Member

Identifies the specific health benefit plan tier or package that governs a member's coverage terms for specialist physician services, including applicable cost-sharing, referral requirements, and network restrictions as defined in the plan's summary of benefits.

The unique policy identifier associated with a member's health insurance coverage for specialist services. Used in claims adjudication and member eligibility systems to link specialist visit claims to the correct benefit plan and validate coverage at the time of service.

The member cost-sharing dollar amount applied under the standard benefit plan tier, representing the member's percentage-based obligation after the deductible is satisfied. Used in claims processing to calculate member liability for services covered under standard plan terms.

Indicates whether a member is actively enrolled in a standard-tier health benefit plan, reflecting their current eligibility state. Used in member enrollment systems to determine applicable benefit levels, cost-sharing structures, and coverage effective dates.

Identifies the standard-tier benefit package to which a member is enrolled, defining the baseline coverage terms, cost-sharing requirements, and network access rules. Used in enrollment and claims systems to apply the correct adjudication rules for covered services.

The unique identifier assigned to a member's standard-tier insurance policy. Used across claims, eligibility, and enrollment systems to associate transactions with the correct benefit plan, ensuring accurate adjudication and member cost-sharing calculations.

The coinsurance dollar amount reflected on a member's billing statement, representing the member's share of costs for covered services after the deductible has been applied. Used in patient billing systems to communicate and track member financial responsibility.

Reflects the enrollment eligibility status of a member as recorded on a billing or Explanation of Benefits statement at the time services were rendered. Used to validate coverage and reconcile billing discrepancies between claim adjudication and member enrollment records.

Identifies the health benefit plan associated with a member's billing or Explanation of Benefits statement, indicating which plan's terms governed the adjudication of services listed. Used to link statement line items to the correct benefit plan for payment reconciliation.

The insurance policy number printed on a member's billing statement or Explanation of Benefits, used to identify the health plan covering the services rendered. Enables members and providers to reference the correct policy when disputing charges or verifying claim adjudication.

The member's coinsurance dollar obligation for an inpatient hospital stay, calculated as a percentage of the allowed amount after any applicable deductible. Captured on inpatient claims and used in benefit administration to determine total member financial liability for a hospitalization.

Indicates a member's active enrollment status in a health plan during an inpatient hospital stay, confirming coverage eligibility for the duration of the admission. Used in claims adjudication to validate benefit entitlement and apply correct inpatient cost-sharing rules.

Identifies the health benefit plan governing coverage terms for a member's inpatient hospital stay, including applicable deductibles, coinsurance, length-of-stay limits, and prior authorization requirements. Used in inpatient claims processing to apply the correct benefit rules.

The insurance policy identifier linked to a member's inpatient hospital stay, used to validate coverage and adjudicate inpatient claims. Referenced in utilization management and claims systems to confirm authorization, apply benefit limits, and calculate member cost-sharing for the admission.

The member cost-sharing amount applicable to a specific drug strength in pharmacy benefit plans, where coinsurance varies by medication concentration or dosage tier. Used in pharmacy claims processing to calculate the member's financial obligation based on the dispensed drug strength.

Indicates whether a member's pharmacy benefit plan enrollment is active and covers a specific drug strength at the time of dispensing. Used in pharmacy benefit management systems to verify eligibility and determine applicable cost-sharing for a prescribed medication concentration.

Identifies the pharmacy benefit plan associated with coverage for a specific drug strength or concentration, defining formulary placement, tier cost-sharing, and quantity limits. Used in pharmacy claims adjudication to apply the correct benefit rules for the dispensed medication dosage.

The pharmacy benefit policy identifier tied to coverage for a specific drug strength, used to validate member eligibility and adjudicate pharmacy claims at point of dispensing. Links the prescribed drug concentration to the correct formulary and cost-sharing terms within the member's plan.

The dollar amount a patient is responsible for paying as their share of costs for a diagnostic imaging study after the deductible has been met. Calculated as a percentage of the allowed amount per the member's health plan benefit structure, captured at the imaging encounter level.

Indicates whether a diagnostic imaging study is actively enrolled, pending, completed, or cancelled within a clinical trial or research protocol. Used in research data systems to track a study's current lifecycle state for regulatory compliance and participant management reporting.