HL7.TERMINOLOGY\PayorParticipationFunction

This page is part of the HL7 Terminology (v2.1.0: 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

ValueSet: PayorParticipationFunction

Summary

Defining URL:

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

Version:

2.0.0

Name:

PayorParticipationFunction

Status:

Active as of 2014-03-26

Definition:

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

OID:

2.16.840.1.113883.1.11.19906 (for OID based terminology systems)

Source Resource:

XML / JSON / Turtle

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)

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

Expansion

This value set contains 6 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	_PayorParticipationFunction	PayorParticipationFunction	Definition: Set of codes indicating the manner in which payors participate in a policy or program.</
1	CLMADJ	claims adjudication	Definition: Manages all operations required to adjudicate fee for service claims or managed care encounter reports.
1	ENROLL	enrollment broker	Definition: Managing the enrollment of covered parties.
1	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.
1	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.
1	PROVMGT	provider management	Definition: Managing provider contracting, provider services, credentialing, profiling, performance measures, and ensuring network adequacy.
1	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.

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