.0,0,,0.0172,none,0,1,0,0,0,6e-06,0,0,,Capitation
CLM0000004847,MBR00000120,Pharmacy,Paid,Electronic_EDI,2023-11-18,2023-11-18,2023-11-18,2023-12-17,Auto_Adjudicated,29,1464997678,1447657873,2084P0800X,Psychiatry,24,In_Network,K21.0,,50458085930,,1,Commercial,PPO,62,F,1.0823,,,184.99,110.81,0.0,110.81,0.0,0.0,74.18,0.0,0.0,0,,0.1165,geographic_mismatch,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004848,MBR00000091,Medical_Professional,Paid,Electronic_EDI,2023-12-21,2023-12-21,2023-12-21,2023-12-30,Auto_Adjudicated,9,1980039511,1005335812,207RG0100X,Gastroenterology,11,In_Network,Z23,,97110,,0,Commercial,PPO,13,F,1.2451,,,1768.96,1294.78,928.49,110.16,24.0,232.12,474.18,0.0,0.0,0,,0.1326,none,0,1,0,1,0,8.6e-05,0,0,,FFS
CLM0000004849,MBR00000116,Medical_Professional,Denied,Provider_Portal,2023-09-16,2023-09-16,2023-09-16,2023-09-19,Manual_Review,3,1374361443,1789540567,207RG0100X,Gastroenterology,11,In_Network,I10,OTHER,12001,,0,Medicaid_MCO,MLTSS,79,F,0.4614,PR-1,Coding_Error,1540.7,755.62,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0158,none,0,1,0,1,0,0.0,0,0,,FFS
CLM0000004850,MBR00000245,Medical_Professional,Paid,Electronic_EDI,2023-11-13,2023-11-13,2023-11-13,2023-12-08,Auto_Adjudicated,25,1826919173,1625992541,207V00000X,Obstetrics & Gynecology,24,In_Network,I10,K57.30|OTHER,73721,,0,Medicaid_MCO,MCO,60,F,0.7502,,,556.17,432.54,430.54,0.0,2.0,0.0,123.63,0.0,0.0,0,,0.0929,unusual_service_frequency,0,1,0,0,0,4e-05,0,0,,Bundled_Payment
CLM0000004851,MBR00000208,Vision,Paid,Electronic_EDI,2023-06-21,2023-06-21,2023-06-21,2023-07-06,Auto_Adjudicated,15,1389116733,1789540567,207V00000X,Obstetrics & Gynecology,11,In_Network,J44.1,L70.0|C50.911,V2100,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,238.54,157.81,120.37,1.35,6.0,30.09,80.73,84.87,21.7,0,,0.1278,none,0,1,0,0,0,1.1e-05,0,0,FUH_Follow_Up_Hospitalization,Shared_Savings
CLM0000004852,MBR00000077,Medical_Professional,Paid,Paper,2023-03-12,2023-03-12,2023-03-12,2023-03-23,Auto_Adjudicated,11,1639236553,1662516615,207R00000X,Internal Medicine,22,In_Network,Z00.00,E11.9|Z23|Z79.4,99385,,0,Medicare_Advantage,MA_HMO,27,F,0.9229,,,363.42,175.23,136.11,1.1,4.0,34.03,188.19,0.0,0.0,0,,0.1268,none,0,1,0,0,0,1.3e-05,0,0,TRC_Transition_of_Care,FFS
CLM0000004853,MBR00000211,Medical_Institutional,Paid,Electronic_EDI,2023-06-16,2023-06-16,2023-06-17,2023-06-28,Auto_Adjudicated,12,1046207613,1029818813,225100000X,Physical Therapist,11,In_Network,OTHER,OTHER,revenue_code:0360,,0,Medicare_Advantage,MA_PPO,68,M,1.3146,,,11386.76,4540.73,3609.29,0.12,29.0,902.32,6846.03,0.0,0.0,0,,0.1586,duplicate_claim_indicator,0,1,0,0,0,0.000334,0,0,,Bundled_Payment
CLM0000004854,MBR00000120,Medical_Professional,Denied,Electronic_EDI,2023-02-05,2023-02-05,2023-02-05,2023-02-23,Auto_Adjudicated,18,1049153238,1489434038,2084P0800X,Psychiatry,31,In_Network,M54.5,OTHER|Z00.01,33510,,0,Commercial,PPO,62,F,1.0823,16,Network,687.75,413.51,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0314,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004855,MBR00000168,Medical_Professional,Paid,Electronic_EDI,2023-08-30,2023-08-30,2023-08-30,2023-09-15,Auto_Adjudicated,16,1014995735,1587454801,207RE0101X,Endocrinology,21,In_Network,M54.5,N40.0|E78.5,97110,,0,Commercial,HMO,76,M,1.2791,,,588.61,430.43,0.0,422.28,8.15,0.0,158.18,0.0,0.0,0,,0.1432,none,0,1,0,0,0,0.0,0,0,CDC_BP_Control,Shared_Savings
CLM0000004856,MBR00000117,Medical_Institutional,Denied,Electronic_EDI,2023-04-29,2023-04-29,2023-04-30,2023-04-30,Manual_Review,1,1637260822,1625992541,207RE0101X,Endocrinology,21,In_Network,I10,C50.911|M54.5|E11.65,revenue_code:0120,683,0,Medicaid_MCO,MLTSS,72,F,0.8628,5,Network,20786.81,10678.06,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0833,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004857,MBR00000159,Medical_Professional,Paid,Provider_Portal,2023-05-02,2023-05-02,2023-05-02,2023-05-06,Manual_Review,4,1907932706,1809122260,2084P0800X,Psychiatry,24,In_Network,J06.9,,20610,,0,Commercial,PPO,70,F,1.2009,,,891.23,741.09,561.61,25.08,14.0,140.4,150.14,0.0,0.0,0,,0.0669,unusual_service_frequency,0,1,0,0,0,5.2e-05,0,0,,FFS
CLM0000004858,MBR00000214,Medical_Institutional,Paid,Electronic_EDI,2023-01-02,2023-01-02,2023-01-05,2023-01-31,Auto_Adjudicated,29,1098094939,1012893364,207RP1001X,Pulmonary Disease,11,In_Network,E13.9,N39.0|OTHER,revenue_code:0450,,0,Commercial,HDHP_HSA,76,M,1.7526,,,47190.13,29157.28,22890.96,543.58,0.0,5722.74,18032.85,20441.12,2105.83,0,,0.1483,none,0,1,1,0,0,0.002119,0,0,FUH_Follow_Up_Hospitalization,FFS
CLM0000004859,MBR00000214,Medical_Institutional,Paid,Paper,2023-12-25,2023-12-25,2023-12-27,2024-01-09,Auto_Adjudicated,15,1618564043,1509799493,207V00000X,Obstetrics & Gynecology,22,Out_of_Network,OTHER,R05.9,revenue_code:0200,,0,Commercial,HDHP_HSA,76,M,1.7526,,,10866.55,8425.2,6567.91,215.31,0.0,1641.98,2441.35,0.0,0.0,1,Prescription Drug Diversion,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|temporal_clustering|duplicate_claim_indicator|unbundling_pattern|phantom_billing_indicator|npi_mismatch|controlled_substance_high_volume,1,5,1,1,0,0.000608,1,0,COA_Care_Transitions,FFS
CLM0000004860,MBR00000221,Medical_Institutional,Denied,Electronic_EDI,2023-06-03,2023-06-03,2023-06-05,2023-07-03,Auto_Adjudicated,30,1309817189,1355732274,246ZN0300X,Neuropsychology,81,In_Network,E11.9,E11.9,revenue_code:0100,,0,Commercial,HDHP_HSA,28,M,1.6683,1,Authorization,11039.53,4547.1,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1253,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004861,MBR00000125,Medical_Institutional,Paid,Electronic_EDI,2023-10-09,2023-10-09,2023-10-10,2023-10-29,Manual_Review,20,1826919173,1575884274,246ZN0300X,Neuropsychology,23,In_Network,I10,Z79.4,revenue_code:0360,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,,,10003.2,6228.91,4944.38,3.43,45.0,1236.1,3774.29,0.0,0.0,0,,0.2415,provider_specialty_mismatch|high_volume_same_code,0,2,0,0,0,0.000458,0,0,POD_Persistence_of_Beta_Blocker,FFS
CLM0000004862,MBR00000206,Medical_Professional,Paid,Electronic_EDI,2023-07-06,2023-07-06,2023-07-06,2023-07-29,Auto_Adjudicated,23,1769163673,1978943761,2084P0800X,Psychiatry,11,Out_of_Network,I10,M79.3,97010,,0,Medicaid_MCO,MLTSS,21,M,1.4038,,,1189.13,997.68,996.68,0.0,1.0,0.0,191.45,0.0,0.0,0,,0.1485,none,0,1,0,1,0,9.2e-05,1,0,,FFS
CLM0000004863,MBR00000075,Pharmacy,Paid,Electronic_EDI,2023-08-19,2023-08-19,2023-08-19,2023-08-29,Auto_Adjudicated,10,1324084461,1662516615,246ZN0300X,Neuropsychology,65,In_Network,I25.10,J06.9|E78.5,59148001506,,2,Medicaid_MCO,MCO,5,M,1.0573,,,77.4,43.91,39.91,0.0,4.0,0.0,33.49,0.0,0.0,0,,0.1657,controlled_substance_high_volume,0,1,0,0,0,4e-06,0,0,,Capitation
CLM0000004864,MBR00000146,Medical_Institutional,Paid,Electronic_EDI,2023-06-17,2023-06-17,2023-06-18,2023-07-13,Auto_Adjudicated,26,1222934819,1689327034,207RG0100X,Gastroenterology,11,Out_of_Network,Z00.01,OTHER|I10|F32.9,revenue_code:0100,,0,Medicaid_MCO,MCO,24,M,0.6484,,,37635.97,27817.24,27808.24,0.0,9.0,0.0,9818.73,0.0,0.0,0,,0.0411,none,0,1,1,0,0,0.002574,0,0,,FFS
