Release 5 Preview #1

This page is part of the FHIR Specification (v4.2.0: R5 Preview #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 . Page versions: R5 R4B R4

8.31 Resource InsurancePlan - Content

Patient Administration Work GroupMaturity Level: 0 Trial UseSecurity Category: Business Compartments: Not linked to any defined compartments

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

8.31.1 Scope and Usage

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

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

8.31.2 Boundaries and Relationships

TBD.

8.31.3 References

This resource is referenced by UsageContext.

This resource does not implement any patterns.

8.31.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan TUDomainResourceDetails of a Health Insurance product/plan provided by an organization
+ Rule: The organization SHALL at least have a name or an idendtifier, and possibly more than one
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier ΣI0..*IdentifierBusiness Identifier for Product
... status ?!Σ0..1codedraft | active | retired | unknown
PublicationStatus (Required)
... type Σ0..*CodeableConceptKind of product
Insurance plan type (Example)
... alias 0..*stringAlternate names
... period 0..1PeriodWhen the product is available
... ownedBy Σ0..1Reference(Organization)Plan issuer
... administeredBy Σ0..1Reference(Organization)Product administrator
... coverageArea Σ0..*Reference(Location)Where product applies
... contact 0..*BackboneElementContact for the product
.... purpose 0..1CodeableConceptThe type of contact
Contact entity type (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
... endpoint 0..*Reference(Endpoint)Technical endpoint
... network 0..*Reference(Organization)What networks are Included
... coverage 0..*BackboneElementCoverage details
.... type 1..1CodeableConceptType of coverage
.... network 0..*Reference(Organization)What networks provide coverage
.... benefit 1..*BackboneElementList of benefits
..... type 1..1CodeableConceptType of benefit
..... requirement 0..1stringReferral requirements
..... limit 0..*BackboneElementBenefit limits
...... value 0..1QuantityMaximum value allowed
...... code 0..1CodeableConceptBenefit limit details
... plan 0..*BackboneElementPlan details
.... identifier Σ0..*IdentifierBusiness Identifier for Product
.... type 0..1CodeableConceptType of plan
.... coverageArea Σ0..*Reference(Location)Where product applies
.... network 0..*Reference(Organization)What networks provide coverage
.... generalCost 0..*BackboneElementOverall costs
..... type 0..1CodeableConceptType of cost
..... groupSize 0..1positiveIntNumber of enrollees
..... cost 0..1MoneyCost value
..... comment 0..1stringAdditional cost information
.... specificCost 0..*BackboneElementSpecific costs
..... category 1..1CodeableConceptGeneral category of benefit
..... benefit 0..*BackboneElementBenefits list
...... type 1..1CodeableConceptType of specific benefit
...... cost 0..*BackboneElementList of the costs
....... type 1..1CodeableConceptType of cost
....... applicability 0..1CodeableConceptin-network | out-of-network | other
Benefit cost applicability (Required)
....... qualifiers 0..*CodeableConceptAdditional information about the cost
....... value 0..1QuantityThe actual cost value

doco Documentation for this format

UML Diagram (Legend)

