HL7 Terminology
2.0.0 - Publication

This page is part of the HL7 Terminology (v2.0.0: Release) based on FHIR R4. The current version which supercedes this version is 2.1.0. For a full list of available versions, see the Directory of published versions

: x_RoleClassCoverage - JSON Representation

Raw json | Download


{
  "resourceType" : "ValueSet",
  "id" : "v3-xRoleClassCoverage",
  "language" : "en",
  "text" : {
    "status" : "extensions",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en\" lang=\"en\"><ul><li>Include these codes as defined in <a href=\"CodeSystem-v3-RoleClass.html\"><code>http://terminology.hl7.org/CodeSystem/v3-RoleClass</code></a><table class=\"none\"><tr><td style=\"white-space:nowrap\"><b>Code</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td><a href=\"CodeSystem-v3-RoleClass.html#v3-RoleClass-COVPTY\">COVPTY</a></td><td>covered party</td><td>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.<br/><br/>*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.<br/><br/>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.</td></tr><tr><td><a href=\"CodeSystem-v3-RoleClass.html#v3-RoleClass-POLHOLD\">POLHOLD</a></td><td>policy holder</td><td>A role played by a person or organization that holds an insurance policy. The underwriter of that policy is the scoping entity.<br/><br/>*Discussion:*The identifier of the policy is captured in 'Role.id' when the Role is a policy holder.<br/><br/>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.</td></tr><tr><td><a href=\"CodeSystem-v3-RoleClass.html#v3-RoleClass-SPNSR\">SPNSR</a></td><td>coverage sponsor</td><td>A role played by an entity, usually an organization that is the sponsor of an insurance plan or a health program. A sponsor is the party that is ultimately accountable for the coverage by employment contract or by law. A sponsor can be an employer, union, government agency, or association. Fully insured sponsors establish the terms of the plan and contract with health insurance plans to assume the risk and to administer the plan. Self-insured sponsors delegate coverage administration, but not risk, to third-party administrators. Program sponsors designate services to be covered in accordance with statute. Program sponsors may administer the coverage themselves, delegate coverage administration, but not risk to third-party administrators, or contract with health insurance plans to assume the risk and administrator a program. Sponsors qualify individuals who may become<br/><br/>1.  a policy holder of the plan;<br/>2.  where the sponsor is the policy holder, who may become a subscriber or a dependent to a policy under the plan; or<br/>3.  where the sponsor is a government agency, who may become program eligibles under a program.<br/><br/>The sponsor role may be further qualified by the SponsorRole.code. Entities playing the sponsor role may also play the role of a Coverage Administrator.<br/><br/>*Example:* An employer, union, government agency, or association.</td></tr><tr><td><a href=\"CodeSystem-v3-RoleClass.html#v3-RoleClass-UNDWRT\">UNDWRT</a></td><td>underwriter</td><td>A role played by a person or an organization. It is the party that<br/><br/>1.  accepts fiscal responsibility for insurance plans and the policies created under those plans;<br/>2.  administers and accepts fiscal responsibility for a program that provides coverage for services to eligible individuals; and/or<br/>3.  has the responsibility to assess the merits of each risk and decide a suitable premium for accepting all or part of the risk. If played by an organization, this role may be further specified by an appropriate RoleCode.<br/><br/>*Example:*<br/><br/>1.  A health insurer;<br/>2.  Medicaid Program;<br/>3.  Lloyd's of London</td></tr></table></li></ul></div>"
  },
  "extension" : [
    {
      "extension" : [
        {
          "url" : "name",
          "valueString" : "Name:Class"
        },
        {
          "url" : "value",
          "valueString" : "planCoverage"
        }
      ],
      "url" : "http://terminology.hl7.org/StructureDefinition/ext-mif-assocConceptProp"
    },
    {
      "extension" : [
        {
          "url" : "name",
          "valueString" : "Name:Role:player:Entity"
        },
        {
          "url" : "value",
          "valueString" : "covered&"
        }
      ],
      "url" : "http://terminology.hl7.org/StructureDefinition/ext-mif-assocConceptProp"
    },
    {
      "extension" : [
        {
          "url" : "name",
          "valueString" : "Name:Role:scoper:Entity"
        },
        {
          "url" : "value",
          "valueString" : "coverageSponsor"
        }
      ],
      "url" : "http://terminology.hl7.org/StructureDefinition/ext-mif-assocConceptProp"
    },
    {
      "extension" : [
        {
          "url" : "name",
          "valueString" : "Sort:Entity:playedRole:Role"
        },
        {
          "url" : "value",
          "valueString" : "AAAAI____"
        }
      ],
      "url" : "http://terminology.hl7.org/StructureDefinition/ext-mif-assocConceptProp"
    },
    {
      "extension" : [
        {
          "url" : "name",
          "valueString" : "Sort:Entity:scopedRole:Role"
        },
        {
          "url" : "value",
          "valueString" : "AAAAI____"
        }
      ],
      "url" : "http://terminology.hl7.org/StructureDefinition/ext-mif-assocConceptProp"
    }
  ],
  "url" : "http://terminology.hl7.org/ValueSet/v3-xRoleClassCoverage",
  "identifier" : [
    {
      "system" : "urn:ietf:rfc:3986",
      "value" : "urn:oid:2.16.840.1.113883.1.11.14008"
    }
  ],
  "version" : "2.0.0",
  "name" : "XRoleClassCoverage",
  "title" : "x_RoleClassCoverage",
  "status" : "active",
  "date" : "2014-03-26",
  "description" : "An abstract domain that encompasses the roles that arise in the context of providing, purchasing, and managing health care coverage and insurance.",
  "compose" : {
    "include" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/v3-RoleClass",
        "concept" : [
          {
            "code" : "COVPTY"
          },
          {
            "code" : "POLHOLD"
          },
          {
            "code" : "SPNSR"
          },
          {
            "code" : "UNDWRT"
          }
        ]
      }
    ]
  }
}