Release 4 5 Preview #3
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8.30 8.32 Resource InsurancePlan - Content

Patient Administration Work Group Maturity Level : 0   Trial Use Security Category : Business Compartments : Not linked to any defined compartments

Details of a Health Insurance product/plan provided by an organization.

A product is a discrete package of health insurance coverage benefits that are offered under a particular network type. A given payer’s products typically differ by network type and/or coverage benefits. A plan pairs the health insurance coverage benefits under a product with the particular cost sharing structure offered to a consumer. A given product may comprise multiple plans.

InsurancePlan describes a health insurance offering comprised of a list of covered benefits (i.e. the product), costs associated with those benefits (i.e. the plan), and additional information about the offering, such as who it is owned and administered by, a coverage area, contact information, etc.

TBD.

This resource is referenced by UsageContext .

This resource does not implement any patterns.

Structure

Name Flags Card. Type Description & Constraints doco
. . InsurancePlan I TU DomainResource Details of a Health Insurance product/plan provided by an organization
+ Rule: The organization SHALL at least have a name or an idendtifier, and possibly more than one
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier Σ I 0..* Identifier Business Identifier for Product
. . . status ?! Σ 0..1 code draft | active | retired | unknown
PublicationStatus ( Required )
. . . type Σ 0..* CodeableConcept Kind of product
Insurance plan type InsurancePlanType ( Example )
. . . alias 0..* string Alternate names
. . . period 0..1 Period When the product is available
. . . ownedBy Σ 0..1 Reference ( Organization ) Plan issuer
. . . administeredBy Σ 0..1 Reference ( Organization ) Product administrator
. . . coverageArea Σ 0..* Reference ( Location ) Where product applies
. . . contact 0..* BackboneElement Contact for the product
. . . . purpose 0..1 CodeableConcept The type of contact
Contact entity type ContactEntityType ( Extensible )
. . . . name 0..1 HumanName A name associated with the contact
. . . . telecom 0..* ContactPoint Contact details (telephone, email, etc.) for a contact
. . . . address 0..1 Address Visiting or postal addresses for the contact
. . . endpoint 0..* Reference ( Endpoint ) Technical endpoint
. . . network 0..* Reference ( Organization ) What networks are Included
. . . coverage 0..* BackboneElement Coverage details
. . . . type 1..1 CodeableConcept Type of coverage
. . . . network 0..* Reference ( Organization ) What networks provide coverage
. . . . benefit 1..* BackboneElement List of benefits
. . . . . type 1..1 CodeableConcept Type of benefit
. . . . . requirement 0..1 string Referral requirements
. . . . . limit 0..* BackboneElement Benefit limits
. . . . . . value 0..1 Quantity Maximum value allowed
. . . . . . code 0..1 CodeableConcept Benefit limit details
. . . plan 0..* BackboneElement Plan details
. . . . identifier Σ 0..* Identifier Business Identifier for Product
. . . . type 0..1 CodeableConcept Type of plan
. . . . coverageArea Σ 0..* Reference ( Location ) Where product applies
. . . . network 0..* Reference ( Organization ) What networks provide coverage
. . . . generalCost 0..* BackboneElement Overall costs
. . . . . type 0..1 CodeableConcept Type of cost
. . . . . groupSize 0..1 positiveInt Number of enrollees
. . . . . cost 0..1 Money Cost value
. . . . . comment 0..1 string Additional cost information
. . . . specificCost 0..* BackboneElement Specific costs
. . . . . category 1..1 CodeableConcept General category of benefit
. . . . . benefit 0..* BackboneElement Benefits list
. . . . . . type 1..1 CodeableConcept Type of specific benefit
. . . . . . cost 0..* BackboneElement List of the costs
. . . . . . . type 1..1 CodeableConcept Type of cost
. . . . . . . applicability 0..1 CodeableConcept in-network | out-of-network | other
Benefit cost applicability BenefitCostApplicability ( Required )
. . . . . . . qualifiers 0..* CodeableConcept Additional information about the cost
. . . . . . . value 0..1 Quantity The actual cost value

doco Documentation for this format

UML Diagram ( Legend )

