This page is part of the HL7 Terminology (v1.0.0: Release) based on FHIR R4. The current version which supercedes this version is 5.2.0. For a full list of available versions, see the Directory of published versions
Summary
Defining URL: | http://terminology.hl7.org/ValueSet/v3-ActCoverageReason |
Version: | 2.0.0 |
Name: | ActCoverageReason |
Status: | Active |
Title: | ActCoverageReason |
Definition: | **Description:**Codes used to specify reasons or criteria relating to coverage provided under a policy or program. May be used to convey reasons pertaining to coverage contractual provisions, including criteria for eligibility, coverage limitations, coverage maximums, or financial participation required of covered parties. |
OID: | 2.16.840.1.113883.1.11.19871 (for OID based terminology systems) |
Source Resource: | XML / JSON / Turtle |
References
This value set is not used
http://terminology.hl7.org/CodeSystem/v3-ActReason
where concept is-a _ActCoverageReason
This value set contains 14 concepts
Expansion based on ActReason v2.0.0 (CodeSystem)
All codes from system http://terminology.hl7.org/CodeSystem/v3-ActReason
Lvl | Code | Display | Definition |
0 | _ActCoverageReason | ActCoverageReason | **Description:**Codes used to specify reasons or criteria relating to coverage provided under a policy or program. May be used to convey reasons pertaining to coverage contractual provisions, including criteria for eligibility, coverage limitations, coverage maximums, or financial participation required of covered parties. |
1 | _EligibilityActReasonCode | EligibilityActReasonCode | 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. |
2 | _ActIneligibilityReason | ActIneligibilityReason | 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. |
3 | COVSUS | coverage suspended | 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). |
3 | DECSD | deceased | Client deceased. |
3 | REGERR | registered in error | Client was registered in error. |
2 | _CoverageEligibilityReason | CoverageEligibilityReason | 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. |
3 | AGE | age eligibility | 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. |
3 | CRIME | crime victim | 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. |
3 | DIS | disability | 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. |
3 | EMPLOY | employment benefit | A person becomes eligible for insurance provided as an employment benefit based on employment status. |
3 | FINAN | financial eligibility | 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. |
3 | HEALTH | health status | 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 |
3 | MULTI | multiple criteria eligibility | 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. |
3 | PNC | property and casualty condition | 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. |
3 | STATUTORY | statutory eligibility | 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. |
3 | VEHIC | motor vehicle accident victim | A person becomes a claimant under a motor vehicle accident insurance because of a motor vehicle accident related health condition or injury. |
3 | WORK | work related | 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. |
1 | _ActCoverageProviderReason | ActCoverageProviderReason | **Description:**Identifies the reason or rationale for coverage of a service or product based on characteristics of the provider, e.g., contractual relationship to payor, such as in or out-of-network; relationship of the covered party to the provider. **Example:**In closed managed care plan, a covered party is assigned a primary care provider who provides primary care services and authorizes referrals and ancillary and non-primary care services. |
1 | _ActCoverageServiceReason | ActCoverageServiceReason | **Description:**Identifies the reason or rationale for coverage of a service or product based on clinical efficacy criteria or practices prescribed by the payor. |
1 | _CoverageExclusionReason | CoverageExclusionReason | **Definition:** Identifies the reason or rationale for coverage of a service or product based on coverage exclusions related to the risk of adverse selection by covered parties. |
1 | _CoverageFinancialParticipationReason | CoverageFinancialParticipationReason | **Description:**Identifies the reason or rationale for coverage of a service or product based on financial participation responsibilities of the covered party. |
1 | _CoverageLimitationReason | CoverageLimitationReason | **Description:**Identifies the reason or rationale for limitations on the coverage of a service or product based on coverage contract provisions. **Example:**The maximum cost per unit; or the maximum number of units per period, which is typically the policy or program effective time. |
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 |
Source | 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 | Custodian | Author | Comment |
2020-05-06 | revise | Vocabulary WG | Ted Klein | Migrated to the UTG maintenance environment and publishing tooling. |
2014-03-26 | revise | 2014T1_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 |