National Directory of Healthcare Providers & Services (NDH) Implementation Guide
1.0.0-ballot - ballot United States of America flag

This page is part of the National Directory of Healthcare Providers and Services (NDH) Implementation Guide (v1.0.0-ballot: STU1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. No current official version has been published yet. For a full list of available versions, see the Directory of published versions

Resource Profile: Payer Provider Network Query InsurancePlan Profile

Official URL: http://hl7.org/fhir/us/ndh/StructureDefinition/ndhPnQry-InsurancePlan Version: 1.0.0-ballot
Active as of 2023-07-30 Computable Name: NdhPnQryInsurancePlan

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 NdhInsurancePlan

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C0..*NdhInsurancePlanDetails of a Health Insurance product/plan provided by an organization
plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type.
... identifier
.... type S0..1CodeableConceptDescription of identifier
.... value S0..1stringThe value that is unique
.... assigner S0..1Reference(Payer Provider Network Query Organization Profile)Organization that issued id (may be just text)
... alias S0..*stringAlternate names
... period S0..1PeriodWhen the product is available
... administeredBy 1..1Reference(Payer Provider Network Query Organization Profile)Product administrator
... coverageArea 0..*Reference(Payer Provider Network Query Location Profile)Where product applies
... contact S0..*BackboneElementContact for the product
.... name S0..1HumanNameA name associated with the contact
..... text S0..1stringText representation of the full name
.... telecom S0..*ContactPointContact details (telephone, email, etc.) for a contact
..... system S0..1codephone | fax | email | pager | url | sms | other
..... value S0..1stringThe actual contact point details
... endpoint S0..*Reference(Payer Provider Network Query Endpoint Profile)Technical endpoint
... network 0..*Reference(Payer Provider Network Query Network Profile)What networks are Included
... coverage
.... network 0..*Reference(Payer Provider Network Query Network Profile)What networks provide coverage
... plan
.... type S0..1CodeableConceptCategorization of the cost sharing for the plan
.... coverageArea S0..*Reference(Payer Provider Network Query Location Profile)Where product applies
.... network 0..*Reference(Payer Provider Network Query Network Profile)What networks provide coverage

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
plan-type-is-distincterrorInsurancePlanEach InsurancePlan.plan should have a distinct plan.type.
: plan.type.coding.code.isDistinct()
NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C0..*NdhInsurancePlanDetails of a Health Insurance product/plan provided by an organization
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... usage-restriction 0..*Reference(NDH Base Restriction) {c}Usage Restriction
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-usage-restriction
... verification-status 0..1CodeableConceptNDH Verification Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status
Binding: NDH Verification Status Value Set (extensible)
... identifier SΣC0..*IdentifierBusiness Identifier for Product
.... identifier-status 0..1codeNDH Identifier Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status
Binding: Identifier Status Value Set (required)
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type SΣ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

.... value SΣ0..1stringThe value that is unique
Example General: 123456
.... assigner SΣ0..1Reference(Payer Provider Network Query Organization Profile)Organization that issued id (may be just text)
... status ?!SΣ1..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 SΣC0..1stringOfficial name
... alias S0..*stringAlternate names
... period S0..1PeriodWhen the product is available
... ownedBy SΣ1..1Reference(Payer Provider Network Query Organization Profile)Plan issuer
... administeredBy SΣ1..1Reference(Payer Provider Network Query Organization Profile)Product administrator
... coverageArea SΣ0..*Reference(Payer Provider Network Query Location Profile)Where product applies
... contact S0..*BackboneElementContact for the product
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... name S0..1HumanNameA name associated with the contact
..... use ?!Σ0..1codeusual | official | temp | nickname | anonymous | old | maiden
Binding: NameUse (required): The use of a human name.

..... text SΣ0..1stringText representation of the full name
.... telecom S0..*ContactPointContact details (telephone, email, etc.) for a contact
..... contactpoint-availabletime 0..*(Complex)NDH Contactpoint Availabletime
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-contactpoint-availabletime
..... via-intermediary 0..1Reference(NDH Base PractitionerRole | NDH Base OrganizationAffiliation Profile | NDH Base Location Profile | NDH Base Organization Profile)Via Intermediary
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-via-intermediary
..... system SΣC0..1codephone | fax | email | pager | url | sms | other
Binding: ContactPointSystem (required): Telecommunications form for contact point.

..... value SΣ0..1stringThe actual contact point details
..... use ?!Σ0..1codehome | work | temp | old | mobile - purpose of this contact point
Binding: ContactPointUse (required): Use of contact point.