InsurancePlan ( DomainResource ) Business identifiers assigned to this health insurance product which remain constant as the resource is updated and propagates from server to server identifier : Identifier [0..*] The current state of the health insurance product (this element modifies the meaning of other elements) status : code [0..1] « The lifecycle status of an artifact. null (Strength=Required) PublicationStatus ! » The kind of health insurance product type : CodeableConcept [0..*] « Used to categorize the product/plan. null (Strength=Example) InsurancePlanType ?? » Official name of the health insurance product as designated by the owner name : string [0..1] A list of alternate names that the product is known as, or was known as in the past alias : string [0..*] The period of time that the health insurance product is available period : Period [0..1] The entity that is providing the health insurance product and underwriting the risk. This is typically an insurance carriers, other third-party payers, or health plan sponsors comonly referred to as 'payers' ownedBy : Reference [0..1] « Organization » An organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owner administeredBy : Reference [0..1] « Organization » The geographic region in which a health insurance product's benefits apply coverageArea : Reference [0..*] « Location » The technical endpoints providing access to services operated for the health insurance product endpoint : Reference [0..*] « Endpoint » Reference to the network included in the health insurance product network : Reference [0..*] « Organization » Contact Indicates a purpose for which the contact can be reached purpose : CodeableConcept [0..1] « The purpose for which you would contact a contact party. null (Strength=Extensible) ContactEntityType + » A name associated with the contact name : HumanName [0..1] A contact detail (e.g. a telephone number or an email address) by which the party may be contacted telecom : ContactPoint [0..*] Visiting or postal addresses for the contact address : Address [0..1] Coverage Type of coverage (Medical; Dental; Mental Health; Substance Abuse; Vision; Drug; Short Term; Long Term Care; Hospice; Home Health) type : CodeableConcept [1..1] Reference to the network that providing the type of coverage network : Reference [0..*] « Organization » CoverageBenefit Type of benefit (primary care; speciality care; inpatient; outpatient) type : CodeableConcept [1..1] The referral requirements to have access/coverage for this benefit requirement : string [0..1] Limit The maximum amount of a service item a plan will pay for a covered benefit. For examples. wellness visits, or eyeglasses value : Quantity [0..1] The specific limit on the benefit code : CodeableConcept [0..1] Plan Business identifiers assigned to this health insurance plan which remain constant as the resource is updated and propagates from server to server identifier : Identifier [0..*] Type of plan. For example, "Platinum" or "High Deductable" type : CodeableConcept [0..1] The geographic region in which a health insurance plan's benefits apply coverageArea : Reference [0..*] « Location » Reference to the network that providing the type of coverage network : Reference [0..*] « Organization » GeneralCost Type of cost type : CodeableConcept [0..1] Number of participants enrolled in the plan groupSize : positiveInt [0..1] Value of the cost cost : Money [0..1] Additional information about the general costs associated with this plan comment : string [0..1] SpecificCost General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health) category : CodeableConcept [1..1] PlanBenefit Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care) type : CodeableConcept [1..1] Cost Type of cost (copay; individual cap; family cap; coinsurance; deductible) type : CodeableConcept [1..1] Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other) applicability : CodeableConcept [0..1] « Whether the cost applies to in-network or out-of-network providers. null (Strength=Required) BenefitCostApplicability ! » Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA) qualifiers : CodeableConcept [0..*] The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance) value : Quantity [0..1] The contact for the health insurance product for a certain purpose contact [0..*] The specific limits on the benefit limit [0..*] Specific benefits under this type of coverage benefit [1..*] Details about the coverage offered by the insurance product coverage [0..*] Overall costs associated with the plan generalCost [0..*] List of the costs associated with a specific benefit cost [0..*] List of the specific benefits under this category of benefit benefit [0..*] Costs associated with the coverage provided by the product specificCost [0..*] Details about an insurance plan plan [0..*]

XML Template

<InsurancePlan xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- ?? 0..* Identifier Business Identifier for Product --></identifier>
 <status value="[code]"/><!-- 0..1 draft | active | retired | unknown -->
 <type><!-- 0..* CodeableConcept Kind of product --></type>
 <name value="[string]"/><!-- ?? 0..1 Official name -->
 <alias value="[string]"/><!-- 0..* Alternate names -->
 <period><!-- 0..1 Period When the product is available --></period>
 <ownedBy><!-- 0..1 Reference(Organization) Plan issuer --></ownedBy>
 <administeredBy><!-- 0..1 Reference(Organization) Product administrator --></administeredBy>
 <coverageArea><!-- 0..* Reference(Location) Where product applies --></coverageArea>
 <contact>  <!-- 0..* Contact for the product -->
  <purpose><!-- 0..1 CodeableConcept The type of contact --></purpose>
  <name><!-- 0..1 HumanName A name associated with the contact --></name>
  <telecom><!-- 0..* ContactPoint Contact details (telephone, email, etc.)  for a contact --></telecom>
  <address><!-- 0..1 Address Visiting or postal addresses for the contact --></address>
 </contact>
 <endpoint><!-- 0..* Reference(Endpoint) Technical endpoint --></endpoint>
 <network><!-- 0..* Reference(Organization) What networks are Included --></network>
 <coverage>  <!-- 0..* Coverage details -->
  <type><!-- 1..1 CodeableConcept Type of coverage --></type>
  <network><!-- 0..* Reference(Organization) What networks provide coverage --></network>
  <benefit>  <!-- 1..* List of benefits -->
   <type><!-- 1..1 CodeableConcept Type of benefit --></type>
   <requirement value="[string]"/><!-- 0..1 Referral requirements -->
   <limit>  <!-- 0..* Benefit limits -->
    <value><!-- 0..1 Quantity Maximum value allowed --></value>
    <code><!-- 0..1 CodeableConcept Benefit limit details --></code>
   </limit>
  </benefit>
 </coverage>
 <plan>  <!-- 0..* Plan details -->
  <identifier><!-- 0..* Identifier Business Identifier for Product --></identifier>
  <type><!-- 0..1 CodeableConcept Type of plan --></type>
  <coverageArea><!-- 0..* Reference(Location) Where product applies --></coverageArea>
  <network><!-- 0..* Reference(Organization) What networks provide coverage --></network>
  <generalCost>  <!-- 0..* Overall costs -->
   <type><!-- 0..1 CodeableConcept Type of cost --></type>
   <groupSize value="[positiveInt]"/><!-- 0..1 Number of enrollees -->
   <cost><!-- 0..1 Money Cost value --></cost>
   <comment value="[string]"/><!-- 0..1 Additional cost information -->
  </generalCost>
  <specificCost>  <!-- 0..* Specific costs -->
   <category><!-- 1..1 CodeableConcept General category of benefit --></category>
   <benefit>  <!-- 0..* Benefits list -->
    <type><!-- 1..1 CodeableConcept Type of specific benefit --></type>
    <cost>  <!-- 0..* List of the costs -->
     <type><!-- 1..1 CodeableConcept Type of cost --></type>
     <applicability><!-- 0..1 CodeableConcept in-network | out-of-network | other --></applicability>
     <qualifiers><!-- 0..* CodeableConcept Additional information about the cost --></qualifiers>
     <value><!-- 0..1 Quantity The actual cost value --></value>
    </cost>
   </benefit>
  </specificCost>
 </plan>
</InsurancePlan>

