National Directory of Healthcare Providers & Services (NDH) Implementation Guide
1.0.0-ballot - ballot
National Directory of Healthcare Providers & Services (NDH) Implementation Guide
1.0.0-ballot - ballot
This page is part of the National Directory of Healthcare Providers and Services (NDH) Implementation Guide (v1.0.0-ballot: STU1 Ballot 1) based on FHIR R4. . For a full list of available versions, see the Directory of published versions 
| Official URL: http://hl7.org/fhir/us/ndh/StructureDefinition/ndh-InsurancePlan | Version: 1.0.0-ballot | |||
| Active as of 2023-07-30 | Computable Name: NdhInsurancePlan | |||
Copyright/Legal: HL7 International |
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An InsurancePlan 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 covered benefits. A plan pairs a product’s covered benefits with the particular cost sharing structure offered to a consumer. A given product may comprise multiple plans (i.e. each plan offers different cost sharing requirements for the same set of covered benefits). 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.
Each insurancePlan has a type which describe the product. An insurancePlan may offer its coverage benefits under a particular network. If an insurancePlan does not have a network, each plan of the insurancePlan must define a distinct plan type (InsurancePlace.plan.type).
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 insurance plan), and additional information about the offering, such as who own it, who administer it, coverage area, contact information, etc.
To change a network in an insurance plan, adjust the insurancePlan.period and genderate a fresh new insurance plan.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from InsurancePlan
| Path | Conformance | ValueSet |
| InsurancePlan.type | extensible | InsuranceProductTypeVS (a valid code from Insurance Product Type Code System) |
| InsurancePlan.coverage.type | extensible | NdhCoverageTypeVS |
| InsurancePlan.coverage.benefit.type | extensible | NdhBenefitTypeVS |
| InsurancePlan.plan.type | extensible | InsurancePlanTypeVS (a valid code from Insurance Plan Type Code System) |
| Id | Grade | Path(s) | Details | Requirements |
| network-or-NatlDirwork | error | InsurancePlan | If an insuranceplan does not define a network, then each plan must define one : network.exists() or coverage.network.exists() or plan.network.exists() | |
| plan-type-is-distinct | error | InsurancePlan | Each InsurancePlan.plan should have a distinct plan.type. : plan.type.coding.code.isDistinct() |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  InsurancePlan | C | 0..* | InsurancePlan | Details of a Health Insurance product/plan provided by an organization network-or-NatlDirwork: If an insuranceplan does not define a network, then each plan must define one plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type. |
  implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
 usage-restriction | 0..* | Reference(NDH Base Restriction) {c} | Usage Restriction URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-usage-restriction | |
| verification-status | 0..1 | CodeableConcept | NDH Verification Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status Binding: NDH Verification Status Value Set (extensible) | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
  identifier | SΣC | 0..* | Identifier | Business Identifier for Product |
 identifier-status | 0..1 | code | NDH Identifier Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status Binding: Identifier Status Value Set (required) | |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
  assigner | Σ | 0..1 | Reference(NDH Base Organization Profile) | Organization that issued id (may be just text) |
| status | ?!SΣ | 1..1 | code | draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact. Fixed Value: active |
| type | SΣ | 1..1 | CodeableConcept | Product Type Binding: Insurance Product Type Value Set (extensible) |
| name | SΣC | 0..1 | string | Official name |
| ownedBy | SΣ | 1..1 | Reference(NDH Base Organization Profile) | Plan issuer |
| administeredBy | SΣ | 1..1 | Reference(NDH Base Organization Profile) | Product administrator |
| coverageArea | SΣ | 0..* | Reference(NDH Base Location Profile) | Where product applies |
| endpoint | 0..* | Reference(NDH Base Endpoint Profile) | Technical endpoint | |
| network | S | 0..* | Reference(NDH Base Network Profile) | What networks are Included |
| coverage | 0..* | BackboneElement | Coverage details | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | 1..1 | CodeableConcept | Type of coverage Binding: NDH Insurance Coverage Type Value Set (extensible) | |