... endpoint S0..*Reference(Payer Provider Network Query Endpoint Profile)Technical endpoint
... network S0..*Reference(Payer Provider Network Query Network Profile)What networks are Included
... coverage 0..*BackboneElementCoverage details
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptType of coverage
Binding: NDH Insurance Coverage Type Value Set (extensible)
.... network S0..*Reference(Payer Provider Network Query Network Profile)What networks provide coverage
.... benefit 1..*BackboneElementList of benefits
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type 1..1CodeableConceptType of benefit
Binding: NDH Benefit Type Value Set (extensible)
... plan 0..*BackboneElementCost sharing details for the plan
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S0..1CodeableConceptCategorization of the cost sharing for the plan
Binding: Insurance Plan Type Value Set (extensible)
.... coverageArea SΣ0..*Reference(Payer Provider Network Query Location Profile)Where product applies
.... network 0..*Reference(Payer Provider Network Query Network Profile)What networks provide coverage

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
InsurancePlan.identifier.userequiredIdentifierUse
InsurancePlan.identifier.typeextensibleIdentifier Type Codes
InsurancePlan.statusrequiredFixed Value: active
InsurancePlan.typeextensibleInsuranceProductTypeVS (a valid code from Insurance Product Type Code System)
InsurancePlan.contact.name.userequiredNameUse
InsurancePlan.contact.telecom.systemrequiredContactPointSystem
InsurancePlan.contact.telecom.userequiredContactPointUse
InsurancePlan.coverage.typeextensibleNdhCoverageTypeVS
InsurancePlan.coverage.benefit.typeextensibleNdhBenefitTypeVS
InsurancePlan.plan.typeextensibleInsurancePlanTypeVS (a valid code from Insurance Plan Type Code System)
NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C0..*NdhInsurancePlanDetails of a Health Insurance product/plan provided by an organization
... id Σ0..1idLogical 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
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... usage-restriction 0..*Reference(NDH Base Restriction) {c}Usage Restriction
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-usage-restriction
... verification-status 0..1CodeableConceptNDH Verification Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status
Binding: NDH Verification Status Value Set (extensible)
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣC0..*IdentifierBusiness Identifier for Product
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... identifier-status 0..1codeNDH Identifier Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status
Binding: Identifier Status Value Set (required)
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type SΣ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

.... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ0..1stringThe value that is unique
Example General: 123456
.... period Σ0..1PeriodTime period when id is/was valid for use
.... assigner SΣ0..1Reference(Payer Provider Network Query Organization Profile)Organization that issued id (may be just text)
... status ?!SΣ1..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 SΣC0..1stringOfficial name
... alias S0..*stringAlternate names
... period S0..1PeriodWhen the product is available
... ownedBy SΣ1..1Reference(Payer Provider Network Query Organization Profile)Plan issuer
... administeredBy SΣ1..1Reference(Payer Provider Network Query Organization Profile)Product administrator
... coverageArea SΣ0..*Reference(Payer Provider Network Query Location Profile)Where product applies
... contact S0..*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 S0..1HumanNameA name associated with the contact
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | nickname | anonymous | old | maiden
Binding: NameUse (required): The use of a human name.

..... text SΣ0..1stringText representation of the full name
..... family Σ0..1stringFamily name (often called 'Surname')
..... given Σ0..*stringGiven names (not always 'first'). Includes middle names
This repeating element order: Given Names appear in the correct order for presenting the name
..... prefix Σ0..*stringParts that come before the name
This repeating element order: Prefixes appear in the correct order for presenting the name
..... suffix Σ0..*stringParts that come after the name
This repeating element order: Suffixes appear in the correct order for presenting the name
..... period Σ0..1PeriodTime period when name was/is in use
.... telecom S0..*ContactPointContact details (telephone, email, etc.) for a contact
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contactpoint-availabletime 0..*(Complex)NDH Contactpoint Availabletime
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-contactpoint-availabletime
..... via-intermediary 0..1Reference(NDH Base PractitionerRole | NDH Base OrganizationAffiliation Profile | NDH Base Location Profile | NDH Base Organization Profile)Via Intermediary
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-via-intermediary
..... system SΣC0..1codephone | fax | email | pager | url | sms | other
Binding: ContactPointSystem (required): Telecommunications form for contact point.

..... value SΣ0..1stringThe actual contact point details
..... use ?!Σ0..1codehome | work | temp | old | mobile - purpose of this contact point
Binding: ContactPointUse (required): Use of contact point.