JSON Template

{doco
  "resourceType" : "InsurancePlan",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // C? Business Identifier for Product
  "status" : "<code>", // draft | active | retired | unknown
  "type" : [{ CodeableConcept }], // Kind of product
  "name" : "<string>", // C? Official name
  "alias" : ["<string>"], // Alternate names
  "period" : { Period }, // When the product is available
  "ownedBy" : { Reference(Organization) }, // Plan issuer
  "administeredBy" : { Reference(Organization) }, // Product administrator
  "coverageArea" : [{ Reference(Location) }], // Where product applies
  "contact" : [{ // Contact for the product
    "purpose" : { CodeableConcept }, // The type of contact
    "name" : { HumanName }, // A name associated with the contact
    "telecom" : [{ ContactPoint }], // Contact details (telephone, email, etc.)  for a contact
    "address" : { Address } // Visiting or postal addresses for the contact
  }],
  "endpoint" : [{ Reference(Endpoint) }], // Technical endpoint
  "network" : [{ Reference(Organization) }], // What networks are Included
  "coverage" : [{ // Coverage details
    "type" : { CodeableConcept }, // R!  Type of coverage
    "network" : [{ Reference(Organization) }], // What networks provide coverage
    "benefit" : [{ // R!  List of benefits
      "type" : { CodeableConcept }, // R!  Type of benefit
      "requirement" : "<string>", // Referral requirements
      "limit" : [{ // Benefit limits
        "value" : { Quantity }, // Maximum value allowed
        "code" : { CodeableConcept } // Benefit limit details
      }]
    }]
  }],
  "plan" : [{ // Plan details
    "identifier" : [{ Identifier }], // Business Identifier for Product
    "type" : { CodeableConcept }, // Type of plan
    "coverageArea" : [{ Reference(Location) }], // Where product applies
    "network" : [{ Reference(Organization) }], // What networks provide coverage
    "generalCost" : [{ // Overall costs
      "type" : { CodeableConcept }, // Type of cost
      "groupSize" : "<positiveInt>", // Number of enrollees
      "cost" : { Money }, // Cost value
      "comment" : "<string>" // Additional cost information
    }],
    "specificCost" : [{ // Specific costs
      "category" : { CodeableConcept }, // R!  General category of benefit
      "benefit" : [{ // Benefits list
        "type" : { CodeableConcept }, // R!  Type of specific benefit
        "cost" : [{ // List of the costs
          "type" : { CodeableConcept }, // R!  Type of cost
          "applicability" : { CodeableConcept }, // in-network | out-of-network | other
          "qualifiers" : [{ CodeableConcept }], // Additional information about the cost
          "value" : { Quantity } // The actual cost value
        }]
      }]
    }]
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco
[ a fhir:InsurancePlan;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root
  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:InsurancePlan.identifier [ Identifier ], ... ; # 0..* Business Identifier for Product
  fhir:InsurancePlan.status [ code ]; # 0..1 draft | active | retired | unknown
  fhir:InsurancePlan.type [ CodeableConcept ], ... ; # 0..* Kind of product
  fhir:InsurancePlan.name [ string ]; # 0..1 Official name
  fhir:InsurancePlan.alias [ string ], ... ; # 0..* Alternate names
  fhir:InsurancePlan.period [ Period ]; # 0..1 When the product is available
  fhir:InsurancePlan.ownedBy [ Reference(Organization) ]; # 0..1 Plan issuer
  fhir:InsurancePlan.administeredBy [ Reference(Organization) ]; # 0..1 Product administrator
  fhir:InsurancePlan.coverageArea [ Reference(Location) ], ... ; # 0..* Where product applies
  fhir:InsurancePlan.contact [ # 0..* Contact for the product
