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.ManagedCarePolicy for use in FHIR R4 - XML Representation

Page standards status: Informative Maturity Level: 0

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<ValueSet xmlns="http://hl7.org/fhir">
  <id value="R5-v3-ManagedCarePolicy-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-ManagedCarePolicy-for-R4</b></p><a name="R5-v3-ManagedCarePolicy-for-R4"> </a><a name="hcR5-v3-ManagedCarePolicy-for-R4"> </a><p>This value set expansion contains 4 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-ManagedCarePolicy-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-MCPOL"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ActCode.html#v3-ActCode-MCPOL">MCPOL</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ActCode</td><td>managed care policy</td><td><div><p><strong>Definition:</strong> Government mandated program providing coverage, disability income, and vocational rehabilitation for injuries sustained in the work place or in the course of employment. Employers may either self-fund the program, purchase commercial coverage, or pay a premium to a government entity that administers the program. Employees may be required to pay premiums toward the cost of coverage as well.</p>
<p>Managed care policies specifically exclude coverage for losses insured under a disability policy, workers' compensation program, liability insurance (including automobile insurance); or for medical expenses, coverage for on-site medical clinics or for limited dental or vision benefits when these are provided under a separate policy.</p>
<p><em>Discussion:</em> Managed care policies are offered by managed care plans that contract with selected providers or health care organizations to provide comprehensive health care at a discount to covered parties and coordinate the financing and delivery of health care. Managed care uses medical protocols and procedures agreed on by the medical profession to be cost effective, also known as medical practice guidelines. Providers are typically reimbursed for covered services by a capitated amount on a per member per month basis that may reflect difference in the health status and level of services anticipated to be needed by the member.</p>
</div></td></tr><tr><td style="white-space:nowrap"><a name="R5-v3-ManagedCarePolicy-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-POS"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ActCode.html#v3-ActCode-POS">POS</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ActCode</td><td>point of service policy</td><td><div><p><strong>Definition:</strong> A policy for a health plan that has features of both an HMO and a FFS plan. Like an HMO, a POS plan encourages the use its HMO network to maintain discounted fees with participating providers, but recognizes that sometimes covered parties want to choose their own provider. The POS plan allows a covered party to use providers who are not part of the HMO network (non-participating providers). However, there is a greater cost associated with choosing these non-network providers. A covered party will usually pay deductibles and coinsurances that are substantially higher than the payments when he or she uses a plan provider. Use of non-participating providers often requires the covered party to pay the provider directly and then to file a claim for reimbursement, like in an FFS plan.</p>
</div></td></tr><tr><td style="white-space:nowrap"><a name="R5-v3-ManagedCarePolicy-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-HMO"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ActCode.html#v3-ActCode-HMO">HMO</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ActCode</td><td>health maintenance organization policy</td><td><div><p><strong>Definition:</strong> A policy for a health plan that provides coverage for health care only through contracted or employed physicians and hospitals located in particular geographic or service areas. HMOs emphasize prevention and early detection of illness. Eligibility to enroll in an HMO is determined by where a covered party lives or works.</p>
</div></td></tr><tr><td style="white-space:nowrap"><a name="R5-v3-ManagedCarePolicy-for-R4-http://terminology.hl7.org/CodeSystem/v3-ActCode-PPO"> </a>  <a href="http://terminology.hl7.org/6.5.0/CodeSystem-v3-ActCode.html#v3-ActCode-PPO">PPO</a></td><td>http://terminology.hl7.org/CodeSystem/v3-ActCode</td><td>preferred provider organization policy</td><td><div><p><strong>Definition:</strong> A network-based, managed care plan that allows a covered party to choose any health care provider. However, if care is received from a &quot;preferred&quot; (participating in-network) provider, there are generally higher benefit coverage and lower deductibles.</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-ManagedCarePolicy-for-R4"/>
  <version value="0.0.1-snapshot-2"/>
  <name value="R5_v3_ManagedCarePolicy_for_R4"/>
  <title
         value="Cross-version VS for R5.ManagedCarePolicy for use in FHIR R4"/>
  <status value="active"/>
  <experimental value="false"/>
  <date value="2025-09-01T22:37:05.220138+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-ManagedCarePolicy|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-ActCode"/>
      <version value="8.0.0"/>
      <concept>
        <code value="MCPOL"/>
        <display value="managed care policy"/>
      </concept>
      <concept>
        <code value="POS"/>
        <display value="point of service policy"/>
      </concept>
      <concept>
        <code value="HMO"/>
        <display value="health maintenance organization policy"/>
      </concept>
      <concept>
        <code value="PPO"/>
        <display value="preferred provider organization policy"/>
      </concept>
    </include>
  </compose>
  <expansion>
    <timestamp value="2025-09-01T22:37:05.220135+10:00"/>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="MCPOL"/>
      <display value="managed care policy"/>
    </contains>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="POS"/>
      <display value="point of service policy"/>
    </contains>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="HMO"/>
      <display value="health maintenance organization policy"/>
    </contains>
    <contains>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
      <version value="8.0.0"/>
      <code value="PPO"/>
      <display value="preferred provider organization policy"/>
    </contains>
  </expansion>
</ValueSet>