Healthcare
21 columns
103 rows
8 formats

Claims Adjudication and Payment Processing

This dataset provides a detailed, flat record of healthcare claims adjudication and payment processing, including allowed amounts, patient cost-sharing, coordination of benefits, and remittance advice linkage. It enables robust financial analysis, compliance auditing, and operational monitoring for healthcare payers and providers, supporting transparency and efficiency in claims management.

last updated 2 Nov 2025
by GoMask

The brief that made it

Claims payment reconciliation and auditing

Sample rows

preview · 8 of 103 rows · all 21 columns

claim_idstring	claim_statusstring	allowed_amountfloat	coordination_of_benefits_flagboolean	service_codestring	patient_idstring	provider_idstring	service_datedate	adjudication_datedate	billed_amountfloat	deductible_appliedfloat	coinsurance_amountfloat	copay_amountfloat	other_payer_amountfloat	payment_amountfloat	remittance_advice_idstring	payment_datedate	denial_reason_codestring	payer_idstring	payer_namestring	patient_responsibility_amountfloat
CLM-00001	adjudicated	312.5	false	99213	PAT-1001	PRV-40011	2022-08-12	2022-08-15	587	25	45	40	blank	180	RA-3001	2022-08-17	blank	PAY-201	BlueCross NC	62.5
CLM-00002	adjudicated	175	false	99214	PAT-1002	PRV-40012	2023-04-18	2023-04-21	340	0	20	20	blank	135	RA-3002	2023-04-22	blank	PAY-202	Aetna Health	40
CLM-00003	paid	75	false	80053	PAT-1003	PRV-40013	2021-07-10	2021-07-15	120	0	0	15	blank	60	RA-3003	2021-07-17	blank	PAY-203	Cigna Midwest	0
CLM-00004	denied	0	false	36415	PAT-1004	PRV-40014	2023-05-02	2023-05-04	0	0	0	0	blank	0	blank	blank	CO16	PAY-204	Humana Inc	0
CLM-00005	adjudicated	138	false	99213	PAT-1005	PRV-40015	2022-11-30	2022-12-04	245	25	18	12	blank	83	RA-3004	2022-12-05	blank	PAY-205	UnitedHealthcare	55
CLM-00006	adjudicated	235	true	99214	PAT-1006	PRV-40016	2024-01-03	2024-01-06	270	0	40	20	55	120	RA-3005	2024-01-08	blank	PAY-206	WellCare	60
CLM-00007	adjudicated	82	false	99213	PAT-1007	PRV-40017	2021-12-12	2021-12-15	115	0	15	17	blank	50	RA-3006	2021-12-17	blank	PAY-207	Anthem CA	32
CLM-00008	adjudicated	210	false	99213	PAT-1008	PRV-40018	2023-07-14	2023-07-19	295	10	30	20	blank	150	RA-3007	2023-07-21	blank	PAY-208	Molina Health	60
CLM-00009	paid	85	false	36415	PAT-1009	PRV-40019	2022-05-20	2022-05-25	120	0	5	15	blank	65	RA-3008	2022-05-27	blank	PAY-209	AmeriHealth	0
CLM-00010	reversed	0	false	99214	PAT-1010	PRV-40020	2023-02-22	2023-02-27	0	0	0	0	blank	0	blank	blank	N56	PAY-210	Oscar Health	0
CLM-00011	adjudicated	450	true	99214	PAT-1011	PRV-40021	2023-09-01	2023-09-04	680	35	60	35	110	210	RA-3009	2023-09-07	blank	PAY-211	Blue Shield TX	110
CLM-00012	adjudicated	180	false	99213	PAT-1012	PRV-40022	2022-01-09	2022-01-11	220	20	40	15	blank	105	RA-3010	2022-01-14	blank	PAY-212	Health Net	75
CLM-00013	adjudicated	135	false	99213	PAT-1013	PRV-40023	2023-03-15	2023-03-17	265	10	35	10	blank	80	RA-3011	2023-03-19	blank	PAY-213	Bright Health	55
CLM-00014	paid	60	false	36415	PAT-1014	PRV-40024	2022-06-11	2022-06-13	110	0	0	10	blank	50	RA-3012	2022-06-15	blank	PAY-214	Aetna Health	0
CLM-00015	adjudicated	5250	true	99285	PAT-1015	PRV-40025	2023-10-10	2023-10-12	7000	850	1200	200	2200	800	RA-3013	2023-10-16	blank	PAY-215	UnitedHealthcare	1200
CLM-00016	pending	0	false	99213	PAT-1016	PRV-40026	2022-03-22	2022-03-27	80	0	0	0	blank	0	blank	blank	blank	PAY-216	Anthem CA	0
CLM-00017	adjudicated	690	false	99499	PAT-1017	PRV-40027	2024-04-30	2024-05-02	980	35	90	20	blank	545	RA-3014	2024-05-06	blank	PAY-217	Molina Health	145
CLM-00018	denied	0	false	99213	PAT-1018	PRV-40028	2022-09-17	2022-09-22	0	0	0	0	blank	0	blank	blank	M50	PAY-218	Oscar Health	0
CLM-00019	adjudicated	320	false	99213	PAT-1019	PRV-40029	2023-01-07	2023-01-10	410	40	35	30	blank	215	RA-3015	2023-01-12	blank	PAY-219	Bright Health	105
CLM-00020	adjudicated	120	false	99213	PAT-1020	PRV-40030	2022-10-13	2022-10-20	190	10	15	10	blank	85	RA-3016	2022-10-22	blank	PAY-220	Health Net	35

