FHIR Cross-Version Extensions package for FHIR R4 from FHIR R5
0.0.1-snapshot-2 - informative International flag

FHIR Cross-Version Extensions package for FHIR R4 from FHIR R5 - Version 0.0.1-snapshot-2. See the Directory of published versions

: Cross-version VS for R5.CoverageParticipationFunction for use in FHIR R4 - XML Representation

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<ValueSet xmlns="http://hl7.org/fhir">
  <id value="R5-v3-CoverageParticipationFunction-for-R4"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: ValueSet R5-v3-CoverageParticipationFunction-for-R4</b></p><a name="R5-v3-CoverageParticipationFunction-for-R4"> </a><a name="hcR5-v3-CoverageParticipationFunction-for-R4"> </a><p>This value set expansion contains 13 concepts.</p><table class="codes"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>System</b></td><td><b>Display</b></td><td><b>Definition</b></td></tr><tr><td style="white-space:nowrap"><a name="R5-v3-CoverageParticipationFunction-for-R4-http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction-CLMADJ"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ParticipationFunction.html#v3-ParticipationFunction-CLMADJ">CLMADJ</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction</td><td>claims adjudication</td><td><div><p><strong>Definition:</strong> Manages all operations required to adjudicate fee for service claims or managed care encounter reports.</p>
</div></td></tr><tr><td style="white-space:nowrap"><a name="R5-v3-CoverageParticipationFunction-for-R4-http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction-ENROLL"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ParticipationFunction.html#v3-ParticipationFunction-ENROLL">ENROLL</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction</td><td>enrollment broker</td><td><div><p><strong>Definition:</strong> Managing the enrollment of covered parties.</p>
</div></td></tr><tr><td style="white-space:nowrap"><a name="R5-v3-CoverageParticipationFunction-for-R4-http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction-FFSMGT"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ParticipationFunction.html#v3-ParticipationFunction-FFSMGT">FFSMGT</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction</td><td>ffs management</td><td><div><p><strong>Definition:</strong> 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.</p>
</div></td></tr><tr><td style="white-space:nowrap"><a name="R5-v3-CoverageParticipationFunction-for-R4-http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction-MCMGT"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ParticipationFunction.html#v3-ParticipationFunction-MCMGT">MCMGT</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction</td><td>managed care management</td><td><div><p><strong>Definition:</strong> 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.</p>
</div></td></tr><tr><td style="white-space:nowrap"><a name="R5-v3-CoverageParticipationFunction-for-R4-http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction-PROVMGT"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ParticipationFunction.html#v3-ParticipationFunction-PROVMGT">PROVMGT</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction</td><td>provider management</td><td><div><p><strong>Definition:</strong> Managing provider contracting, provider services, credentialing, profiling, performance measures, and ensuring network adequacy.</p>
</div></td></tr><tr><td style="white-space:nowrap"><a name="R5-v3-CoverageParticipationFunction-for-R4-http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction-UMGT"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ParticipationFunction.html#v3-ParticipationFunction-UMGT">UMGT</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction</td><td>utilization management</td><td><div><p><strong>Definition:</strong> 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.</p>
</div></td></tr><tr><td style="white-space:nowrap"><a name="R5-v3-CoverageParticipationFunction-for-R4-http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction-FULINRD"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ParticipationFunction.html#v3-ParticipationFunction-FULINRD">FULINRD</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction</td><td>fully insured</td><td><div><p><strong>Definition:</strong> 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.</p>
</div></td></tr><tr><td style="white-space:nowrap"><a name="R5-v3-CoverageParticipationFunction-for-R4-http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction-SELFINRD"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ParticipationFunction.html#v3-ParticipationFunction-SELFINRD">SELFINRD</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction</td><td>self insured</td><td><div><p><strong>Definition:</strong> Responsibility taken by a sponsor to organize the underwriting of risk and administration of a policy or program.</p>