    fhir:InsurancePlan.contact.purpose [ CodeableConcept ]; # 0..1 The type of contact
    fhir:InsurancePlan.contact.name [ HumanName ]; # 0..1 A name associated with the contact
    fhir:InsurancePlan.contact.telecom [ ContactPoint ], ... ; # 0..* Contact details (telephone, email, etc.)  for a contact
    fhir:InsurancePlan.contact.address [ Address ]; # 0..1 Visiting or postal addresses for the contact
  ], ...;
  fhir:InsurancePlan.endpoint [ Reference(Endpoint) ], ... ; # 0..* Technical endpoint
  fhir:InsurancePlan.network [ Reference(Organization) ], ... ; # 0..* What networks are Included
  fhir:InsurancePlan.coverage [ # 0..* Coverage details
    fhir:InsurancePlan.coverage.type [ CodeableConcept ]; # 1..1 Type of coverage
    fhir:InsurancePlan.coverage.network [ Reference(Organization) ], ... ; # 0..* What networks provide coverage
    fhir:InsurancePlan.coverage.benefit [ # 1..* List of benefits
      fhir:InsurancePlan.coverage.benefit.type [ CodeableConcept ]; # 1..1 Type of benefit
      fhir:InsurancePlan.coverage.benefit.requirement [ string ]; # 0..1 Referral requirements
      fhir:InsurancePlan.coverage.benefit.limit [ # 0..* Benefit limits
        fhir:InsurancePlan.coverage.benefit.limit.value [ Quantity ]; # 0..1 Maximum value allowed
        fhir:InsurancePlan.coverage.benefit.limit.code [ CodeableConcept ]; # 0..1 Benefit limit details
      ], ...;
    ], ...;
  ], ...;
  fhir:InsurancePlan.plan [ # 0..* Plan details
    fhir:InsurancePlan.plan.identifier [ Identifier ], ... ; # 0..* Business Identifier for Product
    fhir:InsurancePlan.plan.type [ CodeableConcept ]; # 0..1 Type of plan
    fhir:InsurancePlan.plan.coverageArea [ Reference(Location) ], ... ; # 0..* Where product applies
    fhir:InsurancePlan.plan.network [ Reference(Organization) ], ... ; # 0..* What networks provide coverage
    fhir:InsurancePlan.plan.generalCost [ # 0..* Overall costs
      fhir:InsurancePlan.plan.generalCost.type [ CodeableConcept ]; # 0..1 Type of cost
      fhir:InsurancePlan.plan.generalCost.groupSize [ positiveInt ]; # 0..1 Number of enrollees
      fhir:InsurancePlan.plan.generalCost.cost [ Money ]; # 0..1 Cost value
      fhir:InsurancePlan.plan.generalCost.comment [ string ]; # 0..1 Additional cost information
    ], ...;
    fhir:InsurancePlan.plan.specificCost [ # 0..* Specific costs
      fhir:InsurancePlan.plan.specificCost.category [ CodeableConcept ]; # 1..1 General category of benefit
      fhir:InsurancePlan.plan.specificCost.benefit [ # 0..* Benefits list
        fhir:InsurancePlan.plan.specificCost.benefit.type [ CodeableConcept ]; # 1..1 Type of specific benefit
        fhir:InsurancePlan.plan.specificCost.benefit.cost [ # 0..* List of the costs
          fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ CodeableConcept ]; # 1..1 Type of cost
          fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ CodeableConcept ]; # 0..1 in-network | out-of-network | other
          fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ CodeableConcept ], ... ; # 0..* Additional information about the cost
          fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ Quantity ]; # 0..1 The actual cost value
        ], ...;
      ], ...;
    ], ...;
  ], ...;
]

Changes since R3

InsurancePlan
InsurancePlan.status
  • Change value set from http://hl7.org/fhir/ValueSet/publication-status|4.0.0 to http://hl7.org/fhir/ValueSet/publication-status|4.5.0
InsurancePlan.plan.specificCost.benefit.cost.applicability
  • Change value set from http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.0 to http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.5.0

This resource did not exist in Release 2 See the Full Difference for further information

This analysis is available as XML or JSON .

