Healthcare-Insurance Claims Integration

This dataset provides a comprehensive, flat-structured view of healthcare insurance claims, tracking each claim's journey from clinical service through submission, adjudication, and payment. It includes detailed fields for patient, provider, payer, financials, service location, and claim status, making it ideal for process mining, compliance auditing, and cross-domain healthcare analytics.

  • opened 12 times
  • last updated 22 Jul 2025
  • by GoMask
The brief that made it

Process mining and bottleneck analysis in healthcare claims workflows

Sample rows

preview · 8 of 200 rows · all 25 columns
claim_idstringclaim_statusstringprocessing_time_daysintegerdenial_reasonstringpatient_idstringprovider_idstringencounter_idstringservice_datedateclaim_submission_datedatediagnosis_codestringprocedure_codestringbilled_amountfloatallowed_amountfloatpaid_amountfloatpatient_responsibility_amountfloatadjudication_datedatepayer_idstringpolicy_idstringservice_location_streetstringservice_location_citystringservice_location_statestringservice_location_postal_codestringservice_location_countrystringclaim_typestringsubmission_methodstring
CLM00001paid2blankPAT1001PRV2001ENC30012023-03-122023-03-13E11999213125.5106.7596.0819.672023-03-15PAY4001POL50011234 Main StChicagoIL60616USoutpatientelectronic
CLM00002approved2blankPAT1002PRV2002ENC30022023-04-152023-04-16J06990471175140112282023-04-18PAY4002POL5002567 Oak AveAtlantaGA30303USoutpatientpaper
CLM00003denied5Coverage lapsedPAT1003PRV2003ENC30032023-05-012023-05-06M54597110240002402023-05-11PAY4003POL5003789 Maple DrHoustonTX77002USoutpatientportal
CLM00004paid1blankPAT1004PRV2004ENC30042023-06-182023-06-19I1099214165140.25126.2314.022023-06-20PAY4004POL5004234 Elm StMiamiFL33101USoutpatientelectronic
CLM00005pendingblankblankPAT1005PRV2005ENC30052023-07-042023-07-07R50999212110blankblankblankblankPAY4001POL5005543 Pine LnCharlotteNC28202USoutpatientportal
CLM00006in_reviewblankblankPAT1006PRV2006ENC30062023-08-122023-08-14K21943239180blankblankblankblankPAY4002POL5006876 Willow RdDenverCO80202USoutpatientportal
CLM00007submittedblankblankPAT1007PRV2001ENC30072023-09-012023-09-03N3908100190blankblankblankblankPAY4003POL5007432 Birch BlvdMinneapolisMN55401USoutpatientpaper
CLM00008paid3blankPAT1008PRV2007ENC30082023-10-102023-10-12F41990791210168150182023-10-15PAY4004POL5008123 Cedar CtPhoenixAZ85001USoutpatientportal

What the 200 rows show

from the 200-row sample

Denied (claim status) stands out: mean processing_time_days is 3.7, against 2.2 for the rest.

  • 2median processing_time_days
  • 4submission methods
  • 5claim types
  • 46service location states
  • 140.0median billed_amount
  • 108.0median allowed_amount
Mean processing_time_days by claim_status123 rows
0242.3approved38 rows3.7denied19 rows2.2paid66 rows
processing_time_days123 rows, in bands of 0.5
02040290400360906313.56processing_time_days →

Median 2, from 1 to 6.

denial_reason19 rows with a value · 181 left blank
  1. Coverage lapsed4
  2. Non-covered procedure4
  3. Non-covered provider4
  4. Non-covered diagnosis2
  5. No referral on file1
  6. Eligibility expired1
  7. Missing referral1
  8. Service not eligible1
  9. Plan inactive1
25 columns by typefrom the column list below
  • string 17
  • integer 1
  • float 4
  • date 3

Columns

25 columns in three groups
blueprint · 25 columns
columntypedescriptionexample
Text 17 columns
claim_idstringUnique identifier for each insurance claim.uniqueCLM00001
patient_idstringUnique identifier for the patient associated with the claim.PAT1001
provider_idstringUnique identifier for the healthcare provider submitting the claim.PRV2001
encounter_idstringUnique identifier for the clinical encounter that generated the claim.ENC3001
claim_statusstringCurrent status of the claim (e.g., submitted, in_review, approved, denied, paid, pending).6 valuespaid
diagnosis_codestringPrimary diagnosis code (ICD-10 or similar) associated with the claim.E119
procedure_codestringPrimary procedure code (CPT, HCPCS, etc.) billed in the claim.99213
denial_reasonstringReason for claim denial, if applicable.9 reasons · optionalCoverage lapsed
payer_idstringUnique identifier for the insurance payer (insurer).PAY4001
policy_idstringIdentifier for the insurance policy covering the claim.POL5001
service_location_streetstringStreet address of the service location.optional1234 Main St
service_location_citystringCity of the service location.optionalChicago
service_location_statestringState of the service location.optionalIL
service_location_postal_codestringPostal code of the service location.optional60616
service_location_countrystringCountry of the service location.optionalUS
claim_typestringType of claim (e.g., inpatient, outpatient, pharmacy, dental).inpatient · outpatient · pharmacy · dental · otheroutpatient
submission_methodstringMethod used to submit the claim (e.g., electronic, paper, portal).electronic · paper · portal · other · optionalelectronic
Numbers 5 columns
billed_amountfloatTotal amount billed by the provider for the services rendered.0 or more125.5
allowed_amountfloatAmount allowed by the insurer for the claim after adjudication.0 or more · optional106.75
paid_amountfloatAmount actually paid by the insurer for the claim.0 or more · optional96.08
patient_responsibility_amountfloatAmount the patient is responsible for (copay, deductible, coinsurance).0 or more · optional19.67
processing_time_daysintegerNumber of days taken to process the claim from submission to adjudication.0 or more · optional2
Dates and times 3 columns
service_datedateDate when the clinical service was provided.2023-03-12
claim_submission_datedateDate when the claim was submitted to the insurer.2023-03-13
adjudication_datedateDate when the claim was adjudicated (approved/denied/paid).optional2023-03-15

Use it for

  • median process…2123 rowsmean processing time …2.3approv…3.7denied2.2paid

    A healthcare dashboard

    Processing_time_days by claim_status and a breakdown of denial_reason. Excel, Power BI or Tableau.

  • Why do the 19 denied rows have a mean processing_time_days of 3.7?

    A root-cause class exercise

    Hand out the rows and one question. The answer is in the data, not in the brief.

  • A software demo

    Believable claims with patient_id, provider_id and encounter_id to fill a screen in front of a buyer.

Not quite right?

Make it yours.

Same 25 columns, your size and your rules. See 20 rows before you pay.

Preview 20 rows free

1,000 rows: $1.99 · 10,000: $12.99One-time. No subscription. All prices

This dataset200 rows25 columns
Yours1,000 rows25 columnsservice_location_street: UK only

blueprint · healthcare-insurance-claims-integration

Behind this dataset

Same schema. As many rows as you need.

These 200 rows came out of a blueprint — 25 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
  • Claim status transitions tracked
  • Clinical codes linked to claim reasons
  • Provider and insurer IDs connected
  • Reimbursement timelines measured
  • Appeal and resubmission rates included
Rows
Open the blueprint in Data Factory

1 credit per row. New accounts start with 25 free credits.

Exports
CSV, JSON, JSONL, Parquet, SQL, Excel, TSV, XML
Licence
yours to use, including commercially
API slug
healthcare-insurance-claims-integration

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