Enrollment Span Status Logic
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 |