Optum ZIP5

#Section 6 Unlike the Member table, there may be multiple rows per eligibility period. There is a new row for a member each time any information about the member changes (i.e., state, product). Information to this table should be linked with variable: PATID or PAT\_PATID (for members on multiple plans at same time) After 2006, Medicare patients were excluded from CDM. Patients 65 years still in CDM = still working with commercial insurance, receiving benefits via spouse who is still working The Member Eligibility tables contain information on every member enrolled with the health plan during the specified data period. There are two tables containing member eligibility information: Member and Member Detail. The Member table contains aggregated eligibility information. Each span of eligibility information for a member will have one row. There may be multiple rows per member. Breaks in eligibility will trigger a new row, representing different eligibility and effective dates. Changes in other variables will not trigger the creation of a new row in the Member table. All other variables, such as plan type or state, will be populated based on the entries valid for the last effective date. The Member Detail table also contains member eligibility data. However, this table will have a new row each time any information about the member changes, such as state or product. The Member Detail table will have more rows than the Member table so that changes in information other than eligibility dates can be captured. This table is useful if you are looking at a variable that might change over time such as state or product. Many members will be represented multiple times in the Member Detail table with different information. Use the eligibility dates to choose the appropriate row that matches the date of service of the relevant claim. When looking at continuous enrollment, keep the multiple rows in mind. In the example above, the member has continuous enrollment from January 2005 to December 2007, but you would need to look at multiple rows in Member Detail to calculate that span. Or, the Member table with the simpler structure will have continuous eligibility in one row. Sometimes, enrollment periods overlap each other. It is possible for a member to have more than one insurance product at a time. For example, a member might have both primary and supplemental insurance. When the time periods overlap, there is no clean link between the claims and the eligibility table because there could be multiple rows returned in a match. To solve this problem, the Member Detail table has a column called PAT\_PLANID, which will be a link to the relevant row. If you are using the Member table, then link to the other tables by PATID. If using the Member Detail table, link to other tables by using PAT\_PLANID which identifies both member and product of the eligibility table. In general, queries requiring member information will contain either the Member or Member Detail table, not both. There is a process within our source system that will validly reassign a PATPLANID to a PATID. Someone is most likely to be reassigned a PATPLANID when the person was a previous member and already had a PATID associated with them. Then we re-assign them to the earlier ID so that we can maintain the claims history for that member. The previous claims are not updated with the new information, but the member tables are. You still are able to match the claims to Member Detail using the PAT\_PLANID as stated above. Because of this possibility, the PATID should be selected from the Member Detail table and not from the Medical Claims table. **Notes** Member types: Includes fully insured Administrative Services Only (ASO) Legacy Medicare Choice Unlike the Member table, there may be multiple rows per eligibility period. There is a new row for a member each time any information about the member changes (i.e., state, product, zip code). Information to this table should be linked with variable: PATID or PAT\_PATID (for members on multiple plans at same time) After 2006, Medicare patients were excluded from CDM. Patients 65 years still in CDM = still working with commercial insurance, receiving benefits via spouse who is still working Optum ZIP5 files include 5 digit zip code (but cannot be linked to socio-economic data nor date of death)