This page is part of the FHIR Specification v4.1.0: R4B Ballot. About the R4B version of FHIR. 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
Patient Administration Work Group | Maturity Level: 0 | Trial Use | Security Category: Business | Compartments: Not linked to any defined compartments |
Detailed Descriptions for the elements in the InsurancePlan resource.
InsurancePlan | |||||||||
Element Id | InsurancePlan | ||||||||
Definition | Details of a Health Insurance product/plan provided by an organization. | ||||||||
Cardinality | 0..* | ||||||||
Type | DomainResource | ||||||||
Summary | false | ||||||||
Invariants |
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InsurancePlan.identifier | |||||||||
Element Id | InsurancePlan.identifier | ||||||||
Definition | Business identifiers assigned to this health insurance product which remain constant as the resource is updated and propagates from server to server. | ||||||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||||||
Cardinality | 0..* | ||||||||
Type | Identifier | ||||||||
Summary | true | ||||||||
Invariants |
| ||||||||
InsurancePlan.status | |||||||||
Element Id | InsurancePlan.status | ||||||||
Definition | The current state of the health insurance product. | ||||||||
Cardinality | 0..1 | ||||||||
Terminology Binding | PublicationStatus (Required) | ||||||||
Type | code | ||||||||
Is Modifier | true (Reason: This element is labeled as a modifier because it is a status element that contains codes which means that the resource should not be treated as valid) | ||||||||
Meaning if Missing | Default interpretation is active. | ||||||||
Requirements | Need a flag to indicate a record is no longer to be used and should generally be hidden for the user in the UI. | ||||||||
Summary | true | ||||||||
InsurancePlan.type | |||||||||
Element Id | InsurancePlan.type | ||||||||
Definition | The kind of health insurance product. | ||||||||
Cardinality | 0..* | ||||||||
Terminology Binding | InsurancePlanType (Example) | ||||||||
Type | CodeableConcept | ||||||||
Summary | true | ||||||||
InsurancePlan.name | |||||||||
Element Id | InsurancePlan.name | ||||||||
Definition | Official name of the health insurance product as designated by the owner. | ||||||||
Cardinality | 0..1 | ||||||||
Type | string | ||||||||
Summary | true | ||||||||
Comments | If the name of the product/plan changes, consider putting the old name in the alias column so that it can still be located through searches. | ||||||||
Invariants |
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InsurancePlan.alias | |||||||||
Element Id | InsurancePlan.alias | ||||||||
Definition | A list of alternate names that the product is known as, or was known as in the past. | ||||||||
Cardinality | 0..* | ||||||||
Type | string | ||||||||
Requirements | Over time products/plans go through many changes and can be known by different names. For searching knowing previous names that the product/plan was known by can be very useful. | ||||||||
Summary | false | ||||||||
Comments | There are no dates associated with the alias/historic names, as this is not intended to track when names were used, but to assist in searching so that older names can still result in identifying the product/plan. | ||||||||
InsurancePlan.period | |||||||||
Element Id | InsurancePlan.period | ||||||||
Definition | The period of time that the health insurance product is available. | ||||||||
Cardinality | 0..1 | ||||||||
Type | Period | ||||||||
Summary | false | ||||||||
InsurancePlan.ownedBy | |||||||||
Element Id | InsurancePlan.ownedBy | ||||||||
Definition | 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'. | ||||||||
Cardinality | 0..1 | ||||||||
Type | Reference(Organization) | ||||||||
Alternate Names | Payer | ||||||||
Summary | true | ||||||||
InsurancePlan.administeredBy | |||||||||
