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.PayorParticipationFunction 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-PayorParticipationFunction-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-PayorParticipationFunction-for-R4</b></p><a name="R5-v3-PayorParticipationFunction-for-R4"> </a><a name="hcR5-v3-PayorParticipationFunction-for-R4"> </a><p>This value set expansion contains 6 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-PayorParticipationFunction-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-PayorParticipationFunction-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-PayorParticipationFunction-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-PayorParticipationFunction-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-PayorParticipationFunction-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-PayorParticipationFunction-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></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-PayorParticipationFunction-for-R4"/>
  <version value="0.0.1-snapshot-2"/>
  <name value="R5_v3_PayorParticipationFunction_for_R4"/>
  <title
         value="Cross-version VS for R5.PayorParticipationFunction for use in FHIR R4"/>
  <status value="active"/>
  <experimental value="false"/>
  <date value="2025-09-01T22:37:05.284195+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-PayorParticipationFunction|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>
    </include>
  </compose>
  <expansion>
    <timestamp value="2025-09-01T22:37:05.284193+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>
  </expansion>
</ValueSet>