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member eligibility

mbr_elig
member·Updated Jun 23, 2026

Definition

ISO-11179 Definition

Indicates whether a health plan member is entitled to receive covered benefits on a specific date of service. Member eligibility is the foundation of claims adjudication — before any claim is paid, the payer verifies the member was enrolled and covered on the service date. Eligibility is determined by enrollment effective date, termination date, plan assignment, and benefit period.

In Medicare Advantage, CMS transmits eligibility data via the MARx system. Healthcare data teams build eligibility verification pipelines that process 270/271 EDI transactions and maintain point-in-time eligibility snapshots to support claims adjudication, HEDIS measure denominators, and retroactive coverage audits.

Standard Abbreviation

mbr_elig

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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