Reference 0005

Patient Subscriber Map

A compact model for separating who received care, who owns the coverage, and which coverage is being billed.

Use this when claim matching, eligibility, or registration errors mention patient, insured, member, subscriber, or relationship.

The Four Facts

Code	Fact	Product Question	Common Trap
PAT	Patient	Who received care?	Using the subscriber's demographics for a dependent child.
SUB	Subscriber or insured	Whose coverage is being used?	Assuming the subscriber is always the patient.
REL	Relationship	How is the patient related to the subscriber?	Sending dependent coverage without the relationship fact.
COV	Coverage	Which payer, plan, member ID, and eligibility period apply?	Treating an old insurance card as active coverage.

Confirm patient name, date of birth, sex, and address from registration or the insurance card when applicable.

Record the insured or subscriber when coverage belongs to someone else, such as a parent or spouse.

Use eligibility to confirm payer, member ID, active dates, benefits, and patient liability before claim creation.

CMS MLN Key Patient and Claim Information maps patient name, birth date, sex, address, signature, and illness dates to CMS-1500 and 837P fields.
CMS MLN Insurance and Authorization covers health insurance, insured ID, prior authorization, and the role of insurance card data.
CMS Eligibility Inquiry explains that 270/271 eligibility data helps prepare accurate claims, determine beneficiary liability, and determine eligibility for specific services.
NUCC 1500 Claim Form Instruction Manual is the standardized reference for completing professional claim form fields.