HL7 Terminology (THO)
5.5.0 - Publication International flag

This page is part of the HL7 Terminology (v5.5.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. 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: 3.0.0
Active as of 2014-03-26 Responsible: Health Level Seven International Computable Name: CoverageParticipationFunction
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:oid:2.16.840.1.113883.1.11.19903

Copyright/Legal: This material derives from the HL7 Terminology THO. THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license

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

Expansion based on codesystem ParticipationFunction v3.0.0 (CodeSystem)

This value set contains 17 concepts.

LevelCodeSystemDisplayDefinition
1  _CoverageParticipationFunctionhttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionCoverageParticipationFunction

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

2    _PayorParticipationFunctionhttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionPayorParticipationFunction

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

3      CLMADJhttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionclaims adjudication

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

3      ENROLLhttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionenrollment broker

Definition: Managing the enrollment of covered parties.

3      FFSMGThttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionffs 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.

3      MCMGThttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionmanaged 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.

3      PROVMGThttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionprovider management

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

3      UMGThttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionutilization 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.

2    _SponsorParticipationFunctionhttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionSponsorParticipationFunction

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.

3      FULINRDhttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionfully 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.

3      SELFINRDhttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionself insured

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

2    _UnderwriterParticipationFunctionhttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionUnderwriterParticipationFunction

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

3      PAYORCNTRhttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionpayor 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.

3      REINShttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionreinsures

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

3      RETROCEShttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionretrocessionaires

Definition: Underwriting reinsurance for another reinsurer.

3      SUBCTRThttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionsubcontracting 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 .

3      UNDERWRTNGhttp://terminology.hl7.org/CodeSystem/v3-ParticipationFunctionunderwriting

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

DateActionAuthorCustodianComment
2023-11-14reviseMarc DuteauTSMGAdd standard copyright and contact to internal content; up-476
2022-10-18reviseMarc DuteauTSMGFixing missing metadata; up-349
2020-05-06reviseTed KleinVocabulary WGMigrated to the UTG maintenance environment and publishing tooling.
2014-03-26reviseVocabulary (Woody Beeler) (no record of original request)2014T1_2014-03-26_001283 (RIM release ID)Lock all vaue sets untouched since 2014-03-26 to trackingId 2014T1_2014_03_26