..... rank Σ0..1positiveIntSpecify preferred order of use (1 = highest)
..... period Σ0..1PeriodTime period when the contact point was/is in use
.... address 0..1AddressVisiting or postal addresses for the contact
... endpoint S0..*Reference(Payer Provider Network Query Endpoint Profile)Technical endpoint
... network S0..*Reference(Payer Provider Network Query Network Profile)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
Binding: NDH Insurance Coverage Type Value Set (extensible)
.... network S0..*Reference(Payer Provider Network Query Network Profile)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 1..1CodeableConceptType of benefit
Binding: NDH Benefit Type Value Set (extensible)
..... 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
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... identifier-status 0..1codeNDH Identifier Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status
Binding: Identifier Status Value Set (required)
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ0..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(NDH Base Organization Profile)Organization that issued id (may be just text)
.... type S0..1CodeableConceptCategorization of the cost sharing for the plan
Binding: Insurance Plan Type Value Set (extensible)
.... coverageArea SΣ0..*Reference(Payer Provider Network Query Location Profile)Where product applies
.... network 0..*Reference(Payer Provider Network Query Network Profile)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

Terminology Bindings

PathConformanceValueSet / Code
InsurancePlan.meta.securityextensibleAll Security Labels
InsurancePlan.meta.tagexampleCommonTags
InsurancePlan.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
InsurancePlan.identifier.userequiredIdentifierUse
InsurancePlan.identifier.typeextensibleIdentifier Type Codes
InsurancePlan.statusrequiredFixed Value: active
InsurancePlan.typeextensibleInsuranceProductTypeVS (a valid code from Insurance Product Type Code System)
InsurancePlan.contact.purposeextensibleContactEntityType
InsurancePlan.contact.name.userequiredNameUse
InsurancePlan.contact.telecom.systemrequiredContactPointSystem
InsurancePlan.contact.telecom.userequiredContactPointUse
InsurancePlan.coverage.typeextensibleNdhCoverageTypeVS
InsurancePlan.coverage.benefit.typeextensibleNdhBenefitTypeVS
InsurancePlan.plan.identifier.userequiredIdentifierUse
InsurancePlan.plan.identifier.typeextensibleIdentifier Type Codes
InsurancePlan.plan.typeextensibleInsurancePlanTypeVS (a valid code from Insurance Plan Type Code System)
InsurancePlan.plan.specificCost.benefit.cost.applicabilityrequiredBenefitCostApplicability

Differential View

This structure is derived from NdhInsurancePlan

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C0..*NdhInsurancePlanDetails of a Health Insurance product/plan provided by an organization
plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type.
... identifier
.... type S0..1CodeableConceptDescription of identifier
.... value S0..1stringThe value that is unique
.... assigner S0..1Reference(Payer Provider Network Query Organization Profile)Organization that issued id (may be just text)
... alias S0..*stringAlternate names
... period S0..1PeriodWhen the product is available
... administeredBy 1..1Reference(Payer Provider Network Query Organization Profile)Product administrator
... coverageArea 0..*Reference(Payer Provider Network Query Location Profile)Where product applies
... contact S0..*BackboneElementContact for the product
.... name S0..1HumanNameA name associated with the contact
..... text S0..1stringText representation of the full name
.... telecom S0..*ContactPointContact details (telephone, email, etc.) for a contact
..... system S0..1codephone | fax | email | pager | url | sms | other
..... value S0..1stringThe actual contact point details
... endpoint S0..*Reference(Payer Provider Network Query Endpoint Profile)Technical endpoint
... network 0..*Reference(Payer Provider Network Query Network Profile)What networks are Included
... coverage
.... network 0..*Reference(Payer Provider Network Query Network Profile)What networks provide coverage
... plan
.... type S0..1CodeableConceptCategorization of the cost sharing for the plan
.... coverageArea S0..*Reference(Payer Provider Network Query Location Profile)Where product applies
.... network 0..*Reference(Payer Provider Network Query Network Profile)What networks provide coverage

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
plan-type-is-distincterrorInsurancePlanEach InsurancePlan.plan should have a distinct plan.type.
: plan.type.coding.code.isDistinct()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C0..*NdhInsurancePlanDetails of a Health Insurance product/plan provided by an organization
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... usage-restriction 0..*Reference(NDH Base Restriction) {c}Usage Restriction
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-usage-restriction
... verification-status 0..1CodeableConceptNDH Verification Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status
Binding: NDH Verification Status Value Set (extensible)
... identifier SΣC0..*IdentifierBusiness Identifier for Product
.... identifier-status 0..1codeNDH Identifier Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status
Binding: Identifier Status Value Set (required)
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type SΣ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