Element Id | InsurancePlan.administeredBy | ||||||||
Definition | An organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owner. | ||||||||
Cardinality | 0..1 | ||||||||
Type | Reference(Organization) | ||||||||
Summary | true | ||||||||
InsurancePlan.coverageArea | |||||||||
Element Id | InsurancePlan.coverageArea | ||||||||
Definition | The geographic region in which a health insurance product's benefits apply. | ||||||||
Cardinality | 0..* | ||||||||
Type | Reference(Location) | ||||||||
Summary | true | ||||||||
InsurancePlan.contact | |||||||||
Element Id | InsurancePlan.contact | ||||||||
Definition | The contact for the health insurance product for a certain purpose. | ||||||||
Cardinality | 0..* | ||||||||
Requirements | Need to keep track of assigned contact points within bigger organization. | ||||||||
Summary | false | ||||||||
Comments | Where multiple contacts for the same purpose are provided there is a standard extension that can be used to determine which one is the preferred contact to use. | ||||||||
InsurancePlan.contact.purpose | |||||||||
Element Id | InsurancePlan.contact.purpose | ||||||||
Definition | Indicates a purpose for which the contact can be reached. | ||||||||
Cardinality | 0..1 | ||||||||
Terminology Binding | ContactEntityType (Extensible) | ||||||||
Type | CodeableConcept | ||||||||
Requirements | Need to distinguish between multiple contact persons. | ||||||||
Summary | false | ||||||||
InsurancePlan.contact.name | |||||||||
Element Id | InsurancePlan.contact.name | ||||||||
Definition | A name associated with the contact. | ||||||||
Cardinality | 0..1 | ||||||||
Type | HumanName | ||||||||
Requirements | Need to be able to track the person by name. | ||||||||
Summary | false | ||||||||
InsurancePlan.contact.telecom | |||||||||
Element Id | InsurancePlan.contact.telecom | ||||||||
Definition | A contact detail (e.g. a telephone number or an email address) by which the party may be contacted. | ||||||||
Cardinality | 0..* | ||||||||
Type | ContactPoint | ||||||||
Requirements | People have (primary) ways to contact them in some way such as phone, email. | ||||||||
Summary | false | ||||||||
InsurancePlan.contact.address | |||||||||
Element Id | InsurancePlan.contact.address | ||||||||
Definition | Visiting or postal addresses for the contact. | ||||||||
Cardinality | 0..1 | ||||||||
Type | Address | ||||||||
Requirements | May need to keep track of a contact party's address for contacting, billing or reporting requirements. | ||||||||
Summary | false | ||||||||
InsurancePlan.endpoint | |||||||||
Element Id | InsurancePlan.endpoint | ||||||||
Definition | The technical endpoints providing access to services operated for the health insurance product. | ||||||||
Cardinality | 0..* | ||||||||
Type | Reference(Endpoint) | ||||||||
Requirements | Organizations have multiple systems that provide various services and need to be able to define the technical connection details for how to connect to them, and for what purpose. | ||||||||
Summary | false | ||||||||
InsurancePlan.network | |||||||||
Element Id | InsurancePlan.network | ||||||||
Definition | Reference to the network included in the health insurance product. | ||||||||
Cardinality | 0..* | ||||||||
Type | Reference(Organization) | ||||||||
Summary | false | ||||||||
Comments | Networks are represented as a hierarchy of organization resources. | ||||||||
InsurancePlan.coverage | |||||||||
Element Id | InsurancePlan.coverage | ||||||||
Definition | Details about the coverage offered by the insurance product. | ||||||||
Cardinality | 0..* | ||||||||
Summary | false | ||||||||
InsurancePlan.coverage.type | |||||||||
Element Id | InsurancePlan.coverage.type | ||||||||
Definition | Type of coverage (Medical; Dental; Mental Health; Substance Abuse; Vision; Drug; Short Term; Long Term Care; Hospice; Home Health). | ||||||||
