HL7 Terminology (THO)
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CodeSystem: Medical Management Type

Official URL: http://terminology.hl7.org/CodeSystem/medical-management-type Version: 1.0.0
Active as of 2025-06-10 Maturity Level: 1 Responsible: Health Level Seven International Computable Name: MedicalManagementType
Other Identifiers: OID:2.16.840.1.113883.5.175

Copyright/Legal: This material derives from the HL7 Terminology (THO). THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license

Types of medical management requirements or processes used by health insurers (payers) that may impact whether a service or item is covered or reimbursement rates.

This Code system is referenced in the content logical definition of the following value sets:

Last updated: 2025-05-26 00:00:00+0000

Profile: Shareable CodeSystem

This case-sensitive code system http://terminology.hl7.org/CodeSystem/medical-management-type defines the following codes:

CodeDisplayDefinition
concurrent-review Concurrent Review Review of medical necessity while the patient is actively receiving treatment.
prior-auth Prior Authorization Review of medical necessity prior to receiving treatment.
step-therapy Step Therapy (Fail First) Requirement that lower cost or preferred treatments be tried, or perhaps contra-indicated, before alternatives are utilized. This policy is sometimes referred to as 'fail first'.