| network | S | 0..* | Reference(NDH Base Network Profile) | What networks provide coverage |
 benefit | 1..* | BackboneElement | List of benefits | |
 modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | 1..1 | CodeableConcept | Type of benefit Binding: NDH Benefit Type Value Set (extensible) | |
| plan | 0..* | BackboneElement | Cost sharing details for the plan | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | 0..1 | CodeableConcept | Categorization of the cost sharing for the plan Binding: Insurance Plan Type Value Set (extensible) | |
| coverageArea | Σ | 0..* | Reference(NDH Base Location Profile) | Where product applies |
| network | 0..* | Reference(NDH Base Network Profile) | What networks provide coverage | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| InsurancePlan.identifier.use | required | IdentifierUse |
| InsurancePlan.status | required | Fixed Value: active |
| InsurancePlan.type | extensible | InsuranceProductTypeVS (a valid code from Insurance Product Type Code System) |
| InsurancePlan.coverage.type | extensible | NdhCoverageTypeVS |
| InsurancePlan.coverage.benefit.type | extensible | NdhBenefitTypeVS |
| InsurancePlan.plan.type | extensible | InsurancePlanTypeVS (a valid code from Insurance Plan Type Code System) |
| Id | Grade | Path(s) | Details | Requirements |
| network-or-NatlDirwork | error | InsurancePlan | If an insuranceplan does not define a network, then each plan must define one : network.exists() or coverage.network.exists() or plan.network.exists() | |
| plan-type-is-distinct | error | InsurancePlan | Each InsurancePlan.plan should have a distinct plan.type. : plan.type.coding.code.isDistinct() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| InsurancePlan | C | 0..* | InsurancePlan | Details of a Health Insurance product/plan provided by an organization network-or-NatlDirwork: If an insuranceplan does not define a network, then each plan must define one plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type. | ||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| versionId | Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated | Σ | 1..1 | instant | When the resource version last changed | ||||
| source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile | Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| usage-restriction | 0..* | Reference(NDH Base Restriction) {c} | Usage Restriction URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-usage-restriction | |||||
| verification-status | 0..1 | CodeableConcept | NDH Verification Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status Binding: NDH Verification Status Value Set (extensible) | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | SΣC | 0..* | Identifier | Business Identifier for Product | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| identifier-status | 0..1 | code | NDH Identifier Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status Binding: Identifier Status Value Set (required) | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(NDH Base Organization Profile) | Organization that issued id (may be just text) | ||||
| status | ?!SΣ | 1..1 | code | draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact. Fixed Value: active | ||||
| type | SΣ | 1..1 | CodeableConcept | Product Type Binding: Insurance Product Type Value Set (extensible) | ||||
| name | SΣC | 0..1 | string | Official name | ||||
| alias | 0..* | string | Alternate names | |||||
| period | 0..1 | Period | When the product is available | |||||
| ownedBy | SΣ | 1..1 | Reference(NDH Base Organization Profile) | Plan issuer | ||||
| administeredBy | SΣ | 1..1 | Reference(NDH Base Organization Profile) | Product administrator | ||||
| coverageArea | SΣ | 0..* | Reference(NDH Base Location Profile) | Where product applies | ||||
| contact | 0..* | BackboneElement | Contact for the product | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| purpose | 0..1 | CodeableConcept | The type of contact Binding: ContactEntityType (extensible): The purpose for which you would contact a contact party. | |||||
| name | 0..1 | HumanName | A name associated with the contact | |||||
| telecom | 0..* | ContactPoint | Contact details (telephone, email, etc.) for a contact | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| contactpoint-availabletime | 0..* | (Complex) | NDH Contactpoint Availabletime URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-contactpoint-availabletime | |||||
| via-intermediary | 0..1 | Reference(NDH Base PractitionerRole | NDH Base OrganizationAffiliation Profile | NDH Base Location Profile | NDH Base Organization Profile) | Via Intermediary URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-via-intermediary | |||||
