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

ValueSet: Cross-version VS for R5.PayorRoleType for use in FHIR R4

Official URL: http://hl7.org/fhir/5.0/ValueSet/R5-v3-PayorRoleType-for-R4 Version: 0.0.1-snapshot-2
Standards status: Informative Maturity Level: 0 Computable Name: R5_v3_PayorRoleType_for_R4

This cross-version ValueSet represents concepts from http://terminology.hl7.org/ValueSet/v3-PayorRoleType 2.0.0 for use in FHIR R4. Concepts not present here have direct equivalent mappings crossing all versions from R5 to R4.

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)

  • Include these codes as defined in http://terminology.hl7.org/CodeSystem/v3-RoleCode version 2.2.0
    CodeDisplayDefinition
    ENROLBKREnrollment Broker**Description:**A payor that is responsible for functions related to the enrollment of covered parties.
    TPAThird party administrator**Description:**Third party administrator (TPA) is a payor organization that processes health care claims without carrying insurance risk. Third party administrators are prominent players in the managed care industry and have the expertise and capability to administer all or a portion of the claims process. They are normally contracted by a health insurer or self-insuring companies to administer services, including claims administration, premium collection, enrollment and other administrative activities.

    Self-insured employers often contract with third party administrator to handle their insurance functions. Insurance companies oftentimes outsource the claims, utilization review or membership functions to a TPA. Sometimes TPAs only manage provider networks, only claims or only utilization review.

    While some third-party administrators may operate as units of insurance companies, they are often independent. However, hospitals or provider organizations desiring to set up their own health plans will often outsource certain responsibilities to TPAs. TPAs may perform one or several payor functions, specified by the PayorParticipationFunction value set, such as provider management, enrollment, utilization management, and fee for service claims adjudication management.
    UMOUtilization management organization**Description:**A payor that is responsible for review and case management of health services covered under a policy or program.

 

Expansion

This value set expansion contains 3 concepts.

CodeSystemDisplayDefinition
  ENROLBKRhttp://terminology.hl7.org/CodeSystem/v3-RoleCodeEnrollment Broker

**Description:**A payor that is responsible for functions related to the enrollment of covered parties.

  TPAhttp://terminology.hl7.org/CodeSystem/v3-RoleCodeThird party administrator

**Description:**Third party administrator (TPA) is a payor organization that processes health care claims without carrying insurance risk. Third party administrators are prominent players in the managed care industry and have the expertise and capability to administer all or a portion of the claims process. They are normally contracted by a health insurer or self-insuring companies to administer services, including claims administration, premium collection, enrollment and other administrative activities.

Self-insured employers often contract with third party administrator to handle their insurance functions. Insurance companies oftentimes outsource the claims, utilization review or membership functions to a TPA. Sometimes TPAs only manage provider networks, only claims or only utilization review.

While some third-party administrators may operate as units of insurance companies, they are often independent. However, hospitals or provider organizations desiring to set up their own health plans will often outsource certain responsibilities to TPAs. TPAs may perform one or several payor functions, specified by the PayorParticipationFunction value set, such as provider management, enrollment, utilization management, and fee for service claims adjudication management.

  UMOhttp://terminology.hl7.org/CodeSystem/v3-RoleCodeUtilization management organization

**Description:**A payor that is responsible for review and case management of health services covered under a policy or program.


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