CLM0000004865,MBR00000175,Medical_Institutional,Paid,Paper,2023-09-04,2023-09-04,2023-09-06,2023-09-24,Auto_Adjudicated,20,1813729693,1831337866,246ZN0300X,Neuropsychology,21,In_Network,Z00.01,M54.5|M17.11,revenue_code:0210,292,0,Commercial,PPO,14,F,1.5785,,,9289.56,6526.39,5136.73,57.47,48.0,1284.18,2763.17,0.0,0.0,0,,0.0521,none,0,1,1,0,0,0.000475,0,0,CDC_HbA1c_Poor_Control,Capitation
CLM0000004866,MBR00000205,Medical_Professional,Paid,Provider_Portal,2023-03-13,2023-03-13,2023-03-13,2023-04-05,Auto_Adjudicated,23,1510562885,1297948643,207Q00000X,Family Medicine,11,In_Network,J45.20,,99283,,0,Medicaid_MCO,MCO,1,F,0.9425,,,505.45,263.04,262.04,0.0,1.0,0.0,242.41,0.0,0.0,0,,0.0772,none,0,1,0,0,0,2.4e-05,0,0,,Bundled_Payment
CLM0000004867,MBR00000275,Medical_Professional,Partially_Paid,Provider_Portal,2023-12-24,2023-12-24,2023-12-24,2024-01-01,Auto_Adjudicated,8,1871417879,1144950506,2086S0122X,Orthopedic Surgery,23,In_Network,OTHER,E78.5,99214,,0,Medicare_Advantage,MA_PPO,67,M,0.8169,50,Medical_Necessity,992.69,759.52,303.86,0.15,15.0,75.97,597.71,0.0,0.0,0,,0.0721,none,0,1,0,0,0,2.8e-05,0,0,,P4P
CLM0000004868,MBR00000097,Pharmacy,Partially_Paid,Electronic_EDI,2023-06-03,2023-06-03,2023-06-03,2023-06-21,Clinical_Review,18,1170319307,1267212691,207RP1001X,Pulmonary Disease,11,In_Network,M54.5,J06.9,59148001506,,2,Commercial,EPO,34,M,1.3765,4,Medical_Necessity,409.18,233.77,0.0,152.22,0.0,0.0,256.96,0.0,0.0,0,,0.0163,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004869,MBR00000254,Dental,Paid,Electronic_EDI,2023-01-04,2023-01-04,2023-01-04,2023-01-16,Auto_Adjudicated,12,1002224900,1564691686,207RE0101X,Endocrinology,11,Emergency,I25.10,Z23|E11.65,D0150,,0,Commercial,PPO,22,F,0.9285,,,509.21,276.14,194.91,4.5,28.0,48.73,233.07,0.0,0.0,0,,0.0286,none,0,1,0,0,0,1.8e-05,0,0,CBP_Controlling_BP,Shared_Savings
CLM0000004870,MBR00000099,Medical_Professional,Denied,Electronic_EDI,2023-12-08,2023-12-08,2023-12-08,2024-01-05,Auto_Adjudicated,28,1356408757,1049766043,207RP1001X,Pulmonary Disease,21,Emergency,J45.20,,73721,,0,Commercial,HMO,10,F,0.7843,256,Duplicate,1419.33,967.57,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0248,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004871,MBR00000167,Medical_Professional,Partially_Paid,Electronic_EDI,2023-01-09,2023-01-09,2023-01-09,2023-02-06,Auto_Adjudicated,28,1965812565,1894215172,207RG0100X,Gastroenterology,11,In_Network,Z00.00,Z00.00|K21.0,99204,,0,Commercial,PPO,77,F,0.9377,97,Medical_Necessity,241.69,110.43,0.0,73.14,0.0,0.0,168.55,0.0,0.0,0,,0.1148,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004872,MBR00000247,Medical_Professional,Paid,Electronic_EDI,2023-06-19,2023-06-19,2023-06-19,2023-06-30,Auto_Adjudicated,11,1269185915,1903401648,207RC0000X,Cardiovascular Disease,24,In_Network,Z79.4,E13.9,12001,,0,Medicare_Advantage,MA_PPO,60,F,1.0618,,,781.39,628.02,482.41,20.01,5.0,120.6,153.37,0.0,0.0,0,,0.0605,none,0,1,0,1,0,4.5e-05,0,0,,FFS
CLM0000004873,MBR00000212,Pharmacy,Paid,Electronic_EDI,2023-10-09,2023-10-09,2023-10-09,2023-10-10,Auto_Adjudicated,1,1192302048,1274911960,101YP2500X,Psychologist Clinical,22,In_Network,E78.5,,00310075090,,1,Commercial,HMO,57,F,2.5456,,,105.13,40.31,0.0,40.31,0.0,0.0,64.82,0.0,0.0,0,,0.0668,high_volume_same_code,0,1,0,0,0,0.0,0,1,,P4P
CLM0000004874,MBR00000261,Medical_Professional,Paid,Electronic_EDI,2023-05-13,2023-05-13,2023-05-13,2023-05-21,Manual_Review,8,1213747973,1068662623,101YP2500X,Psychologist Clinical,22,In_Network,Z23,,99385,,0,Medicare_Advantage,MA_PPO,13,F,0.4259,,,206.53,164.96,128.2,3.71,1.0,32.05,41.57,0.0,0.0,0,,0.0738,unbundling_pattern,0,1,0,0,0,1.2e-05,0,0,,Shared_Savings
CLM0000004875,MBR00000242,Behavioral_Health,Denied,Electronic_EDI,2023-03-17,2023-03-17,2023-03-17,2023-03-26,Manual_Review,9,1414670047,1228356980,207RN0300X,Nephrology,11,In_Network,J06.9,,20610,,0,Medicaid_MCO,MLTSS,75,F,0.7104,22,Timely_Filing,256.68,159.31,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1405,phantom_billing_indicator,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004876,MBR00000086,Medical_Professional,Paid,Electronic_EDI,2023-03-28,2023-03-28,2023-03-28,2023-03-29,Clinical_Review,1,1788188920,1055872102,207RC0000X,Cardiovascular Disease,65,In_Network,F10.10,C50.911|E78.5,71046,,0,Medicare_Advantage,MA_PPO,8,M,0.5427,,,695.04,475.75,372.67,1.91,8.0,93.17,219.29,0.0,0.0,0,,0.0882,none,0,1,0,0,0,3.4e-05,0,0,,FFS
CLM0000004877,MBR00000298,Behavioral_Health,Paid,Provider_Portal,2023-09-03,2023-09-03,2023-09-03,2023-10-02,Auto_Adjudicated,29,1826043246,1878017518,207RC0000X,Cardiovascular Disease,21,In_Network,F32.9,J20.9,27130,,0,Medicaid_MCO,MCO,75,M,0.8324,,,272.96,226.17,226.17,0.0,0.0,0.0,46.79,0.0,0.0,0,,0.1321,unbundling_pattern,0,1,0,1,0,2.1e-05,0,0,,Bundled_Payment
CLM0000004878,MBR00000283,Medical_Professional,Paid,Electronic_EDI,2023-07-25,2023-07-25,2023-07-25,2023-08-08,Auto_Adjudicated,14,1214787184,1965244699,207Q00000X,Family Medicine,21,In_Network,OTHER,Z12.11,27130,,0,Medicare_Advantage,MA_HMO,21,M,0.5294,,,19773.13,16420.85,13090.91,43.21,14.0,3272.73,3352.28,0.0,0.0,0,,0.0294,none,0,1,1,0,0,0.001212,0,0,PCR_Plan_All_Cause_Readmission,Shared_Savings
CLM0000004879,MBR00000135,Medical_Professional,Paid,Electronic_EDI,2023-06-30,2023-06-30,2023-06-30,2023-07-05,Auto_Adjudicated,5,1558692441,1054984734,207Q00000X,Family Medicine,11,In_Network,M54.5,,71250,,0,Commercial,PPO,58,F,2.2702,,,533.42,414.1,299.84,2.3,37.0,74.96,119.32,0.0,0.0,0,,0.0899,none,0,1,0,0,0,2.8e-05,0,0,DAE_Drug_Alcohol_Dependence,P4P
CLM0000004880,MBR00000014,Medical_Professional,Paid,Electronic_EDI,2023-07-04,2023-07-04,2023-07-04,2023-07-23,Auto_Adjudicated,19,1102040918,1983760474,207RN0300X,Nephrology,81,In_Network,J20.9,Z00.00|K21.0,99283,,0,Commercial,HMO,77,M,2.8513,,,444.37,325.23,47.32,228.08,38.0,11.83,119.14,0.0,0.0,0,,0.0668,none,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000004881,MBR00000096,Medical_Professional,Paid,Electronic_EDI,2023-04-25,2023-04-25,2023-04-25,2023-05-07,Auto_Adjudicated,12,1097702209,1945682535,207RP1001X,Pulmonary Disease,22,Emergency,OTHER,,99214,,0,Medicaid_MCO,MCO,62,M,0.7948,,,205.62,130.47,128.47,0.0,2.0,0.0,75.15,0.0,0.0,0,,0.0869,benford_violation,0,1,0,0,0,1.2e-05,0,0,,FFS
CLM0000004882,MBR00000250,Behavioral_Health,Paid,Electronic_EDI,2023-12-02,2023-12-02,2023-12-02,2023-12-08,Manual_Review,6,1532359759,1029818813,207RG0100X,Gastroenterology,11,In_Network,K21.0,I50.9,99213,,0,Commercial,PPO,41,M,0.9245,,,249.43,115.45,0.0,115.45,0.0,0.0,133.98,0.0,0.0,0,,0.0156,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004883,MBR00000288,Medical_Institutional,Paid,Electronic_EDI,2023-03-25,2023-03-25,2023-03-28,2023-04-08,Auto_Adjudicated,14,1068197532,1538261819,207V00000X,Obstetrics & Gynecology,11,In_Network,I25.10,OTHER,revenue_code:0100,,0,Commercial,HMO,36,M,0.8408,,,33709.88,19218.16,15254.71,71.77,78.0,3813.68,14491.72,0.0,0.0,0,,0.0244,none,0,1,1,0,0,0.001412,0,0,,Capitation
