{"title":"ARKA-TCOC methodology","generatedFrom":"lib/tcoc/content/methodology.ts","engineVersion":"tcoc-1.0.3","sectionId":"tcoc-attribution-method","attributionLadder":{"summary":"Tier 1 — DIRECT: referring/ordering NPI present on the professional claim. Tier 2 — INFERRED: no ordering NPI, but the beneficiary has a qualifying evaluation-and-management encounter within the lookback window with a related diagnosis; excluded specialties never receive attribution. Tier 3 — UNATTRIBUTED: counted in population totals, excluded from clinician-level figures. Tier 3 published on the front page is required output.","adapters":[{"id":"roster","specVersion":"roster-v1","description":"Buyer-supplied member→clinician roster. Validates coverage defects and assigns tier direct.","methodologyText":"Members are attributed to the clinician listed on the buyer-supplied attribution roster (adapter roster, spec roster-v1). Duplicate roster members keep the lexicographically smallest clinician NPI. Unknown NPIs and members absent from claims are reported in the coverage report and do not silently disappear. Assignments are tier direct with basis 'roster'."},{"id":"encounter-proximity","specVersion":"em-proximity-30d-v1","description":"Imaging-event attribution ladder: Tier-1 ordering NPI, Tier-2 nearest qualifying E/M within 30 days (related diagnosis; excluded specialties never attributed), else Tier-3 unattributed.","methodologyText":"Advanced imaging events are attributed by a three-tier ladder (adapter encounter-proximity, spec em-proximity-30d-v1). Tier 1 (direct): referring/ordering NPI present on the professional claim. Tier 2 (inferred): nearest qualifying E/M encounter within 30 days before the imaging date with a related diagnosis family; radiologists, pathologists, anaesthesiologists and imaging-facility NPIs are never attributed. Same-day-distance ties prefer matching CCSR diagnosis category, then higher E/M allowed charge, then lexicographically smallest NPI (the last tie-break is arbitrary and exists solely for determinism — invariant I6). Tier 3 (unattributed): no qualifying antecedent — counted in population totals, excluded from clinician-level figures. Each inferred assignment carries confidence high|medium|low from days-elapsed and diagnosis concordance."},{"id":"mssp-plurality","specVersion":"mssp-py2025-v1","description":"MSSP plurality assignment for PY2025 (2-step).","methodologyText":"Medicare Shared Savings Program claims-based assignment (adapter mssp-plurality, spec mssp-py2025-v1, performance year 2025). Implemented against: Shared Savings and Losses and Assignment Methodology and Quality Performance Standard Specifications Version 13 (https://www.cms.gov/files/document/medicare-shared-savings-program-shared-savings-losses-assignment-methodology-specifications.pdf, retrieved 2026-08-07). Code list / methodology changes: CY2025 Physician Fee Schedule Final Rule (89 FR 97710; https://www.federalregister.gov/documents/2024/12/09/2024-25382/medicare-and-medicaid-programs-cy-2025-payment-policies-under-the-physician-fee-schedule, retrieved 2026-08-07). Regulation: 42 CFR § 425.400(c)(1)(ix); § 425.402. Assignment uses plurality of Medicare-allowed charges for primary-care service codes in the pinned JSON codeset. Step 1: primary care physicians + NP/PA/CNS. Step 2: physicians with specialty designations under § 425.402(c). This pin runs Steps 1–2 only (no expanded-window Step 3). PY2025 pin: two-step claims-based assignment (Step 1 PCP/NPP plurality, Step 2 specialist plurality). Primary-care code list excludes CY2026 APCM BHI/CoCM add-ons G0568–G0570. CMS Specs Version 13 also described an expanded-window Step 3 for PY2025; this JSON pins the two-step surface so PY2025 results remain replayable under the code+step combination ARKA shipped first."