National Healthcare Directory Query
1.0.0-ballot - ballot US

This page is part of the National Healthcare Query (v1.0.0-ballot: STU 1 Ballot 1) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

Resource Profile: National Directory Endpoint Qry Exchange InsurancePlan

Official URL: http://hl7.org/fhir/us/directory-query/StructureDefinition/NatlDirEndpointQry-InsurancePlan Version: 1.0.0-ballot
Active as of 2022-08-09 Computable Name: NatlDirEndpointQryInsurancePlan

An InsurancePlan 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 covered benefits. A plan pairs a product’s covered benefits with the particular cost sharing structure offered to a consumer. A given product may comprise multiple plans (i.e. each plan offers different cost sharing requirements for the same set of covered benefits).

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.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from InsurancePlan

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan I0..*InsurancePlanDetails of a Health Insurance product/plan provided by an organization
network-or-NatlDirwork: If an insuranceplan does not define a network, then each plan must define one
plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type.
... meta
.... lastUpdated 1..1instantWhen the resource version last changed
... identifier S0..*IdentifierBusiness Identifier for Product
... status 1..1codedraft | active | retired | unknown
Fixed Value: active
... name S0..1stringOfficial name
... ownedBy S1..1Reference(National Directory Endpoint Qry Exchange Organization)Plan issuer
... administeredBy S1..1Reference(National Directory Endpoint Qry Exchange Organization)Product administrator
... coverageArea S0..*Reference(National Directory Endpoint Qry Exchange Location)Where product applies
... endpoint 0..*Reference(National Directory Endpoint Qry Exchange Endpoint)Technical endpoint
... network S0..*Reference(National Directory Endpoint Qry Exchange Network)What networks are Included
... coverage
.... network S0..*Reference(Organization)What networks provide coverage
.... benefit
..... type S1..1CodeableConceptType of benefit
... plan 0..*BackboneElementCost sharing details for the plan
.... type 0..1CodeableConceptCategorization of the cost sharing for the plan
Binding: Insurance Plan Type Value Set (extensible)
.... coverageArea 0..*Reference(National Directory Endpoint Qry Exchange Location)Where product applies
.... network 0..*Reference(National Directory Endpoint Qry Exchange Network)What networks provide coverage

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan I0..*InsurancePlanDetails of a Health Insurance product/plan provided by an organization
network-or-NatlDirwork: If an insuranceplan does not define a network, then each plan must define one
plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type.
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated Σ1..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile Σ0..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣI0..*IdentifierBusiness Identifier for Product
... status ?!Σ1..1codedraft | active | retired | unknown
Binding: PublicationStatus (required): The lifecycle status of an artifact.


Fixed Value: active
... type SΣ1..1CodeableConceptProduct Type
Binding: Insurance Product Type Value Set (extensible)
... name SΣI0..1stringOfficial name
... alias 0..*stringAlternate names
... period 0..1PeriodWhen the product is available
... ownedBy SΣ1..1Reference(National Directory Endpoint Qry Exchange Organization)Plan issuer
... administeredBy SΣ1..1Reference(National Directory Endpoint Qry Exchange Organization)Product administrator
... coverageArea SΣ0..*Reference(National Directory Endpoint Qry Exchange Location)Where product applies
... contact 0..*BackboneElementContact for the product
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... purpose 0..1CodeableConceptThe type of contact
Binding: ContactEntityType (extensible): The purpose for which you would contact a contact party.

