Member

A coded value identifying the type of health insurance plan structure under which a member is enrolled, defining network access rules, referral requirements, and cost-sharing design. Common coverage type codes include HMO (Health Maintenance Organization) requiring primary care physician referrals and in-network services, PPO (Preferred Provider Organization) allowing out-of-network access at higher cost, EPO (Exclusive Provider Organization) with no out-of-network coverage, POS (Point of Service) combining HMO and PPO features, and HDHP (High Deductible Health Plan) paired with Health Savings Accounts. In Medicare Advantage, coverage types include HMO, PPO, PFFS, and SNP. Healthcare data teams use mbr_cov_typ_cd in claims adjudication to apply correct network rules and cost-sharing logic, and in actuarial analysis to model utilization patterns by plan type.

The username or system identifier of the user or automated process that initially created the member enrollment record in the health plan or eligibility system. Used for audit trail purposes to track data entry accountability and support compliance with record integrity requirements.

The date on which an insurance plan enrollee's record was first created in the payer's enrollment or administrative system, typically triggered by an 834 transaction or manual eligibility entry. Data engineers use this field to establish record provenance, detect retroactive enrollment adjustments, and support audit trails in data lineage and compliance reporting workflows.

The exact timestamp indicating when an insurance plan enrollee's record was first created in the enrollment or eligibility system. Used for audit logging, data lineage tracking, and reconciling enrollment file feeds from employers, exchanges, or government agencies against system processing windows.

A flag or indicator identifying the most recent or active version of a member record in a healthcare data system. Used in member data warehouses implementing slowly changing dimension patterns to distinguish current enrollment and demographic information from historical versions.

A business date associated with an insurance plan enrollee within pharmacy or clinical process workflows, representing transaction-relevant dates such as fill dates, eligibility effective dates, or benefit period markers in PBM and payer systems. Data engineers use this field for temporal joins, benefit period validation, and time-series analytics across enrollment and pharmacy data pipelines.

A combined date and timestamp value associated with an insurance plan enrollee event, capturing precise transaction or record timing in EHR, claims, and payer systems. Data engineers use this field to sequence member-level events, resolve event ordering conflicts during ETL, and support real-time eligibility verification and care management trigger logic in downstream platforms.

The Drug Enforcement Administration registration number associated with an insurance plan enrollee, typically applicable when the member is also a licensed prescriber. Used in pharmacy benefit management and controlled substance monitoring programs to cross-reference prescribing and dispensing activity.

The recorded date of death for an insurance plan enrollee, sourced from SSA death master files, state vital records, or EHR mortality data integrated into payer and enrollment systems. Data engineers use this field to terminate eligibility records, suppress deceased members from outreach campaigns, and support mortality-adjusted outcomes reporting in population health and actuarial analytics.

The amount a health plan member must pay out-of-pocket for covered services before the insurance plan begins paying its share of costs. Deductibles reset annually at the plan year start and may apply separately to medical, pharmacy, and behavioral health benefits. Family plans have individual and family aggregate deductibles. In high-deductible health plans paired with HSAs, IRS regulations set minimum deductible thresholds annually. Healthcare data teams track deductible accumulation by processing claims chronologically, maintaining running totals by member and plan year, and surfacing deductible status in real-time eligibility responses used by providers for point-of-service cost estimation and financial counseling.

The running year-to-date total of payments a health plan member has applied toward their annual deductible within a plan year. Once the deductible accumulator reaches the deductible threshold, the insurance plan begins paying its share of covered costs for deductible-subject services. Family plans maintain both individual and family aggregate deductible accumulators. Deductible accumulators reset to zero at the start of each new plan year. Healthcare data teams build deductible tracking pipelines that process medical and pharmacy claims chronologically, apply deductible rules by service category and benefit tier, and expose current deductible accumulator balances through real-time eligibility API responses for provider point-of-service cost estimation.

The cumulative dollar threshold an insurance plan enrollee must pay out-of-pocket for covered services before the health plan begins paying benefits. Tracked across medical and pharmacy claims within a benefit period to determine when cost-sharing transitions from member responsibility to plan coverage.

The calendar date on which an insurance plan enrollee's record was logically removed or inactivated within the enrollment or eligibility system. Used in data governance and audit processes to track when member records were suppressed, often triggered by duplicate resolution or enrollment corrections.

A flag in the member enrollment system indicating that an enrollee's record has been logically deleted or suppressed without physical removal from the database. Used to exclude inactivated or duplicate records from eligibility queries, claims processing, and member-facing communications while preserving historical data.

An individual enrolled in a health plan under the primary policyholder coverage rather than as the primary subscriber. Dependents typically include spouses, domestic partners, and children up to age 26 under ACA rules. Dependent eligibility rules vary by plan type — employer-sponsored plans, Medicare Advantage, and Medicaid each have distinct dependent coverage requirements. Healthcare data teams model dependent relationships using subscriber-dependent linkage tables, process dependent enrollment through 834 EDI transactions, and apply dependent-specific cost-sharing rules in claims adjudication. HEDIS quality measures often require separate denominator identification logic for dependent versus subscriber populations.

Free-text description field associated with a health plan enrollee record in EHR and enrollment systems. Used by data engineers to capture supplemental narrative about member classification, special program participation, or eligibility status for reporting and integration workflows.

Comprehensive set of demographic, eligibility, and enrollment attributes for a health plan enrollee stored in payer and EHR systems. Includes coverage tier, PCP assignment, benefit package, and enrollment dates critical for claims adjudication, care management, and downstream analytics pipelines.

The date an enrolled health plan member is formally released from an inpatient facility, recorded in EHR and claims systems. Used by data engineers to calculate length of stay, trigger post-discharge care management workflows, and validate inpatient claims in adjudication systems.

The process by which a health plan member coverage is terminated either voluntarily by the member or involuntarily due to non-payment, loss of eligibility, employer group termination, or plan exit from a market. Disenrollment triggers coverage termination, premium billing cessation, and CMS notification for Medicare Advantage plans. Retroactive disenrollment requires claim reversal and premium reconciliation. Healthcare data teams track disenrollment events in enrollment span tables, process disenrollment transactions through 834 EDI files, and analyze disenrollment patterns to identify retention risk factors, measure member satisfaction, and comply with CMS reporting requirements for Medicare Advantage voluntary disenrollment rates and plan performance monitoring.

A coded value indicating the type and level of dual Medicare and Medicaid eligibility status for a health plan member. Dual eligible individuals receive coverage from both Medicare and Medicaid simultaneously. CMS defines multiple dual eligibility categories including full benefit dual eligible, qualified Medicare beneficiary, specified low-income Medicare beneficiary, and qualifying individual. Dual eligibility status affects CMS-HCC demographic risk adjustment coefficients, cost-sharing obligations, and eligibility for Dual Special Needs Plans. Healthcare data teams use mbr_dual_elig_cd in risk stratification, capitation payment calculations, health equity analytics, and identification of members eligible for D-SNP enrollment and enhanced care management programs.