CLM0000004884,MBR00000249,Medical_Professional,Denied,Electronic_EDI,2023-10-28,2023-10-28,2023-10-28,2023-11-15,Auto_Adjudicated,18,1514646292,1643673796,207RP1001X,Pulmonary Disease,22,In_Network,I50.9,,83036,,0,ACA_Marketplace,ACA_Silver,36,F,1.2663,170,Medical_Necessity,1068.06,682.84,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.049,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004885,MBR00000126,Behavioral_Health,Denied,Electronic_EDI,2023-10-06,2023-10-06,2023-10-06,2023-10-26,Auto_Adjudicated,20,1961590405,1390802135,207RC0000X,Cardiovascular Disease,11,In_Network,OTHER,Z00.01|K21.0,90837,,0,Medicaid_MCO,MLTSS,48,F,0.637,97,COB,423.85,199.93,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Kickback Arrangement,0.9519,outlier_billing_amount|high_volume_same_code|benford_violation|billing_spike_recent|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|diagnosis_procedure_mismatch|high_oop_waiver,1,5,0,0,0,0.0,0,0,,Capitation
CLM0000004886,MBR00000016,Medical_Professional,Paid,Electronic_EDI,2023-01-03,2023-01-03,2023-01-03,2023-01-10,Auto_Adjudicated,7,1648123576,1607833568,101YP2500X,Psychologist Clinical,22,In_Network,Z79.4,OTHER|F32.9,84443,,0,Commercial,HDHP_HSA,20,F,0.5843,,,512.3,333.66,0.0,333.66,0.0,0.0,178.64,0.0,0.0,0,,0.1264,none,0,1,0,0,0,0.0,0,0,,P4P
CLM0000004887,MBR00000158,Medical_Professional,Denied,Electronic_EDI,2023-03-03,2023-03-03,2023-03-03,2023-03-22,Clinical_Review,19,1055095309,1564691686,207RC0000X,Cardiovascular Disease,11,In_Network,N18.3,OTHER,99233,,0,Commercial,HMO,65,M,1.5361,96,Coding_Error,810.0,511.45,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0514,none,0,1,0,0,0,0.0,0,0,FUM_Follow_Up_ED_Mental_Health,FFS
CLM0000004888,MBR00000119,Medical_Professional,Paid,Electronic_EDI,2023-07-18,2023-07-18,2023-07-18,2023-08-11,Auto_Adjudicated,24,1451329728,1575884274,2084P0800X,Psychiatry,21,In_Network,OTHER,K57.30,10060,,0,Commercial,POS,42,M,0.4987,,,546.37,387.38,192.71,130.49,16.0,48.18,158.99,0.0,0.0,0,,0.1124,phantom_billing_indicator,0,1,0,0,0,1.8e-05,0,0,,FFS
CLM0000004889,MBR00000037,Medical_Institutional,Paid,Electronic_EDI,2023-02-26,2023-02-26,2023-03-02,2023-03-17,Manual_Review,19,1324142620,1995553359,207RP1001X,Pulmonary Disease,24,In_Network,OTHER,,revenue_code:0450,,0,Medicaid_MCO,MLTSS,11,M,1.043,,,11944.87,7948.53,7942.53,0.0,6.0,0.0,3996.34,0.0,0.0,0,,0.1429,benford_violation,0,1,1,0,0,0.000735,0,0,BCS_Breast_Cancer_Screening,FFS
CLM0000004890,MBR00000033,Dental,Paid,Electronic_EDI,2023-11-03,2023-11-03,2023-11-03,2023-12-02,Manual_Review,29,1983779639,1898471307,207R00000X,Internal Medicine,22,Out_of_Network,OTHER,OTHER|Z00.00,D2140,,0,Medicare_Advantage,PFFS,31,F,0.821,,,387.49,303.16,228.12,13.01,5.0,57.03,84.33,0.0,0.0,0,,0.1185,phantom_billing_indicator,0,1,0,0,0,2.1e-05,0,0,SPC_Statin_Therapy,FFS
CLM0000004891,MBR00000049,Medical_Professional,Paid,Electronic_EDI,2023-06-08,2023-06-08,2023-06-08,2023-07-07,Auto_Adjudicated,29,1522998767,1007652766,208600000X,Surgery General,11,In_Network,I10,OTHER,99205,,0,Medicare_Advantage,PFFS,67,M,0.978,,,346.7,194.08,117.29,43.47,4.0,29.32,152.62,0.0,0.0,0,,0.0375,none,0,1,0,1,0,1.1e-05,0,0,,FFS
CLM0000004892,MBR00000062,Pharmacy,Paid,Electronic_EDI,2023-10-28,2023-10-28,2023-10-28,2023-11-12,Auto_Adjudicated,15,1220710861,1509799493,101YP2500X,Psychologist Clinical,21,In_Network,K57.30,I10|I48.91,00071012831,,4,Commercial,HMO,46,F,0.5516,,,106.57,68.02,0.0,53.74,14.28,0.0,38.55,0.0,0.0,0,,0.074,phantom_billing_indicator,0,1,0,0,0,0.0,0,1,,FFS
CLM0000004893,MBR00000221,Medical_Professional,Denied,Electronic_EDI,2023-02-12,2023-02-12,2023-02-12,2023-02-24,Auto_Adjudicated,12,1706018784,1354959095,207RE0101X,Endocrinology,65,In_Network,M54.5,Z23|E13.9,90834,,0,Commercial,HDHP_HSA,28,M,1.6683,16,Timely_Filing,1104.99,721.06,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1417,none,0,1,0,0,0,0.0,0,0,KED_ESRD_Patients,Bundled_Payment
CLM0000004894,MBR00000121,Medical_Professional,Paid,Provider_Portal,2023-01-09,2023-01-09,2023-01-09,2023-01-23,Manual_Review,14,1710668368,1747596016,207RP1001X,Pulmonary Disease,31,In_Network,Z23,Z00.00,99385,,0,Medicare_Advantage,MA_PPO,58,M,1.226,,,343.5,179.97,125.19,5.48,18.0,31.3,163.53,0.0,0.0,0,,0.1512,provider_specialty_mismatch,0,1,0,0,0,1.2e-05,0,0,,P4P
CLM0000004895,MBR00000136,Pharmacy,Paid,Electronic_EDI,2023-08-19,2023-08-19,2023-08-19,2023-09-03,Manual_Review,15,1700802848,1884259357,207RP1001X,Pulmonary Disease,24,In_Network,M79.3,,00003014960,,1,Commercial,POS,2,F,1.2611,,,45.38,30.9,0.0,30.9,0.0,0.0,14.48,0.0,0.0,0,,0.1157,none,0,1,0,0,0,0.0,0,1,,FFS
CLM0000004896,MBR00000180,Pharmacy,Paid,Provider_Portal,2023-10-15,2023-10-15,2023-10-15,2023-10-21,Auto_Adjudicated,6,1627776731,1068662623,207R00000X,Internal Medicine,31,In_Network,I10,Z00.01,00069420020,,4,Medicare_Advantage,MA_PPO,72,F,1.1909,,,23.51,12.11,0.0,11.05,1.06,0.0,11.4,0.0,0.0,0,,0.1388,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004897,MBR00000291,Medical_Institutional,Paid,Electronic_EDI,2023-12-23,2023-12-23,2023-12-26,2024-01-21,Auto_Adjudicated,29,1067329999,1588993671,207Q00000X,Family Medicine,11,In_Network,M47.816,Z00.01,revenue_code:0200,,0,Commercial,PPO,78,M,1.4773,,,7401.53,5469.55,3928.57,482.83,76.0,982.14,1931.98,0.0,0.0,0,,0.0637,none,0,1,0,1,0,0.000364,0,0,,Shared_Savings
CLM0000004898,MBR00000221,Medical_Professional,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-10,2023-10-28,Manual_Review,18,1907932706,1728466420,207RC0000X,Cardiovascular Disease,11,In_Network,M54.5,Z12.11|I10|Z00.00,99393,,0,Commercial,HDHP_HSA,28,M,1.6683,,,152.84,122.87,1.34,121.19,0.0,0.34,29.97,0.0,0.0,0,,0.144,high_volume_same_code,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004899,MBR00000192,Medical_Professional,Paid,Electronic_EDI,2023-09-26,2023-09-26,2023-09-26,2023-09-30,Auto_Adjudicated,4,1356408757,1896197144,207Q00000X,Family Medicine,11,In_Network,OTHER,OTHER,20610,,0,Medicaid_MCO,MCO,22,F,1.1739,,,807.14,384.4,384.4,0.0,0.0,0.0,422.74,0.0,0.0,0,,0.2006,unbundling_pattern,0,2,0,1,0,3.6e-05,0,0,,FFS
CLM0000004900,MBR00000218,Pharmacy,Denied,Electronic_EDI,2023-01-21,2023-01-21,2023-01-21,2023-02-18,Auto_Adjudicated,28,1364214492,1228356980,2086S0122X,Orthopedic Surgery,11,In_Network,Z12.11,M25.511|E11.65,00071012831,,5,Commercial,HDHP_HSA,11,F,0.4964,256,Eligibility,133.42,85.74,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1675,benford_violation,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004901,MBR00000212,Medical_Institutional,Paid,Electronic_EDI,2023-08-05,2023-08-05,2023-08-05,2023-09-03,Clinical_Review,29,1797494973,1774401124,207RE0101X,Endocrinology,31,In_Network,Z00.00,,revenue_code:0120,,0,Commercial,HMO,57,F,2.5456,,,18320.4,14299.79,11097.04,360.49,68.0,2774.26,4020.61,0.0,0.0,0,,0.0097,none,0,1,1,0,0,0.001027,0,0,,Shared_Savings
CLM0000004902,MBR00000206,Medical_Institutional,Denied,Electronic_EDI,2023-09-14,2023-09-14,2023-09-16,2023-10-01,Auto_Adjudicated,17,1688560518,1321680994,207V00000X,Obstetrics & Gynecology,11,In_Network,J44.1,G43.909,revenue_code:0200,,0,Medicaid_MCO,MLTSS,21,M,1.4038,97,Coding_Error,18537.46,11901.89,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0716,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004903,MBR00000154,Medical_Professional,Paid,Electronic_EDI,2023-05-22,2023-05-22,2023-05-22,2023-06-20,Auto_Adjudicated,29,1331264469,1789540567,207RN0300X,Nephrology,22,In_Network,M25.511,M54.5,99213,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,169.34,94.89,65.56,12.94,0.0,16.39,74.45,0.0,0.0,0,,0.091,high_volume_same_code,0,1,0,0,0,6e-06,0,0,,Shared_Savings
