R4 Draft for Comment
AdministrationThis page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
| Patient Administration Work Group | Maturity Level: 0 | Draft | 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.
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.
Structure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ProductPlan | ID | DomainResource | Details of a Health Insurance product/plan provided by an organization + The organization SHALL at least have a name or an id, and possibly more than one Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | |
  identifier | ΣI | 0..* | Identifier | Identifies this product/plan across multiple systems |
 status | ?!Σ | 0..1 | code | Whether the organization's record is still in active use PublicationStatus (Required) |
| type | Σ | 0..* | CodeableConcept | Kind of product/plan ProductPlanType (Example) |
| name | ΣI | 0..1 | string | Official name |
| alias | 0..* | string | A list of alternate names that the product/plan is known as, or was known as in the past | |
| period | 0..1 | Period | The time period the product/plan is available | |
 ownedBy | Σ | 0..1 | Reference(Organization) | Owner of the product/plan |
| administeredBy | Σ | 0..1 | Reference(Organization) | Administrator of the product/plan |
| address | I | 0..* | Address | An address for the organization + An address of an organization can never be of use 'home' |
| coverageArea | Σ | 0..1 | Reference(Location) | The geographic region in which this product/plan is available |
 contact | 0..* | BackboneElement | Contact for the product/plan for a certain purpose | |
 purpose | 0..1 | CodeableConcept | The type of contact 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 | |
| coverage | 0..* | BackboneElement | Details about the coverage offered by the insurance product | |
| type | 1..1 | CodeableConcept | Type of coverage | |
| benefit | 1..* | BackboneElement | Specific benefits under this type of coverage | |
 type | 1..1 | CodeableConcept | Type of benefit | |
| item | 1..* | BackboneElement | Specific benefit and related value | |
| code | 1..1 | CodeableConcept | Coded Details of the specific benefit (days; visits) | |
| benefitValue | 0..1 | Quantity | Value of the specific benefit | |
| plan | 0..* | BackboneElement | Details about an insurance plan | |
| type | 0..1 | CodeableConcept | Type of plan | |
| description | 0..1 | string | Additional descriptive content about the plan | |
| premium | 0..1 | Money | Plan premium | |
| category | 0..* | BackboneElement | List of the costs associated with plan benefits | |
| code | 0..1 | CodeableConcept | General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health) | |
| benefit | 0..* | BackboneElement | List of the specific benefits under this category of benefit | |
| type | 1..1 | CodeableConcept | Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care) | |
| cost | 0..* | BackboneElement | List of the costs associated with a specific benefit | |
| type | 1..1 | CodeableConcept | Type of cost (copay; individual cap; family cap; coinsurance; deductible) | |
| applicability | 0..* | Coding | Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other) | |
| qualifiers | 0..* | string | Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA) | |
| value | 0..1 | Quantity | The actual cost value | |
| endpoint | 0..* | Reference(Endpoint) | Technical endpoints providing access to services operated for the organization | |
| Documentation for this format | ||||
UML Diagram (Legend)
XML Template
<ProductPlan xmlns="http://hl7.org/fhir"><!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!--
0..* Identifier Identifies this product/plan across multiple systems --></identifier> <status value="[code]"/><!-- 0..1 Whether the organization's record is still in active use --> <type><!-- 0..* CodeableConcept Kind of product/plan --></type> <name value="[string]"/><!--
JSON Template
{
"resourceType" : "ProductPlan",
// from Resource: id, meta, implicitRules, and language
// from DomainResource: text, contained, extension, and modifierExtension
"identifier" : [{ Identifier }], // C? Identifies this product/plan across multiple systems
"status" : "<code>", // Whether the organization's record is still in active use
"type" : [{ CodeableConcept }], // Kind of product/plan
"name" : "<string>", // C? Official name
"alias" : ["<string>"], // A list of alternate names that the product/plan is known as, or was known as in the past
"period" : { Period }, // The time period the product/plan is available
"ownedBy" : { Reference(Organization) }, // Owner of the product/plan
"administeredBy" : { Reference(Organization) }, // Administrator of the product/plan
"address" : [{ Address }], // C? An address for the organization
"coverageArea" : { Reference(Location) }, // The geographic region in which this product/plan is available