Cardinality | 1..1 | ||||||||
Type | CodeableConcept | ||||||||
Summary | false | ||||||||
InsurancePlan.coverage.network | |||||||||
Element Id | InsurancePlan.coverage.network | ||||||||
Definition | Reference to the network that providing the type of coverage. | ||||||||
Cardinality | 0..* | ||||||||
Type | Reference(Organization) | ||||||||
Summary | false | ||||||||
Comments | Networks are represented as a hierarchy of organization resources. | ||||||||
InsurancePlan.coverage.benefit | |||||||||
Element Id | InsurancePlan.coverage.benefit | ||||||||
Definition | Specific benefits under this type of coverage. | ||||||||
Cardinality | 1..* | ||||||||
Summary | false | ||||||||
InsurancePlan.coverage.benefit.type | |||||||||
Element Id | InsurancePlan.coverage.benefit.type | ||||||||
Definition | Type of benefit (primary care; speciality care; inpatient; outpatient). | ||||||||
Cardinality | 1..1 | ||||||||
Type | CodeableConcept | ||||||||
Summary | false | ||||||||
InsurancePlan.coverage.benefit.requirement | |||||||||
Element Id | InsurancePlan.coverage.benefit.requirement | ||||||||
Definition | The referral requirements to have access/coverage for this benefit. | ||||||||
Cardinality | 0..1 | ||||||||
Type | string | ||||||||
Summary | false | ||||||||
InsurancePlan.coverage.benefit.limit | |||||||||
Element Id | InsurancePlan.coverage.benefit.limit | ||||||||
Definition | The specific limits on the benefit. | ||||||||
Cardinality | 0..* | ||||||||
Summary | false | ||||||||
InsurancePlan.coverage.benefit.limit.value | |||||||||
Element Id | InsurancePlan.coverage.benefit.limit.value | ||||||||
Definition | The maximum amount of a service item a plan will pay for a covered benefit. For examples. wellness visits, or eyeglasses. | ||||||||
Cardinality | 0..1 | ||||||||
Type | Quantity | ||||||||
Summary | false | ||||||||
Comments | May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”. | ||||||||
InsurancePlan.coverage.benefit.limit.code | |||||||||
Element Id | InsurancePlan.coverage.benefit.limit.code | ||||||||
Definition | The specific limit on the benefit. | ||||||||
Cardinality | 0..1 | ||||||||
Type | CodeableConcept | ||||||||
Summary | false | ||||||||
Comments | Use | ||||||||
InsurancePlan.plan | |||||||||
Element Id | InsurancePlan.plan | ||||||||
Definition | Details about an insurance plan. | ||||||||
Cardinality | 0..* | ||||||||
Summary | false | ||||||||
InsurancePlan.plan.identifier | |||||||||
Element Id | InsurancePlan.plan.identifier | ||||||||
Definition | Business identifiers assigned to this health insurance plan which remain constant as the resource is updated and propagates from server to server. | ||||||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||||||
Cardinality | 0..* | ||||||||
Type | Identifier | ||||||||
Summary | true | ||||||||
InsurancePlan.plan.type | |||||||||
Element Id | InsurancePlan.plan.type | ||||||||
Definition | Type of plan. For example, "Platinum" or "High Deductable". | ||||||||
Cardinality | 0..1 | ||||||||
Type | CodeableConcept | ||||||||
Summary | false | ||||||||
InsurancePlan.plan.coverageArea | |||||||||
Element Id | InsurancePlan.plan.coverageArea | ||||||||
Definition | The geographic region in which a health insurance plan's benefits apply. | ||||||||
Cardinality | 0..* | ||||||||
Type | Reference(Location) | ||||||||
Summary | true | ||||||||
InsurancePlan.plan.network | |||||||||
Element Id | InsurancePlan.plan.network | ||||||||
Definition | Reference to the network that providing the type of coverage. | ||||||||
Cardinality | 0..* | ||||||||
Type | Reference(Organization) | ||||||||
Summary | false | ||||||||
Comments | Networks are represented as a hierarchy of organization resources. | ||||||||
InsurancePlan.plan.generalCost | |||||||||
Element Id | InsurancePlan.plan.generalCost | ||||||||
