Healthcare
20 columns
100 rows
8 formats

Medicare Advantage and Managed Care Encounters

This dataset provides detailed risk adjustment encounter records for Medicare Advantage and Managed Care plans, including HCC codes, RAF scores, RAPS/EDPS submission details, and quality measure documentation. It enables accurate capitation payment calculation, regulatory compliance, and quality performance analysis for healthcare organizations and payers.

last updated 2 Nov 2025
by GoMask

The brief that made it

Risk adjustment and RAF score calculation for Medicare Advantage payments

Sample rows

preview · 8 of 100 rows · all 20 columns

encounter_idstring	hcc_codestring	raf_scorefloat	quality_measure_metboolean	procedure_codestring	member_idstring	plan_idstring	provider_idstring	encounter_datedate	submission_typestring	quality_measure_codestring	diagnosis_codestring	encounter_typestring	service_location_streetstring	service_location_citystring	service_location_statestring	service_location_postal_codestring	service_location_countrystring	submission_datedate	capitation_amountfloat
ENC10001	HCC18	1.12	true	99213	M20001	PMA101	PRV5001	2023-01-05	RAPS	HEDIS001	I10	outpatient	123 Maple Ave	Phoenix	AZ	85001	USA	2023-01-10	520.45
ENC10002	HCC85	0.89	blank	G0439	M20002	PMA102	PRV5002	2023-02-11	EDPS	blank	E11.9	professional	456 Oak St	Houston	TX	77002	USA	2023-02-13	430
ENC10003	HCC108	1.41	false	99214	M20003	PMA103	PRV5003	2023-03-16	RAPS	STAR002	J44.9	outpatient	789 Pine Blvd	Atlanta	GA	30303	USA	2023-03-18	610.75
ENC10004	HCC85	0.76	blank	99406	M20004	PMA104	PRV5004	2023-04-08	EDPS	blank	E78.5	professional	321 Cedar Ln	Chicago	IL	60601	USA	2023-04-10	390
ENC10005	HCC18	1.09	true	G0402	M20005	PMA105	PRV5005	2023-05-09	RAPS	HEDIS002	I50.9	inpatient	654 Spruce Dr	Los Angeles	CA	90001	USA	2023-05-12	895.6
ENC10006	HCC108	1.32	true	blank	M20006	PMA101	PRV5006	2023-06-12	EDPS	STAR003	J45.909	institutional	987 Elm St	Miami	FL	33101	USA	2023-06-14	780
ENC10007	HCC85	0.94	blank	G0438	M20007	PMA102	PRV5007	2023-07-20	RAPS	blank	E11.65	outpatient	143 Willow Way	Denver	CO	80202	USA	2023-07-22	430.9
ENC10008	HCC18	1.21	false	99215	M20008	PMA103	PRV5008	2023-08-15	EDPS	HEDIS003	I10	professional	257 Aspen Ave	Seattle	WA	98101	USA	2023-08-17	510.3
ENC10009	HCC108	1.48	blank	G0403	M20009	PMA104	PRV5009	2023-09-10	RAPS	blank	J44.1	inpatient	369 Birch Ct	Boston	MA	02108	USA	2023-09-13	920
ENC10010	HCC85	0.82	true	99407	M20010	PMA105	PRV5010	2023-10-02	EDPS	STAR004	E78.2	institutional	1000 Palm Rd	Dallas	TX	75201	USA	2023-10-05	800.25
ENC10011	HCC18	1.03	blank	G0439	M20011	PMA101	PRV5011	2023-11-14	RAPS	blank	I11.9	outpatient	500 Magnolia St	San Diego	CA	92101	USA	2023-11-17	540.1
ENC10012	HCC108	1.29	true	99214	M20012	PMA102	PRV5012	2023-12-07	EDPS	HEDIS004	J45.901	professional	2500 Cypress Ave	Orlando	FL	32801	USA	2023-12-10	620
ENC10013	HCC85	0.77	blank	G0438	M20013	PMA103	PRV5013	2022-11-25	RAPS	blank	E11.10	institutional	1720 Redwood Dr	Minneapolis	MN	55401	USA	2022-11-28	780.5
ENC10014	HCC18	1.16	true	99213	M20014	PMA104	PRV5014	2022-10-18	EDPS	STAR005	I10	inpatient	5800 Sycamore Ln	Cleveland	OH	44101	USA	2022-10-20	900
ENC10015	HCC108	1.38	false	G0402	M20015	PMA105	PRV5015	2022-09-12	RAPS	HEDIS005	J44.9	outpatient	999 Bay St	San Francisco	CA	94102	USA	2022-09-14	630
ENC10016	HCC85	0.85	blank	99406	M20016	PMA101	PRV5016	2022-08-04	EDPS	blank	E78.5	professional	4500 Fir Ave	Portland	OR	97201	USA	2022-08-07	410
ENC10017	HCC18	1.1	true	99215	M20017	PMA102	PRV5017	2022-07-10	RAPS	STAR006	I50.9	institutional	1200 Palm Dr	Las Vegas	NV	89101	USA	2022-07-12	830
ENC10018	HCC108	1.25	blank	G0439	M20018	PMA103	PRV5018	2022-06-05	EDPS	blank	J44.1	inpatient	2300 Mulberry St	Charlotte	NC	28202	USA	2022-06-08	870
ENC10019	HCC85	0.92	false	99214	M20019	PMA104	PRV5019	2022-05-19	RAPS	HEDIS006	E11.9	outpatient	3600 Willow Dr	Nashville	TN	37201	USA	2022-05-22	510
ENC10020	HCC18	1.28	true	G0403	M20020	PMA105	PRV5020	2022-04-18	EDPS	STAR007	I10	professional	7000 Holly Ave	Philadelphia	PA	19103	USA	2022-04-20	430.6

