Administration
This
page
is
part
of
the
FHIR
Specification
(v5.0.0:
R5
-
STU
v6.0.0-ballot3:
Release
6
Ballot
(3rd
Draft)
(see
Ballot
Notes
).
This
is
the
The
current
published
version
in
it's
permanent
home
(it
will
always
be
available
at
this
URL).
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
:
|
Trial Use | Security Category : Business | Compartments : No defined compartments |
Details
of
InsurancePlan
describes
the
costs
to
the
subscriber
or
beneficiary
associated
with
benefits,
as
well
as
additional
information
about
the
offering,
such
as
who
administers
the
plan,
a
Health
Insurance
product/plan
provided
coverage
area,
contact
information,
etc.
The
specific
benefits
covered
by
an
organization.
the
plan
are
described
in
the
InsuranceProduct
referenced
in
InsurancePlan.product
.
A
product
is
a
discrete
package
Insurance
offerings
will
be
fully
described
by
the
combination
of
health
insurance
coverage
benefits
both
InsurancePlan
(the
costs)
and
InsuranceProduct
(the
benefits).
However,
some
systems
may
only
need
to
represent
the
InsurancePlan,
so
that
are
offered
under
Coverage
resources
can
describe
which
plan
is
associated
with
a
particular
network
type.
A
given
payer’s
products
typically
differ
by
network
type
and/or
coverage
benefits.
A
plan
beneficiary.
In
that
case,
there
will
be
some
other
system
that
is
responsible
for
tracking
the
benefits
associated
with
the
plan.
An
InsurancePlan
pairs
the
health
insurance
coverage
benefits
under
a
product
an
InsuranceProduct
with
the
particular
cost
sharing
structure
offered
to
a
consumer.
A
given
product
InsuranceProduct
may
comprise
multiple
plans.
InsurancePlans.
InsurancePlan
InsuranceProduct
describes
a
health
insurance
offering
comprised
of
a
list
of
covered
benefits
(i.e.
and
networks
as
well
as
details
about
who
administers
the
product
and
applicable
coverage
areas.
InsurancePlan
describes
the
product),
costs
to
the
subscriber
or
beneficiary
associated
with
those
benefits
(i.e.
the
plan),
and
benefits,
as
well
as
additional
information
about
the
offering,
such
as
who
it
is
owned
and
administered
by,
administers
the
plan,
a
coverage
area,
contact
information,
etc.
The
specific
benefits
covered
by
the
plan
are
described
in
the
InsuranceProduct
referenced
in
InsurancePlan.product.
A
Coverage
8.34.2
Boundaries
resource
establishes
the
link
between
an
InsurancePlan
and
Relationships
TBD.
a
beneficiary
and
optionally
a
subscriber.
Structure
| Name | Flags | Card. | Type |
Description
&
Constraints
|
|---|---|---|---|---|
InsurancePlan
|
TU | DomainResource |
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension |
|
identifier
|
Σ
|
0..* | Identifier |
Business
Identifier
for
|
|
type
|
|
0..1 |
|
Classification
of
|
|
Σ | 0..1 |
Reference
(
|
|
|
|
Σ | 0..* | Reference ( Location ) |
Where
|
|
|
|
0..* | Reference ( Organization ) |
What
networks
provide
coverage
|
|
|
BackboneElement |
|
|
type
|
|
0..1 | CodeableConcept |
|
groupSize
|
|
|
positiveInt |
Number
of
enrollees
|
|
cost
|
0..1 | Money |
Cost
value
|
|
comment
|
0..1 | string |
Additional
cost
information
|
|
specificCost
|
0..* | BackboneElement |
Individual
cost
elements
|
|
category
|
1..1 | CodeableConcept |
General
category
of
benefit
|
|
|
benefit
|
0..* | BackboneElement |
Benefits
list
|
|
|
type
|
1..1 | CodeableConcept |
Classification
of
|
|
|
cost
|
0..* | BackboneElement |
List
of
the
costs
|
|
|
type
|
1..1 | CodeableConcept |
Classification
of
specific
cost
|
|
|
applicability
|
0..1 | CodeableConcept |
in-network
|
out-of-network
|
other
Binding: Benefit Cost Applicability ( Required ) |
|
|
qualifier
