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member risk adjustment

mbr_rsk_adj
member·Updated Jun 23, 2026

Definition

ISO-11179 Definition

The process and associated data elements used to calculate and submit a health plan member predicted cost risk to CMS for Medicare Advantage and ACA marketplace capitation payment purposes. Risk adjustment corrects for differences in member health status across plans by adjusting payments upward for sicker members and downward for healthier members, preventing adverse selection and ensuring plans are fairly compensated for enrolling high-risk populations. The risk adjustment process involves diagnosis code submission through RAPS and EDPS systems, HCC mapping, RAF score calculation, and reconciliation payment settlements.

Healthcare data teams build risk adjustment data pipelines that validate ICD-10 diagnosis submissions, map diagnoses to HCC categories using CMS mapping files, calculate preliminary RAF scores, and produce audit-ready data submissions meeting CMS risk adjustment data validation requirements.

Standard Abbreviation

mbr_rsk_adj

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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