What the 100 rows show

from the 100-row sample

HCC19 (hcc code) stands out: mean raf_score is 2.1, against 1.1 for the rest.

69%quality_measure_met = true
1.2median raf_score
2submission types
4encounter types
11plans
14diagnosis codes

Mean raf_score by hcc_code100 rows

raf_score100 rows, in bands of 0.2

Median 1.2, from 0.76 to 2.2.

procedure_code99 rows with a value · 1 left blank

9921311
9921411
800539
G04397
G04387
946407
829477
992155
432395
930055

20 columns by typefrom the column list below

string 15
float 2
date 2
boolean 1

Columns

20 columns in four groups

blueprint · 20 columns
column	type	description	example
Text 15 columns
`encounter_id`	string	Unique identifier for each encounter record.unique	ENC10001
`member_id`	string	Unique identifier for the Medicare Advantage plan member.	M20001
`plan_id`	string	Identifier for the Medicare Advantage or Managed Care plan.11 plans	PMA101
`provider_id`	string	Identifier for the healthcare provider submitting the encounter.	PRV5001
`submission_type`	string	Type of risk adjustment submission (RAPS or EDPS).RAPS · EDPS	RAPS
`hcc_code`	string	Hierarchical Condition Category (HCC) code reported for risk adjustment.5 codes	HCC18
`quality_measure_code`	string	Code representing the documented quality measure (e.g., HEDIS, STAR).optional	HEDIS001
`diagnosis_code`	string	Primary diagnosis code (ICD-10) associated with the encounter.	I10
`procedure_code`	string	Primary procedure code (CPT/HCPCS) performed during the encounter.optional	99213
`encounter_type`	string	Type of encounter (e.g., inpatient, outpatient, professional, institutional).inpatient · outpatient · professional · institutional	outpatient
`service_location_street`	string	Street address of the service location.optional	123 Maple Ave
`service_location_city`	string	City of the service location.optional	Phoenix
`service_location_state`	string	State of the service location.optional	AZ
`service_location_postal_code`	string	Postal code of the service location.optional	85001
`service_location_country`	string	Country of the service location.optional	USA
Numbers 2 columns
`raf_score`	float	Risk Adjustment Factor (RAF) score calculated for the member based on the encounter.0 or more	1.12
`capitation_amount`	float	Capitation payment amount associated with the encounter.0 or more · optional	520.45
Dates and times 2 columns
`encounter_date`	date	Date when the encounter took place.	2023-01-05
`submission_date`	date	Date the encounter was submitted for risk adjustment.	2023-01-10
True or false 1 column
`quality_measure_met`	boolean	Indicates whether the quality measure was met for this encounter.optional	true

Use it for

A healthcare dashboard
The quality_measure_met rate, raf_score by hcc_code and a breakdown of procedure_code. Excel, Power BI or Tableau.
Why do the 13 HCC19 rows have a mean raf_score of 2.1?
A root-cause class exercise
Hand out the rows and one question. The answer is in the data, not in the brief.
Encounters100
ENC100011.12HCC18
ENC100031.41HCC108
ENC100051.09HCC18
A software demo
Believable encounters with member_id, plan_id and provider_id to fill a screen in front of a buyer.

This dataset100 rows20 columns

Yours10,000 rows20 columnsservice_location_street: UK only

blueprint · medicare-advantage-and-managed-care-encounters

Behind this dataset

Same schema. As many rows as you need.

These 100 rows came out of a blueprint — 20 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

Encounter date of service
ICD-10-CM codes with HCC mapping
HCC categories (diabetes with complications, CHF, COPD, etc.)
RAF (Risk Adjustment Factor) score calculation
Demographic factors: age, gender, Medicaid status
RAPS (Risk Adjustment Processing System) for MA plans
EDPS (Encounter Data Processing System)
Diagnosis supported by face-to-face visit

Rows1,000 rows10,000 rows100,000 rows1,000,000 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: medicare-advantage-and-managed-care-encounters

What should your data show?

No signup. No card.

Sample rows

What the 100 rows show

Columns

Use it for

A healthcare dashboard

A root-cause class exercise

A software demo

Make it yours.

Same schema. As many rows as you need.

More in Healthcare

What should your data show?