Member ID and Group Number on Insurance Cards

The member ID on insurance cards identifies one person, or one policy, to the health plan, and usually sits on the front under a label such as "Member ID", "Subscriber ID" or "ID". The group number identifies the employer or plan group the coverage comes through. Some cards print no group number, because the plan does not need one.

Where the member ID sits on an insurance card

The member ID sits on the front of an insurance card, near the cardholder's name, under a label such as "Member ID", "Subscriber ID", "ID" or "Identification Number". Health plans choose their own layout, so its position moves from card to card, but it is usually printed beside the cardholder's name.

The WEDI Health ID Card Implementation Guide v1.1, posted by the Louisiana Department of Health, is the industry's voluntary guide to card layout. Its table of printed information lists the cardholder identifier as required on the front, with a label "such as" "Subscriber ID", "Member ID" or "ID". It also says the cardholder name and the cardholder ID shall identify the same person. So the name printed nearest the number is the person that number belongs to.

The guide says the cardholder ID is assigned by the card issuer and may contain letters and numbers. Spaces and hyphens may be printed to make it easier to read, but they are not part of the identifier and are ignored. That matters at data entry: a member ID printed as "XQZ 0000 0000" is keyed as XQZ00000000.

An annotated fictional card

Here is a fictional card, front and back. Every value on it is made up for this example, and the IDs are deliberately filled with zeros so they cannot match a real person.

FRONT
+--------------------------------------------------+
| EXAMPLE HEALTH PLAN            PPO               |
| Issuer (80840) 0000000000                        |
| Member: DANA R OKAFOR                            |
| Member ID: XQZ00000000  Sfx 01                   |
| Group No: 000000   Employer: Example Widgets Inc |
| Copays: PCP $XX  Specialist $XX  ER $XXX         |
| RxBIN 000000  RxPCN EXAMPLE  RxGrp EXRX0         |
+--------------------------------------------------+

BACK
+--------------------------------------------------+
| Members: 1-800-555-0100   Providers: 1-800-555-0101 |
| Submit claims to: PO Box 0000, Example City, ST  |
| Precertification required for inpatient stays.   |
+--------------------------------------------------+

The pharmacy lines on the same card are a separate system with their own routing numbers. The guide to what the Rx BIN number routes explains them.

What does the group number on an insurance card identify?

The group number on an insurance card identifies the employer, union or other group whose plan the member is enrolled in. It ties the member to a particular set of benefits that the group bought. Some cards have no group number at all, because the plan can find the coverage from the member ID alone.

The WEDI guide describes this field as a proprietary policy, group or account number, meaning "the identifier assigned by the benefit plan for the group, plan, policy, contract, certificate, or account". It lists the field as situational: required on the card when the payer needs it and it differs from the card issuer identifier. The guide notes that some payers still require the group number to identify the subscriber, which means providers have to collect three identifiers from the card instead of two.

On a claim, the group number goes in Item 11 of the CMS-1500. The NUCC 1500 Claim Form Reference Instruction Manual says to enter the insured's policy or group number as it appears on the card, without a hyphen or space as a separator.

A blank group number is not an error when the card does not print one. It becomes an error when the card prints one and the intake form leaves it out, or when staff copy the Rx group into the medical group field. Many cards label the pharmacy group "RxGrp" precisely so it is not confused with the medical group.

Member ID prefixes and suffixes

A member ID prefix is a set of characters at the start of the ID that tells a provider which plan the member belongs to. A suffix is a short number at the end, such as 01 or 02, that tells the plan which family member is the patient. Both are part of the ID the claim needs.

Prefixes are most familiar on Blue Cross Blue Shield cards. The Blue Cross and Blue Shield of Oklahoma claim tips page says the three-character prefix "identify the plan to which the member belongs and are key to confirming eligibility/coverage". It tells providers to always include the correct prefix and to avoid randomly selecting one, and warns that claims with incorrect or missing member ID numbers cannot be processed.

Suffixes follow a different logic. The WEDI guide says the subscriber and dependents may be uniquely identified using a one- to three-character suffix appended to a base subscriber ID. The subscriber's suffix prints to the right of the base ID, labelled "Suffix" or "SFX", and each dependent's suffix precedes that dependent's name on a family card. The guide adds that leading zeros in suffix values are significant, so 01 and 1 are not the same suffix.

In the example card above, Dana's suffix is 01, so the ID that identifies Dana alone is XQZ0000000001. A dependent child listed with suffix 03 would be XQZ0000000003. Dropping the suffix sends the plan the family's base ID and leaves it to guess the person.

How do Medicaid card fields differ from commercial cards?

Medicaid card fields differ from commercial cards in three ways: the ID is a state-assigned Medicaid number, a group number is often missing, and a patient in a Medicaid managed care plan may carry two cards, one from the state and one from the plan. Which card to bill depends on how the state runs its program.

