Skip to main content

Eligibility

The eligibility table contains enrollment and demographic data of health plan members. Eligibility data typically exists in one of two formats:

  • Enrollment Spans
  • Member Months

The Tuva Input Layer Eligibility table uses the Enrollment Span format. This is the most common format used in claims data. If your eligibility data uses this format it will be relatively easy to complete the mapping. If on the other hand your data uses the member months format, you'll need to convert it.

The primary keys for this table are:

  • patient_id
  • member_id
  • payer
  • plan
  • enrollment_start_date
  • enrollment_end_date
  • data_source

gender​

gender represents the biological sex of a member. It is mapped to either male, female, or unknown.

race​

race represents the physical race of a member.

birth_date​

This field represents the birth date of a member. data type is date in the format YYYY-MM-DD

death_date​

death_date contains the day a member died.

If the source data does not contain explicit death dates do not use claims data (e.g. discharge_disposition and/or claim_end_date) to populate this column.

  • data type is date in the format YYYY-MM-DD

death_flag​

death_flag contains a flag indicating if a member died; 1 for yes 0 for no.

death_flag should be 1 if a death_date is populated. death_flag can be 1 and death_date NULL if only an indicator is available in the source data.

  • data type is int
  • death_flag is populated with a 1 or 0

enrollment_start_date and enrollment_end_date​

The grain of this table will affect how these fields are populated:

  • One row per member month - enrollment_start_date will be the beginning of the month and enrollment_end_date will be the last day of the month.
    • e.g. enrollment_start_date = 2023-01-01 enrollment_end_date = 2023-01-31
  • One row per enrollment span - enrollment_start_date will be the first day of enrollment and enrollment_end_date will be the last day of enrollment.
    • e.g. enrollment_start_date = 2023-01-01 enrollment_end_date = 2023-12-31

In the source data, enrollment end date may be NULL to indicate that the member is actively enrolled. After confirming this with the data provider, enrollment_end_date should be populated with the last day of the current year.

  • data type is date in the format YYYY-MM-DD
  • enrollment_start_date and enrollment_end_date are populated in every row

payer​

payer contains the name of the health insurance payer of the claim (Aetna, Blue Cross Blue Shield, etc)

payer may not be available in the source data and should be hardcoded (e.g. select 'aetna' as payer)

  • payer is populated for every row
  • data type is string

payer_type​

payer_type contains the type of insurance provided by the payer.

  • data type is string
  • payer_type is populated for every row
  • value is mapped to one of the values found to Tuva’s payer_type terminology file.

plan​

plan contains the specific health insurance plan or sub-contract the member is enrolled in (e.g. Aetna Gold, Aetna Bronze 4, BCBS Chicago, etc).

plan may not be available in the source data and should be hardcoded (e.g. select 'aetna bronze 1' as plan and it can be the same as the payer if no plan is needed for analytics.

  • data type is string
  • plan is populated for every row

original_reason_entitlement_code​

original_reason_entitlement_code contains a member’s original reason for Medicare entitlement.

  • original_reason_entitlement_code is helpful for the CMS HCC mart to provide a more accurate risk score.
  • If it's unavailable, medicare_status_code is used. If neither are available, the mart will use a default value of “Aged”.
  • data type is string
  • value is mapped to one of the values found to Tuva’s OREC terminology file.

dual_status_code​

dual_status_code indicates whether a member is enrolled in both Medicare and Medicaid.

  • dual_status_code is helpful for the CMS HCC mart to provide a more accurate risk score.
  • If unavailable, the mart will use a default value of “Non” (i.e., non-dual).
  • data type is string
  • value is mapped to one of the values found to Tuva’s dual status terminology file.

medicare_status_code​

medicare_status_code indicates how a member currently qualifies for Medicare.

  • medicare_status_code is helpful for the CMS HCC mart to provide a more accurate risk score.
  • It’s used when original_reason_entitlement_code is missing.
  • data type is string
  • value is mapped to one of the values found to Tuva’s medicare status terminology file.

data_source​

data_source is populated with the name of the entity providing the data. It may come from the health insurer directly (e.g. Aetna, BCBS) or a third party (e.g. HealthVerity, Datavant).

  • data type is string
  • data_source is populated for every row