CLM0000004904,MBR00000170,Pharmacy,Paid,Electronic_EDI,2023-12-25,2023-12-25,2023-12-25,2024-01-24,Manual_Review,30,1015096289,1553094822,2084P0800X,Psychiatry,11,In_Network,F33.0,Z87.891|N39.0|Z00.01,00006001954,,1,Medicare_Advantage,MA_PPO,86,M,1.7691,,,134.5,93.74,48.65,29.93,3.0,12.16,40.76,0.0,0.0,0,,0.079,none,0,1,0,0,0,5e-06,0,1,,FFS
CLM0000004905,MBR00000143,Medical_Professional,Paid,Electronic_EDI,2023-12-21,2023-12-21,2023-12-21,2024-01-19,Auto_Adjudicated,29,1702283246,1965244699,207R00000X,Internal Medicine,31,In_Network,OTHER,G47.33|OTHER,99204,,0,Commercial,POS,85,M,1.6078,,,212.33,117.03,20.81,55.01,36.0,5.2,95.3,0.0,0.0,0,,0.0986,none,0,1,0,0,0,2e-06,0,0,,Shared_Savings
CLM0000004906,MBR00000125,Medical_Institutional,Denied,Electronic_EDI,2023-11-04,2023-11-04,2023-11-05,2023-12-03,Manual_Review,29,1728728765,1368666316,207RN0300X,Nephrology,24,Emergency,OTHER,,revenue_code:0120,,0,Medicare_Advantage,MA_HMO,3,F,1.9037,50,Timely_Filing,46929.36,27650.38,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1,Duplicate Billing,1.0,outlier_billing_amount|unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|high_volume_same_code|service_date_weekend|unbundling_pattern|diagnosis_procedure_mismatch|controlled_substance_high_volume|high_oop_waiver,1,5,0,0,0,0.0,0,0,COA_Care_Transitions,FFS
CLM0000004907,MBR00000084,Pharmacy,Paid,Electronic_EDI,2023-11-12,2023-11-12,2023-11-12,2023-11-15,Auto_Adjudicated,3,1078576574,1029818813,207R00000X,Internal Medicine,24,In_Network,Z00.00,E78.5|Z00.00|M25.511,00069420020,,2,Medicare_Advantage,MA_HMO,15,F,0.8004,,,489.67,414.44,319.47,4.11,11.0,79.87,75.23,0.0,0.0,0,,0.0657,none,0,1,0,0,0,3e-05,0,1,,FFS
CLM0000004908,MBR00000112,Medical_Professional,Paid,Electronic_EDI,2023-07-23,2023-07-23,2023-07-23,2023-07-24,Auto_Adjudicated,1,1594322174,1894215172,225100000X,Physical Therapist,21,In_Network,Z00.00,,99386,,0,Medicare_Advantage,MA_HMO,18,M,1.01,,,538.13,290.46,227.27,0.37,6.0,56.82,247.67,0.0,0.0,0,,0.0626,none,0,1,0,0,0,2.1e-05,0,0,W30_Well_Child_Visit,FFS
CLM0000004909,MBR00000135,Medical_Institutional,Paid,Electronic_EDI,2023-10-22,2023-10-22,2023-10-26,2023-11-09,Auto_Adjudicated,18,1505049857,1810068286,207RC0000X,Cardiovascular Disease,65,In_Network,E11.9,E78.5,revenue_code:0110,,0,Commercial,PPO,58,F,2.2702,,,10621.78,8536.87,6782.1,0.25,59.0,1695.52,2084.91,0.0,0.0,0,,0.0889,none,0,1,1,0,0,0.000628,0,0,,FFS
CLM0000004910,MBR00000175,Medical_Institutional,Paid,Provider_Portal,2023-01-26,2023-01-26,2023-01-28,2023-02-18,Auto_Adjudicated,23,1549436467,1831337866,101YP2500X,Psychologist Clinical,65,In_Network,E11.9,Z23|Z00.00,revenue_code:0100,,0,Commercial,PPO,14,F,1.5785,,,7041.2,5076.96,3984.66,48.13,48.0,996.17,1964.24,0.0,0.0,0,,0.1062,benford_violation,0,1,0,0,0,0.000369,0,0,,Shared_Savings
CLM0000004911,MBR00000154,Medical_Institutional,Paid,Electronic_EDI,2023-03-24,2023-03-24,2023-03-25,2023-04-19,Auto_Adjudicated,26,1007414142,1355732274,207RG0100X,Gastroenterology,23,Out_of_Network,E11.65,Z00.00,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,5456.59,3056.62,2417.36,10.92,24.0,604.34,2399.97,0.0,0.0,0,,0.0511,none,0,1,0,0,0,0.000224,1,0,AWV_Annual_Wellness_Visit,Capitation
CLM0000004912,MBR00000033,Dental,Paid,Electronic_EDI,2023-08-27,2023-08-27,2023-08-27,2023-09-16,Auto_Adjudicated,20,1338575285,1542515060,246ZN0300X,Neuropsychology,22,Emergency,E11.9,C50.911|OTHER|J44.1,D4341,,0,Medicare_Advantage,PFFS,31,F,0.821,,,535.87,429.27,307.27,40.18,5.0,76.82,106.6,0.0,0.0,0,,0.0048,none,0,1,0,1,0,2.8e-05,0,0,,FFS
CLM0000004913,MBR00000106,Medical_Institutional,Paid,Electronic_EDI,2023-02-14,2023-02-14,2023-02-15,2023-02-24,Auto_Adjudicated,10,1826043246,1878874025,246ZN0300X,Neuropsychology,21,In_Network,J06.9,OTHER|E11.9,revenue_code:0250,292,0,Medicare_Advantage,MA_PPO,69,M,1.7254,,,10963.68,4662.9,3678.69,29.54,35.0,919.67,6300.78,0.0,0.0,0,,0.0731,none,0,1,0,0,1,0.00034,0,0,FUM_Follow_Up_ED_Mental_Health,P4P
CLM0000004914,MBR00000119,Medical_Professional,Paid,Electronic_EDI,2023-10-19,2023-10-19,2023-10-19,2023-11-16,Manual_Review,28,1923937825,1809122260,208600000X,Surgery General,24,In_Network,F32.9,,99215,,0,Commercial,POS,42,M,0.4987,,,194.49,160.8,0.0,160.8,0.0,0.0,33.69,0.0,0.0,0,,0.043,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004915,MBR00000209,Medical_Professional,Paid,Electronic_EDI,2023-03-05,2023-03-05,2023-03-05,2023-03-23,Auto_Adjudicated,18,1756856314,1388050552,207RC0000X,Cardiovascular Disease,71,In_Network,J44.1,Z00.00|J06.9,99285,,0,Medicare_Advantage,MA_HMO,10,F,0.5199,,,438.49,308.38,241.39,4.65,2.0,60.35,130.11,0.0,0.0,0,,0.0349,none,0,1,0,0,0,2.2e-05,0,0,SPD_Spirometry_Testing,Bundled_Payment
CLM0000004916,MBR00000105,Medical_Institutional,Paid,Electronic_EDI,2023-05-06,2023-05-06,2023-05-06,2023-05-27,Auto_Adjudicated,21,1889525696,1581533104,207RG0100X,Gastroenterology,21,In_Network,OTHER,E11.9|F33.0,revenue_code:0110,682,0,Commercial,HMO,74,M,1.1834,,,27351.36,17047.82,13158.46,549.74,50.0,3289.62,10303.54,0.0,0.0,0,,0.0955,none,0,1,1,1,0,0.001218,0,0,,Bundled_Payment
CLM0000004917,MBR00000003,Medical_Professional,Paid,Electronic_EDI,2023-04-03,2023-04-03,2023-04-03,2023-04-11,Auto_Adjudicated,8,1950560596,1355732274,207RP1001X,Pulmonary Disease,11,In_Network,E13.9,OTHER,99386,,0,Commercial,PPO,79,F,1.3879,,,174.26,99.99,54.69,6.63,25.0,13.67,74.27,0.0,0.0,0,,0.0085,none,0,1,0,0,0,5e-06,0,0,CDC_HbA1c_Poor_Control,FFS
CLM0000004918,MBR00000025,Pharmacy,Partially_Paid,Electronic_EDI,2023-07-14,2023-07-14,2023-07-14,2023-08-06,Auto_Adjudicated,23,1466922283,1564691686,246ZN0300X,Neuropsychology,11,In_Network,E78.5,E11.9|OTHER|N39.0,00069420020,,1,Commercial,POS,74,M,1.3309,3,Medical_Necessity,240.37,195.89,100.41,4.9,25.0,25.1,84.96,0.0,0.0,0,,0.088,none,0,1,0,0,0,9e-06,0,0,CCS_Cervical_Cancer_Screening,FFS
CLM0000004919,MBR00000154,Medical_Professional,Paid,Electronic_EDI,2023-01-30,2023-01-30,2023-01-30,2023-02-03,Manual_Review,4,1137079475,1662516615,207RE0101X,Endocrinology,81,Out_of_Network,J06.9,Z00.01|N39.0,27130,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,27179.5,20517.89,16413.59,0.9,0.0,4103.4,6661.61,0.0,0.0,0,,0.1353,benford_violation,0,1,1,0,0,0.001519,1,0,,Shared_Savings
CLM0000004920,MBR00000059,Medical_Professional,Paid,Electronic_EDI,2023-10-19,2023-10-19,2023-10-19,2023-11-15,Auto_Adjudicated,27,1682685390,1365397818,246ZN0300X,Neuropsychology,22,In_Network,Z00.00,F32.9,99284,,0,Medicare_Advantage,SNP,12,F,1.266,,,655.62,409.61,290.79,30.12,16.0,72.7,246.01,0.0,0.0,0,,0.0131,none,0,1,0,0,0,2.7e-05,0,0,,FFS
CLM0000004921,MBR00000154,Medical_Professional,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-12-11,Auto_Adjudicated,26,1728728765,1432077493,225100000X,Physical Therapist,81,In_Network,Z23,,97110,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,,,579.09,438.74,342.82,10.21,0.0,85.71,140.35,0.0,0.0,0,,0.0687,high_volume_same_code,0,1,0,1,0,3.2e-05,0,0,,FFS
