HL7 Terminology (THO)
5.2.0 - Publication
This page is part of the HL7 Terminology (v5.2.0: Release) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
Official URL: http://terminology.hl7.org/ValueSet/v3-ActCoverageReason | Version: 2.0.0 | |||
Active as of 2014-03-26 | Computable Name: ActCoverageReason | |||
Other Identifiers: id: urn:oid:2.16.840.1.113883.1.11.19871 |
Description:Codes used to specify reasons or criteria relating to coverage provided under a policy or program. May be used to convey reasons pertaining to coverage contractual provisions, including criteria for eligibility, coverage limitations, coverage maximums, or financial participation required of covered parties.
References
This value set is not used here; it may be used elsewhere (e.g. specifications and/or implementations that use this content)
http://terminology.hl7.org/CodeSystem/v3-ActReason
where concept is-a _ActCoverageReason
This value set contains 14 concepts
Expansion based on ActReason v2.1.1 (CodeSystem)
Level | Code | System | Display | Definition |
1 | _ActCoverageReason | http://terminology.hl7.org/CodeSystem/v3-ActReason | ActCoverageReason | **Description:**Codes used to specify reasons or criteria relating to coverage provided under a policy or program. May be used to convey reasons pertaining to coverage contractual provisions, including criteria for eligibility, coverage limitations, coverage maximums, or financial participation required of covered parties. |
2 | _EligibilityActReasonCode | http://terminology.hl7.org/CodeSystem/v3-ActReason | EligibilityActReasonCode | Identifies the reason or rational for why a person is eligibile for benefits under an insurance policy or progam. Examples: A person is a claimant under an automobile insurance policy are client deceased & adopted client has been given a new policy identifier. A new employee is eligible for health insurance as an employment benefit. A person meets a government program eligibility criteria for financial, age or health status. |
3 | _ActIneligibilityReason | http://terminology.hl7.org/CodeSystem/v3-ActReason | ActIneligibilityReason | Identifies the reason or rational for why a person is not eligibile for benefits under an insurance policy. Examples are client deceased & adopted client has been given a new policy identifier. |
4 | COVSUS | http://terminology.hl7.org/CodeSystem/v3-ActReason | coverage suspended | When a client has no contact with the health system for an extended period, coverage is suspended. Client will be reinstated to original start date upon proof of identification, residency etc. Example: Coverage may be suspended during a strike situation, when employer benefits for employees are not covered (i.e. not in effect). |
4 | DECSD | http://terminology.hl7.org/CodeSystem/v3-ActReason | deceased | Client deceased. |
4 | REGERR | http://terminology.hl7.org/CodeSystem/v3-ActReason | registered in error | Client was registered in error. |
3 | _CoverageEligibilityReason | http://terminology.hl7.org/CodeSystem/v3-ActReason | CoverageEligibilityReason | Definition: Identifies the reason or rational for why a person is eligibile for benefits under an insurance policy or progam. Examples: A person is a claimant under an automobile insurance policy are client deceased & adopted client has been given a new policy identifier. A new employee is eligible for health insurance as an employment benefit. A person meets a government program eligibility criteria for financial, age or health status. |
4 | AGE | http://terminology.hl7.org/CodeSystem/v3-ActReason | age eligibility | A person becomes eligible for a program based on age. Example: In the U.S., a person who is 65 years of age or older is eligible for Medicare. |
4 | CRIME | http://terminology.hl7.org/CodeSystem/v3-ActReason | crime victim | A person becomes eligible for insurance or a program because of crime related health condition or injury. Example: A person is a claimant under the U.S. Crime Victims Compensation program. |
4 | DIS | http://terminology.hl7.org/CodeSystem/v3-ActReason | disability | A person becomes a claimant under a disability income insurance policy or a disability rehabilitation program because of a health condition or injury which limits the person's ability to earn an income or function without institutionalization. |
4 | EMPLOY | http://terminology.hl7.org/CodeSystem/v3-ActReason | employment benefit | A person becomes eligible for insurance provided as an employment benefit based on employment status. |
