Release 5 Draft Ballot
AdministrationThis page is part of the FHIR Specification (v4.6.0: R5 Draft Ballot - see ballot notes). 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 |
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.
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.
This resource is referenced by UsageContext.
This resource does not implement any patterns.
Structure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  InsurancePlan | TU | DomainResource | Details 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 | ΣI | 0..* | Identifier | Business Identifier for Product |
 status | ?!Σ | 0..1 | code | draft | active | retired | unknown PublicationStatus (Required) |
| type | Σ | 0..* | CodeableConcept | Kind of product InsurancePlanType (Example) |
| name | ΣI | 0..1 | string | Official name |
| alias | 0..* | string | Alternate names | |
| period | 0..1 | Period | When the product is available | |
 ownedBy | Σ | 0..1 | Reference(Organization) | Plan issuer |
| administeredBy | Σ | 0..1 | Reference(Organization) | Product administrator |
| coverageArea | Σ | 0..* | Reference(Location) | Where product applies |
  contact | 0..* | BackboneElement | Contact for the product | |
 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 | |
| endpoint | 0..* | Reference(Endpoint) | Technical endpoint | |
| network | 0..* | Reference(Organization) | What networks are Included | |
| coverage | 0..* | BackboneElement | Coverage details | |
| type | 1..1 | CodeableConcept | Type of coverage | |
| network | 0..* | Reference(Organization) | What networks provide coverage | |
 benefit | 1..* | BackboneElement | List of benefits | |
 type | 1..1 | CodeableConcept | Type of benefit | |
| requirement | 0..1 | string | Referral requirements | |
| limit | 0..* | BackboneElement | Benefit limits | |
| value | 0..1 | Quantity | Maximum value allowed | |
| code | 0..1 | CodeableConcept | Benefit limit details | |
| plan | 0..* | BackboneElement | Plan details | |
| identifier | Σ | 0..* | Identifier | Business Identifier for Product |
| type | 0..1 | CodeableConcept | Type of plan | |
| coverageArea | Σ | 0..* | Reference(Location) | Where product applies |
| network | 0..* | Reference(Organization) | What networks provide coverage | |
| generalCost | 0..* | BackboneElement | Overall costs | |
| type | 0..1 | CodeableConcept | Type of cost | |
| groupSize | 0..1 | positiveInt | Number of enrollees | |
| cost | 0..1 | Money | Cost value | |
| comment | 0..1 | string | Additional cost information | |
| specificCost | 0..* | BackboneElement | Specific costs | |
| category | 1..1 | CodeableConcept | General category of benefit | |
| benefit | 0..* | BackboneElement | Benefits list | |
| type | 1..1 | CodeableConcept | Type of specific benefit | |
| cost | 0..* | BackboneElement | List of the costs | |
| type | 1..1 | CodeableConcept | Type of cost | |
| applicability | 0..1 | CodeableConcept | in-network | out-of-network | other BenefitCostApplicability (Required) | |
| qualifiers | 0..* | CodeableConcept | Additional information about the cost | |
| value | 0..1 | Quantity | The actual cost value | |
| Documentation for this format | ||||
UML Diagram (Legend)
XML Template
<InsurancePlan xmlns="http://hl7.org/fhir"><!-- 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]"/><!--
JSON Template
{
"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/> .
