HL7.TERMINOLOGY\RoleClassCoveredParty

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

RoleClassCoveredParty

Summary

Defining URL:

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

Version:

2.0.0

Name:

RoleClassCoveredParty

Status:

Active

Title:

RoleClassCoveredParty

Definition:

Description: A relationship between a party that receives benefit coverage under the terms of an insurance policy or program and the underwriter of the policy or program. The role is played by the party that receives benefit coverage under the terms of a particular insurance policy or program. The organization playing the underwriter of that policy or program is the scoping entity.

A covered party receives coverage under a policy because of some contractual or other relationship with the policy holder. In most cases, the policy holder has discretion over which parties may be covered under a policy, unless the policy holder assigns or is required by a court to assign this right.

A covered party receives coverage under a program by being determined eligible based on program eligibility criteria specified by the program sponsor.

Discussion: This reason for coverage is specified by use of a role type code from either of the abstract value sets beneath the PolicyOrProgramCoverageRoleType abstract value set.

The CoverageRoleType abstract value set can only be used when the role class is the concept code "covered party" (COVPTY) because this value set contains precoordinated coded concepts relating to coverage criteria that was developed for the Canadian realm. This is to avoid overlapping concepts, e.g., the DEPEN role.class cannot be used with the FAMDEP Role.code

The CoveredPartyRoleType abstract value set may be used with any of the covered party role class codes to support post coordination of coverage criteria. Where coverage under a policy depends on the concurrence of a policy holder, a relationship link with type code of indirect authority should be included using the policy holder role as the source, and the covered party role as the target.

Note: A particular policy may cover several parties, one of whom may be, but need not be, the policy holder. Thus the notion of covered party is a role that is distinct from that of the policy holder.

Note: The entity playing the role of covered party is an organization, a non-person living subject or a group of persons, the role class codes Subscriber and Dependent may not be used.

OID:

2.16.840.1.113883.1.11.19807 (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-RoleClass where concept is-a COVPTY

Expansion

This value set contains 7 concepts

Expansion based on RoleClass v2.0.0 (CodeSystem)