</div></td></tr><tr><td style="white-space:nowrap"><a name="R5-v3-CoverageParticipationFunction-for-R4-http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction-PAYORCNTR"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ParticipationFunction.html#v3-ParticipationFunction-PAYORCNTR">PAYORCNTR</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction</td><td>payor contracting</td><td><div><p><strong>Definition:</strong> 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.</p>
</div></td></tr><tr><td style="white-space:nowrap"><a name="R5-v3-CoverageParticipationFunction-for-R4-http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction-REINS"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ParticipationFunction.html#v3-ParticipationFunction-REINS">REINS</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction</td><td>reinsures</td><td><div><p><strong>Definition:</strong> Underwriting reinsurance for another underwriter for the policy or program.</p>
</div></td></tr><tr><td style="white-space:nowrap"><a name="R5-v3-CoverageParticipationFunction-for-R4-http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction-RETROCES"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ParticipationFunction.html#v3-ParticipationFunction-RETROCES">RETROCES</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction</td><td>retrocessionaires</td><td><div><p><strong>Definition:</strong> Underwriting reinsurance for another reinsurer.</p>
</div></td></tr><tr><td style="white-space:nowrap"><a name="R5-v3-CoverageParticipationFunction-for-R4-http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction-SUBCTRT"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ParticipationFunction.html#v3-ParticipationFunction-SUBCTRT">SUBCTRT</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction</td><td>subcontracting risk</td><td><div><p><strong>Definition:</strong> 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 .</p>
</div></td></tr><tr><td style="white-space:nowrap"><a name="R5-v3-CoverageParticipationFunction-for-R4-http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction-UNDERWRTNG"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ParticipationFunction.html#v3-ParticipationFunction-UNDERWRTNG">UNDERWRTNG</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction</td><td>underwriting</td><td><div><p><strong>Definition:</strong> Provision of underwriting analysis for another underwriter without assumption of risk.</p>
</div></td></tr></table></div>
  </text>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
    <valueCode value="fhir"/>
  </extension>
  <extension url="http://hl7.org/fhir/StructureDefinition/package-source">
    <extension url="packageId">
      <valueId value="hl7.fhir.uv.xver-r5.r4"/>
    </extension>
    <extension url="version">
      <valueString value="0.0.1-snapshot-2"/>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm">
    <valueInteger value="0">
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom">
        <valueCanonical
                        value="http://hl7.org/fhir/5.0/ImplementationGuide/hl7.fhir.uv.xver-r5.r4"/>
      </extension>
    </valueInteger>
  </extension>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status">
    <valueCode value="informative">
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom">
        <valueCanonical
                        value="http://hl7.org/fhir/5.0/ImplementationGuide/hl7.fhir.uv.xver-r5.r4"/>
      </extension>
    </valueCode>
  </extension>
  <url
       value="http://hl7.org/fhir/5.0/ValueSet/R5-v3-CoverageParticipationFunction-for-R4"/>
  <version value="0.0.1-snapshot-2"/>
  <name value="R5_v3_CoverageParticipationFunction_for_R4"/>
  <title
         value="Cross-version VS for R5.CoverageParticipationFunction for use in FHIR R4"/>
  <status value="active"/>
  <experimental value="false"/>
  <date value="2025-09-01T22:37:05.089384+10:00"/>
  <publisher value="FHIR Infrastructure"/>
  <contact>
    <name value="FHIR Infrastructure"/>
    <telecom>
      <system value="url"/>
      <value value="http://www.hl7.org/Special/committees/fiwg"/>
    </telecom>
  </contact>
  <description
               value="This cross-version ValueSet represents concepts from http://terminology.hl7.org/ValueSet/v3-CoverageParticipationFunction|2.0.0 for use in FHIR R4. Concepts not present here have direct `equivalent` mappings crossing all versions from R5 to R4."/>
  <jurisdiction>
    <coding>
      <system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
      <code value="001"/>
      <display value="World"/>
    </coding>