What the 103 rows show

from the 103-row sample

16%coordination_of_benefits_flag = true
86.5median allowed_amount
130median billed_amount
6median deductible_applied
15.0median coinsurance_amount
10median copay_amount

claim_status103 rows by value

allowed_amount103 rows, in bands of 2,000

Median 86.5, from 0.0 to 12,000.

service_code103 rows · 9 values

9921339
9921417
3641511
8005310
992857
992157
992126
994995
870701

21 columns by typefrom the column list below

string 9
float 8
date 3
boolean 1

Columns

21 columns in four groups

blueprint · 21 columns
column	type	description	example
Text 9 columns
`claim_id`	string	Unique identifier for the claim submitted for adjudication.unique	CLM-00001
`patient_id`	string	Unique identifier for the patient associated with the claim.	PAT-1001
`provider_id`	string	Unique identifier for the healthcare provider submitting the claim.	PRV-40011
`remittance_advice_id`	string	Identifier for the remittance advice (835) associated with this claim.optional	RA-3001
`claim_status`	string	Status of the claim (e.g., adjudicated, denied, pending, paid).adjudicated · denied · pending · paid · reversed	adjudicated
`denial_reason_code`	string	Code indicating the reason for claim denial, if applicable.3 codes · optional	CO16
`service_code`	string	Code representing the healthcare service provided (e.g., CPT, HCPCS).9 codes	99213
`payer_id`	string	Unique identifier for the insurance payer responsible for adjudication.	PAY-201
`payer_name`	string	Name of the insurance payer.	BlueCross NC
Numbers 8 columns
`allowed_amount`	float	Amount approved by the payer for the claim after adjudication.0 or more	312.5
`billed_amount`	float	Total amount billed by the provider for the claim.0 or more	587
`deductible_applied`	float	Amount applied to the patient's deductible for this claim.0 or more	25
`coinsurance_amount`	float	Amount of coinsurance the patient is responsible for.0 or more	45
`copay_amount`	float	Copay amount the patient is responsible for.0 or more	40
`other_payer_amount`	float	Amount paid by other payer(s) if coordination of benefits applies.0 or more · optional	55
`payment_amount`	float	Total payment amount issued to the provider for the claim.0 or more	180
`patient_responsibility_amount`	float	Total amount the patient is responsible for after adjudication.0 or more	62.5
Dates and times 3 columns
`service_date`	date	Date the healthcare service was provided.	2022-08-12
`adjudication_date`	date	Date the claim was adjudicated.	2022-08-15
`payment_date`	date	Date the payment was issued to the provider.optional	2022-08-17
True or false 1 column
`coordination_of_benefits_flag`	boolean	Indicates if coordination of benefits with another payer was applied.	false

Use it for

A healthcare dashboard
The coordination_of_benefits_flag rate, allowed_amount by claim_status and a breakdown of service_code. Excel, Power BI or Tableau.
Why do 16 of 103 rows have coordination_of_benefits_flag = true?
A class exercise
Hand out the rows and one question. Everyone works from the same 103 rows.
Claims103
CLM-00001312.5adjudica…
CLM-00006235adjudica…
CLM-00011450adjudica…
A software demo
Believable claims with patient_id, provider_id and service_date to fill a screen in front of a buyer.

This dataset103 rows21 columns

Yours1,000 rows21 columns

blueprint · claims-adjudication-and-payment-processing

Behind this dataset

Same schema. As many rows as you need.

These 103 rows came out of a blueprint — 21 columns with generation rules behind each one. Open it in Data Factory to retune a column, add your own, wire in foreign keys, and run it at the size you actually need.

Rules it was built with

Adjudication ID unique per decision
Billed charges vs allowed amount (contractual allowance)
Deductible remaining and applied to claim
Coinsurance percentage (typically 20% for Medicare)
Copay amount for office visits, ER, etc.
Out-of-pocket maximum tracking
Primary vs secondary insurance coordination
Medicare Secondary Payer (MSP) rules

Rows1,000 rows10,000 rows100,000 rows1,000,000 rows

Open the blueprint in Data Factory

1 credit per row. Preview 20 rows free. Buy rows for the full run.

Exports: CSV, JSON, JSONL, Parquet, SQL, Excel, TSV, XML
Licence: yours to use, including commercially
API slug: claims-adjudication-and-payment-processing

What should your data show?

No signup. No card.

Sample rows

What the 103 rows show

Columns

Use it for

A healthcare dashboard

A class exercise

A software demo

Make it yours.

Same schema. As many rows as you need.

More in Healthcare

What should your data show?