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- README.md: pending edit committed (adds Catches the denial before it happens lead per CONSISTENCY canon) - reference/README.md: new — explains the 8 reference modules + methodology-vs-weights distinction Co-Authored-By: Claude Opus 4.7 (1M context) <noreply@anthropic.com>
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README.md

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# upstream-community
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**Catches the denial before it happens.** Open-source tooling for healthcare operators who need early-warning payer behavior intelligence.
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### Open ML reference implementations for healthcare denial detection.
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The statistical and ML methodology behind Upstream's Care Intelligence Platform. Public CMS data only. No production model weights. No proprietary payer data. No PHI.

reference/README.md

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# Reference Implementations
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Open-source reference modules for the statistical and ML methods Upstream uses in production. All modules use public CMS data only — no PHI, no proprietary payer data, no production model weights.
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## Modules
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| Module | What it demonstrates |
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|---|---|
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| `aba_auth_predictor.py` | Gradient-boosting prior auth approval prediction for ABA therapy. Temporal cross-validation. |
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| `carc_rarc_utils.py` | CARC/RARC denial code registry from public CMS lists. Lookup, classification, severity scoring. |
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| `denial_clustering.py` | K-means clustering of denial patterns using CARC codes. Chi-square baseline comparison for industry signal detection. |
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| `denial_prediction_reference.py` | CatBoost denial prediction with temporal cross-validation and SHAP explainability. The core methodology Upstream uses in production. |
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| `dental_denial_clustering.py` | CDT-code cluster detection for dental billing. Downcoding, bundling, and frequency-limit pattern detection. |
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| `drift_detection_reference.py` | Payer behavioral drift detection — the core signal that Upstream's DriftWatch engine is built on. Chi-square + Kolmogorov-Smirnov tests. |
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| `payer_behavior_detector.py` | Statistical detection of payer adjudication shifts. Chi-square for categorical changes (denial rate by CARC code). |
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## Methodology vs. weights
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These reference modules show **how** Upstream detects payer behavior changes. They do not include production model weights, payer-specific training data, or any PHI. To use the methodology with your own data, follow the notebooks in `../notebooks/` for end-to-end walkthroughs.
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## Running locally
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```bash
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# From the repo root
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pip install -r requirements.txt
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# Run a single module
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python -m reference.denial_prediction_reference
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# Or import in a notebook
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from reference.drift_detection_reference import detect_drift
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```
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## Contributing
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Add new reference implementations that demonstrate methodology with public data. See the org-wide `CONTRIBUTING.md` and the `upstream-community` repo `CONTRIBUTING.md` for the contribution model.
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PHI in any contribution will be rejected. Synthetic data only. Document your data source in any new module.

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