},{"id":"mssp-plurality","specVersion":"mssp-py2026-v1","description":"MSSP plurality assignment for PY2026 (3-step).","methodologyText":"Medicare Shared Savings Program claims-based assignment (adapter mssp-plurality, spec mssp-py2026-v1, performance year 2026). Implemented against: Shared Savings and Losses, Assignment, and Quality Performance Standard Methodology Specifications Version 14 (https://www.cms.gov/files/document/medicare-shared-savings-program-shared-savings-losses-assignment-methodology-specifications-version.pdf-0, retrieved 2026-08-07). Code list / methodology changes: CY2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F) — Medicare Shared Savings Program Changes (90 FR 49757; https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2026-medicare-physician-fee-schedule-final-rule-cms-1832-f-medicare-shared-savings, retrieved 2026-08-07). Regulation: 42 CFR § 425.400(c)(1)(x); § 425.402. Assignment uses plurality of Medicare-allowed charges for primary-care service codes in the pinned JSON codeset. Step 1: primary care physicians + NP/PA/CNS. Step 2: physicians with specialty designations under § 425.402(c). Step 3: expanded 24-month window for beneficiaries who fail the physician pre-step. PY2026+: three-step claims-based assignment. Step 3 uses the 24-month expanded window for beneficiaries who fail the physician pre-step. Primary-care code list adds APCM behavioral-health / CoCM add-ons G0568, G0569, G0570 per CY2026 PFS final rule; G0136 retained with revised descriptor."}]},"measureLibrary":[{"id":"lvi-lbp-imaging","displayName":"Imaging for non-specific low back pain within 6 weeks","serviceCodeCount":22,"indexCodeCount":6,"narrowExclusionCodeCount":17,"broadExclusionCodeCount":12,"licenceClass":"public-academic","citation":"Schwartz AL, Landon BE, Elshaug AG, Chernew ME, McWilliams JM. Measuring Low-Value Care in Medicare. JAMA Intern Med. 2014;174(7):1067-76. ICD-10 carry-forward: Updating a Claims-Based Measure of Low-Value Services Applicable to Medicare Fee-for-Service Beneficiaries. J Gen Intern Med. 2022.","status":"active"},{"id":"lvi-headache-imaging","displayName":"Head imaging for uncomplicated headache","serviceCodeCount":6,"indexCodeCount":6,"narrowExclusionCodeCount":15,"broadExclusionCodeCount":10,"licenceClass":"public-academic","citation":"Schwartz AL, Landon BE, Elshaug AG, Chernew ME, McWilliams JM. Measuring Low-Value Care in Medicare. JAMA Intern Med. 2014;174(7):1067-76. ICD-10 carry-forward: Updating a Claims-Based Measure of Low-Value Services Applicable to Medicare Fee-for-Service Beneficiaries. J Gen Intern Med. 2022.","status":"active"},{"id":"lvi-syncope-imaging","displayName":"Head imaging for syncope","serviceCodeCount":6,"indexCodeCount":1,"narrowExclusionCodeCount":11,"broadExclusionCodeCount":8,"licenceClass":"public-academic","citation":"Schwartz AL, Landon BE, Elshaug AG, Chernew ME, McWilliams JM. Measuring Low-Value Care in Medicare. JAMA Intern Med. 2014;174(7):1067-76. ICD-10 carry-forward: Updating a Claims-Based Measure of Low-Value Services Applicable to Medicare Fee-for-Service Beneficiaries. J Gen Intern Med. 2022.","status":"active"},{"id":"lvi-preop-cxr","displayName":"Preoperative chest radiography before low-risk surgery","serviceCodeCount":4,"indexCodeCount":10,"narrowExclusionCodeCount":12,"broadExclusionCodeCount":7,"licenceClass":"public-academic","citation":"Schwartz AL, Landon BE, Elshaug AG, Chernew ME, McWilliams JM. Measuring