.... name 0..1HumanNameA name associated with the contact
.... telecom 0..*ContactPointContact details (telephone, email, etc.) for a contact
.... address 0..1AddressVisiting or postal addresses for the contact
... endpoint 0..*Reference(National Directory Endpoint Qry Exchange Endpoint)Technical endpoint
... network S0..*Reference(National Directory Endpoint Qry Exchange Network)What networks are Included
... coverage 0..*BackboneElementCoverage details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptType of coverage
.... network S0..*Reference(Organization)What networks provide coverage
.... benefit 1..*BackboneElementList of benefits
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type S1..1CodeableConceptType of benefit
..... requirement 0..1stringReferral requirements
..... limit 0..*BackboneElementBenefit limits
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... value 0..1QuantityMaximum value allowed
...... code 0..1CodeableConceptBenefit limit details
... plan 0..*BackboneElementCost sharing details for the plan
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... identifier Σ0..*IdentifierBusiness Identifier for Product
.... type 0..1CodeableConceptCategorization of the cost sharing for the plan
Binding: Insurance Plan Type Value Set (extensible)
.... coverageArea Σ0..*Reference(National Directory Endpoint Qry Exchange Location)Where product applies
.... network 0..*Reference(National Directory Endpoint Qry Exchange Network)What networks provide coverage
.... generalCost 0..*BackboneElementOverall costs
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type 0..1CodeableConceptType of cost
..... groupSize 0..1positiveIntNumber of enrollees
..... cost 0..1MoneyCost value
..... comment 0..1stringAdditional cost information
.... specificCost 0..*BackboneElementSpecific costs
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptGeneral category of benefit
..... benefit 0..*BackboneElementBenefits list
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... type 1..1CodeableConceptType of specific benefit
...... cost 0..*BackboneElementList of the costs
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
....... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
....... type 1..1CodeableConceptType of cost
....... applicability 0..1CodeableConceptin-network | out-of-network | other
Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.

....... qualifiers 0..*CodeableConceptAdditional information about the cost
....... value 0..1QuantityThe actual cost value

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan I0..*InsurancePlanDetails of a Health Insurance product/plan provided by an organization
network-or-NatlDirwork: If an insuranceplan does not define a network, then each plan must define one
plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type.
... identifier ΣI0..*IdentifierBusiness Identifier for Product
... type Σ1..1CodeableConceptProduct Type
Binding: Insurance Product Type Value Set (extensible)
... name ΣI0..1stringOfficial name
... administeredBy Σ1..1Reference(National Directory Endpoint Qry Exchange Organization)Product administrator
... coverageArea Σ0..*Reference(National Directory Endpoint Qry Exchange Location)Where product applies
... network 0..*Reference(National Directory Endpoint Qry Exchange Network)What networks are Included
... coverage 0..*BackboneElementCoverage details
.... network 0..*Reference(Organization)What networks provide coverage
.... benefit 1..*BackboneElementList of benefits
..... type 1..1CodeableConceptType of benefit

doco Documentation for this format

Differential View

This structure is derived from InsurancePlan

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan I0..*InsurancePlanDetails of a Health Insurance product/plan provided by an organization
network-or-NatlDirwork: If an insuranceplan does not define a network, then each plan must define one
plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type.
... meta
.... lastUpdated 1..1instantWhen the resource version last changed
... identifier S0..*IdentifierBusiness Identifier for Product
... status 1..1codedraft | active | retired | unknown
Fixed Value: active
... name S0..1stringOfficial name
... ownedBy S1..1Reference(National Directory Endpoint Qry Exchange Organization)Plan issuer
... administeredBy S1..1Reference(National Directory Endpoint Qry Exchange Organization)Product administrator
... coverageArea S0..*Reference(National Directory Endpoint Qry Exchange Location)Where product applies
... endpoint 0..*Reference(National Directory Endpoint Qry Exchange Endpoint)Technical endpoint
... network S0..*Reference(National Directory Endpoint Qry Exchange Network)What networks are Included
... coverage
.... network S0..*Reference(Organization)What networks provide coverage
.... benefit
..... type S1..1CodeableConceptType of benefit
... plan 0..*BackboneElementCost sharing details for the plan
.... type 0..1CodeableConceptCategorization of the cost sharing for the plan
Binding: Insurance Plan Type Value Set (extensible)
.... coverageArea 0..*Reference(National Directory Endpoint Qry Exchange Location)Where product applies
.... network 0..*Reference(National Directory Endpoint Qry Exchange Network)What networks provide coverage

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan I0..*InsurancePlanDetails of a Health Insurance product/plan provided by an organization
network-or-NatlDirwork: If an insuranceplan does not define a network, then each plan must define one
plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type.
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated Σ1..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile Σ0..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣI0..*IdentifierBusiness Identifier for Product
... status ?!Σ1..1codedraft | active | retired | unknown
Binding: PublicationStatus (required): The lifecycle status of an artifact.


