HL7 Terminology (THO)
5.5.0 - Publication International flag

This page is part of the HL7 Terminology (v5.5.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

ValueSet: PayorParticipationFunction

Official URL: http://terminology.hl7.org/ValueSet/v3-PayorParticipationFunction Version: 3.0.0
Active as of 2014-03-26 Responsible: Health Level Seven International Computable Name: PayorParticipationFunction
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:oid:2.16.840.1.113883.1.11.19906

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

Definition: Set of codes indicating the manner in which payors 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)

Logical Definition (CLD)

 

Expansion

Expansion based on codesystem ParticipationFunction v3.0.0 (CodeSystem)

This value set contains 7 concepts.

LevelCodeSystemDisplayDefinition
1  _PayorParticipationFunctionhttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionPayorParticipationFunction

Definition: Set of codes indicating the manner in which payors participate in a policy or program.</

2    CLMADJhttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionclaims adjudication

Definition: Manages all operations required to adjudicate fee for service claims or managed care encounter reports.

2    ENROLLhttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionenrollment broker

Definition: Managing the enrollment of covered parties.

2    FFSMGThttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionffs 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.

2    MCMGThttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionmanaged 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.

2    PROVMGThttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionprovider management

Definition: Managing provider contracting, provider services, credentialing, profiling, performance measures, and ensuring network adequacy.

2    UMGThttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionutilization 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.


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

DateActionCustodianAuthorComment
2023-11-14reviseTSMGMarc DuteauAdd standard copyright and contact to internal content; up-476
2022-10-18reviseTSMGMarc DuteauFixing missing metadata; up-349
2020-05-06reviseVocabulary WGTed KleinMigrated to the UTG maintenance environment and publishing tooling.
2014-03-26revise2014T1_2014-03-26_001283 (RIM release ID)Vocabulary (Woody Beeler) (no record of original request)Lock all vaue sets untouched since 2014-03-26 to trackingId 2014T1_2014_03_26