.... value SΣ0..1stringThe value that is unique
Example General: 123456
.... assigner SΣ0..1Reference(Payer Provider Network Query Organization Profile)Organization that issued id (may be just text)
... status ?!SΣ1..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 SΣC0..1stringOfficial name
... alias S0..*stringAlternate names
... period S0..1PeriodWhen the product is available
... ownedBy SΣ1..1Reference(Payer Provider Network Query Organization Profile)Plan issuer
... administeredBy SΣ1..1Reference(Payer Provider Network Query Organization Profile)Product administrator
... coverageArea SΣ0..*Reference(Payer Provider Network Query Location Profile)Where product applies
... contact S0..*BackboneElementContact for the product
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... name S0..1HumanNameA name associated with the contact
..... use ?!Σ0..1codeusual | official | temp | nickname | anonymous | old | maiden
Binding: NameUse (required): The use of a human name.

..... text SΣ0..1stringText representation of the full name
.... telecom S0..*ContactPointContact details (telephone, email, etc.) for a contact
..... contactpoint-availabletime 0..*(Complex)NDH Contactpoint Availabletime
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-contactpoint-availabletime
..... via-intermediary 0..1Reference(NDH Base PractitionerRole | NDH Base OrganizationAffiliation Profile | NDH Base Location Profile | NDH Base Organization Profile)Via Intermediary
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-via-intermediary
..... system SΣC0..1codephone | fax | email | pager | url | sms | other
Binding: ContactPointSystem (required): Telecommunications form for contact point.

..... value SΣ0..1stringThe actual contact point details
..... use ?!Σ0..1codehome | work | temp | old | mobile - purpose of this contact point
Binding: ContactPointUse (required): Use of contact point.

... endpoint S0..*Reference(Payer Provider Network Query Endpoint Profile)Technical endpoint
... network S0..*Reference(Payer Provider Network Query Network Profile)What networks are Included
... coverage 0..*BackboneElementCoverage details
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptType of coverage
Binding: NDH Insurance Coverage Type Value Set (extensible)
.... network S0..*Reference(Payer Provider Network Query Network Profile)What networks provide coverage
.... benefit 1..*BackboneElementList of benefits
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type 1..1CodeableConceptType of benefit
Binding: NDH Benefit Type Value Set (extensible)
... plan 0..*BackboneElementCost sharing details for the plan
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type S0..1CodeableConceptCategorization of the cost sharing for the plan
Binding: Insurance Plan Type Value Set (extensible)
.... coverageArea SΣ0..*Reference(Payer Provider Network Query Location Profile)Where product applies
.... network 0..*Reference(Payer Provider Network Query Network Profile)What networks provide coverage

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
InsurancePlan.identifier.userequiredIdentifierUse
InsurancePlan.identifier.typeextensibleIdentifier Type Codes
InsurancePlan.statusrequiredFixed Value: active
InsurancePlan.typeextensibleInsuranceProductTypeVS (a valid code from Insurance Product Type Code System)
InsurancePlan.contact.name.userequiredNameUse
InsurancePlan.contact.telecom.systemrequiredContactPointSystem
InsurancePlan.contact.telecom.userequiredContactPointUse
InsurancePlan.coverage.typeextensibleNdhCoverageTypeVS
InsurancePlan.coverage.benefit.typeextensibleNdhBenefitTypeVS
InsurancePlan.plan.typeextensibleInsurancePlanTypeVS (a valid code from Insurance Plan Type Code System)

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C0..*NdhInsurancePlanDetails of a Health Insurance product/plan provided by an organization
... id Σ0..1idLogical 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
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... usage-restriction 0..*Reference(NDH Base Restriction) {c}Usage Restriction
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-usage-restriction
... verification-status 0..1CodeableConceptNDH Verification Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status
Binding: NDH Verification Status Value Set (extensible)
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣC0..*IdentifierBusiness Identifier for Product
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... identifier-status 0..1codeNDH Identifier Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status
Binding: Identifier Status Value Set (required)
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type SΣ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

.... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ0..1stringThe value that is unique
Example General: 123456
.... period Σ0..1PeriodTime period when id is/was valid for use
.... assigner SΣ0..1Reference(Payer Provider Network Query Organization Profile)Organization that issued id (may be just text)
... status ?!SΣ1..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 SΣC0..1stringOfficial name
... alias S0..*stringAlternate names
... period S0..1PeriodWhen the product is available
... ownedBy SΣ1..1Reference(Payer Provider Network Query Organization Profile)Plan issuer
... administeredBy SΣ1..1Reference(Payer Provider Network Query Organization Profile)Product administrator
... coverageArea SΣ0..*Reference(Payer Provider Network Query Location Profile)Where product applies
... contact S0..*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 S0..1HumanNameA name associated with the contact
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ0..1codeusual | official | temp | nickname | anonymous | old | maiden
Binding: NameUse (required): The use of a human name.