Low-Value Care in Medicare. JAMA Intern Med. 2014;174(7):1067-76. ICD-10 carry-forward: Updating a Claims-Based Measure of Low-Value Services Applicable to Medicare Fee-for-Service Beneficiaries. J Gen Intern Med. 2022.","status":"active"},{"id":"lvi-preop-echo","displayName":"Preoperative echocardiography before low-risk surgery","serviceCodeCount":6,"indexCodeCount":10,"narrowExclusionCodeCount":12,"broadExclusionCodeCount":7,"licenceClass":"public-academic","citation":"Schwartz AL, Landon BE, Elshaug AG, Chernew ME, McWilliams JM. Measuring Low-Value Care in Medicare. JAMA Intern Med. 2014;174(7):1067-76. ICD-10 carry-forward: Updating a Claims-Based Measure of Low-Value Services Applicable to Medicare Fee-for-Service Beneficiaries. J Gen Intern Med. 2022.","status":"active"},{"id":"lvi-preop-stress","displayName":"Preoperative stress testing before low-risk non-cardiac surgery","serviceCodeCount":9,"indexCodeCount":10,"narrowExclusionCodeCount":10,"broadExclusionCodeCount":5,"licenceClass":"public-academic","citation":"Schwartz AL, Landon BE, Elshaug AG, Chernew ME, McWilliams JM. Measuring Low-Value Care in Medicare. JAMA Intern Med. 2014;174(7):1067-76. ICD-10 carry-forward: Updating a Claims-Based Measure of Low-Value Services Applicable to Medicare Fee-for-Service Beneficiaries. J Gen Intern Med. 2022.","status":"active"},{"id":"lvi-sinusitis-imaging","displayName":"Imaging for uncomplicated acute rhinosinusitis","serviceCodeCount":5,"indexCodeCount":5,"narrowExclusionCodeCount":17,"broadExclusionCodeCount":13,"licenceClass":"public-academic","citation":"Schwartz AL, Landon BE, Elshaug AG, Chernew ME, McWilliams JM. Measuring Low-Value Care in Medicare. JAMA Intern Med. 2014;174(7):1067-76. ICD-10 carry-forward: Updating a Claims-Based Measure of Low-Value Services Applicable to Medicare Fee-for-Service Beneficiaries. J Gen Intern Med. 2022.","status":"active"},{"id":"lvi-asympt-cardiac","displayName":"Cardiac stress testing/imaging in asymptomatic patients without cardiac risk factors","serviceCodeCount":11,"indexCodeCount":4,"narrowExclusionCodeCount":12,"broadExclusionCodeCount":6,"licenceClass":"public-academic","citation":"Schwartz AL, Landon BE, Elshaug AG, Chernew ME, McWilliams JM. Measuring Low-Value Care in Medicare. JAMA Intern Med. 2014;174(7):1067-76. ICD-10 carry-forward: Updating a Claims-Based Measure of Low-Value Services Applicable to Medicare Fee-for-Service Beneficiaries. J Gen Intern Med. 2022.","status":"active"},{"id":"lvi-carotid-asympt","displayName":"Carotid artery imaging in asymptomatic patients","serviceCodeCount":6,"indexCodeCount":5,"narrowExclusionCodeCount":7,"broadExclusionCodeCount":6,"licenceClass":"public-academic","citation":"Schwartz AL, Landon BE, Elshaug AG, Chernew ME, McWilliams JM. Measuring Low-Value Care in Medicare. JAMA Intern Med. 2014;174(7):1067-76. ICD-10 carry-forward: Updating a Claims-Based Measure of Low-Value Services Applicable to Medicare Fee-for-Service Beneficiaries. J Gen Intern Med. 2022.","status":"active"},{"id":"lvi-repeat-ctap","displayName":"CT/MR abdomen-pelvis repeated within the episode window","serviceCodeCount":15,"indexCodeCount":10,"narrowExclusionCodeCount":12,"broadExclusionCodeCount":6,"licenceClass":"public-academic","citation":"Schwartz AL, Landon BE, Elshaug AG, Chernew ME, McWilliams JM. Measuring Low-Value Care in Medicare. JAMA Intern Med. 2014;174(7):1067-76. ICD-10 carry-forward: Updating a Claims-Based Measure of Low-Value Services Applicable to Medicare Fee-for-Service Beneficiaries. J Gen Intern Med. 2022.","status":"active","implementation":"delegated:lib/aiie/episode-dedup"},{"id":"lvi-msk-early-mri","displayName":"Advanced