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Administrative Healthcare Data by Renu Gehring, Craig Dickstein

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Chapter 9: The Members

Introduction

Member Demographics

Member Enrollment

Member Eligibility

Membership Issues of Interest

Membership Maintenance

Electronic Eligibility Inquiry

Changing Member ID

“Cross-Client” Projects

Householding

Member Months

Continuous Enrollment

Rate Setting and Risk Adjustment

Setting Rates

Adjusting Risk

Case Study: Creating Member Months Data

Creating a Callable Macro Program

Member Months Macro Program

Building a Member Months Table

Conclusion

Introduction

Previously in this book we have discussed the primary players—providers and payers—and the data they generate based on claims submission. But without the insured members there would be no submitted claims.

From the provider’s perspective there are “patients” requiring ...

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