Structure

Name Flags Card. Type Description & Constraints doco
. . InsurancePlan I TU DomainResource Details of a Health Insurance product/plan provided by an organization
+ Rule: The organization SHALL at least have a name or an idendtifier, and possibly more than one
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier Σ I 0..* Identifier Business Identifier for Product
. . . status ?! Σ 0..1 code draft | active | retired | unknown
PublicationStatus ( Required )
. . . type Σ 0..* CodeableConcept Kind of product
Insurance plan type InsurancePlanType ( Example )
. . . alias 0..* string Alternate names
. . . period 0..1 Period When the product is available
. . . ownedBy Σ 0..1 Reference ( Organization ) Plan issuer
. . . administeredBy Σ 0..1 Reference ( Organization ) Product administrator
. . . coverageArea Σ 0..* Reference ( Location ) Where product applies
. . . contact 0..* BackboneElement Contact for the product
. . . . purpose 0..1 CodeableConcept The type of contact
Contact entity type ContactEntityType ( Extensible )
. . . . name 0..1 HumanName A name associated with the contact
. . . . telecom 0..* ContactPoint Contact details (telephone, email, etc.) for a contact
. . . . address 0..1 Address Visiting or postal addresses for the contact
. . . endpoint 0..* Reference ( Endpoint ) Technical endpoint
. . . network 0..* Reference ( Organization ) What networks are Included
. . . coverage 0..* BackboneElement Coverage details
. . . . type 1..1 CodeableConcept Type of coverage
. . . . network 0..* Reference ( Organization ) What networks provide coverage
. . . . benefit 1..* BackboneElement List of benefits
. . . . . type 1..1 CodeableConcept Type of benefit
. . . . . requirement 0..1 string Referral requirements
. . . . . limit 0..* BackboneElement Benefit limits
. . . . . . value 0..1 Quantity Maximum value allowed
. . . . . . code 0..1 CodeableConcept Benefit limit details
. . . plan 0..* BackboneElement Plan details
. . . . identifier Σ 0..* Identifier Business Identifier for Product
. . . . type 0..1 CodeableConcept Type of plan
. . . . coverageArea Σ 0..* Reference ( Location ) Where product applies
. . . . network 0..* Reference ( Organization ) What networks provide coverage
. . . . generalCost 0..* BackboneElement Overall costs
. . . . . type 0..1 CodeableConcept Type of cost
. . . . . groupSize 0..1 positiveInt Number of enrollees
. . . . . cost 0..1 Money Cost value
. . . . . comment 0..1 string Additional cost information
. . . . specificCost 0..* BackboneElement Specific costs
. . . . . category 1..1 CodeableConcept General category of benefit
. . . . . benefit 0..* BackboneElement Benefits list
. . . . . . type 1..1 CodeableConcept Type of specific benefit
. . . . . . cost 0..* BackboneElement List of the costs
. . . . . . . type 1..1 CodeableConcept Type of cost
. . . . . . . applicability 0..1 CodeableConcept in-network | out-of-network | other
Benefit cost applicability BenefitCostApplicability ( Required )
. . . . . . . qualifiers 0..* CodeableConcept Additional information about the cost
. . . . . . . value 0..1 Quantity The actual cost value

doco Documentation for this format

UML Diagram ( Legend )

InsurancePlan ( DomainResource ) Business identifiers assigned to this health insurance product which remain constant as the resource is updated and propagates from server to server identifier : Identifier [0..*] The current state of the health insurance product (this element modifies the meaning of other elements) status : code [0..1] « The lifecycle status of an artifact. null (Strength=Required) PublicationStatus ! » The kind of health insurance product type : CodeableConcept [0..*] « Used to categorize the product/plan. null (Strength=Example) InsurancePlanType ?? » Official name of the health insurance product as designated by the owner name : string [0..1] A list of alternate names that the product is known as, or was known as in the past alias : string [0..*] The period of time that the health insurance product is available period : Period [0..1] The entity that is providing the health insurance product and underwriting the risk. This is typically an insurance carriers, other third-party payers, or health plan sponsors comonly referred to as 'payers' ownedBy : Reference [0..1] « Organization » An organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owner administeredBy : Reference [0..1] « Organization » The geographic region in which a health insurance product's benefits apply coverageArea : Reference [0..*] « Location » The technical endpoints providing access to services operated for the health insurance product endpoint : Reference [0..*] « Endpoint » Reference to the network included in the health insurance product network : Reference [0..*] « Organization » Contact Indicates a purpose for which the contact can be reached purpose : CodeableConcept [0..1] « The purpose for which you would contact a contact party. null (Strength=Extensible) ContactEntityType + » A name associated with the contact name : HumanName [0..1] A contact detail (e.g. a telephone number or an email address) by which the party may be contacted telecom : ContactPoint [0..*] Visiting or postal addresses for the contact address : Address [0..1] Coverage Type of coverage (Medical; Dental; Mental Health; Substance Abuse; Vision; Drug; Short Term; Long Term Care; Hospice; Home Health) type : CodeableConcept [1..1] Reference to the network that providing the type of coverage network : Reference [0..*] « Organization » CoverageBenefit Type of benefit (primary care; speciality care; inpatient; outpatient) type : CodeableConcept [1..1] The referral requirements to have access/coverage for this benefit requirement : string [0..1] Limit The maximum amount of a service item a plan will pay for a covered benefit. For examples. wellness visits, or eyeglasses value : Quantity [0..1] The specific limit on the benefit code : CodeableConcept [0..1] Plan Business identifiers assigned to this health insurance plan which remain constant as the resource is updated and propagates from server to server identifier : Identifier [0..*] Type of plan. For example, "Platinum" or "High Deductable" type : CodeableConcept [0..1] The geographic region in which a health insurance plan's benefits apply coverageArea : Reference [0..*] « Location » Reference to the network that providing the type of coverage network : Reference [0..*] « Organization » GeneralCost Type of cost type : CodeableConcept [0..1] Number of participants enrolled in the plan groupSize : positiveInt [0..1] Value of the cost cost : Money [0..1] Additional information about the general costs associated with this plan comment : string [0..1] SpecificCost General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health) category : CodeableConcept [1..1] PlanBenefit Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care) type : CodeableConcept [1..1] Cost Type of cost (copay; individual cap; family cap; coinsurance; deductible) type : CodeableConcept [1..1] Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other) applicability : CodeableConcept [0..1] « Whether the cost applies to in-network or out-of-network providers. null (Strength=Required) BenefitCostApplicability ! » Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA) qualifiers : CodeableConcept [0..*] The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance) value : Quantity [0..1] The contact for the health insurance product for a certain purpose contact [0..*] The specific limits on the benefit limit [0..*] Specific benefits under this type of coverage benefit [1..*] Details about the coverage offered by the insurance product coverage [0..*] Overall costs associated with the plan generalCost [0..*] List of the costs associated with a specific benefit cost [0..*] List of the specific benefits under this category of benefit benefit [0..*] Costs associated with the coverage provided by the product specificCost [0..*] Details about an insurance plan plan [0..*]