imaging for uncomplicated musculoskeletal pain within the conservative-therapy window","serviceCodeCount":14,"indexCodeCount":9,"narrowExclusionCodeCount":8,"broadExclusionCodeCount":6,"licenceClass":"public-academic","citation":"Schwartz AL, Landon BE, Elshaug AG, Chernew ME, McWilliams JM. Measuring Low-Value Care in Medicare. JAMA Intern Med. 2014;174(7):1067-76. ICD-10 carry-forward: Updating a Claims-Based Measure of Low-Value Services Applicable to Medicare Fee-for-Service Beneficiaries. J Gen Intern Med. 2022.","status":"active"}],"riskModel":{"modelId":"cms-hcc-v28+elixhauser-nb","equation":"low_value_events ~ NegBin(mu, theta)\nlog(mu) = b0 + b_age + b_sex + b_dual + b_institutional + b_raf\n          + b_elixhauser + b_panel_acuity + b_specialty + u_clinician\n          + offset(log(attributed_member_months))\nu_clinician ~ N(0, sigma_u^2)","covariates":["age","sex","dual","institutional","raf","elixhauser","panel_acuity","specialty","u_clinician"],"softwareVersions":{"engineVersion":"tcoc-1.0.3","rateModelId":"cms-hcc-v28+elixhauser-nb","hccinfhir":"0.3.3","hccpy":"0.1.9","elixhauserRefined":"v2026.1","ahrqCcsr":"v2026.1","cmsPhysicianPufDataYear":2024,"cmsPhysicianPufReleaseFile":"PHY_R26_P05_V10_D24_Prov_Svc.csv","cmsPhysicianPufRetrievedIso":"2026-08-07","scipy":"1.13.1","statsmodels":"0.14.4"},"specUrl":"/evidence/methodology#risk-adjustment-specification"},"reliability":{"honestParagraph":"Reliability adjustment shrinks each clinician's rate toward the peer average in proportion to how precisely it is measured. A clinician with 400 attributed members moves very little; one with 35 moves a great deal. This makes the comparison fairer and it makes our estimate of the total opportunity SMALLER than the unadjusted number. We show both. The unadjusted figure is the one most vendors report."},"concentration":{"caption":"The dashed (raw) curve is biased upward by measurement error; the solid (reliability-adjusted) curve shrinks noisy small-panel rates toward the peer mean and is the figure we lead with.","footnote":"When the ranking measure is observed with error, the empirical Lorenz curve exaggerates concentration and the Gini coefficient is biased upward (Moskowitz CS, Venkatraman ES, Begg CB. Estimating the empirical Lorenz curve and Gini coefficient in the presence of error with nested data. Biostatistics. 2008. PMID 18172873). We therefore report both curves and lead with the reliability-adjusted figure.","citation":"Moskowitz CS, Venkatraman ES, Begg CB. Estimating the empirical Lorenz curve and Gini coefficient in the presence of error with nested data. Biostatistics. 2008. PMID 18172873."},"cits":{"preRegistrationCommitment":"The analysis plan is written to a file, hashed, and the hash stored on BaselineLock before any peer packet is sent. Changing a locked baseline requires a superseding lock row with a written reason — never UPDATE or DELETE. Module 2 delivery refuses tenants without a lock (invariant I11).","analysisPlan":{"primaryEndpoint":"Difference in slope change between intervention and control after the interruption (β7 — group × time_since_intervention)","model":"controlled-segmented-regression","equation":"Y_t = β0 + β1·time_t + β2·intervention_t + β3·(time_since_intervention)_t + β4·group + β5·(group × time_t) + β6·(group × intervention_t) + β7·(group × time_since_intervention_t) + seasonality + ε_t","outcomeDefinition":"Risk- and reliability-adjusted low-value advanced-imaging events per 1,000 attributed member-months","denominator":"attributed_member_months","distribution":"negative-binomial","autocorrelation":"prais-winsten","sensitivityAnalyses":["Newey–West