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

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

Definition: Manages all operations required to adjudicate fee for service claims or managed care encounter reports.

Definition: Managing the enrollment of covered parties.

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.

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.

Definition: Managing provider contracting, provider services, credentialing, profiling, performance measures, and ensuring network adequacy.

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.

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.

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.

Definition: Responsibility taken by a sponsor to organize the underwriting of risk and administration of a policy or program.

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

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.

Definition: Underwriting reinsurance for another underwriter for the policy or program.

Definition: Underwriting reinsurance for another reinsurer.

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 .

Definition: Provision of underwriting analysis for another underwriter without assumption of risk.