CLM0000004922,MBR00000173,Dental,Paid,Electronic_EDI,2023-09-26,2023-09-26,2023-09-26,2023-10-17,Auto_Adjudicated,21,1333969109,1763260577,207RG0100X,Gastroenterology,22,In_Network,J44.1,,D3310,,0,Medicare_Advantage,PFFS,23,F,1.0279,,,350.04,220.29,161.19,4.81,14.0,40.3,129.75,0.0,0.0,0,,0.199,duplicate_claim_indicator,0,1,0,0,0,1.5e-05,0,0,,FFS
CLM0000004923,MBR00000282,Pharmacy,Paid,Electronic_EDI,2023-03-08,2023-03-08,2023-03-08,2023-04-07,Manual_Review,30,1671999102,1408846353,207RN0300X,Nephrology,11,In_Network,OTHER,,59148001506,,1,Medicare_Advantage,MA_HMO,16,M,0.7304,,,305.45,218.04,125.07,43.71,18.0,31.27,87.41,0.0,0.0,0,,0.048,none,0,1,0,0,0,1.2e-05,0,1,,FFS
CLM0000004924,MBR00000195,Medical_Institutional,Paid,Electronic_EDI,2023-04-15,2023-04-15,2023-04-17,2023-05-13,Auto_Adjudicated,28,1519595029,1098360555,207RE0101X,Endocrinology,22,In_Network,E78.5,I48.91,revenue_code:0110,,0,Commercial,PPO,13,F,0.5967,,,37597.96,25134.4,19996.39,106.91,32.0,4999.1,12463.56,0.0,0.0,0,,0.0004,none,0,1,1,0,0,0.001851,0,0,CDC_BP_Control,FFS
CLM0000004925,MBR00000010,Medical_Professional,Paid,Electronic_EDI,2023-03-23,2023-03-23,2023-03-23,2023-03-26,Auto_Adjudicated,3,1899326088,1912895973,207R00000X,Internal Medicine,11,Emergency,E11.9,I48.91,99385,,0,Medicare_Advantage,MA_HMO,44,F,1.4631,,,342.1,153.06,109.3,12.43,4.0,27.33,189.04,0.0,0.0,0,,0.1367,npi_mismatch,0,1,0,0,0,1e-05,0,0,,FFS
CLM0000004926,MBR00000121,Dental,Paid,Electronic_EDI,2023-08-05,2023-08-05,2023-08-05,2023-08-12,Auto_Adjudicated,7,1650193199,1690197969,246ZN0300X,Neuropsychology,22,Out_of_Network,Z00.00,,D1110,,0,Medicare_Advantage,MA_PPO,58,M,1.226,,,400.7,183.82,125.5,8.94,18.0,31.38,216.88,0.0,0.0,0,,0.0899,none,0,1,0,0,0,1.2e-05,0,0,BPD_BP_Declined,FFS
CLM0000004927,MBR00000235,Dental,Paid,Electronic_EDI,2023-11-15,2023-11-15,2023-11-15,2023-11-19,Auto_Adjudicated,4,1451464799,1616762819,208600000X,Surgery General,22,In_Network,I25.10,M79.3,D0120,,0,Commercial,HDHP_HSA,85,F,1.4308,,,249.92,177.69,38.56,129.49,0.0,9.64,72.23,0.0,0.0,0,,0.1161,geographic_mismatch,0,1,0,0,0,4e-06,0,0,,FFS
CLM0000004928,MBR00000081,Medical_Professional,Paid,Electronic_EDI,2023-11-12,2023-11-12,2023-11-12,2023-11-22,Clinical_Review,10,1120678352,1694343357,207RN0300X,Nephrology,22,In_Network,OTHER,,97012,,0,Medicare_Advantage,SNP,66,F,2.159,,,518.24,254.0,188.67,13.16,5.0,47.17,264.24,0.0,0.0,0,,0.1575,upcoding_pattern,0,1,0,0,0,1.7e-05,0,0,,Shared_Savings
CLM0000004929,MBR00000279,Pharmacy,Paid,Electronic_EDI,2023-12-10,2023-12-10,2023-12-10,2023-12-28,Auto_Adjudicated,18,1478458171,1575884274,207RC0000X,Cardiovascular Disease,21,In_Network,Z12.11,I50.9|N18.3|E11.9,16590051660,,1,Medicare_Advantage,MA_PPO,81,M,1.6817,,,159.78,127.3,87.22,9.27,9.0,21.81,32.48,0.0,0.0,0,,0.0636,none,0,1,0,0,0,8e-06,0,1,,FFS
CLM0000004930,MBR00000161,Dental,Paid,Electronic_EDI,2023-09-05,2023-09-05,2023-09-05,2023-09-10,Auto_Adjudicated,5,1451464799,1688513262,2086S0122X,Orthopedic Surgery,22,In_Network,F41.1,OTHER|E11.9,D1110,,0,Medicaid_MCO,MLTSS,9,F,0.8354,,,533.09,328.48,324.48,0.0,4.0,0.0,204.61,0.0,0.0,0,,0.0813,none,0,1,0,0,0,3e-05,0,0,,FFS
CLM0000004931,MBR00000028,Medical_Professional,Paid,Electronic_EDI,2023-03-21,2023-03-21,2023-03-21,2023-03-24,Auto_Adjudicated,3,1124477249,1415734567,207RC0000X,Cardiovascular Disease,32,Emergency,Z00.00,,99203,,0,Commercial,HMO,3,F,2.116,,,350.43,146.94,0.0,146.94,0.0,0.0,203.49,0.0,0.0,0,,0.079,controlled_substance_high_volume,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004932,MBR00000076,Medical_Professional,Paid,Electronic_EDI,2023-05-23,2023-05-23,2023-05-23,2023-06-12,Auto_Adjudicated,20,1092800235,1406199453,246ZN0300X,Neuropsychology,11,In_Network,E11.65,,97140,,0,Commercial,HMO,26,M,2.1785,,,401.23,294.15,198.29,14.28,32.0,49.57,107.08,0.0,0.0,0,,0.1467,none,0,1,0,0,0,1.8e-05,0,0,,Capitation
CLM0000004933,MBR00000274,Medical_Institutional,Denied,Electronic_EDI,2023-04-16,2023-04-16,2023-04-17,2023-05-05,Auto_Adjudicated,19,1175448241,1672803287,2084P0800X,Psychiatry,65,In_Network,E11.9,J44.1|OTHER|Z00.01,revenue_code:0250,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,96,Eligibility,25782.54,18681.94,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0793,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004934,MBR00000298,Medical_Institutional,Paid,Electronic_EDI,2023-01-23,2023-01-23,2023-01-25,2023-02-03,Auto_Adjudicated,11,1958981650,1061149198,208600000X,Surgery General,22,In_Network,Z00.00,,revenue_code:0370,,0,Medicaid_MCO,MCO,75,M,0.8324,,,10306.04,6960.74,6960.74,0.0,0.0,0.0,3345.3,0.0,0.0,0,,0.0445,none,0,1,1,0,0,0.000644,0,0,,Shared_Savings
CLM0000004935,MBR00000261,Pharmacy,Paid,Paper,2023-10-15,2023-10-15,2023-10-15,2023-11-06,Auto_Adjudicated,22,1051254008,1027261156,207RP1001X,Pulmonary Disease,23,In_Network,E13.9,K21.0|Z00.00,00071015523,,1,Medicare_Advantage,MA_PPO,13,F,0.4259,,,159.03,127.94,100.95,0.75,1.0,25.24,31.09,0.0,0.0,0,,0.195,high_volume_same_code|impossible_service_combo,0,1,0,1,0,9e-06,0,0,COL_Colorectal_Cancer_Screening,Shared_Savings
CLM0000004936,MBR00000102,Medical_Institutional,Denied,Electronic_EDI,2023-07-27,2023-07-27,2023-07-28,2023-08-14,Auto_Adjudicated,18,1147937670,1452088018,207RG0100X,Gastroenterology,11,In_Network,I10,,revenue_code:0300,,0,Commercial,POS,68,M,1.6864,4,COB,23954.23,17320.15,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0175,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004937,MBR00000226,Medical_Professional,Denied,Electronic_EDI,2023-12-15,2023-12-15,2023-12-15,2023-12-28,Auto_Adjudicated,13,1474985672,1447186817,207R00000X,Internal Medicine,11,In_Network,Z00.01,E11.9,43239,,0,Medicare_Advantage,MA_PPO,84,M,1.0796,16,Medical_Necessity,1214.27,893.77,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1978,upcoding_pattern,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004938,MBR00000069,Medical_Professional,Paid,Electronic_EDI,2023-10-30,2023-10-30,2023-10-30,2023-11-02,Auto_Adjudicated,3,1571330665,1489993356,207R00000X,Internal Medicine,24,In_Network,E11.9,Z79.4,27447,,0,Medicare_Advantage,MA_PPO,2,M,0.5765,,,22931.19,13809.0,11015.86,31.18,8.0,2753.96,9122.19,0.0,0.0,0,,0.1255,none,0,1,1,0,0,0.00102,0,0,,FFS
CLM0000004939,MBR00000122,Pharmacy,Paid,Electronic_EDI,2023-08-22,2023-08-22,2023-08-22,2023-09-14,Manual_Review,23,1229304423,1289435414,207RN0300X,Nephrology,65,In_Network,I10,OTHER,00071012831,,1,Commercial,EPO,64,F,0.8625,,,804.49,589.01,273.38,209.29,38.0,68.34,215.48,0.0,0.0,0,,0.0031,none,0,1,0,0,0,2.5e-05,0,1,,Shared_Savings
CLM0000004940,MBR00000207,Medical_Professional,Paid,Electronic_EDI,2023-01-16,2023-01-16,2023-01-16,2023-02-04,Auto_Adjudicated,19,1205744244,1774401124,207RN0300X,Nephrology,22,In_Network,F33.0,M54.5|OTHER,74177,,0,Medicaid_MCO,MLTSS,11,F,1.6522,,,174.97,98.62,98.62,0.0,0.0,0.0,76.35,0.0,0.0,0,,0.0779,none,0,1,0,1,0,9e-06,0,0,MMA_Medication_Management,Shared_Savings
CLM0000004941,MBR00000293,Medical_Professional,Paid,Electronic_EDI,2023-06-08,2023-06-08,2023-06-08,2023-06-12,Manual_Review,4,1647029816,1354959095,246ZN0300X,Neuropsychology,11,In_Network,E78.5,N39.0|OTHER|F32.9,99285,,0,Medicare_Advantage,MA_HMO,84,F,2.8513,,,453.78,260.75,197.39,3.02,11.0,49.35,193.03,0.0,0.0,0,,0.0556,none,0,1,0,0,0,1.8e-05,0,0,BPD_BP_Declined,Capitation