HAC standard errors (reported sensitivity; not primary)","Quasi-binomial proportion model","Alternate transition window (0 / 2 months)"],"seasonalityTerms":{"harmonics":2,"periodMonths":12},"transitionWindowMonths":1,"minimumPrePeriods":12,"minimumPostPeriods":12,"controlGroupDefinition":"Matched non-participating clinicians in the same organisation (Vol III §17 Study 2), enumerated and fixed before any peer packet is sent (Part A.8 / Wagner 12/12).","matchingVariables":["specialty","panel_size_decile","pre_period_rate_decile","attributed_member_months","mean_panel_raf"],"parallelTrendsTest":"Pre-period OLS interaction of treatment × time on group-month means; fail closed if the Wald CI excludes 0 at α = 0.05","multiplicityHandling":"Primary estimand (β7) pre-registered; secondary measures and sensitivities reported without claim of family-wise error control","stoppingRules":"No interim looks; analysis runs only after the sealed post-period month count is reached and the baseline lock is in force","arms":[]}},"sourceRegister":{"path":"docs/arka-tcoc/SOURCE_REGISTER.md","rows":[{"source":"Schwartz AL, Landon BE, Elshaug AG, Chernew ME, McWilliams JM. Measuring Low-Value Care in Medicare. *JAMA Intern Med.* 2014;174(7):1067-76.","type":"Peer-reviewed measure specification (31 services; narrow/broad)","licenceStatus":"`public-academic`","coiClass":"`independent-academic`","version":"2014 print; methods supplement","dateRetrieved":"2026-08-07","whereUsed":"`lib/tcoc/measures/definitions/` — primary anchor for all eleven LVI measures; cited in `docs/arka-tcoc/SPEC.md` §4"},{"source":"Updating a Claims-Based Measure of Low-Value Services Applicable to Medicare Fee-for-Service Beneficiaries. *J Gen Intern Med.* 2022.","type":"Peer-reviewed ICD-9→ICD-10 GEM carry-forward + programming code","licenceStatus":"`public-academic`","coiClass":"`independent-academic`","version":"2022 JGIM","dateRetrieved":"2026-08-07","whereUsed":"`lib/tcoc/measures/definitions/` — ICD-10 codesets; evaluator coding-era path"},{"source":"Milliman MedInsight Health Waste Calculator (with VBID Health)","type":"Commercial proprietary waste algorithm","licenceStatus":"**`licensed-do-not-embed`** — do not embed, reverse-engineer or “model”","coiClass":"`commercial-competitor`","version":"Named comparator only; no version embedded","dateRetrieved":"2026-08-07","whereUsed":"Source Register + SPEC §4 only; `lib/tcoc/measures/measure-schema.ts` rejects `licenceClass: licensed-do-not-embed` definitions that ship codesets"},{"source":"NCQA HEDIS — e.g. Use of Imaging Studies for Low Back Pain (LBP)","type":"Licensed quality measure / value sets","licenceStatus":"`licensed-do-not-embed` — reference by name only; do not ship value sets","coiClass":"`standards-body`","version":"HEDIS MY as published by NCQA (not embedded)","dateRetrieved":"2026-08-07","whereUsed":"Named in SPEC §4 / clinician-facing disclaimers only; no value-set import under `lib/tcoc/`"},{"source":"USPSTF D-rated services","type":"Federal recommendation grades","licenceStatus":"`federal-public`","coiClass":"`federal-public`","version":"USPSTF current as of retrieval","dateRetrieved":"2026-08-07","whereUsed":"Deferred non-imaging expansion (Vol III §25.3 item 41); not in Phase 4 eleven"},{"source":"Choosing Wisely (ABIM Foundation)","type":"Recommendation corpus / mark","licenceStatus":"Recommendations public; mark held by ABIM Foundation — cite, do not brand","coiClass":"`standards-body`","version":"Recommendation texts as cited per measure","dateRetrieved":"2026-08-07","whereUsed":"Provenance