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member coverage type

mbr_cov_typ_cd
member·Updated Jun 23, 2026

Definition

ISO-11179 Definition

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.

Standard Abbreviation

mbr_cov_typ_cd

Category

member

Production DDL — DIM_MEMBER

DIM_MEMBER.sql
CREATE OR REPLACE TABLE DIM_MEMBER (
    mbr_key           INTEGER        NOT NULL  -- surrogate key,
    mbr_id            VARCHAR(50)    NOT NULL  -- member identifier,
    mbr_first_nm      VARCHAR(100)             -- first name,
    mbr_last_nm       VARCHAR(100)             -- last name,
    mbr_birth_dt      DATE                     -- date of birth,
    mbr_gndr_cd       CHAR(1)                  -- gender code M/F/U,
    mbr_age           SMALLINT                 -- age in years,
    mbr_state_cd      CHAR(2)                  -- state code,
    mbr_zip_cd        VARCHAR(10)              -- zip code,
    mbr_elig_ind      BOOLEAN                  -- eligibility indicator,
    mbr_enrl_dt       DATE                     -- enrollment date,
    mbr_term_dt       DATE                     -- termination date,
    mbr_plan_cd       VARCHAR(20)              -- plan code,
    mbr_dual_elig_cd  VARCHAR(10)              -- dual eligibility code,
    load_dt           TIMESTAMP_NTZ  NOT NULL  -- load timestamp
);

Standard Snowflake DDL for the canonical member table. Convert to BigQuery or Databricks →

Why This Term Matters

Member and enrollment data governs who receives care and who pays for it — making it foundational to every downstream healthcare analytics workflow. Data engineers who understand member terminology build eligibility pipelines that prevent coverage gaps, correctly identify dual-eligible members, and support accurate risk adjustment submissions to CMS. Enrollment errors directly affect capitation payments and can trigger CMS corrective action plans.

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