| system | ΣC | 0..1 | code | phone | fax | email | pager | url | sms | other Binding: ContactPointSystem (required): Telecommunications form for contact point. | ||||
| value | Σ | 0..1 | string | The actual contact point details | ||||
| use | ?!Σ | 0..1 | code | home | work | temp | old | mobile - purpose of this contact point Binding: ContactPointUse (required): Use of contact point. | ||||
| rank | Σ | 0..1 | positiveInt | Specify preferred order of use (1 = highest) | ||||
| period | Σ | 0..1 | Period | Time period when the contact point was/is in use | ||||
| address | 0..1 | Address | Visiting or postal addresses for the contact | |||||
| endpoint | 0..* | Reference(NDH Base Endpoint Profile) | Technical endpoint | |||||
| network | S | 0..* | Reference(NDH Base Network Profile) | What networks are Included | ||||
| coverage | 0..* | BackboneElement | Coverage details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Type of coverage Binding: NDH Insurance Coverage Type Value Set (extensible) | |||||
| network | S | 0..* | Reference(NDH Base Network Profile) | What networks provide coverage | ||||
| benefit | 1..* | BackboneElement | List of benefits | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Type of benefit Binding: NDH Benefit Type Value Set (extensible) | |||||
| requirement | 0..1 | string | Referral requirements | |||||
| limit | 0..* | BackboneElement | Benefit limits | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| value | 0..1 | Quantity | Maximum value allowed | |||||
| code | 0..1 | CodeableConcept | Benefit limit details | |||||
| plan | 0..* | BackboneElement | Cost sharing details for the plan | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| identifier | Σ | 0..* | Identifier | Business Identifier for Product | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| identifier-status | 0..1 | code | NDH Identifier Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status Binding: Identifier Status Value Set (required) | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(NDH Base Organization Profile) | Organization that issued id (may be just text) | ||||
| type | 0..1 | CodeableConcept | Categorization of the cost sharing for the plan Binding: Insurance Plan Type Value Set (extensible) | |||||
| coverageArea | Σ | 0..* | Reference(NDH Base Location Profile) | Where product applies | ||||
| network | 0..* | Reference(NDH Base Network Profile) | What networks provide coverage | |||||
| generalCost | 0..* | BackboneElement | Overall costs | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| 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 | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category | 1..1 | CodeableConcept | General category of benefit | |||||
| benefit | 0..* | BackboneElement | Benefits list | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Type of specific benefit | |||||
| cost | 0..* | BackboneElement | List of the costs | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Type of cost | |||||
| applicability | 0..1 | CodeableConcept | in-network | out-of-network | other Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers. | |||||
| qualifiers | 0..* | CodeableConcept | Additional information about the cost | |||||
| value | 0..1 | Quantity | The actual cost value | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| InsurancePlan.meta.security | extensible | All Security Labels | ||||
| InsurancePlan.meta.tag | example | CommonTags | ||||
| InsurancePlan.language | preferred | CommonLanguages
| ||||
| InsurancePlan.identifier.use | required | IdentifierUse | ||||
| InsurancePlan.identifier.type | extensible | Identifier Type Codes | ||||
| InsurancePlan.status | required | Fixed Value: active | ||||
| InsurancePlan.type | extensible | InsuranceProductTypeVS (a valid code from Insurance Product Type Code System) | ||||
| InsurancePlan.contact.purpose | extensible | ContactEntityType | ||||
| InsurancePlan.contact.telecom.system | required | ContactPointSystem | ||||
| InsurancePlan.contact.telecom.use | required | ContactPointUse | ||||
| InsurancePlan.coverage.type | extensible | NdhCoverageTypeVS | ||||
| InsurancePlan.coverage.benefit.type | extensible | NdhBenefitTypeVS | ||||
| InsurancePlan.plan.identifier.use | required | IdentifierUse | ||||
| InsurancePlan.plan.identifier.type | extensible | Identifier Type Codes | ||||
| InsurancePlan.plan.type | extensible | InsurancePlanTypeVS (a valid code from Insurance Plan Type Code System) | ||||
| InsurancePlan.plan.specificCost.benefit.cost.applicability | required | BenefitCostApplicability |
This structure is derived from InsurancePlan
Summary
