Validated Healthcare Directory IG STU1 Draft for Comment

This page is part of the Validated Healthcare Directory FHIR IG (v0.1.0: STU 1 Draft) based on FHIR v3.2.0. . For a full list of available versions, see the Directory of published versions

1.0 - StructureDefinition: vhdir-productPlan - Content

This profile sets minimum expectations for searching for and fetching information associated with a health insurance product/plan. It identifies which core elements, extensions, vocabularies and value sets SHALL be present in the productPlan resource when using this profile.

Background & Scope

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.

ProductPlan 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.

We propose to create a new productPlan resource as part of the base FHIR specification.

Examples:

The following are example uses for the vhdir-productPlan profile:

  • TBD

Mandatory Data Elements

The following data-elements are mandatory (i.e data MUST be present). These are presented below in a simple human-readable explanation. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each productPlan resource must have:

  1. At least one covered benefit described in productPlan.productCoverage. This attribute consists of a number of other mandatory attributes:
    1. One type in productPlan.productCoverage.coverageType
    2. At least one benefit described in productPlan.productCoverage.benefits
    3. One type in productPlan.productCoverage.benefits.type
    4. At least one specific benefit described in productPlan.productCoverage.benefits.benefitList
    5. One description of the benefit in productPlan.productCoverage.benefits.benefitList.description
  2. At least one cost described in productPlan.plan.
    1. For each cost in productPlan.benefitCategory.benefit.costs, one type in productPlan.benefitCategory.benefit.costs.type

Profile specific implementation guidance:

  • TBD

Extensions:

  1. Restriction (0..*) - indicates restrictions on the use/release of information associated with a product/plan

Terminology

TBD

1.2 - Formal Views of Profile Content

The official URL for this profile is: 

http://hl7.org/fhir/ig/vhdir/StructureDefinition/vhdir-productPlan

The details of a health insurance product/plan

This profile builds on ProductPlan.

This profile was published on Wed Dec 06 04:38:42 AEDT 2017 as a draft by null.

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

Complete Summary of the Mandatory Requirements

  1. At least one covered benefit described in productPlan.productCoverage. This attribute consists of a number of other mandatory attributes:
    1. One type in productPlan.productCoverage.coverageType
    2. At least one benefit described in productPlan.productCoverage.benefits
    3. One type in productPlan.productCoverage.benefits.type
    4. At least one specific benefit described in productPlan.productCoverage.benefits.benefitList
    5. One description of the benefit in productPlan.productCoverage.benefits.benefitList.description
  2. At least one cost described in productPlan.plan.
    1. For each cost in productPlan.benefitCategory.benefit.costs, one type in productPlan.benefitCategory.benefit.costs.type
NameFlagsCard.TypeDescription & Constraintsdoco
.. ProductPlan I0..*Details of a Health Insurance product/plan provided by an organization
... id SΣ0..1idLogical id of this artifact
... meta SΣ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text SI0..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 ΣI0..*IdentifierIdentifies this product/plan across multiple systems
.... id 0..1stringxml:id (or equivalent in JSON)
.... identifier-status 0..1codeExtension
URL: http://hl7.org/fhir/ig/vhdir/StructureDefinition/identifier-status
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible)
.... system Σ0..1uriThe namespace for the identifier value
Example General': http://www.acme.com/identifiers/patient or urn:ietf:rfc:3986 if the Identifier.value itself is a full uri
.... value Σ0..1stringThe value that is unique
Example General': 123456
.... period Σ0..1PeriodTime period when id is/was valid for use
.... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!Σ0..1codeWhether the organization's record is still in active use
Binding: PublicationStatus (required)
... type Σ0..*CodeableConceptKind of product/plan
Binding: ProductPlanType (example)
... name ΣI0..1stringOfficial name
... alias 0..*stringA list of alternate names that the product/plan is known as, or was known as in the past
... period 0..1PeriodThe time period the product/plan is available
... ownedBy Σ0..1Reference(Organization)Owner of the product/plan
... administeredBy Σ0..1Reference(Organization)Administrator of the product/plan
... address I0..*AddressAn address for the organization
ppn-2: An address of an organization can never be of use 'home'
... coverageArea Σ0..1Reference(Location)The geographic region in which this product/plan is available
... contact I0..*BackboneElementContact for the product/plan for a certain purpose
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... purpose 0..1CodeableConceptThe type of contact
Binding: ContactEntityType (extensible)
.... 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
... coverage I0..*BackboneElementDetails about the coverage offered by the insurance product
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... type 1..1CodeableConceptType of coverage
.... benefit I1..*BackboneElementSpecific benefits under this type of coverage
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... type 1..1CodeableConceptType of benefit
..... item I1..*BackboneElementSpecific benefit and related value
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
...... code 1..1CodeableConceptCoded Details of the specific benefit (days; visits)
...... benefitValue 0..1QuantityValue of the specific benefit
... plan I0..*BackboneElementDetails about an insurance plan
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... type 0..1CodeableConceptType of plan
.... description 0..1stringAdditional descriptive content about the plan
.... premium 0..1MoneyPlan premium
.... category I0..*BackboneElementList of the costs associated with plan benefits
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... code 0..1CodeableConceptGeneral category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health)
..... benefit I0..*BackboneElementList of the specific benefits under this category of benefit
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
...... type 1..1CodeableConceptType of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care)
...... cost I0..*BackboneElementList of the costs associated with a specific benefit
....... id 0..1stringxml:id (or equivalent in JSON)
....... extension 0..*ExtensionAdditional Content defined by implementations
....... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
....... type 1..1CodeableConceptType of cost (copay; individual cap; family cap; coinsurance; deductible)
....... applicability 0..*CodingWhether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other)
....... qualifiers 0..*stringAdditional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA)
....... value 0..1QuantityThe actual cost value
... endpoint 0..*Reference(Endpoint)Technical endpoints providing access to services operated for the organization

