HL7 Terminology (THO)
3.1.0 - Publication International flag

This page is part of the HL7 Terminology (v3.1.0: 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: CoverageParticipationFunction

Official URL: http://terminology.hl7.org/ValueSet/v3-CoverageParticipationFunction Version: 2.0.0
Active as of 2014-03-26 Computable Name: CoverageParticipationFunction
Other Identifiers: : urn:oid:2.16.840.1.113883.1.11.19903

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

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)

 

Expansion

This value set contains 13 concepts

Expansion based on ParticipationFunction v2.1.0 (CodeSystem)

All codes in this table are from the system http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction

LvlCodeDisplayDefinition
0_CoverageParticipationFunctionCoverageParticipationFunction**Definition:** Set of codes indicating the manner in which sponsors, underwriters, and payers participate in a policy or program.
1  _PayorParticipationFunctionPayorParticipationFunction**Definition:** Set of codes indicating the manner in which payors participate in a policy or program.</
2    CLMADJclaims adjudication**Definition:** Manages all operations required to adjudicate fee for service claims or managed care encounter reports.
2    ENROLLenrollment broker**Definition:** Managing the enrollment of covered parties.
2    FFSMGTffs 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    MCMGTmanaged 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    PROVMGTprovider management**Definition:** Managing provider contracting, provider services, credentialing, profiling, performance measures, and ensuring network adequacy.
2    UMGTutilization 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  _SponsorParticipationFunctionSponsorParticipationFunction**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    FULINRDfully 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    SELFINRDself insured**Definition:** Responsibility taken by a sponsor to organize the underwriting of risk and administration of a policy or program.
1  _UnderwriterParticipationFunctionUnderwriterParticipationFunction**Definition:** Set of codes indicating the manner in which underwriters participate in a policy or program.
2    PAYORCNTRpayor 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    REINSreinsures**Definition:** Underwriting reinsurance for another underwriter for the policy or program.
2    RETROCESretrocessionaires**Definition:** Underwriting reinsurance for another reinsurer.
2    SUBCTRTsubcontracting 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    UNDERWRTNGunderwriting**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
System 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

DateActionCustodianAuthorComment
2020-05-06reviseVocabulary WGTed KleinMigrated to the UTG maintenance environment and publishing tooling.
2014-03-26revise2014T1_2014-03-26_001283 (RIM release ID)Vocabulary (Woody Beeler) (no record of original request)Lock all vaue sets untouched since 2014-03-26 to trackingId 2014T1_2014_03_26