  </jurisdiction>
  <compose>
    <include>
      <system
              value="http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction"/>
      <version value="2.1.0"/>
      <concept>
        <code value="CLMADJ"/>
        <display value="claims adjudication"/>
      </concept>
      <concept>
        <code value="ENROLL"/>
        <display value="enrollment broker"/>
      </concept>
      <concept>
        <code value="FFSMGT"/>
        <display value="ffs management"/>
      </concept>
      <concept>
        <code value="MCMGT"/>
        <display value="managed care management"/>
      </concept>
      <concept>
        <code value="PROVMGT"/>
        <display value="provider management"/>
      </concept>
      <concept>
        <code value="UMGT"/>
        <display value="utilization management"/>
      </concept>
      <concept>
        <code value="FULINRD"/>
        <display value="fully insured"/>
      </concept>
      <concept>
        <code value="SELFINRD"/>
        <display value="self insured"/>
      </concept>
      <concept>
        <code value="PAYORCNTR"/>
        <display value="payor contracting"/>
      </concept>
      <concept>
        <code value="REINS"/>
        <display value="reinsures"/>
      </concept>
      <concept>
        <code value="RETROCES"/>
        <display value="retrocessionaires"/>
      </concept>
      <concept>
        <code value="SUBCTRT"/>
        <display value="subcontracting risk"/>
      </concept>
      <concept>
        <code value="UNDERWRTNG"/>
        <display value="underwriting"/>
      </concept>
    </include>
  </compose>
  <expansion>
    <timestamp value="2025-09-01T22:37:05.089379+10:00"/>
    <contains>
      <system
              value="http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction"/>
      <version value="2.1.0"/>
      <code value="CLMADJ"/>
      <display value="claims adjudication"/>
    </contains>
    <contains>
      <system
              value="http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction"/>
      <version value="2.1.0"/>
      <code value="ENROLL"/>
      <display value="enrollment broker"/>
    </contains>
    <contains>
      <system
              value="http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction"/>
      <version value="2.1.0"/>
      <code value="FFSMGT"/>
      <display value="ffs management"/>
    </contains>
    <contains>
      <system
              value="http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction"/>
      <version value="2.1.0"/>
      <code value="MCMGT"/>
      <display value="managed care management"/>
    </contains>
    <contains>
      <system
              value="http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction"/>
      <version value="2.1.0"/>
      <code value="PROVMGT"/>
      <display value="provider management"/>
    </contains>
    <contains>
      <system
              value="http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction"/>
      <version value="2.1.0"/>
      <code value="UMGT"/>
      <display value="utilization management"/>
    </contains>
    <contains>
      <system
              value="http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction"/>
      <version value="2.1.0"/>
      <code value="FULINRD"/>
      <display value="fully insured"/>
    </contains>
    <contains>
      <system
              value="http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction"/>
      <version value="2.1.0"/>
      <code value="SELFINRD"/>
      <display value="self insured"/>
    </contains>
    <contains>
      <system
              value="http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction"/>
      <version value="2.1.0"/>
      <code value="PAYORCNTR"/>
      <display value="payor contracting"/>
    </contains>
    <contains>
      <system
              value="http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction"/>
      <version value="2.1.0"/>
      <code value="REINS"/>
      <display value="reinsures"/>
    </contains>
    <contains>
      <system
              value="http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction"/>
      <version value="2.1.0"/>
      <code value="RETROCES"/>
      <display value="retrocessionaires"/>
    </contains>
    <contains>
      <system
              value="http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction"/>
      <version value="2.1.0"/>
      <code value="SUBCTRT"/>
      <display value="subcontracting risk"/>
    </contains>
    <contains>
      <system
              value="http://terminology.hl7.org/CodeSystem/v3-ParticipationFunction"/>
      <version value="2.1.0"/>
      <code value="UNDERWRTNG"/>
      <display value="underwriting"/>
    </contains>
  </expansion>
</ValueSet>