Mandatory: 4 elements (1 nested mandatory element)
Must-Support: 9 elements
Fixed Value: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
This structure is derived from InsurancePlan
| Path | Conformance | ValueSet |
| InsurancePlan.type | extensible | InsuranceProductTypeVS (a valid code from Insurance Product Type Code System) |
| InsurancePlan.coverage.type | extensible | NdhCoverageTypeVS |
| InsurancePlan.coverage.benefit.type | extensible | NdhBenefitTypeVS |
| InsurancePlan.plan.type | extensible | InsurancePlanTypeVS (a valid code from Insurance Plan Type Code System) |
| Id | Grade | Path(s) | Details | Requirements |
| network-or-NatlDirwork | error | InsurancePlan | If an insuranceplan does not define a network, then each plan must define one : network.exists() or coverage.network.exists() or plan.network.exists() | |
| plan-type-is-distinct | error | InsurancePlan | Each InsurancePlan.plan should have a distinct plan.type. : plan.type.coding.code.isDistinct() |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| InsurancePlan | C | 0..* | InsurancePlan | Details of a Health Insurance product/plan provided by an organization network-or-NatlDirwork: If an insuranceplan does not define a network, then each plan must define one plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type. |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| usage-restriction | 0..* | Reference(NDH Base Restriction) {c} | Usage Restriction URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-usage-restriction | |
| verification-status | 0..1 | CodeableConcept | NDH Verification Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status Binding: NDH Verification Status Value Set (extensible) | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SΣC | 0..* | Identifier | Business Identifier for Product |
| identifier-status | 0..1 | code | NDH Identifier Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status Binding: Identifier Status Value Set (required) | |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| assigner | Σ | 0..1 | Reference(NDH Base Organization Profile) | Organization that issued id (may be just text) |
| status | ?!SΣ | 1..1 | code | draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact. Fixed Value: active |
| type | SΣ | 1..1 | CodeableConcept | Product Type Binding: Insurance Product Type Value Set (extensible) |
| name | SΣC | 0..1 | string | Official name |
| ownedBy | SΣ | 1..1 | Reference(NDH Base Organization Profile) | Plan issuer |
| administeredBy | SΣ | 1..1 | Reference(NDH Base Organization Profile) | Product administrator |
| coverageArea | SΣ | 0..* | Reference(NDH Base Location Profile) | Where product applies |
| endpoint | 0..* | Reference(NDH Base Endpoint Profile) | Technical endpoint | |
| network | S | 0..* | Reference(NDH Base Network Profile) | What networks are Included |
| coverage | 0..* | BackboneElement | Coverage details | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | 1..1 | CodeableConcept | Type of coverage Binding: NDH Insurance Coverage Type Value Set (extensible) | |
| network | S | 0..* | Reference(NDH Base Network Profile) | What networks provide coverage |
| benefit | 1..* | BackboneElement | List of benefits | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | 1..1 | CodeableConcept | Type of benefit Binding: NDH Benefit Type Value Set (extensible) | |
| plan | 0..* | BackboneElement | Cost sharing details for the plan | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | 0..1 | CodeableConcept | Categorization of the cost sharing for the plan Binding: Insurance Plan Type Value Set (extensible) | |
| coverageArea | Σ | 0..* | Reference(NDH Base Location Profile) | Where product applies |
| network | 0..* | Reference(NDH Base Network Profile) | What networks provide coverage | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| InsurancePlan.identifier.use | required | IdentifierUse |
| InsurancePlan.status | required | Fixed Value: active |
| InsurancePlan.type | extensible | InsuranceProductTypeVS (a valid code from Insurance Product Type Code System) |
| InsurancePlan.coverage.type | extensible | NdhCoverageTypeVS |
| InsurancePlan.coverage.benefit.type | extensible | NdhBenefitTypeVS |
| InsurancePlan.plan.type | extensible | InsurancePlanTypeVS (a valid code from Insurance Plan Type Code System) |
| Id | Grade | Path(s) | Details | Requirements |
| network-or-NatlDirwork | error | InsurancePlan | If an insuranceplan does not define a network, then each plan must define one : network.exists() or coverage.network.exists() or plan.network.exists() | |