The Indiana Medicaid eligibility verification page shows the pattern. Indiana's state card, the Hoosier Health Card, identifies enrollment in fee-for-service Medicaid. Managed care organizations issue their own cards, and those cards include the member's state Medicaid ID for eligibility checks. The page is blunt that viewing a member's ID card alone does not ensure eligibility, and tells providers to verify eligibility on the date of service every time.

That last point is the main difference for intake. A Medicaid card can stay in a patient's wallet after coverage ends or moves to a different managed care plan, so the card is a starting point for the eligibility check, not proof of coverage. Each state publishes its own card images and rules, so a practice near a state line may need to know two layouts.

Medicare cards follow a federal format of their own, the 11-character Medicare Beneficiary Identifier. The guide to Medicare Beneficiary Identifier character positions covers it.

Payer ID, plan type and other card fields billing needs

Besides the member ID and group number, billing needs the plan name and type, the card issuer or payer identifier, the claims address and provider phone number, and any effective date the card prints. Together they tell billing where to send the claim, what kind of plan it is, and whether coverage applied on the date of service.

The WEDI guide lists plan type, such as HMO, POS, EPO or PPO, as required on the front, though it may be implied by a plan or network logo. It lists at least one claims address and at least one phone number for eligibility, claims and precertification questions as required, recommended for the back. It lists date of birth, the date the card was issued and the date benefits take effect as recommended or discretionary, so many cards leave them off.

The card issuer identifier in the guide is a 15-digit number that begins with the ISO prefix 80840, "80" for health and "840" for the United States. Few cards in wallets today print it, but some do.

The electronic payer ID that a clearinghouse uses to route an electronic claim is a different thing. If a card does not show the payer ID your clearinghouse expects, call the provider phone number on the back and record what they tell you against the plan, so the next patient with that card does not start the search again.

Network names and logos matter too. A plan can sell several networks under one name, and the network logo on the card is often how the front desk confirms the practice is in network for that patient.

When the member ID on the card is the wrong one to bill

The member ID on the card is the wrong one to bill when the card is not the coverage that applies on the date of service. Common cases are a new card not yet in effect, an old card for ended coverage, a card for one benefit such as dental, and a Medicare card for a Medicare Advantage enrollee.

A new card often arrives before its effective date. A patient who changed jobs in December may hand over a card that starts on January 1 for a visit on December 20. The card itself may print a "Benefits Effective" date, which the WEDI guide lists as a discretionary field, but an eligibility check is the reliable way to tell.

A single-benefit card is another trap. The WEDI guide permits a plan to issue a separate card for each benefit, so a patient may carry a dental card, a vision card and a medical card with three different member IDs. A medical claim sent with the dental member ID will not find the coverage.

A dependent with a unique member ID is the third case. The NUCC manual says that when a dependent has a unique member identification number and the payer requires it on the claim, the claim reports "Self", since the patient is reported as the insured. Who counts as subscriber and patient in each case is covered in the post on subscriber vs patient on an insurance card.

When any of these is in doubt, ask the patient for every card they have and run an eligibility check before the visit.

Using member ID and group number for eligibility checks

Using the member ID and group number for an eligibility check means sending the plan an electronic inquiry built from the card and the intake form, and reading the response before the visit. The inquiry asks whether the patient is covered on the date of service. The response returns coverage status, plan details and benefits such as copays and deductibles.

The transaction is defined in federal rules. Under 45 CFR 162.1201 on the eCFR, the eligibility for a health plan transaction is an inquiry from a provider to a health plan about an enrollee's eligibility, coverage or benefits, and the plan's response. For dental, professional and institutional care, 45 CFR 162.1202 on the eCFR adopts the X12 270 inquiry and 271 response as the standard.

The WEDI guide shows how card data fills the 270. If the card shows a group number, it goes into the subscriber's additional identification. If the patient is the cardholder, the member ID and the cardholder's name and date of birth fill the subscriber fields. If the patient is a dependent with a suffix, the base ID plus the suffix becomes the member ID, and the dependent's own name and birth date go in the subscriber fields.

What comes back is either an active coverage response with benefit details, or a rejection that usually points to one field: an ID the plan does not recognise, a name or birth date that does not match, or coverage that is not active on that date. Fix the field the rejection names, not the whole record.

Keying the member ID wrong at intake is the most common way to get that rejection. Schema Care reads the insurance fields on a patient intake form and sends a member ID it is unsure of to a person, who sees it highlighted on the original page; the human review section shows that workflow. Extracting the same fields from a card image is covered in the guide to insurance card OCR fields worth extracting, and what happens to those IDs when the payment comes back is in the EOBs and remittances category.