Member

A federally and state-funded insurance program providing coverage to low-income children, administered through Medicaid or separate state programs. Member enrollment systems track CHIP eligibility segments, plan codes, and income-based qualifying criteria, while claims data uses specific payer IDs and CMS program identifiers for adjudication and reporting.

The member-borne percentage of covered healthcare service costs applied after the deductible is met, typically 20%, stored in benefits configuration tables within PBM, claims adjudication, and member enrollment systems. COINS values drive cost-share calculations in EOB generation, remittance advice, and member liability reporting.

A high-deductible health plan design paired with tax-advantaged accounts such as HSA or HRA, tracked in member enrollment and PBM systems. Data engineers use CDHP enrollment indicators to segment claims, apply deductible logic, and model member cost-sharing accurately.

A process used by payers, EHR systems, and claims platforms to determine payment order when a member holds multiple health plans. COB data is stored in eligibility files (834 transactions), adjudication engines, and PBM systems to prevent duplicate payments and ensure correct primary/secondary payer sequencing.

An entity—such as an employer group, health plan sponsor, broker, or government agency—that contracts with a healthcare payer, PBM, or managed care organization for benefit administration services. Referenced across enrollment, billing, and contract management systems to associate members and claims to a sponsoring account.

Digital version of the EOB document delivered to members or providers via online portals or secure email. Generated by payer systems after claims adjudication, detailing benefits applied, amounts paid, member cost-sharing, and denial reasons for each service rendered.

Real-time or batch process of confirming a member's active insurance coverage, benefit plan details, and cost-sharing obligations using ANSI X12 270/271 transactions or API calls. Critical in EHR, practice management, and claims systems to validate coverage prior to service delivery and reduce claim denials.

Organization-wide patient identity repository spanning all facilities, EHR instances, and ancillary systems. EMPI links disparate patient identifiers — MRNs, member IDs, SSNs — into a single golden record, enabling data engineers to resolve duplicate records and support enterprise-wide interoperability across Epic, Cerner, claims, and PBM platforms.

A legal document issued by health plans or insurers detailing the benefits, exclusions, cost-sharing, and coverage rules for enrolled members. Used in EHR, member enrollment, and claims systems to validate benefit eligibility and resolve coverage disputes during adjudication.

A statement sent by a health insurance company to covered individuals explaining what medical treatments and services were paid for, including billed amounts, allowed amounts, plan payments, and member liability. Generated from claims adjudication systems and used by data engineers to reconcile remittance data in EHR and claims platforms.

A medical device or biological material surgically placed within the body, documented in EHR procedure records, claims, and device registries using ICD-10-PCS, CPT, and UDI codes. Implant data is tracked across supply chain, claims adjudication, and post-market surveillance systems for recall management and outcomes reporting.

A network model where independent physician practices contract together to negotiate with health plans and provide coordinated care while maintaining practice independence. IPAs allow small practices to participate in managed care contracts and value-based payment arrangements that require network scale.

The maximum cumulative dollar amount a health plan will reimburse for covered services over a member's lifetime, stored as LTM in member enrollment and benefits configuration data within health plan and PBM systems. Post-ACA, lifetime maximums are prohibited for essential health benefits but remain applicable in certain specialty or ancillary benefit structures.

Enterprise-wide index that links multiple patient identifiers across EHR, claims, pharmacy, and enrollment systems into a single longitudinal patient view. Critical for data engineers performing patient-level joins across source systems where a patient may carry different MRNs, member IDs, or subscriber numbers across payers and facilities.

Medicare Advantage (MA), also known as Medicare Part C, is the private health plan alternative to traditional Medicare fee-for-service coverage, administered by CMS-approved commercial health plans. Medicare beneficiaries who choose Medicare Advantage enroll in a plan offered by an insurer such as UnitedHealthcare, Humana, CVS/Aetna, or Centene rather than receiving coverage directly from the federal government. Medicare Advantage plans receive monthly capitation payments from CMS for each enrolled member — the payment amount is risk-adjusted using the CMS-HCC model based on each member's demographic characteristics and documented chronic conditions. Plans must cover all Original Medicare benefits and may offer supplemental benefits such as dental, vision, hearing, and fitness programs. Medicare Advantage is the fastest-growing segment of the US healthcare market, covering more than 33 million beneficiaries as of 2025 — over half of all Medicare-eligible Americans. The financial stakes of MA data quality are enormous: a single RAF score point difference across a plan's membership can represent millions of dollars in capitation revenue annually. CMS audits MA plans through Risk Adjustment Data Validation (RADV) audits, which review medical records to verify that submitted HCC diagnoses are supported by clinical documentation from face-to-face encounters with eligible provider types. Plans with high error rates face recoupment of overpaid capitation amounts, making accurate risk adjustment data pipelines a direct revenue integrity concern. Healthcare data engineers working with Medicare Advantage data build and maintain the complete risk adjustment data lifecycle: claim ingestion from provider encounters, ICD-10 to HCC mapping using the CMS crosswalk, RAF score calculation using the CMS-HCC V28 model coefficients, encounter data submission to CMS through the Encounter Data Processing System (EDPS), and RADV audit support pipelines that retrieve supporting medical records. Key MA-specific data elements include the CMS contract ID (H-number), the plan benefit package (PBP) identifier, the risk adjustment processing system (RAPS) submission identifier, and the dual eligibility code that affects both capitation rates and member cost-sharing. Stars ratings, which depend heavily on HEDIS quality measure performance, are also a primary focus for MA data engineering teams because they determine quality bonus payments from CMS.

An 11-character alphanumeric identifier replacing the Social Security-based HICN on Medicare claims and eligibility files as of 2018. Stored in member enrollment and claims systems, the MBI is required on all CMS transactions including 837 claim submissions, 835 remittance files, and eligibility verification responses.

The Medicare benefit covering inpatient hospital, skilled nursing facility, hospice, and home health services. Enrollment and coverage data are stored in CMS eligibility files and payer member tables. Claims submitted under Part A use the UB-04 institutional format, with reimbursement based on MS-DRG and per diem rate structures.

The Medicare benefit covering outpatient physician services, durable medical equipment, and preventive care. Claims are submitted via CMS-1500 professional claim format using HCPCS and CPT codes. Part B enrollment flags are stored in eligibility and member enrollment tables, driving fee schedule lookups and coordination of benefits logic in claims systems.

The Medicare Advantage program allowing beneficiaries to receive Medicare benefits through CMS-contracted private health plans. Enrollment data flows through CMS's MARx system into payer member management platforms. Encounter data submissions replace traditional FFS claims, and risk adjustment RAF scores are calculated from diagnosis data using the CMS-HCC model.

The Medicare outpatient prescription drug benefit administered through CMS-contracted PDP and MA-PD plans. Pharmacy claims are processed through PBM systems using NCPDP transaction standards. Plan data including formulary tiers, coverage gap thresholds, and low-income subsidy flags are stored in benefit configuration and member enrollment tables.