| plan-type-is-distinct | error | InsurancePlan | Each InsurancePlan.plan should have a distinct plan.type. : plan.type.coding.code.isDistinct() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| InsurancePlan | C | 0..* | InsurancePlan | Details of a Health Insurance product/plan provided by an organization network-or-NatlDirwork: If an insuranceplan does not define a network, then each plan must define one plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type. | ||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| versionId | Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated | Σ | 1..1 | instant | When the resource version last changed | ||||
| source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile | Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| usage-restriction | 0..* | Reference(NDH Base Restriction) {c} | Usage Restriction URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-usage-restriction | |||||
| verification-status | 0..1 | CodeableConcept | NDH Verification Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status Binding: NDH Verification Status Value Set (extensible) | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | SΣC | 0..* | Identifier | Business Identifier for Product | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| identifier-status | 0..1 | code | NDH Identifier Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status Binding: Identifier Status Value Set (required) | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(NDH Base Organization Profile) | Organization that issued id (may be just text) | ||||
| status | ?!SΣ | 1..1 | code | draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact. Fixed Value: active | ||||
| type | SΣ | 1..1 | CodeableConcept | Product Type Binding: Insurance Product Type Value Set (extensible) | ||||
| name | SΣC | 0..1 | string | Official name | ||||
| alias | 0..* | string | Alternate names | |||||
| period | 0..1 | Period | When the product is available | |||||
| ownedBy | SΣ | 1..1 | Reference(NDH Base Organization Profile) | Plan issuer | ||||
| administeredBy | SΣ | 1..1 | Reference(NDH Base Organization Profile) | Product administrator | ||||
| coverageArea | SΣ | 0..* | Reference(NDH Base Location Profile) | Where product applies | ||||
| contact | 0..* | BackboneElement | Contact for the product | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| purpose | 0..1 | CodeableConcept | The type of contact Binding: ContactEntityType (extensible): The purpose for which you would contact a contact party. | |||||
| name | 0..1 | HumanName | A name associated with the contact | |||||
| telecom | 0..* | ContactPoint | Contact details (telephone, email, etc.) for a contact | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| contactpoint-availabletime | 0..* | (Complex) | NDH Contactpoint Availabletime URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-contactpoint-availabletime | |||||
| via-intermediary | 0..1 | Reference(NDH Base PractitionerRole | NDH Base OrganizationAffiliation Profile | NDH Base Location Profile | NDH Base Organization Profile) | Via Intermediary URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-via-intermediary | |||||
| system | ΣC | 0..1 | code | phone | fax | email | pager | url | sms | other Binding: ContactPointSystem (required): Telecommunications form for contact point. | ||||
| value | Σ | 0..1 | string | The actual contact point details | ||||
| use | ?!Σ | 0..1 | code | home | work | temp | old | mobile - purpose of this contact point Binding: ContactPointUse (required): Use of contact point. | ||||
| rank | Σ | 0..1 | positiveInt | Specify preferred order of use (1 = highest) | ||||
| period | Σ | 0..1 | Period | Time period when the contact point was/is in use | ||||
| address | 0..1 | Address | Visiting or postal addresses for the contact | |||||
| endpoint | 0..* | Reference(NDH Base Endpoint Profile) | Technical endpoint | |||||
| network | S | 0..* | Reference(NDH Base Network Profile) | What networks are Included | ||||
| coverage | 0..* | BackboneElement | Coverage details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Type of coverage Binding: NDH Insurance Coverage Type Value Set (extensible) | |||||
| network | S | 0..* | Reference(NDH Base Network Profile) | What networks provide coverage | ||||
| benefit | 1..* | BackboneElement | List of benefits | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Type of benefit Binding: NDH Benefit Type Value Set (extensible) | |||||
| requirement | 0..1 | string | Referral requirements | |||||
| limit | 0..* | BackboneElement | Benefit limits | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| value | 0..1 | Quantity | Maximum value allowed | |||||
| code | 0..1 | CodeableConcept | Benefit limit details | |||||