"contact" : [{ // Contact for the product/plan for a certain purpose
"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
}],
"coverage" : [{ // Details about the coverage offered by the insurance product
"type" : { CodeableConcept }, // R! Type of coverage
"benefit" : [{ // R! Specific benefits under this type of coverage
"type" : { CodeableConcept }, // R! Type of benefit
"item" : [{ // R! Specific benefit and related value
"code" : { CodeableConcept }, // R! Coded Details of the specific benefit (days; visits)
"benefitValue" : { Quantity } // Value of the specific benefit
}]
}]
}],
"plan" : [{ // Details about an insurance plan
"type" : { CodeableConcept }, // Type of plan
"description" : "<string>", // Additional descriptive content about the plan
"premium" : { Money }, // Plan premium
"category" : [{ // List of the costs associated with plan benefits
"code" : { CodeableConcept }, // General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health)
"benefit" : [{ // List of the specific benefits under this category of benefit
"type" : { CodeableConcept }, // R! Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care)
"cost" : [{ // List of the costs associated with a specific benefit
"type" : { CodeableConcept }, // R! Type of cost (copay; individual cap; family cap; coinsurance; deductible)
"applicability" : [{ Coding }], // Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other)
"qualifiers" : ["<string>"], // Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA)
"value" : { Quantity } // The actual cost value
}]
}]
}]
}],
"endpoint" : [{ Reference(Endpoint) }] // Technical endpoints providing access to services operated for the organization
}
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> .
Structure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ProductPlan | ID | DomainResource | Details of a Health Insurance product/plan provided by an organization + The organization SHALL at least have a name or an id, and possibly more than one Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | |
| identifier | ΣI | 0..* | Identifier | Identifies this product/plan across multiple systems |
| status | ?!Σ | 0..1 | code | Whether the organization's record is still in active use PublicationStatus (Required) |
| type | Σ | 0..* | CodeableConcept | Kind of product/plan ProductPlanType (Example) |
| name | ΣI | 0..1 | string | Official name |
| alias | 0..* | string | A list of alternate names that the product/plan is known as, or was known as in the past | |
| period | 0..1 | Period | The time period the product/plan is available | |
| ownedBy | Σ | 0..1 | Reference(Organization) | Owner of the product/plan |
| administeredBy | Σ | 0..1 | Reference(Organization) | Administrator of the product/plan |
| address | I | 0..* | Address | An address for the organization + An address of an organization can never be of use 'home' |
| coverageArea | Σ | 0..1 | Reference(Location) | The geographic region in which this product/plan is available |
| contact | 0..* | BackboneElement | Contact for the product/plan for a certain purpose | |
| purpose | 0..1 | CodeableConcept | The type of contact 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 | |
| coverage | 0..* | BackboneElement | Details about the coverage offered by the insurance product | |
| type | 1..1 | CodeableConcept | Type of coverage | |
| benefit | 1..* | BackboneElement | Specific benefits under this type of coverage | |
| type | 1..1 | CodeableConcept | Type of benefit | |
| item | 1..* | BackboneElement | Specific benefit and related value | |
| code | 1..1 | CodeableConcept | Coded Details of the specific benefit (days; visits) | |
| benefitValue | 0..1 | Quantity | Value of the specific benefit | |
| plan | 0..* | BackboneElement | Details about an insurance plan | |
| type | 0..1 | CodeableConcept | Type of plan | |
| description | 0..1 | string | Additional descriptive content about the plan | |
| premium | 0..1 | Money | Plan premium | |
| category | 0..* | BackboneElement | List of the costs associated with plan benefits | |
| code | 0..1 | CodeableConcept | General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health) | |
| benefit | 0..* | BackboneElement | List of the specific benefits under this category of benefit | |
| type | 1..1 | CodeableConcept | Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care) | |
| cost | 0..* | BackboneElement | List of the costs associated with a specific benefit | |
| type | 1..1 | CodeableConcept | Type of cost (copay; individual cap; family cap; coinsurance; deductible) | |
| applicability | 0..* | Coding | Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other) | |
| qualifiers | 0..* | string | Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA) | |
| value | 0..1 | Quantity | The actual cost value | |
| endpoint | 0..* | Reference(Endpoint) | Technical endpoints providing access to services operated for the organization | |
