Claims

Enterprise master identifier assigned to the insurer or insured member record through an identity resolution process, enabling consistent cross-system matching. Links member records across claims, enrollment, and clinical data sources while eliminating duplicate insurer entries.

Maximum benefit threshold applicable to the insured member's coverage, such as an out-of-pocket maximum or lifetime benefit limit defined in the health plan. Used during claims adjudication to determine when cost-sharing obligations cease or when benefit limits have been reached.

Middle name or initial of the insured member as captured during enrollment or policy application. Used in conjunction with first and last name fields to disambiguate members with common names during eligibility verification, claims matching, and coordination of benefits.

Minimum threshold value associated with the insured member's benefit structure, such as a deductible floor or minimum coverage amount defined in the health plan. Referenced during claims adjudication to determine when cost-sharing obligations begin for the member.

Mobile telephone number of the insured member on file with the health plan. Used to deliver outreach communications including appointment reminders, care gap alerts, enrollment confirmations, and urgent coverage notifications via SMS or automated voice messaging systems.

Username or system identifier of the user or automated process that last updated the insurer or member record. Captured as part of the audit trail to support data governance, compliance reviews, and troubleshooting of unexpected changes to enrollment or coverage records.

Calendar date on which the insurer or member record was most recently updated in the system. Used in audit logging, change data capture pipelines, and eligibility reconciliation processes to identify records altered since the last data extract or file transmission.

Timestamp indicating the exact time of day when the insurer or member record was last modified. Combined with the modified date field to provide a precise audit trail for compliance tracking, record versioning, and sequence-of-events analysis in enrollment systems.

Display name of the insurance carrier or insured member as shown in member portals, explanation of benefits statements, and eligibility inquiry responses. Derived from legal name fields and formatted for readability in member-facing and operational reporting contexts.

Assigned numeric identifier for the insured member's policy or membership record within the health plan's enrollment system. Serves as a primary reference on insurance cards, claims submissions, eligibility verification transactions, and provider billing systems.

Date on which the insured member's coverage or a specific benefit period became effective under the health plan. Used in eligibility verification, claims adjudication, and coordination of benefits processing to confirm that services rendered fall within an active coverage period.

Recorded blood oxygen saturation level of the insured member, typically captured during a health risk assessment or clinical encounter submitted to the health plan. Used by care management programs to identify members with respiratory conditions requiring targeted outreach or disease management intervention.

Dollar amount paid by the insurance carrier toward a covered claim after applying deductibles, copayments, coinsurance, and contractual adjustments. Recorded on remittance advice and used in financial reconciliation, cost reporting, and actuarial analysis of claim payment performance.

The date on which the insurance carrier remitted payment for a claim. Used in claims adjudication and reconciliation workflows to track payment timing, measure insurer responsiveness, and reconcile remittance advice against expected reimbursement schedules.

Identifies the parent insurance carrier or holding company to which a subsidiary insurer belongs. Used in member enrollment and claims systems to support hierarchical insurer relationships, enabling consolidated reporting, contract management, and network affiliation tracking across related insurance entities.

The dollar amount remitted by the insurance carrier toward a claim after adjudication, reflecting allowed amounts minus any member cost-sharing. Used in claims payment reconciliation to verify remittance accuracy and calculate provider reimbursement against billed charges.

Indicates the current processing state of a payment from the insurance carrier, such as pending, issued, denied, or reversed. Used in claims management workflows to monitor remittance activity, flag outstanding balances, and trigger follow-up actions for unresolved claim payments.

The proportion of covered costs the insurance carrier is responsible for paying after applicable deductibles and cost-sharing are applied. Used in benefits administration and claims adjudication to calculate insurer liability based on coinsurance terms defined in the member's plan.

The defined time interval during which an insurer's coverage, contract terms, or payment obligations are in effect. Used in member enrollment and claims processing to validate coverage dates, apply correct benefit plan terms, and ensure claims fall within active policy periods.

The contact telephone number for the insurance carrier, used by providers and members to reach the insurer for claims inquiries, authorizations, and eligibility verification. Stored in payer directories and enrollment systems to facilitate administrative communications.