HL7.TERMINOLOGY\CoverageParticipationFunction

HL7 Terminology
1.0.0 - Publication

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

CoverageParticipationFunction

Summary

Defining URL:

http://terminology.hl7.org/ValueSet/v3-CoverageParticipationFunction

Version:

2.0.0

Name:

CoverageParticipationFunction

Status:

Active

Title:

CoverageParticipationFunction

Definition:

Definition: Set of codes indicating the manner in which sponsors, underwriters, and payers participate in a policy or program.

OID:

2.16.840.1.113883.1.11.19903 (for OID based terminology systems)

Source Resource:

XML / JSON / Turtle

References

This value set is not used

Content Logical Definition

Logical Definition (CLD)

Include codes from http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction where concept is-a _CoverageParticipationFunction

Expansion

This value set contains 13 concepts

Expansion based on ParticipationFunction v2.0.0 (CodeSystem)

All codes from system http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction

Lvl	Code	Display	Definition
0	_CoverageParticipationFunction	CoverageParticipationFunction	Definition: Set of codes indicating the manner in which sponsors, underwriters, and payers participate in a policy or program.
1	_PayorParticipationFunction	PayorParticipationFunction	Definition: Set of codes indicating the manner in which payors participate in a policy or program.</
2	CLMADJ	claims adjudication	Definition: Manages all operations required to adjudicate fee for service claims or managed care encounter reports.
2	ENROLL	enrollment broker	Definition: Managing the enrollment of covered parties.
2	FFSMGT	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.
2	MCMGT	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.
2	PROVMGT	provider management	Definition: Managing provider contracting, provider services, credentialing, profiling, performance measures, and ensuring network adequacy.
2	UMGT	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.
1	_SponsorParticipationFunction	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.
2	FULINRD	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.
2	SELFINRD	self insured	Definition: Responsibility taken by a sponsor to organize the underwriting of risk and administration of a policy or program.
1	_UnderwriterParticipationFunction	UnderwriterParticipationFunction	Definition: Set of codes indicating the manner in which underwriters participate in a policy or program.
2	PAYORCNTR	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.
2	REINS	reinsures	Definition: Underwriting reinsurance for another underwriter for the policy or program.
2	RETROCES	retrocessionaires	Definition: Underwriting reinsurance for another reinsurer.
2	SUBCTRT	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 .
2	UNDERWRTNG	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

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