Member

A reference to the prior version of a member record in a healthcare data system. Used in member data management to track historical changes to enrollment, demographic, and coverage information. Supports audit trail requirements and longitudinal member analysis in healthcare data warehouses.

The out-of-pocket cost amount owed by a health plan enrollee for a specific service, product, or premium obligation. Calculated based on the member's plan cost-sharing structure including deductibles, copayments, and coinsurance, and used in billing and explanation of benefits processing.

A flag identifying whether a health plan enrollee holds the primary policyholder status on a contract, as opposed to a dependent. Used in enrollment and claims coordination systems to determine billing hierarchy, coordination of benefits sequencing, and subscriber-level reporting.

A ranking or importance designation assigned to a health plan enrollee, used in care management, utilization review, and outreach systems to triage high-risk members. Supports data engineers in building stratification logic and priority-based workflow routing pipelines.

The date on which a clinical procedure or medical service was performed for a health plan enrollee. Captured in claims and utilization management systems to validate authorization timelines, apply benefit period rules, and support medical record auditing and quality reporting.

A numeric count or volume value associated with a health plan member, such as the number of dependents, authorized service units, or prescription fills. Used in eligibility, PBM, and benefits administration systems for plan configuration and utilization analytics.

Records the racial identity of a health plan enrollee as self-reported or administratively assigned, using standard classifications such as OMB categories. Used in population health analytics, HEDIS reporting, and health equity programs to identify and address disparities in care access and outcomes.

A combined or separate classification of a health plan member racial identity and ethnic identity as self-reported during enrollment, aligned with Office of Management and Budget standards for race and ethnicity data collection. Collected to support CMS health equity reporting requirements, HEDIS measure stratification by race and ethnicity, and identification of disparities in care quality and access. CMS requires Medicare Advantage plans to collect and report race and ethnicity data as part of the Health Equity Index framework introduced in the 2023 Star Ratings. Healthcare data teams use mbr_race_ethn in population health dashboards, HEDIS stratified measure reporting, and care gap analytics to measure and close racial and ethnic disparities across member populations.

The Risk Adjustment Factor score calculated for an individual health plan member representing their predicted healthcare cost relative to the average Medicare beneficiary. RAF scores are calculated by CMS using the CMS-HCC model which combines demographic factors including age, gender, and enrollment status with diagnosis-based hierarchical condition category coefficients derived from submitted ICD-10 codes. A RAF score of 1.0 represents average expected cost, scores above 1.0 indicate higher predicted utilization, and scores below 1.0 indicate lower expected costs. CMS multiplies the county-level base payment rate by the member RAF score to calculate monthly capitation payments to Medicare Advantage plans. Healthcare data teams store mbr_raf_scr as DECIMAL(10,3) in member risk score tables and use it in care management prioritization, network adequacy planning, and actuarial analysis.

A defined span of values associated with a health plan enrollee, such as acceptable age bands, benefit limits, or risk score thresholds in eligibility and analytics systems. Used by data engineers to apply boundary conditions and validate member-level data within configured plan parameters.

The unit price or premium amount associated with a health plan enrollee, such as per-member-per-month capitation or premium billing rates in enrollment and financial systems. Critical for actuarial calculations, premium reconciliation, and payer-provider contract analytics.

A score or classification assigned to a health plan enrollee based on actuarial, risk adjustment, or quality-related criteria. Used in underwriting, premium setting, and care management programs to stratify members by health complexity, predicted cost, or engagement level.

A calculated proportional metric associated with a health plan enrollee, such as the ratio of plan-paid costs to total allowed amounts or utilization rates relative to a benchmark population. Used in financial analysis, care management stratification, and population health reporting.

A coded or descriptive reason associated with a member-level action or status in compliance and enrollment systems, such as a disenrollment reason or exception code. Used by data engineers for audit reporting, regulatory submissions, and workflow routing in payer platforms.

The date on which an enrollment application, referral, appeal, or other member-submitted document was received by the health plan. Used in enrollment operations and member services workflows to track processing timelines, ensure regulatory compliance, and audit response deadlines.

An external pointer or cross-system identifier linking a health plan enrollee to records in partner, provider, or government systems such as Medicaid, Medicare, or PBM platforms. Used by data engineers to maintain referential integrity and enable cross-system member data federation.

A standardized code identifying the relationship of a health plan member to the primary subscriber or policyholder. Common relationship codes follow X12 EDI standards: 18 for self, 01 for spouse, 19 for child, 53 for life partner, and 34 for other adult dependent. Relationship codes drive dependent eligibility rules, coordination of benefits sequencing, and premium tier assignment. In CMS enrollment systems, relationship codes determine Medicare beneficiary category assignments. Healthcare data teams use mbr_rel_cd in enrollment tables to validate dependent eligibility, apply correct cost-sharing rules, and identify family structures for population health segmentation and pediatric quality measure calculations.

The date on which a health plan member coverage automatically renews for the next plan year, resetting benefit accumulators, deductibles, and out-of-pocket maximums. For most commercial plans, the renewal date aligns with the plan year start date. For Medicare Advantage, coverage renews automatically on January 1 unless the member actively disenrolls or switches plans during the Annual Enrollment Period. Renewal dates trigger premium billing system resets, benefit limit reinitialization, and plan benefit table updates when plan designs change for the new year. Healthcare data teams use mbr_rnwl_dt in enrollment span management to close the prior year coverage record and open a new enrollment span, in accumulator reset pipelines, and in member communications systems to generate renewal notices and annual coverage change notifications.

The date on which a member's grievance, appeal, authorization request, or case management issue was formally resolved by the health plan. Used in compliance tracking and member services reporting to measure turnaround times against regulatory and accreditation standards.

The recorded outcome or measurement associated with a health plan enrollee, such as a clinical assessment result, care gap closure status, or quality measure outcome in EHR and care management systems. Used by data engineers to populate HEDIS, Stars, and population health reporting pipelines.