XML Template

<InsurancePlan xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- ?? 0..* Identifier Business Identifier for Product --></identifier>
 <status value="[code]"/><!-- 0..1 draft | active | retired | unknown -->
 <type><!-- 0..* CodeableConcept Kind of product --></type>
 <name value="[string]"/><!-- ?? 0..1 Official name -->
 <alias value="[string]"/><!-- 0..* Alternate names -->
 <period><!-- 0..1 Period When the product is available --></period>
 <ownedBy><!-- 0..1 Reference(Organization) Plan issuer --></ownedBy>
 <administeredBy><!-- 0..1 Reference(Organization) Product administrator --></administeredBy>
 <coverageArea><!-- 0..* Reference(Location) Where product applies --></coverageArea>
 <contact>  <!-- 0..* Contact for the product -->
  <purpose><!-- 0..1 CodeableConcept The type of contact --></purpose>
  <name><!-- 0..1 HumanName A name associated with the contact --></name>
  <telecom><!-- 0..* ContactPoint Contact details (telephone, email, etc.)  for a contact --></telecom>
  <address><!-- 0..1 Address Visiting or postal addresses for the contact --></address>
 </contact>
 <endpoint><!-- 0..* Reference(Endpoint) Technical endpoint --></endpoint>
 <network><!-- 0..* Reference(Organization) What networks are Included --></network>
 <coverage>  <!-- 0..* Coverage details -->
  <type><!-- 1..1 CodeableConcept Type of coverage --></type>
  <network><!-- 0..* Reference(Organization) What networks provide coverage --></network>
  <benefit>  <!-- 1..* List of benefits -->
   <type><!-- 1..1 CodeableConcept Type of benefit --></type>
   <requirement value="[string]"/><!-- 0..1 Referral requirements -->
   <limit>  <!-- 0..* Benefit limits -->
    <value><!-- 0..1 Quantity Maximum value allowed --></value>
    <code><!-- 0..1 CodeableConcept Benefit limit details --></code>
   </limit>
  </benefit>
 </coverage>
 <plan>  <!-- 0..* Plan details -->
  <identifier><!-- 0..* Identifier Business Identifier for Product --></identifier>
  <type><!-- 0..1 CodeableConcept Type of plan --></type>
  <coverageArea><!-- 0..* Reference(Location) Where product applies --></coverageArea>
  <network><!-- 0..* Reference(Organization) What networks provide coverage --></network>
  <generalCost>  <!-- 0..* Overall costs -->
   <type><!-- 0..1 CodeableConcept Type of cost --></type>
   <groupSize value="[positiveInt]"/><!-- 0..1 Number of enrollees -->
   <cost><!-- 0..1 Money Cost value --></cost>
   <comment value="[string]"/><!-- 0..1 Additional cost information -->
  </generalCost>
  <specificCost>  <!-- 0..* Specific costs -->
   <category><!-- 1..1 CodeableConcept General category of benefit --></category>
   <benefit>  <!-- 0..* Benefits list -->
    <type><!-- 1..1 CodeableConcept Type of specific benefit --></type>
    <cost>  <!-- 0..* List of the costs -->
     <type><!-- 1..1 CodeableConcept Type of cost --></type>
     <applicability><!-- 0..1 CodeableConcept in-network | out-of-network | other --></applicability>
     <qualifiers><!-- 0..* CodeableConcept Additional information about the cost --></qualifiers>
     <value><!-- 0..1 Quantity The actual cost value --></value>
    </cost>
   </benefit>
  </specificCost>
 </plan>
</InsurancePlan>