| plan | 0..* | BackboneElement | Cost sharing details for the plan | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| identifier | Σ | 0..* | Identifier | Business Identifier for Product | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| identifier-status | 0..1 | code | NDH Identifier Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status Binding: Identifier Status Value Set (required) | |||||
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
| value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
| period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner | Σ | 0..1 | Reference(NDH Base Organization Profile) | Organization that issued id (may be just text) | ||||
| type | 0..1 | CodeableConcept | Categorization of the cost sharing for the plan Binding: Insurance Plan Type Value Set (extensible) | |||||
| coverageArea | Σ | 0..* | Reference(NDH Base Location Profile) | Where product applies | ||||
| network | 0..* | Reference(NDH Base Network Profile) | What networks provide coverage | |||||
| generalCost | 0..* | BackboneElement | Overall costs | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| 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 | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category | 1..1 | CodeableConcept | General category of benefit | |||||
| benefit | 0..* | BackboneElement | Benefits list | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Type of specific benefit | |||||
| cost | 0..* | BackboneElement | List of the costs | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Type of cost | |||||
| applicability | 0..1 | CodeableConcept | in-network | out-of-network | other Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers. | |||||
| qualifiers | 0..* | CodeableConcept | Additional information about the cost | |||||
| value | 0..1 | Quantity | The actual cost value | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| InsurancePlan.meta.security | extensible | All Security Labels | ||||
| InsurancePlan.meta.tag | example | CommonTags | ||||
| InsurancePlan.language | preferred | CommonLanguages
| ||||
| InsurancePlan.identifier.use | required | IdentifierUse | ||||
| InsurancePlan.identifier.type | extensible | Identifier Type Codes | ||||
| InsurancePlan.status | required | Fixed Value: active | ||||
| InsurancePlan.type | extensible | InsuranceProductTypeVS (a valid code from Insurance Product Type Code System) | ||||
| InsurancePlan.contact.purpose | extensible | ContactEntityType | ||||
| InsurancePlan.contact.telecom.system | required | ContactPointSystem | ||||
| InsurancePlan.contact.telecom.use | required | ContactPointUse | ||||
| InsurancePlan.coverage.type | extensible | NdhCoverageTypeVS | ||||
| InsurancePlan.coverage.benefit.type | extensible | NdhBenefitTypeVS | ||||
| InsurancePlan.plan.identifier.use | required | IdentifierUse | ||||
| InsurancePlan.plan.identifier.type | extensible | Identifier Type Codes | ||||
| InsurancePlan.plan.type | extensible | InsurancePlanTypeVS (a valid code from Insurance Plan Type Code System) | ||||
| InsurancePlan.plan.specificCost.benefit.cost.applicability | required | BenefitCostApplicability |
This structure is derived from InsurancePlan
Summary
Mandatory: 4 elements (1 nested mandatory element)
Must-Support: 9 elements
Fixed Value: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Other representations of profile: CSV, Excel, Schematron
| **SearchParameter Name ** | Type | Example |
|---|---|---|
| insuranceplan-coverage-area | reference | GET [base]/InsurancePlan?insuranceplan-coverage-area.address-state=CT |
| insuranceplan-coverage-benefit-type | token | GET [base]/InsurancePlan?insuranceplan-coverage-benefit-type=pcpov |
| insuranceplan-coverage-type | token | GET [base]/InsurancePlan?insuranceplan-coverage-type=medical |
| insuranceplan-coverage-network | reference | GET [base]/InsurancePlan?insuranceplan-coverage-network.type=ntwk&insuranceplan-coverage-network.address-state=CT |
| insuranceplan-network | reference | GET [base]/InsurancePlan?insuranceplan-network.type=ntwk&insuranceplan-network.address-state=CT |
| insuranceplan-plan-network | reference | `GET [base]/InsurancePlan?insuranceplan-plan-network.type=ntwk&insuranceplan-plan-network.address-state=CT |
| insuranceplan-plan-type | token | `GET [base]/InsurancePlan?insuranceplan-plan-type=gold |
| insuranceplan-verification-status | token | GET [base]/InsurancePlan?insuranceplan-verification-status=complete |
Since there is no direct individual url for each Search Parameter defined by FHIR Serach Parameter Registry, we have provided the following links for you to access more information about them.