doco Documentation for this format

Complete Summary of the Mandatory Requirements

  1. At least one covered benefit described in productPlan.productCoverage. This attribute consists of a number of other mandatory attributes:
    1. One type in productPlan.productCoverage.coverageType
    2. At least one benefit described in productPlan.productCoverage.benefits
    3. One type in productPlan.productCoverage.benefits.type
    4. At least one specific benefit described in productPlan.productCoverage.benefits.benefitList
    5. One description of the benefit in productPlan.productCoverage.benefits.benefitList.description
  2. At least one cost described in productPlan.plan.
    1. For each cost in productPlan.benefitCategory.benefit.costs, one type in productPlan.benefitCategory.benefit.costs.type

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ProductPlan I0..*Details of a Health Insurance product/plan provided by an organization
... id SΣ0..1idLogical id of this artifact
... meta SΣ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text SI0..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 ΣI0..*IdentifierIdentifies this product/plan across multiple systems
.... id 0..1stringxml:id (or equivalent in JSON)
.... identifier-status 0..1codeExtension
URL: http://hl7.org/fhir/ig/vhdir/StructureDefinition/identifier-status
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type Σ0..1CodeableConceptDescription of identifier
Binding: Identifier Type Codes (extensible)
.... system Σ0..1uriThe namespace for the identifier value
Example General': http://www.acme.com/identifiers/patient or urn:ietf:rfc:3986 if the Identifier.value itself is a full uri
.... value Σ0..1stringThe value that is unique
Example General': 123456
.... period Σ0..1PeriodTime period when id is/was valid for use
.... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!Σ0..1codeWhether the organization's record is still in active use
Binding: PublicationStatus (required)
... type Σ0..*CodeableConceptKind of product/plan
Binding: ProductPlanType (example)
... name ΣI0..1stringOfficial name
... alias 0..*stringA list of alternate names that the product/plan is known as, or was known as in the past
... period 0..1PeriodThe time period the product/plan is available
... ownedBy Σ0..1Reference(Organization)Owner of the product/plan
... administeredBy Σ0..1Reference(Organization)Administrator of the product/plan
... address I0..*AddressAn address for the organization
ppn-2: An address of an organization can never be of use 'home'
... coverageArea Σ0..1Reference(Location)The geographic region in which this product/plan is available
... contact I0..*BackboneElementContact for the product/plan for a certain purpose
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... purpose 0..1CodeableConceptThe type of contact
Binding: ContactEntityType (extensible)
.... 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
... coverage I0..*BackboneElementDetails about the coverage offered by the insurance product
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... type 1..1CodeableConceptType of coverage
.... benefit I1..*BackboneElementSpecific benefits under this type of coverage
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... type 1..1CodeableConceptType of benefit
..... item I1..*BackboneElementSpecific benefit and related value
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
...... code 1..1CodeableConceptCoded Details of the specific benefit (days; visits)
...... benefitValue 0..1QuantityValue of the specific benefit
... plan I0..*BackboneElementDetails about an insurance plan
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... type 0..1CodeableConceptType of plan
.... description 0..1stringAdditional descriptive content about the plan
.... premium 0..1MoneyPlan premium
.... category I0..*BackboneElementList of the costs associated with plan benefits
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... code 0..1CodeableConceptGeneral category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health)
..... benefit I0..*BackboneElementList of the specific benefits under this category of benefit
...... id 0..1stringxml:id (or equivalent in JSON)
...... extension 0..*ExtensionAdditional Content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
...... type 1..1CodeableConceptType of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care)
...... cost I0..*BackboneElementList of the costs associated with a specific benefit
....... id 0..1stringxml:id (or equivalent in JSON)
....... extension 0..*ExtensionAdditional Content defined by implementations
....... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
....... type 1..1CodeableConceptType of cost (copay; individual cap; family cap; coinsurance; deductible)
....... applicability 0..*CodingWhether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other)
....... qualifiers 0..*stringAdditional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA)
....... value 0..1QuantityThe actual cost value
... endpoint 0..*Reference(Endpoint)Technical endpoints providing access to services operated for the organization

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON, CSV), Schema: XML Schematron

 

1.3 - Quick Start

Below is an overview of the required search and read operations for this profile. See the Conformance requirements for the US Core Server for a complete list of supported RESTful operations and search parameters for this IG.

TBD