JSON Template

{doco
  "resourceType" : "InsurancePlan",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // C? Business Identifier for Product
  "status" : "<code>", // draft | active | retired | unknown
  "type" : [{ CodeableConcept }], // Kind of product
  "name" : "<string>", // C? Official name
  "alias" : ["<string>"], // Alternate names
  "period" : { Period }, // When the product is available
  "ownedBy" : { Reference(Organization) }, // Plan issuer
  "administeredBy" : { Reference(Organization) }, // Product administrator
  "coverageArea" : [{ Reference(Location) }], // Where product applies
  "contact" : [{ // Contact for the product
    "purpose" : { CodeableConcept }, // The type of contact
    "name" : { HumanName }, // A name associated with the contact
    "telecom" : [{ ContactPoint }], // Contact details (telephone, email, etc.)  for a contact
    "address" : { Address } // Visiting or postal addresses for the contact
  }],
  "endpoint" : [{ Reference(Endpoint) }], // Technical endpoint
  "network" : [{ Reference(Organization) }], // What networks are Included
  "coverage" : [{ // Coverage details
    "type" : { CodeableConcept }, // R!  Type of coverage
    "network" : [{ Reference(Organization) }], // What networks provide coverage
    "benefit" : [{ // R!  List of benefits
      "type" : { CodeableConcept }, // R!  Type of benefit
      "requirement" : "<string>", // Referral requirements
      "limit" : [{ // Benefit limits
        "value" : { Quantity }, // Maximum value allowed
        "code" : { CodeableConcept } // Benefit limit details
      }]
    }]
  }],
  "plan" : [{ // Plan details
    "identifier" : [{ Identifier }], // Business Identifier for Product
    "type" : { CodeableConcept }, // Type of plan
    "coverageArea" : [{ Reference(Location) }], // Where product applies
    "network" : [{ Reference(Organization) }], // What networks provide coverage
    "generalCost" : [{ // Overall costs
      "type" : { CodeableConcept }, // Type of cost
      "groupSize" : "<positiveInt>", // Number of enrollees
      "cost" : { Money }, // Cost value
      "comment" : "<string>" // Additional cost information
    }],
    "specificCost" : [{ // Specific costs
      "category" : { CodeableConcept }, // R!  General category of benefit
      "benefit" : [{ // Benefits list
        "type" : { CodeableConcept }, // R!  Type of specific benefit
        "cost" : [{ // List of the costs
          "type" : { CodeableConcept }, // R!  Type of cost
          "applicability" : { CodeableConcept }, // in-network | out-of-network | other
          "qualifiers" : [{ CodeableConcept }], // Additional information about the cost
          "value" : { Quantity } // The actual cost value
        }]
      }]
    }]
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco
[ a fhir:InsurancePlan;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root
  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:InsurancePlan.identifier [ Identifier ], ... ; # 0..* Business Identifier for Product
  fhir:InsurancePlan.status [ code ]; # 0..1 draft | active | retired | unknown
  fhir:InsurancePlan.type [ CodeableConcept ], ... ; # 0..* Kind of product
  fhir:InsurancePlan.name [ string ]; # 0..1 Official name
  fhir:InsurancePlan.alias [ string ], ... ; # 0..* Alternate names
  fhir:InsurancePlan.period [ Period ]; # 0..1 When the product is available
  fhir:InsurancePlan.ownedBy [ Reference(Organization) ]; # 0..1 Plan issuer
  fhir:InsurancePlan.administeredBy [ Reference(Organization) ]; # 0..1 Product administrator
  fhir:InsurancePlan.coverageArea [ Reference(Location) ], ... ; # 0..* Where product applies
  fhir:InsurancePlan.contact [ # 0..* Contact for the product
    fhir:InsurancePlan.contact.purpose [ CodeableConcept ]; # 0..1 The type of contact
    fhir:InsurancePlan.contact.name [ HumanName ]; # 0..1 A name associated with the contact
    fhir:InsurancePlan.contact.telecom [ ContactPoint ], ... ; # 0..* Contact details (telephone, email, etc.)  for a contact
    fhir:InsurancePlan.contact.address [ Address ]; # 0..1 Visiting or postal addresses for the contact
  ], ...;
  fhir:InsurancePlan.endpoint [ Reference(Endpoint) ], ... ; # 0..* Technical endpoint
  fhir:InsurancePlan.network [ Reference(Organization) ], ... ; # 0..* What networks are Included
  fhir:InsurancePlan.coverage [ # 0..* Coverage details
    fhir:InsurancePlan.coverage.type [ CodeableConcept ]; # 1..1 Type of coverage
    fhir:InsurancePlan.coverage.network [ Reference(Organization) ], ... ; # 0..* What networks provide coverage
    fhir:InsurancePlan.coverage.benefit [ # 1..* List of benefits
      fhir:InsurancePlan.coverage.benefit.type [ CodeableConcept ]; # 1..1 Type of benefit
      fhir:InsurancePlan.coverage.benefit.requirement [ string ]; # 0..1 Referral requirements
      fhir:InsurancePlan.coverage.benefit.limit [ # 0..* Benefit limits
        fhir:InsurancePlan.coverage.benefit.limit.value [ Quantity ]; # 0..1 Maximum value allowed
        fhir:InsurancePlan.coverage.benefit.limit.code [ CodeableConcept ]; # 0..1 Benefit limit details
      ], ...;
    ], ...;
  ], ...;
  fhir:InsurancePlan.plan [ # 0..* Plan details
    fhir:InsurancePlan.plan.identifier [ Identifier ], ... ; # 0..* Business Identifier for Product
    fhir:InsurancePlan.plan.type [ CodeableConcept ]; # 0..1 Type of plan
    fhir:InsurancePlan.plan.coverageArea [ Reference(Location) ], ... ; # 0..* Where product applies
    fhir:InsurancePlan.plan.network [ Reference(Organization) ], ... ; # 0..* What networks provide coverage
    fhir:InsurancePlan.plan.generalCost [ # 0..* Overall costs
      fhir:InsurancePlan.plan.generalCost.type [ CodeableConcept ]; # 0..1 Type of cost
      fhir:InsurancePlan.plan.generalCost.groupSize [ positiveInt ]; # 0..1 Number of enrollees
      fhir:InsurancePlan.plan.generalCost.cost [ Money ]; # 0..1 Cost value
      fhir:InsurancePlan.plan.generalCost.comment [ string ]; # 0..1 Additional cost information
    ], ...;
    fhir:InsurancePlan.plan.specificCost [ # 0..* Specific costs
      fhir:InsurancePlan.plan.specificCost.category [ CodeableConcept ]; # 1..1 General category of benefit
      fhir:InsurancePlan.plan.specificCost.benefit [ # 0..* Benefits list
        fhir:InsurancePlan.plan.specificCost.benefit.type [ CodeableConcept ]; # 1..1 Type of specific benefit
        fhir:InsurancePlan.plan.specificCost.benefit.cost [ # 0..* List of the costs
          fhir:InsurancePlan.plan.specificCost.benefit.cost.type [ CodeableConcept ]; # 1..1 Type of cost
          fhir:InsurancePlan.plan.specificCost.benefit.cost.applicability [ CodeableConcept ]; # 0..1 in-network | out-of-network | other
          fhir:InsurancePlan.plan.specificCost.benefit.cost.qualifiers [ CodeableConcept ], ... ; # 0..* Additional information about the cost
          fhir:InsurancePlan.plan.specificCost.benefit.cost.value [ Quantity ]; # 0..1 The actual cost value
        ], ...;
      ], ...;
    ], ...;
  ], ...;
]

