Member

A CMS regulatory framework determining when Medicare pays secondary to other insurance coverage, such as employer group health plans or workers' compensation. MSP data is captured in eligibility and COB records within claims systems, with MSP reason codes on 837 transactions driving primary payer routing and claim adjudication sequencing logic.

An individual enrolled in a health insurance plan sponsored by an employer, government program, or individual market. Members are identified by member ID in healthcare data systems and are the primary unit of analysis in enrollment, eligibility, utilization, and quality reporting.

The given name of a health plan enrollee captured during enrollment intake, stored in payer and PBM systems. Data engineers rely on this field for member deduplication, probabilistic matching across EHR and claims platforms, and populating member dimension tables in enterprise healthcare data warehouses.

A unique numeric identifier assigned to a health plan member for identification within a specific insurance plan. Used on insurance cards, claims submissions, and eligibility verification transactions. Distinct from the member surrogate key used internally in healthcare data warehouse systems.

Full legal name of the health plan member as captured in enrollment, adjudication, and EHR systems. Used by data engineers for member identity resolution, record linkage, and compliance reporting across PBM and eligibility platforms.

A porous filtration device used in pharmaceutical compounding and laboratory processing to remove microbial contaminants from drug solutions. Referenced in pharmacy compounding records and quality control datasets within EHR and health system laboratory information systems.

The dollar amount remitted by a primary insurer in a coordination of benefits scenario, captured in pharmacy claims (NCPDP field 431-DV) and medical claims to calculate secondary payer liability, reduce duplicate payment risk, and reconcile COB transactions in PBM and payer adjudication systems.

The account reference number for a individual receiving medical care. Used as a unique reference to identify and track the patient across healthcare systems. This field is commonly used in electronic health records (EHR), healthcare information systems (HIS), and clinical data warehouses for patient management and reporting.

A pain management method allowing patients to self-administer controlled doses of analgesic medication through a pump device. Used in inpatient clinical settings for post-surgical and chronic pain management. Documented in EHR medication administration records and clinical data warehouses as a medication order type.

Documented pharmacist-provided medication guidance captured in pharmacy and PBM systems, including drug interactions, dosage instructions, and adherence advice. Used in clinical quality reporting, MTM program tracking, and CMS Star Ratings analytics within pharmacy data pipelines.

The payment received value for a individual receiving medical care. Used to capture financial data associated with patient transactions. This field is commonly used in electronic health records (EHR), healthcare information systems (HIS), and clinical data warehouses for patient management and reporting.

A standardized code identifying the patient's relationship to the insurance subscriber in claims and eligibility systems, using X12 values such as 18=Self, 01=Spouse, and 19=Child. Used by data engineers to correctly attribute claim costs, validate member eligibility, and model family benefit structures in payer data systems.

The calculated dollar amount a patient owes after insurance adjudication in claims systems, comprising deductibles, copays, and coinsurance components. Data engineers use this field in EOB processing, cost-sharing analytics, and financial reconciliation pipelines across payer and provider billing platforms.

The internal database identifier or industry-standard code, such as NAIC or NPPES payer ID, uniquely identifying an insurance payer within claims, EDI 837/835 transactions, and EHR systems. Critical for routing, adjudication, remittance matching, and payer-level analytics in healthcare data engineering workflows.

The full legal or trade name of the insurance company transmitted in EDI 837 Loop 2010BB as the payer entity responsible for claim reimbursement. Used in claims processing, remittance reconciliation, and payer contract analytics within clearinghouse, EHR, and revenue cycle management data systems.

A healthcare cost and utilization metric expressing the average expenditure or resource use per enrolled member on a monthly basis. Widely used in actuarial analysis, capitation payment calculations, and population health management. Standard unit of measurement in Medicare Advantage and Medicaid managed care financial reporting.

A healthcare cost and utilization metric expressing the average expenditure or resource use per enrolled member on an annual basis. Used in actuarial modeling, benefit design, and population health analytics to understand annualized cost trends. Calculated by multiplying PMPM by 12 months.

A health insurance plan certified by a state or federal exchange to meet ACA essential health benefit requirements and offer coverage through the Health Insurance Marketplace. QHP certification requires compliance with network adequacy, quality reporting, and consumer protection standards set by CMS.

A federally defined window outside Open Enrollment allowing eligible members to enroll in ACA marketplace, employer-sponsored, or Medicaid plans after qualifying life events. EHR and enrollment systems capture SEP reason codes (marriage, job loss, birth) to validate coverage start dates and ensure regulatory compliance.

The unique identification number assigned to the primary insured individual, referenced as Loop 2010BA in X12 EDI 837 transactions. Foundational key used by data engineers to join member enrollment, claims, eligibility, and pharmacy records across payer, PBM, and clearinghouse systems.