4 | FINAN | http://terminology.hl7.org/CodeSystem/v3-ActReason | financial eligibility | A person becomes eligible for a program based on financial criteria. Example: A person whose family income is below a financial threshold for eligibility for Medicaid or SCHIP. |
4 | HEALTH | http://terminology.hl7.org/CodeSystem/v3-ActReason | health status | A person becomes eligible for a program because of a qualifying health condition or injury. Examples: A person is determined to have a qualifying health conditions include pregnancy, HIV/AIDs, tuberculosis, end stage renal disease, breast or cervical cancer, or other condition requiring specialized health services, hospice, institutional or community based care provided under a program |
4 | MULTI | http://terminology.hl7.org/CodeSystem/v3-ActReason | multiple criteria eligibility | A person becomes eligible for a program based on more than one criterion. Examples: In the U.S., a child whose familiy income meets Medicaid financial thresholds and whose age is less than 18 is eligible for the Early and Periodic Screening, Diagnostic, and Treatment program (EPSDT). A person whose family income meets Medicaid financial thresholds and whose age is 65 years or older is eligible for Medicaid and Medicare, and are referred to as dual eligibles. |
4 | PNC | http://terminology.hl7.org/CodeSystem/v3-ActReason | property and casualty condition | A person becomes a claimant under a property and casualty insurance policy because of a related health condition or injury resulting from a circumstance covered under the terms of the policy. Example: A person is a claimant under a homeowners insurance policy because of an injury sustained on the policyholderaTMs premises. |
4 | STATUTORY | http://terminology.hl7.org/CodeSystem/v3-ActReason | statutory eligibility | A person becomes eligible for a program based on statutory criteria. Examples: A person is a member of an indigenous group, a veteran of military service, or in the U.S., a recipient of adoption assistance and foster care under Title IV-E of the Social Security. |
4 | VEHIC | http://terminology.hl7.org/CodeSystem/v3-ActReason | motor vehicle accident victim | A person becomes a claimant under a motor vehicle accident insurance because of a motor vehicle accident related health condition or injury. |
4 | WORK | http://terminology.hl7.org/CodeSystem/v3-ActReason | work related | A person becomes eligible for insurance or a program because of a work related health condition or injury. Example: A person is a claimant under the U.S. Black Lung Program. |
2 | _ActCoverageProviderReason | http://terminology.hl7.org/CodeSystem/v3-ActReason | ActCoverageProviderReason | **Description:**Identifies the reason or rationale for coverage of a service or product based on characteristics of the provider, e.g., contractual relationship to payor, such as in or out-of-network; relationship of the covered party to the provider. **Example:**In closed managed care plan, a covered party is assigned a primary care provider who provides primary care services and authorizes referrals and ancillary and non-primary care services. |
2 | _ActCoverageServiceReason | http://terminology.hl7.org/CodeSystem/v3-ActReason | ActCoverageServiceReason | **Description:**Identifies the reason or rationale for coverage of a service or product based on clinical efficacy criteria or practices prescribed by the payor. |
2 | _CoverageExclusionReason | http://terminology.hl7.org/CodeSystem/v3-ActReason | CoverageExclusionReason | Definition: Identifies the reason or rationale for coverage of a service or product based on coverage exclusions related to the risk of adverse selection by covered parties. |
2 | _CoverageFinancialParticipationReason | http://terminology.hl7.org/CodeSystem/v3-ActReason | CoverageFinancialParticipationReason | **Description:**Identifies the reason or rationale for coverage of a service or product based on financial participation responsibilities of the covered party. |
2 | _CoverageLimitationReason | http://terminology.hl7.org/CodeSystem/v3-ActReason | CoverageLimitationReason | **Description:**Identifies the reason or rationale for limitations on the coverage of a service or product based on coverage contract provisions. **Example:**The maximum cost per unit; or the maximum number of units per period, which is typically the policy or program effective time. |
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
Date | Action | Custodian | Author | Comment |
2022-10-18 | revise | TSMG | Marc Duteau | Fixing missing metadata; up-349 |
2020-05-06 | revise | Vocabulary WG | Ted Klein | Migrated to the UTG maintenance environment and publishing tooling. |
2014-03-26 | revise | 2014T1_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 |