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Member match frequently used terms

Updated on August 31, 2021

Member: a member is a person covered under a health plan, either the subscriber or an eligible dependent.

Subscriber: the subscriber is the person responsible for payment of premiums, or whose employment is the basis for eligibility for membership in a health insurance plan. In SCE, when the subscriber is referenced, the reference is to the member indicated in the subscriber fields on a claim regardless of whether that person is the policyholder.

Patient: the patient is the person who is receiving medical care.

Donor: the donor is the person whose organs and/or tissues have been or will be donated for transplantation.

Recipient: the recipient is the person who has or will receive an organ or tissue transplant.

Newborn: in SCE, newborn references an unenrolled member who meets the state definition of a newborn. Typically, the state sets an age limit in days – patients receiving services within the defined number of days are considered newborns; their claims are subject to exception processing.

To support the member match, validations and policy selections, the following supporting data sources are required:

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