HL7 Terminology
1.0.0 - Publication

This page is part of the HL7 Terminology (v1.0.0: Release) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

PolicyOrProgramCoverageRoleType

Summary

Defining URL:http://terminology.hl7.org/ValueSet/v3-PolicyOrProgramCoverageRoleType
Version:2.0.0
Name:PolicyOrProgramCoverageRoleType
Status:Active
Title:PolicyOrProgramCoverageRoleType
Definition:

Description: A role recognized through the eligibility of an identified party for benefits covered under an insurance policy or a program based on meeting eligibility criteria.

Eligibility as a covered party may be conditioned on the party meeting criteria to qualify for coverage under a policy or program, which may be mandated by law. These criteria may be:

  1. The sole basis for coverage, e.g., being differently abled may qualify a person for disability coverage
  2. May more fully qualify a covered party role e.g, being differently abled may qualify an adult child as a dependent
  3. May impact the level of coverage for a covered party under a policy or program, e.g., being differently abled may qualify a program eligible for additional benefits.

Discussion: The Abstract Value Set "CoverageRoleType", which was developed for use in the Canadian realm "pre-coordinate" coverage roles with other roles that a covered party must play in order to be eligible for coverage, e.g., "handicapped dependent". These role.codes may only be used with COVPTY to avoid overlapping concepts that would result from using them to specify the specializations of COVPTY, e.g., the role.class DEPEN should not be used with the role.code family dependent because that relationship has overlapping concepts due to the role.code precoodination and is conveyed in FICO with the personal relationship role that has a PART role link to the covered party role. For the same reasons, the role.class DEPEN should not be used with the role.code HANDIC (handicapped dependent); the role.code DIFFABLE (differently abled) should be used instead.

In summary, the coded concepts in the Abstract Value Set "CoveredPartyRoleType" can be "post-coordinated" with the "RoleClassCoveredParty" Abstract Value Set. Decoupling these concepts is intended to support an expansive range of covered party concepts and their semantic comparability.

OID:2.16.840.1.113883.1.11.19809 (for OID based terminology systems)
Source Resource:XML / JSON / Turtle

References

This value set is not used

Content Logical Definition

Logical Definition (CLD)

 

Expansion

This value set contains 27 concepts

Expansion based on RoleCode v2.0.0 (CodeSystem)

