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Member data model and keyring

Suggest edit Updated on August 31, 2021

The following diagram shows the key relationships between the member, subscriber and policy classes that are used to drive the member match, validations, and policy selection logic.

The member data model includes the support for multiple other identifiers, known as the “Member keyring”.

Example ID’s:

  • Pega Subscriber
  • Pega Member
  • Medicaid
  • Medicare

All the ID’s associated to a unique member are maintained as a list in the other information section. The Type is configurable and can be repeated within a member keyring.

Search and match logic with Elastic Search can utilize the keyring IDs along with member demographic information to identify the correct member. The search will yield all members associated with the submitted ID. Results are then filtered by date of service. SCE can be configured to select the submitted policy, internally ranked policy, or externally ranked policy based on the desired outcome.

Alternatively, customers can customize the selection process to apply the preferred member ID based on specific business logic.

There are multiple pages that are used to provide information for the member match, validations, and policy selection. These pages will need to be populated for the SCE to perform the necessary lookups and validations.

PageUsage
D_MemberUsed to hold member information and address fields for the member lookup and validation.
D_MemberSearchUsed to fetch member instances for elastic search.
D_MemberLookupUsed to look up member information based on the Member ID.
D_MemberDetailsUsed to look up a list of subscribers based on the Member ID
D_PlansForMemberUsed to look up a list of plans for the member based on the Member ID
D_CE_PolicyByIDUsed to look up information on the member policy based on the policy ID
D_CE_PayerHolds information on the payer for validation.
D_CE_COB_PolicyHolds COB policy information to support external payer information
D_CE_ContractHolds policy contract information for validations
D_CE_PolicyByIDUsed to look up information on the member policy based on the policy ID
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