|
0..* | CodeableConcept |
Additional
information
about
the
cost
|
|
|
value
|
0..1 | Quantity |
The
actual
cost
value
|
|
|
Documentation
for
this
format
|
||||
See the Extensions for this resource
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> < <</type> < < <</period> <</ownedBy> <</administeredBy> <</coverageArea> <</contact> <</endpoint> <</network> < <</type> <</network> < <</type> < < <</value> <</code> </limit><identifier><!-- 0..* Identifier Business Identifier for Plan --></identifier> <type><!-- 0..1 CodeableConcept Classification of Plan --></type> <product><!-- 0..1 Reference(InsuranceProduct) The product that this plan is available under --></product> <coverageArea><!-- 0..* Reference(Location) Where product-plan applies --></coverageArea> <network><!-- 0..* Reference(Organization) What networks provide coverage --></network> <generalCost> <!-- 0..* Overall costs --> <type><!-- 0..1 CodeableConcept Classification of specific 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..* Individual cost elements --> <category><!-- 1..1 CodeableConcept General category of benefit --></category> <benefit> <!-- 0..* Benefits list --> <type><!-- 1..1 CodeableConcept Classification of benefit provided --></type> <cost> <!-- 0..* List of the costs --> <type><!-- 1..1 CodeableConcept Classification of specific cost --></type> <applicability><!-- 0..1 CodeableConcept in-network | out-of-network | other --></applicability> <qualifier><!-- 0..* CodeableConcept Additional information about the cost --></qualifier> <value><!-- 0..1 Quantity The actual cost value --></value> </cost> </benefit></coverage> < <</identifier> <</type> <</coverageArea> <</network> < <</type> < <</cost> < </generalCost> < <</category> < <</type> < <</type> <</applicability> <</qualifiers> <</value> </cost> </benefit> </specificCost> </plan></specificCost> </InsurancePlan>
JSON Template
{
"resourceType" : "",
"resourceType" : "InsurancePlan",
// from Resource: id, meta, implicitRules, and language
// from DomainResource: text, contained, extension, and modifierExtension
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
}]
}]
"identifier" : [{ Identifier }], // Business Identifier for Plan
"type" : { CodeableConcept }, // Classification of Plan
"product" : { Reference(InsuranceProduct) }, // The product that this plan is available under
"coverageArea" : [{ Reference(Location) }], // Where product-plan applies
"network" : [{ Reference(Organization) }], // What networks provide coverage
"generalCost" : [{ // Overall costs
"type" : { CodeableConcept }, // Classification of specific cost
"groupSize" : "<positiveInt>", // Number of enrollees
"cost" : { Money }, // Cost value
"comment" : "<string>" // Additional cost information
}],
"
"
"
"
"
"
"
"
"
"
}],
"
"
"
"
"
"
"
"
"
}]
"specificCost" : [{ // Individual cost elements
"category" : { CodeableConcept }, // R! General category of benefit
"benefit" : [{ // Benefits list
"type" : { CodeableConcept }, // R! Classification of benefit provided
"cost" : [{ // List of the costs
"type" : { CodeableConcept }, // R! Classification of specific cost
"applicability" : { CodeableConcept }, // in-network | out-of-network | other
"qualifier" : [{ CodeableConcept }], // Additional information about the cost
"value" : { Quantity } // The actual cost value
}]
}]
}]
}