| Documentation for this format | ||||
XML Template
<ProductPlan xmlns="http://hl7.org/fhir">
JSON Template
{
"resourceType" : "ProductPlan",
// from Resource: id, meta, implicitRules, and language
// from DomainResource: text, contained, extension, and modifierExtension
"identifier" : [{ Identifier }], // C? Identifies this product/plan across multiple systems
"status" : "<code>", // Whether the organization's record is still in active use
"type" : [{ CodeableConcept }], // Kind of product/plan
"name" : "<string>", // C? Official name
"alias" : ["<string>"], // A list of alternate names that the product/plan is known as, or was known as in the past
"period" : { Period }, // The time period the product/plan is available
"ownedBy" : { Reference(Organization) }, // Owner of the product/plan
"administeredBy" : { Reference(Organization) }, // Administrator of the product/plan
"address" : [{ Address }], // C? An address for the organization
"coverageArea" : { Reference(Location) }, // The geographic region in which this product/plan is available
"contact" : [{ // Contact for the product/plan for a certain purpose
"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
}],
"coverage" : [{ // Details about the coverage offered by the insurance product
"type" : { CodeableConcept }, // R! Type of coverage
"benefit" : [{ // R! Specific benefits under this type of coverage
"type" : { CodeableConcept }, // R! Type of benefit
"item" : [{ // R! Specific benefit and related value
"code" : { CodeableConcept }, // R! Coded Details of the specific benefit (days; visits)
"benefitValue" : { Quantity } // Value of the specific benefit
}]
}]
}],
"plan" : [{ // Details about an insurance plan
"type" : { CodeableConcept }, // Type of plan
"description" : "<string>", // Additional descriptive content about the plan
"premium" : { Money }, // Plan premium
"category" : [{ // List of the costs associated with plan benefits
"code" : { CodeableConcept }, // General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health)
"benefit" : [{ // List of the specific benefits under this category of benefit
"type" : { CodeableConcept }, // R! Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care)
"cost" : [{ // List of the costs associated with a specific benefit
"type" : { CodeableConcept }, // R! Type of cost (copay; individual cap; family cap; coinsurance; deductible)
"applicability" : [{ Coding }], // Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other)
"qualifiers" : ["<string>"], // Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA)
"value" : { Quantity } // The actual cost value
}]
}]
}]
}],
"endpoint" : [{ Reference(Endpoint) }] // Technical endpoints providing access to services operated for the organization
}
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> .
Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions & the dependency analysis
| Path | Definition | Type | Reference |
|---|---|---|---|
| ProductPlan.status | ProductPlan status | Required | PublicationStatus |
| ProductPlan.type | Used to categorize the product/plan | Example | ProductPlanType |
| ProductPlan.contact.purpose | The purpose for which you would contact a contact party | Extensible | ContactEntityType |
: (identifier.count() + name.count()) > 0) on ProductPlan.address: where(use = 'home').empty())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 | ProductPlan.address | |
| address-city | string | A city specified in an address | ProductPlan.address.city | |
| address-country | string | A country specified in an address | ProductPlan.address.country | |
| address-postalcode | string | A postal code specified in an address | ProductPlan.address.postalCode | |
| address-state | string | A state specified in an address | ProductPlan.address.state | |
| address-use | token | A use code specified in an address | ProductPlan.address.use | |
| administered-by | reference | Administrator of the product/plan | ProductPlan.administeredBy (Organization) | |
| endpoint | reference | Technical endpoints providing access to services operated for the organization | ProductPlan.endpoint (Endpoint) | |
| identifier | token | Any identifier for the organization (not the accreditation issuer's identifier) | ProductPlan.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 | ProductPlan.ownedBy (Organization) | |
| phonetic | string | A portion of the organization's name using some kind of phonetic matching algorithm | ProductPlan.name | |
| status | token | Is the Organization record active | ProductPlan.status | |
| type | token | A code for the type of organization | ProductPlan.type |
®© HL7.org 2011+. FHIR Release 4 Draft for Comment (Jan-2018 v3.2.0-12885) generated on Wed, Dec 20, 2017 15:58+1100. QA Page
Links: Search |
Version History |
Table of Contents |
Credits |
Compare to DSTU3 |
|
Propose a change