Member

A numeric ordering value assigned to eligibility records when a member has multiple coverage spans, plan enrollments, or coordination of benefits layers. Used in member enrollment and claims adjudication systems to establish the correct order of primary, secondary, and tertiary coverage.

The date on which a covered service was rendered, used to validate whether a member's health plan eligibility was active at the time of care. Critical in claims adjudication to confirm coverage was in force and benefits apply to services billed on that specific date.

A classification indicating the seriousness of a member's eligibility issue or coverage gap, used in health plan enrollment systems to prioritize resolution of enrollment discrepancies, retroactive terminations, or Medicaid disenrollment cases that may impact access to care.

The biological sex of a member as recorded in the health plan's enrollment system, used to determine eligibility for sex-specific benefits such as maternity coverage, gender-affirming care, or preventive screenings. Sourced from 834 EDI enrollment transactions or employer group files.

The originating system, entity, or data feed from which a member's eligibility information was obtained, such as an employer group 834 EDI file, CMS Medicare enrollment data, state Medicaid agency feed, or direct member application submitted through an ACA marketplace exchange.

The date on which a member's health insurance coverage becomes active under a specific plan or benefit package. Used in member enrollment systems to determine coverage windows, validate claims, and confirm that services rendered fall within an active coverage period.

The specific time of day at which a member's health insurance coverage becomes effective on the eligibility start date. Used in enrollment systems where intra-day coverage activation is required, such as same-day enrollment scenarios or real-time eligibility verification transactions.

The two-letter US state or territory code associated with a member's eligibility record, typically reflecting the state of residence or the state governing the insurance plan. Used in enrollment systems to determine applicable state mandates, benefit rules, and regulatory compliance requirements.

A coded value indicating whether a member's health insurance coverage is currently active, terminated, suspended, or pending. Used in member enrollment and claims adjudication systems to determine if a member is covered for services on a given date of service.

The primary street address associated with a member's eligibility record, typically representing the member's home or mailing address on file with the health plan. Used in enrollment systems for correspondence, plan assignment, network determination, and coordination of benefits processes.

The drug dosage concentration associated with a member's pharmacy benefit eligibility record, such as milligrams per tablet or milliliters per dose. Used in pharmacy benefit management systems to validate formulary coverage and apply appropriate cost-sharing rules for specific drug strengths.

A partial aggregated dollar or count value within an eligibility reporting context, representing a subset of total eligible members or costs within a defined segment such as plan type, employer group, or benefit tier. Used in enrollment analytics and financial reconciliation reporting.

A unique system-generated key assigned to an eligibility record within a health plan's enrollment or benefits administration platform. Used to reference, track, and reconcile a specific member's coverage record across internal systems, clearinghouses, and external data exchange partners.

The intended destination system, population segment, or benefit program toward which an eligibility record or transaction is directed. Used in enrollment data exchange workflows to route 834 EDI transactions or eligibility updates to the correct plan, payer, or downstream system.

A National Uniform Claim Committee (NUCC) taxonomy code linked to an eligibility record to classify the type of healthcare provider or facility associated with a member's plan coverage. Used in enrollment and claims systems to validate provider specialty alignment with covered benefit categories.

A recorded body temperature measurement associated with a member's clinical eligibility assessment, such as for disease management program enrollment or value-based care risk stratification. Used in population health platforms to qualify members for condition-specific benefit programs.

The date on which a member's health insurance coverage ends under a specific plan or benefit package. Used in member enrollment and claims adjudication systems to validate that services were rendered prior to coverage lapse and to manage COBRA, disenrollment, and run-out period processing.

The time of day associated with a specific eligibility event or transaction, such as when a coverage inquiry was submitted or when an enrollment change was processed. Used in real-time eligibility verification systems to timestamp 270/271 EDI transactions and audit eligibility determinations.

The combined date and time value recording when an eligibility event occurred or was processed, such as enrollment creation, status change, or system update. Used in member enrollment audit trails and data warehouse logging to establish a precise chronological record of coverage changes.

A formal name or label assigned to an eligibility record, benefit package, or coverage category within a health plan's enrollment system. Used to identify and distinguish plan offerings, such as naming a specific benefit tier or employer group contract associated with a member's coverage.