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> .[ a fhir:;[ 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 .modifierExtensionfhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: ] ... ) ; ] ... ) ;fhir:identifier ( [ Identifier ] ... ) ; # 0..* Business Identifier for Plan fhir:type [ CodeableConcept ] ; # 0..1 Classification of Plan fhir:product [ Reference(InsuranceProduct) ] ; # 0..1 The product that this plan is available under fhir:coverageArea ( [ Reference(Location) ] ... ) ; # 0..* Where product-plan applies fhir:network ( [ Reference(Organization) ] ... ) ; # 0..* What networks provide coverage fhir:generalCost ( [ # 0..* Overall costs fhir:type [ CodeableConcept ] ; # 0..1 Classification of specific cost fhir:groupSize [ positiveInt ] ; # 0..1 Number of enrollees fhir:cost [ Money ] ; # 0..1 Cost value fhir:comment [ string ] ; # 0..1 Additional cost information ] ... ) ;fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: ] ... ) ; fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: ] ... ) ;fhir:specificCost ( [ # 0..* Individual cost elements fhir:category [ CodeableConcept ] ; # 1..1 General category of benefit fhir:benefit ( [ # 0..* Benefits list fhir:type [ CodeableConcept ] ; # 1..1 Classification of benefit provided fhir:cost ( [ # 0..* List of the costs fhir:type [ CodeableConcept ] ; # 1..1 Classification of specific cost fhir:applicability [ CodeableConcept ] ; # 0..1 in-network | out-of-network | other fhir:qualifier ( [ CodeableConcept ] ... ) ; # 0..* Additional information about the cost fhir:value [ Quantity ] ; # 0..1 The actual cost value ] ... ) ; ] ... ) ; ] ... ) ; ]
Changes from both R4 and R4B
| InsurancePlan | |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| InsurancePlan.generalCost.cost |
|
| InsurancePlan.generalCost.comment |
|
| InsurancePlan.specificCost |
|
| InsurancePlan.specificCost.category |
|
| InsurancePlan.specificCost.benefit |
|
| InsurancePlan.specificCost.benefit.type |
|
| InsurancePlan.specificCost.benefit.cost |
|
| InsurancePlan.specificCost.benefit.cost.type |
|
| InsurancePlan.specificCost.benefit.cost.applicability |
|
| InsurancePlan.specificCost.benefit.cost.qualifier |
|
| InsurancePlan.specificCost.benefit.cost.value |
|
| InsurancePlan.status |
|
| InsurancePlan.name |
|
| InsurancePlan.alias |
|
| InsurancePlan.period |
|
| InsurancePlan.ownedBy |
|
| InsurancePlan.administeredBy |
|
| InsurancePlan.contact |
|
| InsurancePlan.endpoint |
|
| InsurancePlan.coverage |
|
| InsurancePlan.plan |
|
See
the
Full
Difference
0..*
Reference
for
further
information
This
analysis
is
available
for
R4
as
XML
(
Organization
or
JSON
)
What
networks
are
Included
coverage
and
for
R4B
as
XML
or
JSON
.
Structure
|
|
Flags
|
|
Type |
Description
&
Constraints
|
|---|---|---|---|---|
|
InsurancePlan
|
TU
|
|
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension |
|
|
|
|
0..* |
|
|
|
|
|
|
CodeableConcept |
Classification
of
Plan
|
|
product
|
Σ |
|
|
The
product
that
this
plan
is
available
under
|
|
coverageArea
|
Σ | 0..* | Reference ( Location ) |
Where
|
|
network
|
0..* | Reference ( Organization ) |
What
networks
provide
coverage
|
|
|
generalCost
|
0..* | BackboneElement |
Overall
costs
|
|
|
type
|
0..1 | CodeableConcept |
Classification
of
specific
cost
|
|
|
groupSize
|
0..1 | positiveInt |
Number
of
enrollees
|
|
|
cost
|
0..1 | Money |
Cost
value
|
|
|
comment
|
0..1 | string |
Additional
cost
information
|
|
|
specificCost
|
0..* | BackboneElement |
Individual
cost
elements
|
|
|
category
|
1..1 | CodeableConcept |
General
category
of
benefit
|
|
|
benefit
|
0..* | BackboneElement |
Benefits
list
|
|
|
type
|
1..1 | CodeableConcept |
Classification
of
|
|
|
cost
|
0..* | BackboneElement |
List
of
the
costs
|
|
|
type
|
1..1 | CodeableConcept |
Classification
of
specific
cost
|
|
|
applicability
|