Changes since R3
| InsurancePlan | |
| InsurancePlan.status |
|
| InsurancePlan.plan.specificCost.benefit.cost.applicability |
|
See the Full Difference for further information
Structure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| InsurancePlan | TU | DomainResource | Details 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 | ΣI | 0..* | Identifier | Business Identifier for Product |
| status | ?!Σ | 0..1 | code | draft | active | retired | unknown PublicationStatus (Required) |
| type | Σ | 0..* | CodeableConcept | Kind of product InsurancePlanType (Example) |
| name | ΣI | 0..1 | string | Official name |
| alias | 0..* | string | Alternate names | |
| period | 0..1 | Period | When the product is available | |
| ownedBy | Σ | 0..1 | Reference(Organization) | Plan issuer |
| administeredBy | Σ | 0..1 | Reference(Organization) | Product administrator |
| coverageArea | Σ | 0..* | Reference(Location) | Where product applies |
| contact | 0..* | BackboneElement | Contact for the product | |
| 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 | |
| endpoint | 0..* | Reference(Endpoint) | Technical endpoint | |
| network | 0..* | Reference(Organization) | What networks are Included | |
| coverage | 0..* | BackboneElement | Coverage details | |
| type | 1..1 | CodeableConcept | Type of coverage | |
| network | 0..* | Reference(Organization) | What networks provide coverage | |
| benefit | 1..* | BackboneElement | List of benefits | |
| type | 1..1 | CodeableConcept | Type of benefit | |
| requirement | 0..1 | string | Referral requirements | |
| limit | 0..* | BackboneElement | Benefit limits | |
| value | 0..1 | Quantity | Maximum value allowed | |
| code | 0..1 | CodeableConcept | Benefit limit details | |
| plan | 0..* | BackboneElement | Plan details | |
| identifier | Σ | 0..* | Identifier | Business Identifier for Product |
| type | 0..1 | CodeableConcept | Type of plan | |
| coverageArea | Σ | 0..* | Reference(Location) | Where product applies |
| network | 0..* | Reference(Organization) | What networks provide coverage | |
| generalCost | 0..* | BackboneElement | Overall costs | |
| type | 0..1 | CodeableConcept | Type of cost | |
| groupSize | 0..1 | positiveInt | Number of enrollees | |
| cost | 0..1 | Money | Cost value | |
| comment | 0..1 | string | Additional cost information | |
| specificCost | 0..* | BackboneElement | Specific costs | |
| category | 1..1 | CodeableConcept | General category of benefit | |
| benefit | 0..* | BackboneElement | Benefits list | |
| type | 1..1 | CodeableConcept | Type of specific benefit | |
| cost | 0..* | BackboneElement | List of the costs | |
| type | 1..1 | CodeableConcept | Type of cost | |
| applicability | 0..1 | CodeableConcept | in-network | out-of-network | other BenefitCostApplicability (Required) | |
| qualifiers | 0..* | CodeableConcept | Additional information about the cost | |
| value | 0..1 | Quantity | The actual cost value | |
| Documentation for this format | ||||
XML Template
<InsurancePlan xmlns="http://hl7.org/fhir">
JSON Template
{
"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/> .
Changes since Release 3
| InsurancePlan | |
| InsurancePlan.status |
|
| InsurancePlan.plan.specificCost.benefit.cost.applicability |
|
See the Full Difference for further information
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
| Path | Definition | Type | Reference |
|---|---|---|---|
| InsurancePlan.status | Required | PublicationStatus | |
| InsurancePlan.type | Example | InsurancePlanType | |
| InsurancePlan.contact.purpose | Extensible | ContactEntityType | |
| InsurancePlan.plan.specificCost.benefit.cost.applicability | Required | BenefitCostApplicability |
| id | Level | Location | Description | Expression |
| ipn-1 | Rule | (base) | The organization SHALL at least have a name or an idendtifier, and possibly more than one | (identifier.count() + name.count()) > 0 |
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 | InsurancePlan.contact.address | |
| address-city N | string | A city specified in an address | InsurancePlan.contact.address.city | |
| address-country N | string | A country specified in an address | InsurancePlan.contact.address.country | |
| address-postalcode N | string | A postal code specified in an address | InsurancePlan.contact.address.postalCode | |
| address-state N | string | A state specified in an address | InsurancePlan.contact.address.state | |
| address-use N | token | A use code specified in an address | InsurancePlan.contact.address.use | |
| administered-by | reference | Product administrator | InsurancePlan.administeredBy (Organization) | |
| endpoint | reference | Technical endpoint | InsurancePlan.endpoint (Endpoint) | |
| identifier | token | Any identifier for the organization (not the accreditation issuer's identifier) | InsurancePlan.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 | InsurancePlan.ownedBy (Organization) | |
| phonetic N | string | A portion of the organization's name using some kind of phonetic matching algorithm | InsurancePlan.name | |
| status N | token | Is the Organization record active | InsurancePlan.status | |
| type | token | A code for the type of organization | InsurancePlan.type |
FHIR ®© HL7.org 2011+. FHIR R5 Draft Ballot hl7.fhir.core#4.6.0 generated on Thu, Apr 15, 2021 12:28+1000.
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