citations on measure definitions; no Choosing Wisely branding in UI"},{"source":"MedPAC low-value care analyses (Schwartz measures applied to Medicare)","type":"Federal advisory published rates","licenceStatus":"`federal-public`","coiClass":"`federal-public`","version":"Report year matched to measure-year under test","dateRetrieved":"2026-08-07","whereUsed":"`tools/tcoc/src/benchmarks.json` + `docs/arka-tcoc/MEASURE_VALIDATION.md` (Prompt 4.5) — national rate check vs public samples"},{"source":"CMS-HCC V28 (payment year 2024+; full phase-in 2026)","type":"Federal risk-adjustment model","licenceStatus":"`federal-public`","coiClass":"`federal-public`","version":"V28","dateRetrieved":"2026-08-07","whereUsed":"`lib/tcoc/stats/risk-covariates.ts`; `RiskAdjustmentSpec.modelId` = `cms-hcc-v28+elixhauser-nb`"},{"source":"`hccinfhir` (mimilabs)","type":"Open-source HCC scoring (FHIR EOB / X12 / diagnoses)","licenceStatus":"Open-source (package licence as published on install)","coiClass":"`open-source-tool`","version":"`0.3.3`","dateRetrieved":"2026-08-07","whereUsed":"`ml-service/tcoc/risk.py` — primary HCC engine; version into `softwareVersions`"},{"source":"`hccpy`","type":"Open-source HCC scoring fallback (V22/V24/V28, ESRD, HHS-HCC)","licenceStatus":"Open-source (package licence as published on install)","coiClass":"`open-source-tool`","version":"`0.1.9`","dateRetrieved":"2026-08-07","whereUsed":"`ml-service/tcoc/risk.py` — fallback HCC engine"},{"source":"AHRQ Elixhauser Comorbidity Software Refined","type":"Federal comorbidity classification","licenceStatus":"`federal-public`","coiClass":"`federal-public`","version":"Refined ICD-10-CM `v2026.1`","dateRetrieved":"2026-08-07","whereUsed":"`ml-service/tcoc/elixhauser.py`; fetch ZIP `CMR-v2026-1.zip`"},{"source":"AHRQ CCSR (Clinical Classifications Software Refined)","type":"Federal diagnosis grouping","licenceStatus":"`federal-public`","coiClass":"`federal-public`","version":"`v2026.1` (DXCCSR)","dateRetrieved":"2026-08-07","whereUsed":"`lib/tcoc/measures/cohorts.ts`; fetch via `npm run tcoc:fetch-ccsr` → `lib/tcoc/measures/data/ccsr-v2026.1.csv` (gitignored, >20 MB); packet gap cohorts"},{"source":"Meeker D et al. Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing. *JAMA.* 2016.","type":"Cluster-RCT (peer comparison arm)","licenceStatus":"Published academic","coiClass":"`trial-evidence`","version":"2016; 47 practices / 248 clinicians / 18 months","dateRetrieved":"2026-08-07","whereUsed":"`lib/tcoc/content/nudge-evidence.ts`; SPEC §7; peer packet contract"},{"source":"Meeker D et al. durability follow-up. *JAMA.* 2017.","type":"Post-removal durability of peer comparison","licenceStatus":"Published academic","coiClass":"`trial-evidence`","version":"2017 (12 months post-removal)","dateRetrieved":"2026-08-07","whereUsed":"`lib/tcoc/content/nudge-evidence.ts`; `lib/tcoc/stats/persistence.ts`; SPEC §7"},{"source":"Brehaut JC et al. Practice Feedback Interventions: 15 Suggestions for Optimizing Effectiveness. *Ann Intern Med.* 2016;164(6):435-441.","type":"Feedback-design guidance","licenceStatus":"Published academic","coiClass":"`independent-academic`","version":"2016;164(6)","dateRetrieved":"2026-08-07","whereUsed":"`lib/tcoc/peer/packet-types.ts` — named alternative, key messages, actionable suggestion"},{"source":"Ivers N et al. Audit and feedback: effects on professional practice (Cochrane).","type":"Systematic review (effect-size honesty)","licenceStatus":"Published / Cochrane","coiClass":"`independent-academic`","version":"Most recently updated 2025 per build book","dateRetrieved":"2026-08-07","whereUsed":"Methodology / evidence