Definition | Overall costs associated with the plan. | ||||||||
Cardinality | 0..* | ||||||||
Summary | false | ||||||||
InsurancePlan.plan.generalCost.type | |||||||||
Element Id | InsurancePlan.plan.generalCost.type | ||||||||
Definition | Type of cost. | ||||||||
Cardinality | 0..1 | ||||||||
Type | CodeableConcept | ||||||||
Summary | false | ||||||||
InsurancePlan.plan.generalCost.groupSize | |||||||||
Element Id | InsurancePlan.plan.generalCost.groupSize | ||||||||
Definition | Number of participants enrolled in the plan. | ||||||||
Cardinality | 0..1 | ||||||||
Type | positiveInt | ||||||||
Summary | false | ||||||||
InsurancePlan.plan.generalCost.cost | |||||||||
Element Id | InsurancePlan.plan.generalCost.cost | ||||||||
Definition | Value of the cost. | ||||||||
Cardinality | 0..1 | ||||||||
Type | Money | ||||||||
Summary | false | ||||||||
InsurancePlan.plan.generalCost.comment | |||||||||
Element Id | InsurancePlan.plan.generalCost.comment | ||||||||
Definition | Additional information about the general costs associated with this plan. | ||||||||
Cardinality | 0..1 | ||||||||
Type | string | ||||||||
Summary | false | ||||||||
InsurancePlan.plan.specificCost | |||||||||
Element Id | InsurancePlan.plan.specificCost | ||||||||
Definition | Costs associated with the coverage provided by the product. | ||||||||
Cardinality | 0..* | ||||||||
Summary | false | ||||||||
InsurancePlan.plan.specificCost.category | |||||||||
Element Id | InsurancePlan.plan.specificCost.category | ||||||||
Definition | General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health). | ||||||||
Cardinality | 1..1 | ||||||||
Type | CodeableConcept | ||||||||
Summary | false | ||||||||
InsurancePlan.plan.specificCost.benefit | |||||||||
Element Id | InsurancePlan.plan.specificCost.benefit | ||||||||
Definition | List of the specific benefits under this category of benefit. | ||||||||
Cardinality | 0..* | ||||||||
Summary | false | ||||||||
InsurancePlan.plan.specificCost.benefit.type | |||||||||
Element Id | InsurancePlan.plan.specificCost.benefit.type | ||||||||
Definition | Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care). | ||||||||
Cardinality | 1..1 | ||||||||
Type | CodeableConcept | ||||||||
Summary | false | ||||||||
InsurancePlan.plan.specificCost.benefit.cost | |||||||||
Element Id | InsurancePlan.plan.specificCost.benefit.cost | ||||||||
Definition | List of the costs associated with a specific benefit. | ||||||||
Cardinality | 0..* | ||||||||
Summary | false | ||||||||
InsurancePlan.plan.specificCost.benefit.cost.type | |||||||||
Element Id | InsurancePlan.plan.specificCost.benefit.cost.type | ||||||||
Definition | Type of cost (copay; individual cap; family cap; coinsurance; deductible). | ||||||||
Cardinality | 1..1 | ||||||||
Type | CodeableConcept | ||||||||
Summary | false | ||||||||
InsurancePlan.plan.specificCost.benefit.cost.applicability | |||||||||
Element Id | InsurancePlan.plan.specificCost.benefit.cost.applicability | ||||||||
Definition | Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other). | ||||||||
Cardinality | 0..1 | ||||||||
Terminology Binding | BenefitCostApplicability (Required) | ||||||||
Type | CodeableConcept | ||||||||
Summary | false | ||||||||
InsurancePlan.plan.specificCost.benefit.cost.qualifiers | |||||||||
Element Id | InsurancePlan.plan.specificCost.benefit.cost.qualifiers | ||||||||
Definition | Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA). | ||||||||
Cardinality | 0..* | ||||||||
Type | CodeableConcept | ||||||||
Summary | false | ||||||||
InsurancePlan.plan.specificCost.benefit.cost.value | |||||||||
Element Id | InsurancePlan.plan.specificCost.benefit.cost.value | ||||||||
Definition | The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance). | ||||||||
Cardinality | 0..1 | ||||||||
Type | Quantity | ||||||||
Summary | false |