Member

The date on which the insurer issued payment for a covered claim or service under a specific insurance policy. Used in claims financial reporting and remittance reconciliation to track payment cycle times, cash flow, and compliance with prompt payment regulations.

The identifier or reference to a higher-level coverage record from which a subordinate coverage record is derived. Used in hierarchical insurance plan structures to link child coverage tiers, riders, or dependent policies back to the primary subscribing plan or group contract.

A numeric percentage value representing the proportion of covered costs a plan will reimburse for a specific service or benefit tier, such as coinsurance rates. Stored in benefits configuration and claims adjudication systems within payer and PBM platforms, used to calculate member cost-sharing obligations after deductibles are met.

The defined start and end date range during which a member is entitled to insurance benefits under a specific plan. Used in member enrollment, claims eligibility verification, and benefit administration to validate whether services rendered fall within an active and billable coverage window.

The telephone contact number associated with the insurance plan or payer responsible for a member's coverage. Used by providers and members to reach the insurer for eligibility verification, prior authorization requests, claims status inquiries, and benefit plan questions.

The specific insurance benefit plan under which a member is enrolled, defining covered services, cost-sharing structures, network requirements, and benefit limits. Used in eligibility verification, claims adjudication, and member enrollment to identify applicable benefits and reimbursement rules.

The unique alphanumeric identifier assigned by an insurer to a specific insurance policy or group contract. Used across claims processing, eligibility verification, and coordination of benefits to link members to their correct plan terms, benefits, and payer reimbursement agreements.

The human-readable display name designated for an insurance coverage record, often a marketing or consumer-friendly plan name used alongside technical plan codes. Used in member portals, explanation of benefits documents, and enrollment materials to clearly communicate plan identity to members.

The monetary cost associated with an insurance coverage plan, typically reflecting premium amounts charged to the member, employer, or both. Used in enrollment financial management, billing reconciliation, and actuarial reporting to track plan pricing structures and premium revenue collection.

A flag designating whether a specific insurance coverage is the primary payer responsible for first-dollar benefit adjudication when a member holds multiple coverages. Used in coordination of benefits processing to sequence payer responsibility and prevent duplicate or conflicting claim payments.

The numerical or categorical ranking that establishes payer order when a member is covered by multiple insurance plans. Used in coordination of benefits workflows to determine which insurer adjudicates claims first, second, or as a tertiary payer, following standard COB rules and payer agreements.

A misaligned field label likely resulting from a data modeling error. If present, this field may store clinical pulse or heart rate readings erroneously mapped to a coverage record. Requires data governance review to confirm correct source mapping and intended use within enrollment or claims context.

A numeric field capturing the allowable or applicable quantity associated with a specific coverage benefit, such as the number of covered visits, units, or days authorized under a plan. Used in benefits configuration, utilization management, and claims adjudication systems across payer, EHR, and PBM platforms.

The racial or ethnic classification recorded in association with a member's insurance coverage record, used to support health equity reporting, social determinants of health analysis, and regulatory compliance. Collected under HEDIS, CMS, and state-mandated demographic reporting requirements for covered populations.

The per-unit reimbursement or premium rate applied under an insurance coverage agreement, such as a contracted fee schedule rate or per-member-per-month premium rate. Used in actuarial pricing, claims payment calculation, and employer group billing within health plan financial management systems.

A score or classification applied to an insurance coverage based on risk factors, plan performance metrics, or regulatory quality assessments such as CMS Star Ratings. Used in plan management, actuarial underwriting, and quality reporting to evaluate coverage tiers and benchmark plan performance.

The proportional relationship between covered benefits and total costs or services under an insurance plan, such as the percentage of a claim amount covered after cost-sharing. Used in actuarial analysis, benefit design evaluation, and member cost-sharing calculations within health plan reporting systems.

The documented explanation for a specific coverage determination, enrollment action, or benefit decision associated with an insurance policy. Used in member enrollment management, appeals processing, and audit trails to record why coverage was granted, denied, modified, or terminated for a given member.

The date on which a coverage application, enrollment request, or coverage-related document was received by the insurer or plan administrator. Used in enrollment processing workflows to track submission timeliness, trigger eligibility effective date calculations, and support regulatory compliance auditing.

An external identifier or pointer linking a member's insurance coverage record to related systems, plans, or payer contracts. Used in enrollment and claims processing to cross-reference coverage details across health plan platforms and clearinghouses.