Reference 0007

Insurance Entity Invariants

A compact reference for assigning insurance facts to stable entities and protecting submitted claims from silent data drift.

Use this when designing tables, reviewing billing bugs, or deciding whether a fact belongs to registration, eligibility, authorization, coverage, or claim history.

Entity Boundary Map

Code	Entity	Question It Answers	Invariant
PAT	Patient	Who received care?	Patient demographics must not imply subscriber identity.
SUB	Subscriber	Whose insurance coverage is used?	Subscriber can equal patient, but the relationship must be explicit.
COV	Coverage	Which payer and member relationship applies?	Member ID is scoped to payer, plan when known, subscriber, and coverage.
ELG	Eligibility Check	What did the payer say for this service-date check?	Eligibility is a dated observation, not a payment guarantee.
AUT	Authorization	What payer approval/reference supports this service?	Authorization is payer, service, and date scoped.
CLM	Claim Snapshot	What insurance facts were actually submitted?	Submitted claim facts are immutable except through explicit versioning.

Graph Rule

Coverage connects people to a payer. Eligibility observes coverage. Authorization supports a service. Claim snapshot freezes what was sent.

Review Checklist

Question	If No
Can the patient and subscriber be different people?	The model will fail dependent coverage.
Can the same patient have multiple coverages with priority?	The model will fail coordination and payer switching.
Is coverage active checked against service date?	Old claims and corrected claims will be validated incorrectly.
Are eligibility checks stored as dated raw and parsed responses?	Support cannot audit payer or clearinghouse behavior.
Can authorization be tied to payer, coverage, service, and date?	The product will over-trust stale or unrelated auth numbers.
Does each submitted claim preserve an insurance snapshot?	Registration edits can rewrite history.

Safe State Names

Coverage

draft, needs_eligibility, active_for_date, inactive_for_date, unmatched, replaced

Eligibility

requested, matched, unmatched, active, inactive, ambiguous, error

Claim Snapshot

draft, validated, submitted, rejected, corrected, voided

Source Anchors

CMS MLN Claim Completion separates successful claim submission data into provider or supplier information, patient information, and payer information.
CMS MLN Key Patient and Claim Information maps patient name, birth date, sex, address, and related patient facts.
CMS MLN Insurance and Authorization covers health insurance, insured ID, insurance card data, and prior authorization numbers.
CMS Eligibility Inquiry frames 270/271 eligibility as data for preparing accurate claims, determining beneficiary liability, or checking eligibility for specific services.
CMS Electronic Health Care Claims describes front-end edits, implementation-guide edits, coverage/payment edits, rejection, correction, and denial pathways.