HL7.TERMINOLOGY\PayorRoleType

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: PayorRoleType

Summary

Defining URL:

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

Version:

2.0.0

Name:

PayorRoleType

Status:

Active as of 2014-03-26

Definition:

**Description:**PayorRoleType for a particular type of policy or program benefit package or plan where more detail about the coverage administration role of the Payor is required. The functions performed by a Payor qualified by a PayorRoleType may be specified by the PayorParticpationFunction value set.

**Examples:**A Payor that is a TPA may administer a managed care plan without underwriting the risk.

OID:

2.16.840.1.113883.1.11.19853 (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-RoleCode where concept is-a _PayorRoleType

Expansion

This value set contains 3 concepts

Expansion based on RoleCode v2.1.0 (CodeSystem)

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

Lvl	Code	Display	Definition
0	_PayorRoleType	PayorRoleType	Description:PayorRoleType for a particular type of policy or program benefit package or plan where more detail about the coverage administration role of the Payor is required. The functions performed by a Payor qualified by a PayorRoleType may be specified by the PayorParticpationFunction value set. Examples:A Payor that is a TPA may administer a managed care plan without underwriting the risk.
1	ENROLBKR	Enrollment Broker	Description:A payor that is responsible for functions related to the enrollment of covered parties.
1	TPA	Third party administrator	Description:Third party administrator (TPA) is a payor organization that processes health care claims without carrying insurance risk. Third party administrators are prominent players in the managed care industry and have the expertise and capability to administer all or a portion of the claims process. They are normally contracted by a health insurer or self-insuring companies to administer services, including claims administration, premium collection, enrollment and other administrative activities. Self-insured employers often contract with third party administrator to handle their insurance functions. Insurance companies oftentimes outsource the claims, utilization review or membership functions to a TPA. Sometimes TPAs only manage provider networks, only claims or only utilization review. While some third-party administrators may operate as units of insurance companies, they are often independent. However, hospitals or provider organizations desiring to set up their own health plans will often outsource certain responsibilities to TPAs. TPAs may perform one or several payor functions, specified by the PayorParticipationFunction value set, such as provider management, enrollment, utilization management, and fee for service claims adjudication management.
1	UMO	Utilization management organization	Description:A payor that is responsible for review and case management of health services covered under a policy or program.

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