0..1 | CodeableConcept |
in-network
|
out-of-network
|
other
Binding: Benefit Cost Applicability ( Required ) |
|
|
qualifier
|
0..* | CodeableConcept |
Additional
information
about
the
cost
|
|
|
value
|
0..1 | Quantity |
The
actual
cost
value
|
|
|
Documentation
for
this
format
|
||||
See the Extensions for this resource
XML Template
<<InsurancePlan xmlns="http://hl7.org/fhir"><</identifier> < <</type> < < <</period> <</ownedBy> <</administeredBy> <</coverageArea> <</contact> <</endpoint> <</network> < <</type> <</network> < <</type> < < <</value> <</code> </limit><identifier><!-- 0..* Identifier Business Identifier for Plan --></identifier> <type><!-- 0..1 CodeableConcept Classification of Plan --></type> <product><!-- 0..1 Reference(InsuranceProduct) The product that this plan is available under --></product> <coverageArea><!-- 0..* Reference(Location) Where product-plan applies --></coverageArea> <network><!-- 0..* Reference(Organization) What networks provide coverage --></network> <generalCost> <!-- 0..* Overall costs --> <type><!-- 0..1 CodeableConcept Classification of specific 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..* Individual cost elements --> <category><!-- 1..1 CodeableConcept General category of benefit --></category> <benefit> <!-- 0..* Benefits list --> <type><!-- 1..1 CodeableConcept Classification of benefit provided --></type> <cost> <!-- 0..* List of the costs --> <type><!-- 1..1 CodeableConcept Classification of specific cost --></type> <applicability><!-- 0..1 CodeableConcept in-network | out-of-network | other --></applicability> <qualifier><!-- 0..* CodeableConcept Additional information about the cost --></qualifier> <value><!-- 0..1 Quantity The actual cost value --></value> </cost> </benefit></coverage> < <</identifier> <</type> <</coverageArea> <</network> < <</type> < <</cost> < </generalCost> < <</category> < <</type> < <</type> <</applicability> <</qualifiers> <</value> </cost> </benefit> </specificCost> </plan></specificCost> </InsurancePlan>
JSON Template
{
"resourceType" : "",
"resourceType" : "InsurancePlan",
// from Resource: id, meta, implicitRules, and language
// from DomainResource: text, contained, extension, and modifierExtension
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
}]
}]
"identifier" : [{ Identifier }], // Business Identifier for Plan
"type" : { CodeableConcept }, // Classification of Plan
"product" : { Reference(InsuranceProduct) }, // The product that this plan is available under
"coverageArea" : [{ Reference(Location) }], // Where product-plan applies
"network" : [{ Reference(Organization) }], // What networks provide coverage
"generalCost" : [{ // Overall costs
"type" : { CodeableConcept }, // Classification of specific cost
"groupSize" : "<positiveInt>", // Number of enrollees
"cost" : { Money }, // Cost value
"comment" : "<string>" // Additional cost information
}],
"
"
"
"
"
"
"
"
"
"
}],
"
"
"
"
"
"
"
"
"
}]
"specificCost" : [{ // Individual cost elements
"category" : { CodeableConcept }, // R! General category of benefit
"benefit" : [{ // Benefits list
"type" : { CodeableConcept }, // R! Classification of benefit provided
"cost" : [{ // List of the costs
"type" : { CodeableConcept }, // R! Classification of specific cost
"applicability" : { CodeableConcept }, // in-network | out-of-network | other
"qualifier" : [{ CodeableConcept }], // Additional information about the cost
"value" : { Quantity } // The actual cost value
}]
}]
}]
}