CLM0000004942,MBR00000138,Medical_Professional,Denied,Electronic_EDI,2023-06-20,2023-06-20,2023-06-20,2023-06-26,Auto_Adjudicated,6,1097702209,1867626800,101YP2500X,Psychologist Clinical,24,In_Network,I50.9,Z23,43239,,0,Commercial,HDHP_HSA,47,M,0.996,5,Network,322.92,210.01,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.125,none,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000004943,MBR00000154,Pharmacy,Paid,Electronic_EDI,2023-08-31,2023-08-31,2023-08-31,2023-09-10,Auto_Adjudicated,10,1567711165,1513198866,207RN0300X,Nephrology,65,In_Network,J20.9,I25.10,00310075090,,1,Medicare_Advantage,MA_HMO,54,F,1.9463,,,177.58,129.36,100.17,4.15,0.0,25.04,48.22,0.0,0.0,0,,0.199,benford_violation,0,1,0,0,0,9e-06,0,1,TRC_Transition_of_Care,Capitation
CLM0000004944,MBR00000068,Medical_Professional,Paid,Electronic_EDI,2023-07-23,2023-07-23,2023-07-23,2023-07-29,Auto_Adjudicated,6,1091395764,1025886739,207RN0300X,Nephrology,23,In_Network,J06.9,E13.9|OTHER,99213,,0,Medicare_Advantage,MA_HMO,28,F,0.8494,,,283.45,112.16,70.61,15.9,8.0,17.65,171.29,0.0,0.0,0,,0.0568,diagnosis_procedure_mismatch,0,1,0,1,0,7e-06,0,0,,P4P
CLM0000004945,MBR00000128,Medical_Professional,Paid,Electronic_EDI,2023-10-08,2023-10-08,2023-10-08,2023-11-02,Auto_Adjudicated,25,1648123576,1945682535,207RC0000X,Cardiovascular Disease,11,In_Network,E11.9,J20.9|OTHER,99213,,0,Commercial,PPO,13,F,1.4203,,,273.15,161.76,99.96,23.81,13.0,24.99,111.39,0.0,0.0,0,,0.0589,none,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000004946,MBR00000019,Pharmacy,Paid,Provider_Portal,2023-01-08,2023-01-08,2023-01-08,2023-02-06,Auto_Adjudicated,29,1677021292,1318978078,207RC0000X,Cardiovascular Disease,21,In_Network,I50.9,,00169751112,,1,Commercial,PPO,77,M,0.6521,,,87.43,31.19,0.0,31.19,0.0,0.0,56.24,0.0,0.0,0,,0.1147,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004947,MBR00000259,Medical_Professional,Paid,Electronic_EDI,2023-02-10,2023-02-10,2023-02-10,2023-02-13,Auto_Adjudicated,3,1469009511,1903401648,207V00000X,Obstetrics & Gynecology,71,In_Network,N39.0,Z12.11,99213,,0,Medicare_Advantage,MA_PPO,5,M,1.6554,,,142.61,85.69,60.89,2.58,7.0,15.22,56.92,0.0,0.0,0,,0.0409,none,0,1,0,0,0,6e-06,0,0,AWV_Annual_Wellness_Visit,Shared_Savings
CLM0000004948,MBR00000008,Pharmacy,Paid,Electronic_EDI,2023-12-09,2023-12-09,2023-12-09,2023-12-17,Manual_Review,8,1176378924,1291071007,207R00000X,Internal Medicine,11,In_Network,F10.10,OTHER,00078043215,,3,Medicaid_MCO,MCO,74,M,0.8375,,,38.93,22.05,21.05,0.0,1.0,0.0,16.88,0.0,0.0,0,,0.1654,diagnosis_procedure_mismatch,0,1,0,0,0,2e-06,0,0,PCR_Plan_All_Cause_Readmission,FFS
CLM0000004949,MBR00000204,Medical_Professional,Paid,Electronic_EDI,2023-06-06,2023-06-06,2023-06-06,2023-06-15,Auto_Adjudicated,9,1568777164,1887266184,207Q00000X,Family Medicine,11,In_Network,M17.11,N18.3,99396,,0,Commercial,HMO,12,M,0.8716,,,253.45,96.55,0.0,96.55,0.0,0.0,156.9,0.0,0.0,0,,0.1237,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004950,MBR00000085,Pharmacy,Paid,Electronic_EDI,2023-10-23,2023-10-23,2023-10-23,2023-11-22,Auto_Adjudicated,30,1843445592,1672803287,101YP2500X,Psychologist Clinical,23,In_Network,OTHER,Z00.00|M17.11,00006001954,,3,Medicare_Advantage,SNP,2,M,0.7823,,,201.92,106.47,72.27,1.13,15.0,18.07,95.45,60.46,9.51,0,,0.2498,upcoding_pattern|phantom_billing_indicator,0,2,0,0,0,7e-06,0,1,,Bundled_Payment
CLM0000004951,MBR00000146,Medical_Professional,Denied,Electronic_EDI,2023-11-04,2023-11-04,2023-11-04,2023-11-23,Auto_Adjudicated,19,1389116733,1811797489,246ZN0300X,Neuropsychology,22,In_Network,J20.9,OTHER|I50.9,97140,,0,Medicaid_MCO,MCO,24,M,0.6484,16,Eligibility,991.34,486.76,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1499,none,0,1,0,0,0,0.0,0,0,HBD_Hemoglobin_A1c_Testing,FFS
CLM0000004952,MBR00000088,Medical_Professional,Paid,Electronic_EDI,2023-02-13,2023-02-13,2023-02-13,2023-03-14,Auto_Adjudicated,29,1183801932,1789540567,207RG0100X,Gastroenterology,11,In_Network,OTHER,E11.65|OTHER,85025,,0,ACA_Marketplace,ACA_Silver,45,M,1.4166,,,1474.37,1174.37,717.14,111.89,38.0,307.34,300.0,0.0,0.0,0,,0.1122,none,0,1,0,1,0,6.6e-05,0,0,,Bundled_Payment
CLM0000004953,MBR00000128,Medical_Professional,Paid,Provider_Portal,2023-09-11,2023-09-11,2023-09-11,2023-09-19,Auto_Adjudicated,8,1878453830,1878874025,207RE0101X,Endocrinology,22,Out_of_Network,J20.9,OTHER,99215,,0,Commercial,PPO,13,F,1.4203,,,428.06,243.58,109.99,93.09,13.0,27.5,184.48,0.0,0.0,0,,0.192,phantom_billing_indicator,0,1,0,0,0,1e-05,1,0,,FFS
CLM0000004954,MBR00000166,Vision,Paid,Electronic_EDI,2023-03-04,2023-03-04,2023-03-04,2023-03-07,Auto_Adjudicated,3,1325430913,1220755708,207R00000X,Internal Medicine,65,Out_of_Network,OTHER,I10|E78.5,V2320,,0,ACA_Marketplace,ACA_Silver,35,F,2.2266,,,646.37,254.51,0.0,254.51,0.0,0.0,391.86,0.0,0.0,1,DME Fraud,1.0,unusual_service_frequency|geographic_mismatch|provider_specialty_mismatch|benford_violation|duplicate_claim_indicator|upcoding_pattern|unbundling_pattern|phantom_billing_indicator|npi_mismatch|diagnosis_procedure_mismatch,1,5,0,0,0,0.0,1,0,COA_Care_Transitions,Shared_Savings
CLM0000004955,MBR00000190,Pharmacy,Paid,Electronic_EDI,2023-02-25,2023-02-25,2023-02-25,2023-03-12,Auto_Adjudicated,15,1771383741,1764064254,207R00000X,Internal Medicine,31,In_Network,OTHER,,00078043215,,1,Commercial,PPO,24,F,0.3232,,,438.45,241.2,123.39,51.97,35.0,30.85,197.25,0.0,0.0,0,,0.1383,none,0,1,0,0,0,1.1e-05,0,0,,Shared_Savings
CLM0000004956,MBR00000285,Medical_Professional,Paid,Electronic_EDI,2023-03-29,2023-03-29,2023-03-29,2023-04-23,Auto_Adjudicated,25,1713343912,1054984734,208600000X,Surgery General,11,In_Network,E78.5,,99213,,0,Commercial,HDHP_HSA,56,M,0.9226,,,339.08,227.56,176.0,7.56,0.0,44.0,111.52,0.0,0.0,0,,0.0524,none,0,1,0,0,0,1.6e-05,0,0,,FFS
CLM0000004957,MBR00000105,Medical_Professional,Paid,Electronic_EDI,2023-09-29,2023-09-29,2023-09-29,2023-10-25,Auto_Adjudicated,26,1159640414,1666461892,246ZN0300X,Neuropsychology,32,Out_of_Network,G43.909,OTHER,99386,,0,Commercial,HMO,74,M,1.1834,,,146.86,118.69,0.0,118.69,0.0,0.0,28.17,0.0,0.0,0,,0.1492,none,0,1,0,0,0,0.0,0,0,AMR_Asthma_Medication_Ratio,Shared_Savings
CLM0000004958,MBR00000176,Medical_Professional,Paid,Electronic_EDI,2023-02-03,2023-02-03,2023-02-03,2023-02-18,Auto_Adjudicated,15,1871417879,1672803287,207V00000X,Obstetrics & Gynecology,23,In_Network,I10,E11.9,99222,,0,Commercial,POS,4,M,0.8792,,,480.36,377.72,80.64,255.92,21.0,20.16,102.64,0.0,0.0,0,,0.0909,billing_spike_recent,0,1,0,1,0,7e-06,0,0,,FFS
CLM0000004959,MBR00000273,Medical_Professional,Paid,Electronic_EDI,2023-08-28,2023-08-28,2023-08-28,2023-09-06,Auto_Adjudicated,9,1958171947,1049766043,246ZN0300X,Neuropsychology,11,Emergency,OTHER,OTHER|N39.0,97035,,0,ACA_Marketplace,ACA_Bronze,4,M,1.3569,,,352.69,200.9,0.0,200.9,0.0,0.0,151.79,0.0,0.0,0,,0.0804,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004960,MBR00000091,Medical_Professional,Paid,Electronic_EDI,2023-05-17,2023-05-17,2023-05-17,2023-05-19,Clinical_Review,2,1887698203,1542515060,225100000X,Physical Therapist,11,In_Network,J06.9,Z12.11|G43.909,10060,,0,Commercial,PPO,13,F,1.2451,,,316.67,211.07,14.41,169.06,24.0,3.6,105.6,0.0,0.0,0,,0.0929,high_volume_same_code,0,1,0,0,0,1e-06,0,0,,FFS