Fixed Value: active
... type SΣ1..1CodeableConceptProduct Type
Binding: Insurance Product Type Value Set (extensible)
... name SΣI0..1stringOfficial name
... alias 0..*stringAlternate names
... period 0..1PeriodWhen the product is available
... ownedBy SΣ1..1Reference(National Directory Endpoint Qry Exchange Organization)Plan issuer
... administeredBy SΣ1..1Reference(National Directory Endpoint Qry Exchange Organization)Product administrator
... coverageArea SΣ0..*Reference(National Directory Endpoint Qry Exchange Location)Where product applies
... contact 0..*BackboneElementContact for the product
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... purpose 0..1CodeableConceptThe type of contact
Binding: ContactEntityType (extensible): The purpose for which you would contact a contact party.

.... name 0..1HumanNameA name associated with the contact
.... telecom 0..*ContactPointContact details (telephone, email, etc.) for a contact
.... address 0..1AddressVisiting or postal addresses for the contact
... endpoint 0..*Reference(National Directory Endpoint Qry Exchange Endpoint)Technical endpoint
... network S0..*Reference(National Directory Endpoint Qry Exchange Network)What networks are Included
... coverage 0..*BackboneElementCoverage details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptType of coverage
.... network S0..*Reference(Organization)What networks provide coverage
.... benefit 1..*BackboneElementList of benefits
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type S1..1CodeableConceptType of benefit
..... requirement 0..1stringReferral requirements
..... limit 0..*BackboneElementBenefit limits
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... value 0..1QuantityMaximum value allowed
...... code 0..1CodeableConceptBenefit limit details
... plan 0..*BackboneElementCost sharing details for the plan
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... identifier Σ0..*IdentifierBusiness Identifier for Product
.... type 0..1CodeableConceptCategorization of the cost sharing for the plan
Binding: Insurance Plan Type Value Set (extensible)
.... coverageArea Σ0..*Reference(National Directory Endpoint Qry Exchange Location)Where product applies
.... network 0..*Reference(National Directory Endpoint Qry Exchange Network)What networks provide coverage
.... generalCost 0..*BackboneElementOverall costs
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type 0..1CodeableConceptType of cost
..... groupSize 0..1positiveIntNumber of enrollees
..... cost 0..1MoneyCost value
..... comment 0..1stringAdditional cost information
.... specificCost 0..*BackboneElementSpecific costs
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptGeneral category of benefit
..... benefit 0..*BackboneElementBenefits list
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... type 1..1CodeableConceptType of specific benefit
...... cost 0..*BackboneElementList of the costs
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
....... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
....... type 1..1CodeableConceptType of cost
....... applicability 0..1CodeableConceptin-network | out-of-network | other
Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.

....... qualifiers 0..*CodeableConceptAdditional information about the cost
....... value 0..1QuantityThe actual cost value

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
InsurancePlan.meta.securityextensibleAll Security Labels
InsurancePlan.meta.tagexampleCommonTags
InsurancePlan.languagepreferredCommonLanguages
Max Binding: AllLanguages
InsurancePlan.statusrequiredFixed Value: active
InsurancePlan.typeextensibleInsuranceProductTypeVS
InsurancePlan.contact.purposeextensibleContactEntityType
InsurancePlan.plan.typeextensibleInsurancePlanTypeVS
InsurancePlan.plan.specificCost.benefit.cost.applicabilityrequiredBenefitCostApplicability

Constraints

IdGradePathDetailsRequirements
network-or-NatlDirworkerrorInsurancePlanIf an insuranceplan does not define a network, then each plan must define one
: network.exists() or plan.network.exists.allTrue()
plan-type-is-distincterrorInsurancePlanEach InsurancePlan.plan should have a distinct plan.type.
: plan.type.coding.code.isDistinct()