Changes since Release 3

InsurancePlan
InsurancePlan.status
  • Change value set from http://hl7.org/fhir/ValueSet/publication-status|4.0.0 to http://hl7.org/fhir/ValueSet/publication-status|4.5.0
InsurancePlan.plan.specificCost.benefit.cost.applicability
  • Change value set from http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.0 to http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.5.0

This resource did not exist in Release 2 See the Full Difference for further information

This analysis is available as XML or JSON .

 

See the Profiles & Extensions and the alternate definitions: Master Definition XML + JSON , XML Schema / Schematron + JSON Schema , ShEx (for Turtle ) + see the extensions , the spreadsheet version & the dependency analysis a

Path Definition Type Reference
InsurancePlan.status The lifecycle status of an artifact. Required PublicationStatus
InsurancePlan.type Used to categorize the product/plan. Example InsurancePlanType
InsurancePlan.contact.purpose The purpose for which you would contact a contact party. Extensible ContactEntityType
InsurancePlan.plan.specificCost.benefit.cost.applicability Whether the cost applies to in-network or out-of-network providers. Required BenefitCostApplicability

id Level Location Description Expression
ipn-1 Rule (base) The organization SHALL at least have a name or an idendtifier, and possibly more than one (identifier.count() + name.count()) > 0

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
address string A server defined search that may match any of the string fields in the Address, including line, city, district, state, country, postalCode, and/or text InsurancePlan.contact.address
address-city N string A city specified in an address InsurancePlan.contact.address.city
address-country N string A country specified in an address InsurancePlan.contact.address.country
address-postalcode N string A postal code specified in an address InsurancePlan.contact.address.postalCode
address-state N string A state specified in an address InsurancePlan.contact.address.state
address-use N token A use code specified in an address InsurancePlan.contact.address.use
administered-by reference Product administrator InsurancePlan.administeredBy
( Organization )
endpoint reference Technical endpoint InsurancePlan.endpoint
( Endpoint )
identifier token Any identifier for the organization (not the accreditation issuer's identifier) InsurancePlan.identifier
name string A portion of the organization's name or alias name | alias
owned-by reference An organization of which this organization forms a part InsurancePlan.ownedBy
( Organization )
phonetic N string A portion of the organization's name using some kind of phonetic matching algorithm InsurancePlan.name
status N token Is the Organization record active InsurancePlan.status
type token A code for the type of organization InsurancePlan.type