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Enrollment Span Status Logic

Enrollment Span Status Logic

Owned by Balaji Varadharajan
Mar 10, 2023
1 min read

Algorithm

Status

Algorithm

Status

1
Effectuation Date == NULL AND [(“Enrollment Span End Date” Greater than “Enrollment Span Start Date”) OR (“Enrollment Span One Day Span Indicator = TRUE”)] AND Delinquency Indicator is FALSE

PRE MEMBER

2
Effectuation Date != NULL AND [(“Enrollment Span End Date” Greater than “Enrollment Span Start Date”) OR (“Enrollment Span One Day Span Indicator = TRUE”)] AND Delinquency Indicator is FALSE

ENROLLED

3
(“Enrollment Span End Date” Less than “Enrollment Span Start Date”)

CANCELED

4
Effectuation Date != NULL AND Delinquency Indicator is TRUE AND [((Claim Paid Through Date IS NOT NULL) AND (Current System Date < Claim Paid Through Date )) OR (Claim Paid Through Date IS NOT NULL AND Prior Enrollment Span is Present AND Prior Enrollment span and Current Enrollment span have same plan AND Current span has no gap in coverage with the prior enrollment span) ]

DELINQUENT

5
Effectuation Date != NULL AND Delinquency Indicator is TRUE AND [(Claim Paid Through Date IS NULL) OR (Current System Date > Claim Paid Through Date )]

SUSPENDED

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