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> .[ a fhir:;[ 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 .modifierExtensionfhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: ] ... ) ; ] ... ) ;fhir:identifier ( [ Identifier ] ... ) ; # 0..* Business Identifier for Plan fhir:type [ CodeableConcept ] ; # 0..1 Classification of Plan fhir:product [ Reference(InsuranceProduct) ] ; # 0..1 The product that this plan is available under fhir:coverageArea ( [ Reference(Location) ] ... ) ; # 0..* Where product-plan applies fhir:network ( [ Reference(Organization) ] ... ) ; # 0..* What networks provide coverage fhir:generalCost ( [ # 0..* Overall costs fhir:type [ CodeableConcept ] ; # 0..1 Classification of specific cost fhir:groupSize [ positiveInt ] ; # 0..1 Number of enrollees fhir:cost [ Money ] ; # 0..1 Cost value fhir:comment [ string ] ; # 0..1 Additional cost information ] ... ) ;fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: ] ... ) ; fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: fhir: ] ... ) ;fhir:specificCost ( [ # 0..* Individual cost elements fhir:category [ CodeableConcept ] ; # 1..1 General category of benefit fhir:benefit ( [ # 0..* Benefits list fhir:type [ CodeableConcept ] ; # 1..1 Classification of benefit provided fhir:cost ( [ # 0..* List of the costs fhir:type [ CodeableConcept ] ; # 1..1 Classification of specific cost fhir:applicability [ CodeableConcept ] ; # 0..1 in-network | out-of-network | other fhir:qualifier ( [ CodeableConcept ] ... ) ; # 0..* Additional information about the cost fhir:value [ Quantity ] ; # 0..1 The actual cost value ] ... ) ; ] ... ) ; ] ... ) ; ]
Changes from both R4 and R4B
| InsurancePlan | |
|
|
|
| InsurancePlan.product |
|
|
|
|
| InsurancePlan.generalCost.type |
|
| InsurancePlan.generalCost.groupSize |
|
| InsurancePlan.generalCost.cost |
|
| InsurancePlan.generalCost.comment |
|
| InsurancePlan.specificCost |
|
| InsurancePlan.specificCost.category |
|
| InsurancePlan.specificCost.benefit |
|
| InsurancePlan.specificCost.benefit.type |
|
| InsurancePlan.specificCost.benefit.cost |
|
| InsurancePlan.specificCost.benefit.cost.type |
|
| InsurancePlan.specificCost.benefit.cost.applicability |
|
| InsurancePlan.specificCost.benefit.cost.qualifier |
|
| InsurancePlan.specificCost.benefit.cost.value |
|
| InsurancePlan.status |
|
| InsurancePlan.name |
|
|
|
|
| InsurancePlan.period |
|
| InsurancePlan.ownedBy |
|
|
|
|
| InsurancePlan.contact |
|
| InsurancePlan.endpoint |
|
|
|
|
| InsurancePlan.plan |
|
See the Full Difference for further information
This analysis is available for R4 as XML or JSON and for R4B as XML or JSON .
Additional definitions: Master Definition XML + JSON , XML Schema / Schematron + JSON Schema , ShEx (for Turtle ) + see the extensions , the spreadsheet version & the dependency analysis
| Path | ValueSet | Type | Documentation |
|---|---|---|---|
|
|
BenefitCostApplicability | Required |
Whether the cost applies to in-network or out-of-network providers. |
Search parameters for this resource. See also the full list of search parameters for this resource , and check the Extensions registry for search parameters on extensions related to 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 |
|
|
reference |
|
( |
|
| identifier | token |
|
InsurancePlan.identifier | |
|
|
reference |
|
( Organization ) |
|
|
|
|
|
( InsuranceProduct |
|
| type | token |
A
code
for
the
type
of
|
InsurancePlan.type |
FHIR
®©
HL7.org
2011+.
FHIR
R5
hl7.fhir.core#5.0.0
R6
hl7.fhir.core#6.0.0-ballot3
generated
on
Sun,
Mar
26,
2023
15:25+1100.
Tue,
Apr
1,
2025
12:25+1100.
Links:
Search
|
Version
History
|
Contents
|
Glossary
|
QA
|
Compare
to
R4
|
Compare
to
R4B
R5
|
|
Propose
a
change