Identifies the reason or rational for why a person is eligibile for benefits under an insurance policy or progam.

Examples: A person is a claimant under an automobile insurance policy are client deceased & adopted client has been given a new policy identifier. A new employee is eligible for health insurance as an employment benefit. A person meets a government program eligibility criteria for financial, age or health status.

Identifies the reason or rational for why a person is not eligibile for benefits under an insurance policy.

Examples are client deceased & adopted client has been given a new policy identifier.

When a client has no contact with the health system for an extended period, coverage is suspended. Client will be reinstated to original start date upon proof of identification, residency etc.

Example: Coverage may be suspended during a strike situation, when employer benefits for employees are not covered (i.e. not in effect).

Client deceased.

Client was registered in error.

Definition: Identifies the reason or rational for why a person is eligibile for benefits under an insurance policy or progam.

Examples: A person is a claimant under an automobile insurance policy are client deceased & adopted client has been given a new policy identifier. A new employee is eligible for health insurance as an employment benefit. A person meets a government program eligibility criteria for financial, age or health status.

A person becomes eligible for a program based on age.

Example: In the U.S., a person who is 65 years of age or older is eligible for Medicare.

A person becomes eligible for insurance or a program because of crime related health condition or injury.

Example: A person is a claimant under the U.S. Crime Victims Compensation program.

A person becomes a claimant under a disability income insurance policy or a disability rehabilitation program because of a health condition or injury which limits the person's ability to earn an income or function without institutionalization.

A person becomes eligible for insurance provided as an employment benefit based on employment status.

A person becomes eligible for a program based on financial criteria.

Example: A person whose family income is below a financial threshold for eligibility for Medicaid or SCHIP.

A person becomes eligible for a program because of a qualifying health condition or injury.

Examples: A person is determined to have a qualifying health conditions include pregnancy, HIV/AIDs, tuberculosis, end stage renal disease, breast or cervical cancer, or other condition requiring specialized health services, hospice, institutional or community based care provided under a program

A person becomes eligible for a program based on more than one criterion.

Examples: In the U.S., a child whose familiy income meets Medicaid financial thresholds and whose age is less than 18 is eligible for the Early and Periodic Screening, Diagnostic, and Treatment program (EPSDT). A person whose family income meets Medicaid financial thresholds and whose age is 65 years or older is eligible for Medicaid and Medicare, and are referred to as dual eligibles.

A person becomes a claimant under a property and casualty insurance policy because of a related health condition or injury resulting from a circumstance covered under the terms of the policy.

Example: A person is a claimant under a homeowners insurance policy because of an injury sustained on the policyholderaTMs premises.

A person becomes eligible for a program based on statutory criteria.

Examples: A person is a member of an indigenous group, a veteran of military service, or in the U.S., a recipient of adoption assistance and foster care under Title IV-E of the Social Security.

A person becomes a claimant under a motor vehicle accident insurance because of a motor vehicle accident related health condition or injury.

A person becomes eligible for insurance or a program because of a work related health condition or injury.

Example: A person is a claimant under the U.S. Black Lung Program.