..... text SΣ0..1stringText representation of the full name
..... family Σ0..1stringFamily name (often called 'Surname')
..... given Σ0..*stringGiven names (not always 'first'). Includes middle names
This repeating element order: Given Names appear in the correct order for presenting the name
..... prefix Σ0..*stringParts that come before the name
This repeating element order: Prefixes appear in the correct order for presenting the name
..... suffix Σ0..*stringParts that come after the name
This repeating element order: Suffixes appear in the correct order for presenting the name
..... period Σ0..1PeriodTime period when name was/is in use
.... telecom S0..*ContactPointContact details (telephone, email, etc.) for a contact
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contactpoint-availabletime 0..*(Complex)NDH Contactpoint Availabletime
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-contactpoint-availabletime
..... via-intermediary 0..1Reference(NDH Base PractitionerRole | NDH Base OrganizationAffiliation Profile | NDH Base Location Profile | NDH Base Organization Profile)Via Intermediary
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-via-intermediary
..... system SΣC0..1codephone | fax | email | pager | url | sms | other
Binding: ContactPointSystem (required): Telecommunications form for contact point.

..... value SΣ0..1stringThe actual contact point details
..... use ?!Σ0..1codehome | work | temp | old | mobile - purpose of this contact point
Binding: ContactPointUse (required): Use of contact point.

..... rank Σ0..1positiveIntSpecify preferred order of use (1 = highest)
..... period Σ0..1PeriodTime period when the contact point was/is in use
.... address 0..1AddressVisiting or postal addresses for the contact
... endpoint S0..*Reference(Payer Provider Network Query Endpoint Profile)Technical endpoint
... network S0..*Reference(Payer Provider Network Query Network Profile)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
Binding: NDH Insurance Coverage Type Value Set (extensible)
.... network S0..*Reference(Payer Provider Network Query Network Profile)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 1..1CodeableConceptType of benefit
Binding: NDH Benefit Type Value Set (extensible)
..... 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
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... identifier-status 0..1codeNDH Identifier Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status
Binding: Identifier Status Value Set (required)
..... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

..... system Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ0..1stringThe value that is unique
Example General: 123456
..... period Σ0..1PeriodTime period when id is/was valid for use
..... assigner Σ0..1Reference(NDH Base Organization Profile)Organization that issued id (may be just text)
.... type S0..1CodeableConceptCategorization of the cost sharing for the plan
Binding: Insurance Plan Type Value Set (extensible)
.... coverageArea SΣ0..*Reference(Payer Provider Network Query Location Profile)Where product applies
.... network 0..*Reference(Payer Provider Network Query Network Profile)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

Terminology Bindings

PathConformanceValueSet / Code
InsurancePlan.meta.securityextensibleAll Security Labels
InsurancePlan.meta.tagexampleCommonTags
InsurancePlan.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
InsurancePlan.identifier.userequiredIdentifierUse
InsurancePlan.identifier.typeextensibleIdentifier Type Codes
InsurancePlan.statusrequiredFixed Value: active
InsurancePlan.typeextensibleInsuranceProductTypeVS (a valid code from Insurance Product Type Code System)
InsurancePlan.contact.purposeextensibleContactEntityType
InsurancePlan.contact.name.userequiredNameUse
InsurancePlan.contact.telecom.systemrequiredContactPointSystem
InsurancePlan.contact.telecom.userequiredContactPointUse
InsurancePlan.coverage.typeextensibleNdhCoverageTypeVS
InsurancePlan.coverage.benefit.typeextensibleNdhBenefitTypeVS
InsurancePlan.plan.identifier.userequiredIdentifierUse
InsurancePlan.plan.identifier.typeextensibleIdentifier Type Codes
InsurancePlan.plan.typeextensibleInsurancePlanTypeVS (a valid code from Insurance Plan Type Code System)
InsurancePlan.plan.specificCost.benefit.cost.applicabilityrequiredBenefitCostApplicability

 

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