CLM0000004961,MBR00000262,Dental,Denied,Electronic_EDI,2023-04-06,2023-04-06,2023-04-06,2023-04-20,Auto_Adjudicated,14,1727787144,1977073565,207RN0300X,Nephrology,81,Out_of_Network,F41.1,M25.511,D3310,,0,Medicare_Advantage,PFFS,77,F,1.7452,3,Authorization,887.72,740.11,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0207,none,0,1,0,0,0,0.0,1,0,,FFS
CLM0000004962,MBR00000291,Medical_Professional,Denied,Electronic_EDI,2023-03-28,2023-03-28,2023-03-28,2023-04-14,Manual_Review,17,1002224900,1623053477,207R00000X,Internal Medicine,11,Out_of_Network,Z00.00,,80053,,0,Commercial,PPO,78,M,1.4773,2,Coding_Error,773.18,328.21,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0269,none,0,1,0,0,0,0.0,1,0,,Capitation
CLM0000004963,MBR00000254,Dental,Paid,Electronic_EDI,2023-05-04,2023-05-04,2023-05-04,2023-05-05,Auto_Adjudicated,1,1901547390,1469642907,207RE0101X,Endocrinology,11,In_Network,OTHER,,D4341,,0,Commercial,PPO,22,F,0.9285,,,188.18,148.96,87.71,11.32,28.0,21.93,39.22,0.0,0.0,0,,0.0725,none,0,1,0,0,0,8e-06,0,0,MPT_Annual_Monitoring,Capitation
CLM0000004964,MBR00000170,Medical_Professional,Paid,Provider_Portal,2023-05-06,2023-05-06,2023-05-06,2023-06-04,Manual_Review,29,1466922283,1020312030,2084P0800X,Psychiatry,23,In_Network,OTHER,E78.5,99204,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,214.88,166.16,116.08,18.06,3.0,29.02,48.72,0.0,0.0,0,,0.1457,unusual_service_frequency|upcoding_pattern,0,1,0,0,0,1.1e-05,0,0,,FFS
CLM0000004965,MBR00000212,Pharmacy,Paid,Electronic_EDI,2023-04-23,2023-04-23,2023-04-23,2023-05-15,Auto_Adjudicated,22,1921056264,1513198866,2086S0122X,Orthopedic Surgery,24,In_Network,F32.9,Z00.00|OTHER,00085163102,,1,Commercial,HMO,57,F,2.5456,,,422.44,341.05,169.82,110.77,18.0,42.46,81.39,0.0,0.0,0,,0.1127,none,0,1,0,0,0,1.6e-05,0,0,,FFS
CLM0000004966,MBR00000148,Medical_Institutional,Paid,Electronic_EDI,2023-07-06,2023-07-06,2023-07-08,2023-07-16,Auto_Adjudicated,10,1558692441,1312595355,207RN0300X,Nephrology,11,In_Network,I10,E13.9|Z00.01|Z00.00,revenue_code:0210,,0,Commercial,EPO,51,F,0.6534,,,4102.88,3419.44,2320.95,471.26,47.0,580.24,683.44,0.0,0.0,0,,0.098,none,0,1,0,0,0,0.000215,0,0,,FFS
CLM0000004967,MBR00000180,Medical_Professional,Partially_Paid,Electronic_EDI,2023-12-23,2023-12-23,2023-12-23,2024-01-03,Auto_Adjudicated,11,1930591083,1965244699,101YP2500X,Psychologist Clinical,24,In_Network,M47.816,,97110,,0,Medicare_Advantage,MA_PPO,72,F,1.1909,22,Medical_Necessity,592.06,255.98,92.2,12.33,17.0,23.05,447.48,0.0,0.0,0,,0.1783,high_volume_same_code,0,1,0,0,0,9e-06,0,0,,FFS
CLM0000004968,MBR00000293,Pharmacy,Denied,Paper,2023-06-12,2023-06-12,2023-06-12,2023-06-23,Manual_Review,11,1923332120,1489434038,101YP2500X,Psychologist Clinical,24,In_Network,M54.5,G47.33|N18.3,00085163102,,1,Medicare_Advantage,MA_HMO,84,F,2.8513,256,Authorization,161.71,101.93,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0822,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004969,MBR00000078,Medical_Professional,Paid,Electronic_EDI,2023-03-07,2023-03-07,2023-03-07,2023-04-02,Auto_Adjudicated,26,1981853293,1105733833,2086S0122X,Orthopedic Surgery,24,In_Network,OTHER,OTHER|M17.11,70553,,0,Commercial,EPO,65,F,1.3174,,,4395.83,1902.37,1425.89,83.01,37.0,356.47,2493.46,0.0,0.0,0,,0.0948,none,0,1,0,0,0,0.000132,0,0,,Shared_Savings
CLM0000004970,MBR00000235,Dental,Paid,Provider_Portal,2023-08-08,2023-08-08,2023-08-08,2023-08-30,Auto_Adjudicated,22,1887363539,1827839595,101YP2500X,Psychologist Clinical,24,In_Network,M54.5,Z79.4,D3310,,0,Commercial,HDHP_HSA,85,F,1.4308,,,146.67,71.17,0.0,71.17,0.0,0.0,75.5,0.0,0.0,0,,0.1487,none,0,1,0,0,0,0.0,0,0,,FFS
CLM0000004971,MBR00000156,Pharmacy,Paid,Electronic_EDI,2023-10-25,2023-10-25,2023-10-25,2023-10-28,Auto_Adjudicated,3,1404237143,1274911960,101YP2500X,Psychologist Clinical,11,In_Network,I25.10,,50458085930,,1,Medicare_Advantage,MA_PPO,66,F,1.8933,,,58.35,43.6,12.0,15.6,13.0,3.0,14.75,0.0,0.0,0,,0.1049,none,0,1,0,1,0,1e-06,0,0,,FFS
CLM0000004972,MBR00000055,Behavioral_Health,Paid,Electronic_EDI,2023-08-04,2023-08-04,2023-08-04,2023-08-14,Auto_Adjudicated,10,1364214492,1040061910,207RC0000X,Cardiovascular Disease,32,In_Network,Z00.00,,99386,,0,Commercial,PPO,68,F,1.2896,,,166.35,131.35,6.91,112.72,10.0,1.73,35.0,0.0,0.0,0,,0.0706,none,0,1,0,0,0,1e-06,0,0,SPD_Spirometry_Testing,P4P
CLM0000004973,MBR00000191,Pharmacy,Paid,Electronic_EDI,2023-07-10,2023-07-10,2023-07-10,2023-08-03,Manual_Review,24,1402424417,1564636990,207RG0100X,Gastroenterology,22,In_Network,OTHER,N39.0,00069420020,,1,Commercial,POS,85,F,0.9729,,,108.56,62.82,0.0,62.82,0.0,0.0,45.74,0.0,0.0,0,,0.0012,none,0,1,0,1,0,0.0,0,1,,P4P
CLM0000004974,MBR00000235,Medical_Professional,Paid,Electronic_EDI,2023-08-29,2023-08-29,2023-08-29,2023-09-09,Manual_Review,11,1108756266,1148659045,208600000X,Surgery General,21,In_Network,I25.10,E11.65|OTHER,99215,,0,Commercial,HDHP_HSA,85,F,1.4308,,,286.07,207.07,0.0,207.07,0.0,0.0,79.0,0.0,0.0,0,,0.0612,high_volume_same_code,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004975,MBR00000170,Medical_Institutional,Paid,Electronic_EDI,2023-11-13,2023-11-13,2023-11-16,2023-12-08,Auto_Adjudicated,25,1466478716,1297948643,246ZN0300X,Neuropsychology,11,In_Network,OTHER,Z00.00,revenue_code:0360,,0,Medicare_Advantage,MA_PPO,86,M,1.7691,,,7905.65,3575.38,2813.49,12.51,46.0,703.37,4330.27,0.0,0.0,0,,0.0975,upcoding_pattern,0,1,0,0,0,0.00026,0,0,KED_ESRD_Patients,Capitation
CLM0000004976,MBR00000250,Pharmacy,Paid,Electronic_EDI,2023-01-28,2023-01-28,2023-01-28,2023-02-13,Manual_Review,16,1309817189,1747935894,225100000X,Physical Therapist,22,In_Network,M54.5,J20.9|E78.5,59148001506,,2,Commercial,PPO,41,M,0.9245,,,356.63,205.51,0.0,205.51,0.0,0.0,151.12,0.0,0.0,0,,0.0119,none,0,1,0,0,0,0.0,0,1,,Capitation
CLM0000004977,MBR00000115,Medical_Professional,Paid,Electronic_EDI,2023-12-19,2023-12-19,2023-12-19,2024-01-12,Auto_Adjudicated,24,1231231881,1878017518,207RC0000X,Cardiovascular Disease,11,In_Network,N39.0,G43.909,99387,,0,Commercial,PPO,15,F,0.7398,,,293.73,103.42,0.0,103.42,0.0,0.0,190.31,0.0,0.0,0,,0.0788,none,0,1,0,0,0,0.0,0,0,KED_ESRD_Patients,Capitation
CLM0000004978,MBR00000276,Medical_Institutional,Paid,Paper,2023-11-17,2023-11-17,2023-11-20,2023-12-03,Auto_Adjudicated,16,1295273693,1577226132,207RP1001X,Pulmonary Disease,22,In_Network,Z00.00,,revenue_code:0370,,0,Commercial,POS,38,M,0.8085,,,5068.6,3747.5,2945.63,18.46,47.0,736.41,1321.1,0.0,0.0,0,,0.1089,none,0,1,0,0,0,0.000273,0,0,,Capitation
CLM0000004979,MBR00000192,Medical_Professional,Paid,Electronic_EDI,2023-12-12,2023-12-12,2023-12-12,2024-01-04,Auto_Adjudicated,23,1994365754,1643673796,225100000X,Physical Therapist,11,In_Network,OTHER,,85025,,0,Medicaid_MCO,MCO,22,F,1.1739,,,553.47,267.46,267.46,0.0,0.0,0.0,286.01,0.0,0.0,0,,0.0563,none,0,1,0,0,0,2.5e-05,0,0,,Shared_Savings