InsurancePlan (DomainResource)Business identifiers assigned to this health insurance product which remain constant as the resource is updated and propagates from server to serveridentifier : Identifier [0..*]The current state of the health insurance product (this element modifies the meaning of other elements)status : code [0..1] « The lifecycle status of an artifact. (Strength=Required)PublicationStatus! »The kind of health insurance producttype : CodeableConcept [0..*] « Used to categorize the product/plan. (Strength=Example)InsurancePlanType?? »Official name of the health insurance product as designated by the ownername : string [0..1]A list of alternate names that the product is known as, or was known as in the pastalias : string [0..*]The period of time that the health insurance product is availableperiod : Period [0..1]The entity that is providing the health insurance product and underwriting the risk. This is typically an insurance carriers, other third-party payers, or health plan sponsors comonly referred to as 'payers'ownedBy : Reference [0..1] « Organization »An organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owneradministeredBy : Reference [0..1] « Organization »The geographic region in which a health insurance product's benefits applycoverageArea : Reference [0..*] « Location »The technical endpoints providing access to services operated for the health insurance productendpoint : Reference [0..*] « Endpoint »Reference to the network included in the health insurance productnetwork : Reference [0..*] « Organization »ContactIndicates a purpose for which the contact can be reachedpurpose : CodeableConcept [0..1] « The purpose for which you would contact a contact party. (Strength=Extensible)ContactEntityType+ »A name associated with the contactname : HumanName [0..1]A contact detail (e.g. a telephone number or an email address) by which the party may be contactedtelecom : ContactPoint [0..*]Visiting or postal addresses for the contactaddress : Address [0..1]CoverageType of coverage (Medical; Dental; Mental Health; Substance Abuse; Vision; Drug; Short Term; Long Term Care; Hospice; Home Health)type : CodeableConcept [1..1]Reference to the network that providing the type of coveragenetwork : Reference [0..*] « Organization »CoverageBenefitType of benefit (primary care; speciality care; inpatient; outpatient)type : CodeableConcept [1..1]The referral requirements to have access/coverage for this benefitrequirement : string [0..1]LimitThe maximum amount of a service item a plan will pay for a covered benefit. For examples. wellness visits, or eyeglassesvalue : Quantity [0..1]The specific limit on the benefitcode : CodeableConcept [0..1]PlanBusiness identifiers assigned to this health insurance plan which remain constant as the resource is updated and propagates from server to serveridentifier : Identifier [0..*]Type of plan. For example, "Platinum" or "High Deductable"type : CodeableConcept [0..1]The geographic region in which a health insurance plan's benefits applycoverageArea : Reference [0..*] « Location »Reference to the network that providing the type of coveragenetwork : Reference [0..*] « Organization »GeneralCostType of costtype : CodeableConcept [0..1]Number of participants enrolled in the plangroupSize : positiveInt [0..1]Value of the costcost : Money [0..1]Additional information about the general costs associated with this plancomment : string [0..1]SpecificCostGeneral category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health)category : CodeableConcept [1..1]PlanBenefitType of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care)type : CodeableConcept [1..1]CostType of cost (copay; individual cap; family cap; coinsurance; deductible)type : CodeableConcept [1..1]Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other)applicability : CodeableConcept [0..1] « Whether the cost applies to in-network or out-of-network providers. (Strength=Required)BenefitCostApplicability! »Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA)qualifiers : CodeableConcept [0..*]The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance)value : Quantity [0..1]The contact for the health insurance product for a certain purposecontact[0..*]The specific limits on the benefitlimit[0..*]Specific benefits under this type of coveragebenefit[1..*]Details about the coverage offered by the insurance productcoverage[0..*]Overall costs associated with the plangeneralCost[0..*]List of the costs associated with a specific benefitcost[0..*]List of the specific benefits under this category of benefitbenefit[0..*]Costs associated with the coverage provided by the productspecificCost[0..*]Details about an insurance planplan[0..*]

XML Template

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

JSON Template

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

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:InsurancePlan;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

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

Changes since R3

InsurancePlan
InsurancePlan.status
  • Change value set from http://hl7.org/fhir/ValueSet/publication-status|4.0.0 to http://hl7.org/fhir/ValueSet/publication-status|4.2.0
InsurancePlan.plan.specificCost.benefit.cost.applicability
  • Change value set from http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.0 to http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.2.0

