HL7 Terminology (THO)
6.0.2 - Continuous Process Integration (ci build)
HL7 Terminology (THO), published by HL7 International - Vocabulary Work Group. This guide is not an authorized publication; it is the continuous build for version 6.0.2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/UTG/ and changes regularly. See the Directory of published versions
Official URL: http://terminology.hl7.org/ValueSet/v3-CoverageParticipationFunction | Version: 3.0.0 | |||
Active as of 2014-03-26 | Responsible: Health Level Seven International | Computable Name: CoverageParticipationFunction | ||
Other Identifiers: OID:2.16.840.1.113883.1.11.19903 | ||||
Copyright/Legal: This material derives from the HL7 Terminology THO. THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license.html |
Definition: Set of codes indicating the manner in which sponsors, underwriters, and payers participate in a policy or program.
References
This value set is not used here; it may be used elsewhere (e.g. specifications and/or implementations that use this content)
Generated Narrative: ValueSet v3-CoverageParticipationFunction
Language: en
http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction
where concept is-a _CoverageParticipationFunction
Generated Narrative: ValueSet
Language: en
Expansion based on codesystem ParticipationFunction v3.0.0 (CodeSystem)
This value set contains 17 concepts
Level | Code | System | Display | Definition |
1 | _CoverageParticipationFunction | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | CoverageParticipationFunction | Definition: Set of codes indicating the manner in which sponsors, underwriters, and payers participate in a policy or program. |
2 | _PayorParticipationFunction | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | PayorParticipationFunction | Definition: Set of codes indicating the manner in which payors participate in a policy or program.</ |
3 | CLMADJ | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | claims adjudication | Definition: Manages all operations required to adjudicate fee for service claims or managed care encounter reports. |
3 | ENROLL | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | enrollment broker | Definition: Managing the enrollment of covered parties. |
3 | FFSMGT | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | ffs management | Definition: Managing all operations required to administer a fee for service or indemnity health plan including enrolling covered parties and providing customer service, provider contracting, claims payment, care management and utilization review. |
3 | MCMGT | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | managed care management | Definition: Managing all operations required to administer a managed care plan including enrolling covered parties and providing customer service,, provider contracting, claims payment, care management and utilization review. |
3 | PROVMGT | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | provider management | Definition: Managing provider contracting, provider services, credentialing, profiling, performance measures, and ensuring network adequacy. |
3 | UMGT | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | utilization management | Definition: Managing utilization of services by ensuring that providers adhere to, e.g., payeraTMs clinical protocols for medical appropriateness and standards of medical necessity. May include management of authorizations for services and referrals. |
2 | _SponsorParticipationFunction | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | SponsorParticipationFunction | Definition: Set of codes indicating the manner in which sponsors participate in a policy or program. NOTE: use only when the Sponsor is not further specified with a SponsorRoleType as being either a fully insured sponsor or a self insured sponsor. |
3 | FULINRD | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | fully insured | Definition: Responsibility taken by a sponsor to contract with one or more underwriters for the assumption of full responsibility for the risk and administration of a policy or program. |
3 | SELFINRD | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | self insured | Definition: Responsibility taken by a sponsor to organize the underwriting of risk and administration of a policy or program. |
2 | _UnderwriterParticipationFunction | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | UnderwriterParticipationFunction | Definition: Set of codes indicating the manner in which underwriters participate in a policy or program. |
3 | PAYORCNTR | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | payor contracting | Definition: Contracting for the provision and administration of health services to payors while retaining the risk for coverage. Contracting may be for all provision and administration; or for provision of certain types of services; for provision of services by region; and by types of administration, e.g., claims adjudication, enrollment, provider management, and utilization management. Typically done by underwriters for sponsors who need coverage provided to covered parties in multiple regions. The underwriter may act as the payor in some, but not all of the regions in which coverage is provided. |
3 | REINS | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | reinsures | Definition: Underwriting reinsurance for another underwriter for the policy or program. |
3 | RETROCES | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | retrocessionaires | Definition: Underwriting reinsurance for another reinsurer. |
3 | SUBCTRT | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | subcontracting risk | Definition: Delegating risk for a policy or program to one or more subcontracting underwriters, e.g., a major health insurer may delegate risk for provision of coverage under a national health plan to other underwriters by region . |
3 | UNDERWRTNG | http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction | underwriting | Definition: Provision of underwriting analysis for another underwriter without assumption of risk. |
Explanation of the columns that may appear on this page:
Level | A few code lists that FHIR defines are hierarchical - each code is assigned a level. In this scheme, some codes are under other codes, and imply that the code they are under also applies |
System | The source of the definition of the code (when the value set draws in codes defined elsewhere) |
Code | The code (used as the code in the resource instance) |
Display | The display (used in the display element of a Coding). If there is no display, implementers should not simply display the code, but map the concept into their application |
Definition | An explanation of the meaning of the concept |
Comments | Additional notes about how to use the code |
History
Date | Action | Author | Custodian | Comment |
2023-11-14 | revise | Marc Duteau | TSMG | Add standard copyright and contact to internal content; up-476 |
2022-10-18 | revise | Marc Duteau | TSMG | Fixing missing metadata; up-349 |
2020-05-06 | revise | Ted Klein | Vocabulary WG | Migrated to the UTG maintenance environment and publishing tooling. |
2014-03-26 | revise | Vocabulary (Woody Beeler) (no record of original request) | 2014T1_2014-03-26_001283 (RIM release ID) | Lock all vaue sets untouched since 2014-03-26 to trackingId 2014T1_2014_03_26 |