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

CodeDisplayDefinition
_PolicyOrProgramCoverageRoleTypePolicyOrProgramCoverageRoleType**Description:** A role recognized through the eligibility of an identified party for benefits covered under an insurance policy or a program based on meeting eligibility criteria. Eligibility as a covered party may be conditioned on the party meeting criteria to qualify for coverage under a policy or program, which may be mandated by law. These criteria may be: 1. The sole basis for coverage, e.g., being differently abled may qualify a person for disability coverage 2. May more fully qualify a covered party role e.g, being differently abled may qualify an adult child as a dependent 3. May impact the level of coverage for a covered party under a policy or program, e.g., being differently abled may qualify a program eligible for additional benefits. **Discussion:** The Abstract Value Set "CoverageRoleType", which was developed for use in the Canadian realm "pre-coordinate" coverage roles with other roles that a covered party must play in order to be eligible for coverage, e.g., "handicapped dependent". These role.codes may only be used with COVPTY to avoid overlapping concepts that would result from using them to specify the specializations of COVPTY, e.g., the role.class DEPEN should not be used with the role.code family dependent because that relationship has overlapping concepts due to the role.code precoodination and is conveyed in FICO with the personal relationship role that has a PART role link to the covered party role. For the same reasons, the role.class DEPEN should not be used with the role.code HANDIC (handicapped dependent); the role.code DIFFABLE (differently abled) should be used instead. In summary, the coded concepts in the Abstract Value Set "CoveredPartyRoleType" can be "post-coordinated" with the "RoleClassCoveredParty" Abstract Value Set. Decoupling these concepts is intended to support an expansive range of covered party concepts and their semantic comparability.
_CoverageRoleTypeCoverageRoleTypeRole recognized through the issuance of insurance coverage to an identified covered party who has this relationship with the policy holder such as the policy holder themselves (self), spouse, child, etc
FAMDEPfamily dependentThe player of the role is dependent of the scoping entity.
HANDIChandicapped dependentCovered party is a dependent of the policy holder with a physical or mental disability causing a disadvantage that makes independent achievement unusually difficult.
INJinjured plaintiffCovered party is an injured party with a legal claim for compensation against a policy holder under an insurance policy.
SELFselfCovered party is the policy holder. Also known as the subscriber.
SPONsponsored dependentCovered party is an individual that the policy holder has assumed responsibility for, such as foster child or legal ward.
STUDstudentCovered party to an insurance policy has coverage through full-time or part-time attendance at a recognized educational institution as defined by a particular insurance policy.
FSTUDfull-time studentCovered party to an insurance policy has coverage through full-time attendance at a recognized educational institution as defined by a particular insurance policy.
PSTUDpart-time studentCovered party to an insurance policy has coverage through part-time attendance at a recognized educational institution as defined by a particular insurance policy.
ADOPTadopted childA child taken into one's family through legal means and raised as one's own child.
GCHILDgrandchildA child of one's son or daughter.
GPARNTgrandparentparent of a parent of the subject.
NATnatural childA child as determined by birth.
NIENEniece/nephewA child of one's brother or sister or of the brother or sister of one's spouse.
PARNTparentOne that begets or brings forth offspring or a person who brings up and cares for for another (Webster's Collegiate Dictionary)
SPSEspouseA marriage partner; a husband or wife.
STEPstep childA child receiving parental care and nurture from a person who is related to them through marriage to their parent.
_CoveredPartyRoleTypecovered party role typeA role recognized through the eligibility of an identified living subject for benefits covered under an insurance policy or a program. Eligibility as a covered party may be conditioned on a relationship with (1) the policy holder such as the policy holder who is covered as an individual under a poliy or as a party sponsored for coverage by the policy holder. **Example:**An employee as a subscriber; or (2) on being scoped another covered party such as the subscriber, as in the case of a dependent. **Discussion:** The Abstract Value Set "CoverageRoleType", which was developed for use in the Canadian realm "pre-coordinate" coverage roles with other roles that a covered party must play in order to be eligible for coverage, e.g., "handicapped dependent". Other codes in the Abstract Value Set CoveredPartyRoleType domain can be "post-coordinated" with the EligiblePartyRoleType codes to denote comparable concepts. Decoupling the concepts is intended to support a wider range of concepts and semantic comparability of coded concepts.
_ClaimantCoveredPartyRoleTypeClaimantCoveredPartyRoleType**Description**A role recognized through the eligibility of a party play a claimant for benefits covered or provided under an insurance policy.
CRIMEVICcrime victim**Description:** A person playing the role of program eligible under a program based on allegations of being the victim of a crime. **Discussion:** This CoveredPartyRoleType.code is typically used when the CoveredPartyRole class code is "program eligible" and the person's status as a crime victim meets jurisdictional or program criteria.
INJWKRinjured worker**Description:** A person playing the role of program eligible under a workers compensation program based on the filing of work-related injury claim. **Discussion:** This CoveredPartyRoleType.code is used when the CoveredPartyRole class code is either "program eligible", a "named insured", and "individual insured", or "dependent", and the person's status as differently abled or "handicapped" meets jurisdictional, policy, or program criteria.
_DependentCoveredPartyRoleTypeDependentCoveredPartyRoleType**Description:** A role recognized through the eligibility of a party to play a dependent for benefits covered or provided under a health insurance policy because of an association with the subscriber that is recognized by the policy underwriter.
COCBENcontinuity of coverage beneficiary**Description:** A person playing the role of an individual insured with continuity of coverage under a policy which is being terminated based on loss of original status that was the basis for coverage. Criteria for qualifying for continuity of coverage may be set by law. **Discussion:** This CoveredPartyRoleType.code is typically used when the CoveredPartyRole class code is either "program eligible" or "subscriber" and the person's status as a continuity of coverage beneficiary meets jurisdictional or policy criteria.
DIFFABLdifferently abled**Description:** A person playing the role of program eligible under a program based on meeting criteria for health or functional limitation set by law or by the program. **Discussion:** This CoveredPartyRoleType.code is typically used when the CoveredPartyRole class code is either "program eligible", "named insured", "individual insured", or "dependent", and the person's status as differently abled meets jurisdictional, policy, or program criteria.
WARDward**Description:** A person, who is a minor or is deemed incompetent, who plays the role of a program eligible where eligibility for coverage is based on meeting program eligibility criteria for status as a ward of a court or jurisdiction. **Discussion:** This CoveredPartyRoleType.code is typically used when the CoveredPartyRole class code is a "claimant", "program eligible", a "named insured", an "individual Insured" or a "dependent", and the person's status as a ward meets program or policy criteria. In the case of a ward covered under a program providing financial or health benefits, a governmental agency may take temporary custody of a minor or incompetent for his/her protection and care, e.g., if the ward is suffering from neglect or abuse, or has been in trouble with the law.
_IndividualInsuredPartyRoleTypeIndividualInsuredPartyRoleTypeA role recognized through the eligibility of a party to play an individual insured for benefits covered or provided under an insurance policy where the party is also the policy holder.
RETIREEretiree**Description:** A person playing the role of an individual insured under a policy based on meeting criteria for the employment status of retired set by law or the policy. **Discussion:** This CoveredPartyRoleType.code is typically used when the CoveredPartyRole class code is either "program eligible" or "subscriber" and the person's status as a retiree meets jurisdictional or policy criteria.
_ProgramEligiblePartyRoleTypeProgramEligiblePartyRoleType**Description:**A role recognized through the eligibility of a party to play a program eligible for benefits covered or provided under a program.
INDIGmember of an indigenous people**Description:** A person playing the role of program eligible under a program based on aboriginal ancestry or as a member of an aboriginal community. **Discussion:** This CoveredPartyRoleType.code is typically used when the CoveredPartyRole class code is "program eligible" and the person's status as a member of an indigenous people meets jurisdictional or program criteria.
MILmilitary**Definition:** A person playing the role of program eligible under a program based on military status. **Discussion:** This CoveredPartyRoleType.code is typically used when the CoveredPartyRole class code is either "program eligible" or "subscriber" and the person's status as a member of the military meets jurisdictional or program criteria
ACTMILactive duty military**Description:** A person playing the role of program eligible under a program based on active military status. **Discussion:** This CoveredPartyRoleType.code is typically used when the CoveredPartyRole class code is either "program eligible" or "subscriber" and the persons status as active duty military meets jurisdictional or program criteria.
RETMILretired military**Description:** A person playing the role of program eligible under a program based on retired military status. **Discussion:** This CoveredPartyRoleType.code is typically used when the CoveredPartyRole class code is either "program eligible" or "subscriber" and the persons status as retired military meets jurisdictional or program criteria.
VETveteran**Description:** A person playing the role of program eligible under a program based on status as a military veteran. **Discussion:** This CoveredPartyRoleType.code is typically used when the CoveredPartyRole class code is either "program eligible" or "subscriber" and the persons status as a veteran meets jurisdictional or program criteria.
_SubscriberCoveredPartyRoleTypeSubscriberCoveredPartyRoleType**Description:** A role recognized through the eligibility of a party to play a subscriber for benefits covered or provided under a health insurance policy.

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

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