See the Full Difference for further information

This analysis is available as XML or JSON.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan TUDomainResourceDetails of a Health Insurance product/plan provided by an organization
+ Rule: The organization SHALL at least have a name or an idendtifier, and possibly more than one
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier ΣI0..*IdentifierBusiness Identifier for Product
... status ?!Σ0..1codedraft | active | retired | unknown
PublicationStatus (Required)
... type Σ0..*CodeableConceptKind of product
Insurance plan type (Example)
... alias 0..*stringAlternate names
... period 0..1PeriodWhen the product is available
... ownedBy Σ0..1Reference(Organization)Plan issuer
... administeredBy Σ0..1Reference(Organization)Product administrator
... coverageArea Σ0..*Reference(Location)Where product applies
... contact 0..*BackboneElementContact for the product
.... purpose 0..1CodeableConceptThe type of contact
Contact entity type (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
... endpoint 0..*Reference(Endpoint)Technical endpoint
... network 0..*Reference(Organization)What networks are Included
... coverage 0..*BackboneElementCoverage details
.... type 1..1CodeableConceptType of coverage
.... network 0..*Reference(Organization)What networks provide coverage
.... benefit 1..*BackboneElementList of benefits
..... type 1..1CodeableConceptType of benefit
..... requirement 0..1stringReferral requirements
..... limit 0..*BackboneElementBenefit limits
...... value 0..1QuantityMaximum value allowed
...... code 0..1CodeableConceptBenefit limit details
... plan 0..*BackboneElementPlan details
.... identifier Σ0..*IdentifierBusiness Identifier for Product
.... type 0..1CodeableConceptType of plan
.... coverageArea Σ0..*Reference(Location)Where product applies
.... network 0..*Reference(Organization)What networks provide coverage
.... generalCost 0..*BackboneElementOverall costs
..... type 0..1CodeableConceptType of cost
..... groupSize 0..1positiveIntNumber of enrollees
..... cost 0..1MoneyCost value
..... comment 0..1stringAdditional cost information
.... specificCost 0..*BackboneElementSpecific costs
..... category 1..1CodeableConceptGeneral category of benefit
..... benefit 0..*BackboneElementBenefits list
...... type 1..1CodeableConceptType of specific benefit
...... cost 0..*BackboneElementList of the costs
....... type 1..1CodeableConceptType of cost
....... applicability 0..1CodeableConceptin-network | out-of-network | other
Benefit cost applicability (Required)
....... qualifiers 0..*CodeableConceptAdditional information about the cost
....... value 0..1QuantityThe actual cost value

doco Documentation for this format

UML Diagram (Legend)

InsurancePlan (DomainResource)Business identifiers assigned to this health insurance product which remain constant as the resource is updated and propagates from server to serveridentifier : Identifier [0..*]The current state of the health insurance product (this element modifies the meaning of other elements)status : code [0..1] « The lifecycle status of an artifact. (Strength=Required)PublicationStatus! »The kind of health insurance producttype : CodeableConcept [0..*] « Used to categorize the product/plan. (Strength=Example)InsurancePlanType?? »Official name of the health insurance product as designated by the ownername : string [0..1]A list of alternate names that the product is known as, or was known as in the pastalias : string [0..*]The period of time that the health insurance product is availableperiod : Period [0..1]The entity that is providing the health insurance product and underwriting the risk. This is typically an insurance carriers, other third-party payers, or health plan sponsors comonly referred to as 'payers'ownedBy : Reference [0..1] « Organization »An organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owneradministeredBy : Reference [0..1] « Organization »The geographic region in which a health insurance product's benefits applycoverageArea : Reference [0..*] « Location »The technical endpoints providing access to services operated for the health insurance productendpoint : Reference [0..*] « Endpoint »Reference to the network included in the health insurance productnetwork : Reference [0..*] « Organization »ContactIndicates a purpose for which the contact can be reachedpurpose : CodeableConcept [0..1] « The purpose for which you would contact a contact party. (Strength=Extensible)ContactEntityType+ »A name associated with the contactname : HumanName [0..1]A contact detail (e.g. a telephone number or an email address) by which the party may be contactedtelecom : ContactPoint [0..*]Visiting or postal addresses for the contactaddress : Address [0..1]CoverageType of coverage (Medical; Dental; Mental Health; Substance Abuse; Vision; Drug; Short Term; Long Term Care; Hospice; Home Health)type : CodeableConcept [1..1]Reference to the network that providing the type of coveragenetwork : Reference [0..*] « Organization »CoverageBenefitType of benefit (primary care; speciality care; inpatient; outpatient)type : CodeableConcept [1..1]The referral requirements to have access/coverage for this benefitrequirement : string [0..1]LimitThe maximum amount of a service item a plan will pay for a covered benefit. For examples. wellness visits, or eyeglassesvalue : Quantity [0..1]The specific limit on the benefitcode : CodeableConcept [0..1]PlanBusiness identifiers assigned to this health insurance plan which remain constant as the resource is updated and propagates from server to serveridentifier : Identifier [0..*]Type of plan. For example, "Platinum" or "High Deductable"type : CodeableConcept [0..1]The geographic region in which a health insurance plan's benefits applycoverageArea : Reference [0..*] « Location »Reference to the network that providing the type of coveragenetwork : Reference [0..*] « Organization »GeneralCostType of costtype : CodeableConcept [0..1]Number of participants enrolled in the plangroupSize : positiveInt [0..1]Value of the costcost : Money [0..1]Additional information about the general costs associated with this plancomment : string [0..1]SpecificCostGeneral category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health)category : CodeableConcept [1..1]PlanBenefitType of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care)type : CodeableConcept [1..1]CostType of cost (copay; individual cap; family cap; coinsurance; deductible)type : CodeableConcept [1..1]Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other)applicability : CodeableConcept [0..1] « Whether the cost applies to in-network or out-of-network providers. (Strength=Required)BenefitCostApplicability! »Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA)qualifiers : CodeableConcept [0..*]The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance)value : Quantity [0..1]The contact for the health insurance product for a certain purposecontact[0..*]The specific limits on the benefitlimit[0..*]Specific benefits under this type of coveragebenefit[1..*]Details about the coverage offered by the insurance productcoverage[0..*]Overall costs associated with the plangeneralCost[0..*]List of the costs associated with a specific benefitcost[0..*]List of the specific benefits under this category of benefitbenefit[0..*]Costs associated with the coverage provided by the productspecificCost[0..*]Details about an insurance planplan[0..*]