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

Lvl	Code	Display	Definition
0	COVPTY	covered party	A role class played by a person who receives benefit coverage under the terms of a particular insurance policy. The underwriter of that policy is the scoping entity. The covered party receives coverage because of some contractual or other relationship with the holder of that policy. Discussion:This reason for coverage is captured in 'Role.code' and a relationship link with type code of indirect authority should be included using the policy holder role as the source, and the covered party role as the target. Note that a particular policy may cover several individuals one of whom may be, but need not be, the policy holder. Thus the notion of covered party is a role that is distinct from that of the policy holder.
1	CLAIM	claimant	Description: A role played by a party making a claim for coverage under a policy or program. A claimant must be either a person or organization, or a group of persons or organizations. A claimant is not a named insured or a program eligible. Discussion: With respect to liability insurance such as property and casualty insurance, a claimant must file a claim requesting indemnification for a loss that the claimant considers covered under the policy of a named insured. The claims adjuster for the policy underwriter will review the claim to determine whether the loss meets the benefit coverage criteria under a policy, and base any indemnification or coverage payment on that review. If a third party is liable in whole or part for the loss, the underwriter may pursue third party liability recovery. A claimant may be involved in civil or criminal legal proceedings involving claims against a defendant party that is indemnified by an insurance policy or to protest the finding of a claims adjustor. With respect to life insurance, a beneficiary designated by a named insured becomes a claimant of the proceeds of coverage, as in the case of a life insurance policy. However, a claimant for coverage under life insurance is not necessarily a designated beneficiary. Note: A claimant is not a named insured. However, a named insured may make a claim under a policy, e.g., an insured driver may make a claim for an injury under his or her comprehensive automobile insurance policy. Similarly, a program eligible may make a claim under program, e.g., an unemployed worker may claim benefits under an unemployment insurance program, but parties playing these covered party role classes are not, for purposes of this vocabulary and in an effort to clearly distinguish role classes, considered claimants. In the case of a named insured making a claim, a role type code INSCLM (insured claimant) subtypes the class to indicate that either a named insured or an individual insured has filed a claim for a loss. In the case of a program eligible, a role type code INJWKR (injured worker) subtypes the class to indicate that the covered party in a workers compensation program is an injured worker, and as such, has filed a "claim" under the program for benefits. Likewise, a covered role type code UNEMP (unemployed worker) subtypes the program eligible class to indicate that the covered party in an unemployment insurance program has filed a claim for unemployment benefits. Example: A claimant under automobile policy that is not the named insured.
1	NAMED	named insured	Description: A role played by a party to an insurance policy to which the insurer agrees to indemnify for losses, provides benefits for, or renders services. A named insured may be either a person, non-person living subject, or an organization, or a group of persons, non-person living subjects, or organizations. Discussion: The coded concept NAMED should not be used where a more specific child concept in this Specializable value set applies. In some cases, the named insured may not be the policy holder, e.g., where a policy holder purchases life insurance policy in which another party is the named insured and the policy holder is the beneficiary of the policy. Note: The party playing the role of a named insured is not a claimant in the sense conveyed by the RoleClassCoveredParty CLAIM (claimant). However, a named insured may make a claim under a policy, e.g., e.g., a party that is the named insured and policy holder under a comprehensive automobile insurance policy may become the claimant for coverage under that policy e.g., if injured in an automobile accident and there is no liable third party. In the case of a named insured making a claim, a role type code INSCLM (insured claimant) subtypes the class to indicate that a named insured has filed a claim for a loss. Example: The named insured under a comprehensive automobile, disability, or property and casualty policy that is the named insured and may or may not be the policy holder.
2	DEPEN	dependent	Description: A role played by a person covered under a policy or program based on an association with a subscriber, which is recognized by the policy holder. Note: The party playing the role of a dependent is not a claimant in the sense conveyed by the RoleClassCoveredParty CLAIM (claimant). However, a dependent may make a claim under a policy, e.g., a dependent under a health insurance policy may become the claimant for coverage under that policy for wellness examines or if injured and there is no liable third party. In the case of a dependent making a claim, a role type code INSCLM (insured claimant) subtypes the class to indicate that the dependent has filed a claim for services covered under the health insurance policy. Example: The dependent has an association with the subscriber such as a financial dependency or personal relationship such as that of a spouse, or a natural or adopted child. The policy holder may be required by law to recognize certain associations or may have discretion about the associations. For example, a policy holder may dictate the criteria for the dependent status of adult children who are students, such as requiring full time enrollment, or may recognize domestic partners as dependents. Under certain circumstances, the dependent may be under the indirect authority of a responsible party acting as a surrogate for the subscriber, for example, if the subscriber is differently abled or deceased, a guardian ad Lidem or estate executor may be appointed to assume the subscriberaTMs legal standing in the relationship with the dependent.
2	INDIV	individual	Description: A role played by a party covered under a policy as the policy holder. An individual may be either a person or an organization. Note: The party playing the role of an individual insured is not a claimant in the sense conveyed by the RoleClassCoveredParty CLAIM (claimant). However, a named insured may make a claim under a policy, e.g., a party that is the named insured and policy holder under a comprehensive automobile insurance policy may become the claimant for coverage under that policy if injured in an automobile accident and there is no liable third party. In the case of an individual insured making a claim, a role type code INSCLM (insured claimant) subtypes the class to indicate that an individual insured has filed a claim for a loss. Example: The individual insured under a comprehensive automobile, disability, or property and casualty policy that is the policy holder.
2	SUBSCR	subscriber	Description: A role played by a person covered under a policy based on association with a sponsor who is the policy holder, and whose association may provide for the eligibility of dependents for coverage. Discussion: The policy holder holds the contract with the policy or program underwriter. The subscriber holds a certificate of coverage under the contract. In legal proceedings concerning the policy or program, the terms of the contract takes precedence over the terms of the certificate of coverage if there are any inconsistencies. Note: The party playing the role of a subscriber is not a claimant in the sense conveyed by the RoleClassCoveredParty CLAIM (claimant). However, a subscriber may make a claim under a policy, e.g., a subscriber under a health insurance policy may become the claimant for coverage under that policy for wellness examines or if injured and there is no liable third party. In the case of a subscriber making a claim, a role type code INSCLM (insured claimant) subtypes the class to indicate that the subscriber has filed a claim for services covered under the health insurance policy. Example: An employee or a member of an association.
1	PROG	program eligible	Description: A role played by a party that meets the eligibility criteria for coverage under a program. A program eligible may be either a person, non-person living subject, or an organization, or a group of persons, non-person living subjects, or organizations. Discussion: A program as typically government administered coverage for parties determined eligible under the terms of the program. Note: The party playing a program eligible is not a claimant in the sense conveyed by the RoleClassCoveredParty CLAIM (claimant). However a program eligible may make a claim under program, e.g., an unemployed worker may claim benefits under an unemployment insurance program, but parties playing these covered party role classes are not, for purposes of this vocabulary and in an effort to clearly distinguish role classes, considered claimants. In the case of a program eligible, a role type code INJWKR (injured worker) subtypes the class to indicate that the covered party in a workers compensation program is an injured worker, and as such, has filed a "claim" under the program for benefits. Likewise, a covered role type code UNEMP (unemployed worker) subtypes the program eligible class to indicate that the covered party in an unemployment insurance program has filed a claim for unemployment benefits. Example: A party meeting eligibility criteria related to health or financial status, e.g., in the U.S., persons meeting health, demographic, or financial criteria established by state and federal law are eligible for Medicaid.

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

Author

Custodian

Comment

2020-05-06

revise