Member

The insurance policy identifier tied to coverage for services that require documented patient consent prior to administration. Used in claims processing to link consent-required procedures to the correct payer contract, supporting accurate benefit determination and reimbursement for authorized treatments.

The member's coinsurance dollar liability for specialist consultation services after the deductible is satisfied. Calculated as the member's contracted percentage of the allowed amount for the consultation claim, reflecting cost-sharing obligations under the member's health plan for referred specialist encounters.

The member's health plan enrollment state at the time a specialist consultation was performed or requested. Used during claims adjudication to verify active coverage eligibility for consultation services, ensuring benefits are applied correctly when primary care providers refer members to specialists.

The health insurance plan under which specialist consultation services are covered and reimbursed. Identifies the benefit tier, network requirements, referral authorization rules, and cost-sharing structure applicable to consultation claims, ensuring correct adjudication of specialist visit encounters billed to the member's plan.

The insurance policy identifier associated with coverage for specialist consultation services. Used to link consultation claims to the correct payer contract during adjudication, supporting referral authorization verification, network status confirmation, and accurate reimbursement for specialist opinion encounters.

The member's coinsurance dollar amount owed for covered single-use medical supply items such as wound dressings, syringes, or ostomy supplies. Represents the member's cost-sharing percentage of the allowed amount after deductible for consumable supplies billed on durable medical equipment or outpatient claims.

Indicates the member's health plan enrollment state at the time single-use medical supplies were dispensed or billed. Used to confirm active coverage eligibility when processing claims for consumable items such as catheters, bandages, or diabetic testing supplies under medical or DME benefits.

The health insurance plan under which single-use medical supply items are covered, identifying the applicable benefit category, coverage limits, and cost-sharing rules. Used in claims adjudication to determine reimbursement eligibility for consumable supplies billed under durable medical equipment or outpatient supply benefits.

Unique policy identifier assigned to a single-use medical supply item, such as wound dressings, syringes, or IV tubing. Used in billing and inventory systems to link consumable supply charges to the correct insurance policy for reimbursement and cost tracking.

Indicates whether a member is currently enrolled in a copayment structure under their health plan. Tracks active, inactive, pending, or terminated states within member enrollment records, determining the fixed out-of-pocket amount a member owes at the point of service for covered benefits.

The dollar amount representing the member's coinsurance responsibility for mental health counseling services after the deductible is met. Captured on claims and remittance records to reflect the percentage-based cost-sharing split between the health plan and the member for licensed counselor visits.

Reflects the current participation status of a licensed mental health counselor within a health plan's network or credentialing system. Indicates whether the counselor is actively enrolled, pending credentialing, suspended, or terminated from the plan's behavioral health provider panel.

The specific health benefit plan under which a licensed mental health counselor is contracted and credentialed to provide services. Used in behavioral health enrollment and claims systems to link the counselor to the correct plan tier, reimbursement schedule, and covered service rules.

The unique policy identifier associated with a licensed mental health counselor's participation agreement or malpractice coverage within a health plan or credentialing system. Used to track and verify the counselor's insurance and enrollment credentials across behavioral health administrative systems.

A binary flag indicating whether a member's insurance coverage is currently active and in force. Used in eligibility and enrollment systems to determine whether claims submitted for a specific coverage period should be adjudicated or rejected due to lapsed, terminated, or future-dated coverage.

Describes the current lifecycle state of a member's insurance coverage, such as active, inactive, terminated, or suspended. Used in member eligibility systems to determine real-time coverage validity during claims adjudication, prior authorization requests, and point-of-service eligibility verification.

The member's age at the time their insurance coverage begins or is evaluated, calculated from date of birth against the coverage effective date. Used in enrollment and underwriting systems to apply age-based eligibility rules, premium tiers, and benefit limitations defined by the health plan.

The maximum dollar amount a health plan will reimburse for a covered service under a specific insurance policy, based on contractual fee schedules or usual and customary rates. Drives claims adjudication calculations including member cost-sharing responsibilities such as copays, coinsurance, and deductibles.

A numeric monetary value representing a coverage-level financial attribute within member enrollment, benefits, or claims systems, such as maximum benefit limits, deductible amounts, or out-of-pocket caps. Used in plan configuration tables and benefits adjudication logic across EHR and payer platforms.

Indicates the current authorization state of a member's coverage request, such as approved, pending review, denied, or conditionally approved. Used in enrollment and underwriting workflows to track whether a submitted coverage application has completed the plan's required review and approval process.