| SearchParameter Name | Type | Example |
|---|---|---|
| address | string | GET [base]/InsurancePlan?address=456 Main Street |
| address-city | string | GET [base]/InsurancePlan?address-city=Norwalk |
| address-country | string | GET [base]/InsurancePlan?address-country=USA |
| address-postalcode | string | GET [base]/InsurancePlan?address-postalcode=34997 |
| address-state | string | GET [base]/InsurancePlan?address-state=FL |
| administered-by | reference | GET [base]/InsurancePlan?administered-by.name=HOPE INC |
| endpoint | reference | GET [base]/InsurancePlan?endpoint.connection-type=hl7-fhir-rest |
| identifier | token | GET [base]/InsurancePlan?identifier=12345 |
| name | string | GET [base]/InsurancePlan?name=Florida Blue |
| owned-by | reference | GET [base]/InsurancePlan?owned-by.name=Florida Blue |
| status | token | GET [base]/InsurancePlan?status=active |
| type | token | GET [base]/InsurancePlan?type=commppo |
| _include | Example |
|---|---|
| InsurancePlan:administered-by | GET [base]/InsurancePlan?_include=InsurancePlan:administered-by |
| InsurancePlan:endpoint | GET [base]/InsurancePlan?_include=InsurancePlan:endpoint |
| InsurancePlan:owned-by | GET [base]/InsurancePlan?_include=InsurancePlan:owned-by |
| InsurancePlan:insuranceplan-coverage-area | GET [base]/InsurancePlan?_include=InsurancePlan:insuranceplan-coverage-area |
| InsurancePlan:insuranceplan-coverage-network | GET [base]/InsurancePlan?_include=InsurancePlan:insuranceplan-coverage-network |
| InsurancePlan:insuranceplan-plan-coverage-area | GET [base]/InsurancePlan?_include=InsurancePlan:insuranceplan-coverage-area |
| InsurancePlan:insuranceplan-plan-network | GET [base]/InsurancePlan?_include=InsurancePlan:insuranceplan-plan-network |
| InsurancePlan:insuranceplan-network | GET [base]/InsurancePlan?_include=InsurancePlan:insuranceplan-network |
If you only want to search for networks associated with an InsurancePlan, you can use the following approach: The primary resource in this context is the Organization, while the InsurancePlan resources serve as references to it. To accomplish this, the _revinclude feature is utilized. As the Network resource profile is derived from the Organization resource, the type=ntwk parameter must be included in your search.
GET [base]/Organization?type=ntwk&_revinclude=InsurancePlan:insuranceplan-network
The relationship between InsurancePlans and Networks is many-to-many. A plan may be associated with multipe networks. The NDH model is having InsurancePlan reference networks.
A payer’s products typically differ by network type and/or covered benefits. A insurance plan pairs a product’s covered benefits with the particular cost sharing structure offered to a consumer. A given payer’s product may comprise multiple insurance plans (i.e. each insurance plan offers different cost sharing requirements for the same set of covered benefits).
IG © 2023+ HL7 International - Patient Administration Work Group. Package hl7.fhir.us.ndh#1.0.0-ballot based on FHIR 4.0.1. Generated 2023-07-30
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