XML Template

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

JSON Template

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

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:InsurancePlan;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

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

Changes since Release 3

InsurancePlan
InsurancePlan.status
  • Change value set from http://hl7.org/fhir/ValueSet/publication-status|4.0.0 to http://hl7.org/fhir/ValueSet/publication-status|4.2.0
InsurancePlan.plan.specificCost.benefit.cost.applicability
  • Change value set from http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.0 to http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.2.0

See the Full Difference for further information

This analysis is available as XML or JSON.

 

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

8.31.4.1 Terminology Bindings

PathDefinitionTypeReference
InsurancePlan.status The lifecycle status of an artifact.RequiredPublicationStatus
InsurancePlan.type Used to categorize the product/plan.ExampleInsurancePlanType
InsurancePlan.contact.purpose The purpose for which you would contact a contact party.ExtensibleContactEntityType
InsurancePlan.plan.specificCost.benefit.cost.applicability Whether the cost applies to in-network or out-of-network providers.RequiredBenefitCostApplicability

8.31.4.2 Constraints

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

8.31.5 Notes:

8.31.6 Search Parameters

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

NameTypeDescriptionExpressionIn Common
addressstringA server defined search that may match any of the string fields in the Address, including line, city, district, state, country, postalCode, and/or textInsurancePlan.contact.address
address-city NstringA city specified in an addressInsurancePlan.contact.address.city
address-country NstringA country specified in an addressInsurancePlan.contact.address.country
address-postalcode NstringA postal code specified in an addressInsurancePlan.contact.address.postalCode
address-state NstringA state specified in an addressInsurancePlan.contact.address.state
address-use NtokenA use code specified in an addressInsurancePlan.contact.address.use
administered-byreferenceProduct administratorInsurancePlan.administeredBy
(Organization)
endpointreferenceTechnical endpointInsurancePlan.endpoint
(Endpoint)
identifiertokenAny identifier for the organization (not the accreditation issuer's identifier)InsurancePlan.identifier
namestringA portion of the organization's name or aliasname | alias
owned-byreferenceAn organization of which this organization forms a partInsurancePlan.ownedBy
(Organization)
phonetic NstringA portion of the organization's name using some kind of phonetic matching algorithmInsurancePlan.name
status NtokenIs the Organization record activeInsurancePlan.status
typetokenA code for the type of organizationInsurancePlan.type