copy; counterweight quote in materials"},{"source":"Medicare Physician & Other Practitioners — by Provider and Service (`data.cms.gov`)","type":"Public claims PUF (NPI × HCPCS)","licenceStatus":"`federal-public`","coiClass":"`federal-public`","version":"CMS release year under ingest","dateRetrieved":"2026-08-07","whereUsed":"`lib/tcoc/ingest/adapters/cms-physician-other-practitioners.ts` — pricing, specialty benchmarks; `lib/tcoc/attribution/excluded-specialties.ts` — Tier-2 specialty exclusion labels from `Rndrng_Prvdr_Type`"},{"source":"Medicare Physician & Other Practitioners — by Geography & Service","type":"Public claims PUF (geo × HCPCS)","licenceStatus":"`federal-public`","coiClass":"`federal-public`","version":"CMS release year under ingest","dateRetrieved":"2026-08-07","whereUsed":"`lib/tcoc/ingest/` + ledger dollar / specialty benchmark paths — state/national band"},{"source":"CMS DE-SynPUF (Data Entrepreneurs’ Synthetic PUF)","type":"Synthetic beneficiary-level claims","licenceStatus":"`federal-public` (synthetic)","coiClass":"`federal-public`","version":"2008–2010 5% / 20 datasets","dateRetrieved":"2026-08-07","whereUsed":"`lib/tcoc/ingest/adapters/de-synpuf.ts` — pipeline proof (attribution, HCC, CITS)"},{"source":"Synthea (MITRE) + CMS RIF exporter","type":"Synthetic longitudinal FHIR + ICD-10 claims","licenceStatus":"Open-source (Synthea licence as published)","coiClass":"`open-source-tool`","version":"Seed `SYNTHEA_GOLDEN_SEED` (`lib/tcoc/ingest/adapters/synthea.ts`); jar pinned at gen time","dateRetrieved":"2026-08-07","whereUsed":"`lib/tcoc/ingest/adapters/synthea.ts`; `tools/tcoc/src/gen-synthea.ts` — ICD-10 bridge; Module 1 ↔ IRE join tests"},{"source":"MSSP / ACO Shared Savings Program PUFs","type":"ACO-level expenditure & utilisation benchmarks","licenceStatus":"`federal-public`","coiClass":"`federal-public`","version":"Performance year under calibration","dateRetrieved":"2026-08-07","whereUsed":"`lib/tcoc/ledger/dollars.ts` — organisation-level dollar-model calibration constants"},{"source":"CMS ordering/referring NPI enforcement (advanced imaging; PECOS; Item 17b / K3)","type":"Federal claims policy / data dictionary","licenceStatus":"`federal-public`","coiClass":"`federal-public`","version":"Policy effective 2014-01-06; dictionaries as retrieved","dateRetrieved":"2026-08-07","whereUsed":"SPEC §3 attribution ladder; `NormalizedClaimLine.orderingOrReferringNpi`"},{"source":"Wagner / Fretheim / Penfold / Cochrane EPOC ITS guidance","type":"Methodological standards for interrupted time series","licenceStatus":"Published academic / Cochrane EPOC","coiClass":"`independent-academic`","version":"As cited in Part A.8 (Wagner 12/12 default)","dateRetrieved":"2026-08-07","whereUsed":"`docs/arka-tcoc/SPEC.md` §8; `lib/tcoc/baseline/analysis-plan.ts` Part A.8 defaults"},{"source":"AWS SES (HIPAA-eligible under AWS BAA; opportunistic TLS by default)","type":"Commercial email transport","licenceStatus":"Commercial — BAA via AWS; reconfirm before each deployment","coiClass":"`commercial-competitor` (subprocessor)","version":"SES docs as of 2026-08-07","dateRetrieved":"2026-08-07","whereUsed":"`lib/tcoc/delivery/adapters/ses.ts`; `docs/arka-tcoc/EMAIL_VENDOR_NOTE.md`"},{"source":"Paubox Email API (BAA with every customer; TLS 1.2+ by default)","type":"Commercial healthcare email","licenceStatus":"Commercial — vendor BAA; reconfirm before each deployment","coiClass":"`commercial-competitor` (subprocessor)","version":"Paubox posture as of 2026-08-07","dateRetrieved":"2026-08-07","whereUsed":"`lib/tcoc/delivery/adapters/paubox.ts`; `docs/arka-tcoc/EMAIL_VENDOR_NOTE.md`"}]}}