CLM0000004980,MBR00000237,Pharmacy,Paid,Electronic_EDI,2023-06-28,2023-06-28,2023-06-28,2023-07-11,Auto_Adjudicated,13,1170319307,1312595355,207RG0100X,Gastroenterology,23,In_Network,I10,I48.91|E78.5,00006001954,,1,Commercial,PPO,45,M,0.7983,,,145.97,53.59,0.0,53.59,0.0,0.0,92.38,0.0,0.0,0,,0.0129,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004981,MBR00000085,Medical_Professional,Denied,Electronic_EDI,2023-11-03,2023-11-03,2023-11-03,2023-11-11,Auto_Adjudicated,8,1918160357,1704466150,246ZN0300X,Neuropsychology,11,In_Network,Z23,OTHER,90832,,0,Medicare_Advantage,SNP,2,M,0.7823,22,Eligibility,1456.18,765.7,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0935,benford_violation,0,1,0,0,0,0.0,0,0,,P4P
CLM0000004982,MBR00000139,Medical_Professional,Paid,Provider_Portal,2023-01-30,2023-01-30,2023-01-30,2023-02-26,Auto_Adjudicated,27,1594587354,1179350099,207RG0100X,Gastroenterology,22,In_Network,I50.9,M79.3|OTHER,99213,,0,Commercial,PPO,74,M,1.7701,,,433.49,229.29,92.51,92.65,21.0,23.13,204.2,0.0,0.0,0,,0.082,none,0,1,0,0,0,9e-06,0,0,CCS_Cervical_Cancer_Screening,Shared_Savings
CLM0000004983,MBR00000274,Vision,Paid,Electronic_EDI,2023-05-29,2023-05-29,2023-05-29,2023-06-11,Auto_Adjudicated,13,1469822310,1951488764,207RN0300X,Nephrology,23,In_Network,Z00.01,OTHER,V2115,,0,Medicare_Advantage,MA_HMO,58,F,2.1025,,,401.9,285.26,210.58,22.03,0.0,52.65,116.64,0.0,0.0,0,,0.0068,none,0,1,0,0,0,1.9e-05,0,0,,Capitation
CLM0000004984,MBR00000014,Pharmacy,Paid,Electronic_EDI,2023-11-12,2023-11-12,2023-11-12,2023-11-13,Clinical_Review,1,1091395764,1625992541,246ZN0300X,Neuropsychology,21,In_Network,OTHER,,59148001506,,2,Commercial,HMO,77,M,2.8513,,,101.38,54.05,0.0,54.05,0.0,0.0,47.33,0.0,0.0,0,,0.0611,npi_mismatch,0,1,0,1,0,0.0,0,0,,Capitation
CLM0000004985,MBR00000129,Medical_Professional,Paid,Electronic_EDI,2023-04-08,2023-04-08,2023-04-08,2023-04-20,Auto_Adjudicated,12,1770431137,1728466420,101YP2500X,Psychologist Clinical,65,In_Network,OTHER,OTHER|I10,84443,,0,Medicare_Advantage,MA_PPO,9,F,0.8196,,,814.73,407.75,309.04,4.45,17.0,77.26,406.98,0.0,0.0,0,,0.1493,none,0,1,0,0,0,2.9e-05,0,0,MMA_Medication_Management,Shared_Savings
CLM0000004986,MBR00000230,Medical_Professional,Paid,Electronic_EDI,2023-10-02,2023-10-02,2023-10-02,2023-10-15,Auto_Adjudicated,13,1155203600,1330485436,207RC0000X,Cardiovascular Disease,22,In_Network,N39.0,OTHER,99387,,0,Commercial,HMO,9,M,0.4087,,,158.21,56.02,30.94,4.35,13.0,7.73,102.19,0.0,0.0,0,,0.147,none,0,1,0,1,0,3e-06,0,0,,FFS
CLM0000004987,MBR00000218,Pharmacy,Paid,Electronic_EDI,2023-04-25,2023-04-25,2023-04-25,2023-05-03,Auto_Adjudicated,8,1965812565,1513198866,207RN0300X,Nephrology,24,In_Network,N18.3,OTHER|E11.65,59148001506,,4,Commercial,HDHP_HSA,11,F,0.4964,,,305.79,226.54,28.54,190.86,0.0,7.14,79.25,0.0,0.0,0,,0.1661,unbundling_pattern,0,1,0,0,0,3e-06,0,0,DDE_Diabetes_Short_Term_Complications,P4P
CLM0000004988,MBR00000257,Medical_Professional,Paid,Provider_Portal,2023-07-31,2023-07-31,2023-07-31,2023-08-27,Auto_Adjudicated,27,1078576574,1983760474,2084P0800X,Psychiatry,22,In_Network,Z00.01,,99214,,0,Medicaid_MCO,MCO,76,F,0.8322,,,516.93,199.83,198.83,0.0,1.0,0.0,317.1,0.0,0.0,0,,0.1113,none,0,1,0,0,0,1.8e-05,0,0,,Bundled_Payment
CLM0000004989,MBR00000216,Medical_Institutional,Paid,Electronic_EDI,2023-08-23,2023-08-23,2023-08-27,2023-09-07,Auto_Adjudicated,15,1325430913,1865266296,207V00000X,Obstetrics & Gynecology,24,In_Network,K21.0,,revenue_code:0210,,0,Medicare_Advantage,MA_HMO,71,F,0.7117,,,1851.02,965.02,722.12,21.37,41.0,180.53,886.0,0.0,0.0,0,,0.1341,phantom_billing_indicator,0,1,0,0,0,6.7e-05,0,0,LCS_Lung_Cancer_Screening,Capitation
CLM0000004990,MBR00000287,Pharmacy,Paid,Electronic_EDI,2023-11-12,2023-11-12,2023-11-12,2023-11-24,Auto_Adjudicated,12,1017424540,1140170394,207RP1001X,Pulmonary Disease,65,In_Network,OTHER,OTHER,00085163102,,2,Commercial,PPO,4,M,0.7685,,,169.64,80.27,0.0,80.27,0.0,0.0,89.37,0.0,0.0,0,,0.0793,provider_specialty_mismatch,0,1,0,0,0,0.0,0,1,PCR_Plan_All_Cause_Readmission,FFS
CLM0000004991,MBR00000154,Medical_Professional,Denied,Electronic_EDI,2023-05-03,2023-05-03,2023-05-03,2023-05-24,Clinical_Review,21,1756856314,1978943761,207RP1001X,Pulmonary Disease,21,In_Network,Z00.01,N18.3,43239,,0,Medicare_Advantage,MA_HMO,54,F,1.9463,PR-1,Duplicate,616.71,510.35,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0348,none,0,1,0,0,0,0.0,0,0,CDC_BP_Control,FFS
CLM0000004992,MBR00000186,Medical_Professional,Paid,Electronic_EDI,2023-10-10,2023-10-10,2023-10-10,2023-10-30,Auto_Adjudicated,20,1671999102,1132693989,207RC0000X,Cardiovascular Disease,81,In_Network,OTHER,,20610,,0,Commercial,PPO,65,M,1.6983,,,1239.37,809.49,621.43,20.7,12.0,155.36,429.88,0.0,0.0,0,,0.1982,geographic_mismatch,0,1,0,0,0,5.8e-05,0,0,,FFS
CLM0000004993,MBR00000254,Medical_Professional,Denied,Electronic_EDI,2023-06-06,2023-06-06,2023-06-06,2023-06-21,Auto_Adjudicated,15,1102590784,1874728994,246ZN0300X,Neuropsychology,11,In_Network,F41.1,Z00.00,99284,,0,Commercial,PPO,22,F,0.9285,50,Network,210.08,76.58,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.0144,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004994,MBR00000208,Medical_Professional,Paid,Electronic_EDI,2023-05-22,2023-05-22,2023-05-22,2023-06-21,Auto_Adjudicated,30,1886537420,1616762819,207RG0100X,Gastroenterology,31,In_Network,Z00.00,F32.9,90847,,0,Medicare_Advantage,MA_HMO,66,M,2.1466,,,430.51,296.09,227.63,5.55,6.0,56.91,134.42,0.0,0.0,0,,0.0433,none,0,1,0,0,0,2.1e-05,0,0,AWV_Annual_Wellness_Visit,FFS
CLM0000004995,MBR00000031,Medical_Institutional,Paid,Electronic_EDI,2023-01-29,2023-01-29,2023-01-29,2023-02-28,Auto_Adjudicated,30,1637260822,1788579687,207RN0300X,Nephrology,22,In_Network,J06.9,E78.5,revenue_code:0120,,0,Commercial,PPO,71,M,0.6746,,,14094.27,11153.97,8869.35,33.28,34.0,2217.34,2940.3,0.0,0.0,0,,0.0639,none,0,1,1,0,0,0.000821,0,0,,FFS
CLM0000004996,MBR00000116,Medical_Professional,Denied,Electronic_EDI,2023-01-28,2023-01-28,2023-01-28,2023-02-12,Auto_Adjudicated,15,1611521069,1432077493,207RP1001X,Pulmonary Disease,11,In_Network,M17.11,,27130,,0,Medicaid_MCO,MLTSS,79,F,0.4614,4,Timely_Filing,27915.59,19096.44,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1424,none,0,1,0,0,0,0.0,0,0,,Shared_Savings
CLM0000004997,MBR00000167,Vision,Paid,Electronic_EDI,2023-10-04,2023-10-04,2023-10-04,2023-10-26,Manual_Review,22,1017424540,1318978078,207V00000X,Obstetrics & Gynecology,23,In_Network,OTHER,M54.5|E78.5|Z79.4,92014,,0,Commercial,PPO,77,F,0.9377,,,313.39,191.73,0.0,191.73,0.0,0.0,121.66,0.0,0.0,0,,0.0454,none,0,1,0,0,0,0.0,0,0,,Capitation
CLM0000004998,MBR00000221,Pharmacy,Denied,Electronic_EDI,2023-02-07,2023-02-07,2023-02-07,2023-02-09,Auto_Adjudicated,2,1001149267,1300957944,207RN0300X,Nephrology,11,In_Network,Z87.891,,00006001954,,2,Commercial,HDHP_HSA,28,M,1.6683,1,Coding_Error,370.05,189.97,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0,,0.1392,none,0,1,0,0,0,0.0,0,0,,Bundled_Payment
CLM0000004999,MBR00000165,Medical_Professional,Paid,Electronic_EDI,2023-02-10,2023-02-10,2023-02-10,2023-02-24,Auto_Adjudicated,14,1484438840,1978943761,207V00000X,Obstetrics & Gynecology,32,In_Network,I25.10,,99214,,0,ACA_Marketplace,ACA_Bronze,55,M,0.9775,,,399.09,263.23,0.0,263.23,0.0,0.0,135.86,0.0,0.0,0,,0.1597,benford_violation,0,1,0,0,0,0.0,0,0,DAE_Drug_Alcohol_Dependence,Shared_Savings