Release 4B 5

This page is part of the FHIR Specification (v4.3.0: R4B (v5.0.0: R5 - STU ). The This is the current published version which supercedes in it's permanent home (it will always be available at this version is 5.0.0 . URL). For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R5 R4B R4

8.31 8.34 Resource InsurancePlan - Content

Patient Administration icon Work Group Maturity Level : 0   Trial Use Security Category : Business Compartments : Not linked to any No defined compartments

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

8.31.1 8.34.1 Scope and Usage

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

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

8.31.2 8.34.2 Boundaries and Relationships

TBD.

8.31.3 8.34.3 References to this Resource

This resource is referenced by

8.31.4 8.34.4 Resource Content

Structure

Name Flags Card. Type Description & Constraints doco
. . 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, identifier, and possibly more than one

Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier Σ I C 0..* Identifier Business Identifier for Product

. . . status ?! Σ 0..1 code draft | active | retired | unknown
Binding: PublicationStatus ( Required )
. . . type Σ 0..* CodeableConcept Kind of product
Binding: InsurancePlanType Insurance Plan Type ( Example )

. . . alias 0..* string Alternate names

. . . period 0..1 Period When the product is available
. . . ownedBy Σ 0..1 Reference ( Organization ) Plan Product 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 contact 0..1 0..* HumanName ExtendedContactDetail A name associated with the Official contact telecom 0..* ContactPoint Contact details (telephone, email, etc.) for a contact relevant to the health insurance plan/product
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
Binding: BenefitCostApplicability Benefit Cost Applicability ( Required )
. . . . . . . qualifiers 0..* CodeableConcept Additional information about the cost

. . . . . . . value 0..1 Quantity The actual cost value

doco Documentation for this format icon

See the Extensions for this resource

UML Diagram ( Legend )

InsurancePlan ( DomainResource ) Business identifiers assigned to this health insurance product which remain constant as the resource is updated and propagates from server to server identifier : Identifier [0..*] « This element has or is affected by some invariants C » The current state of the health insurance product (this element modifies the meaning of other elements) status : code [0..1] « null (Strength=Required) PublicationStatus ! » The kind of health insurance product type : CodeableConcept [0..*] « null (Strength=Example) InsurancePlanType ?? » Official name of the health insurance product as designated by the owner name : string [0..1] « This element has or is affected by some invariants C » A list of alternate names that the product is known as, or was known as in the past alias : string [0..*] The period of time that the health insurance product is available period : Period [0..1] The entity that is providing the health insurance product and underwriting the risk. This is typically an insurance carriers, other third-party payers, or health plan sponsors comonly referred to as 'payers' ownedBy : Reference [0..1] « Organization » An organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owner administeredBy : Reference [0..1] « Organization » The geographic region in which a health insurance product's benefits apply coverageArea : Reference [0..*] « Location » The contact details of communication devices available relevant to the specific Insurance Plan/Product. This can include addresses, phone numbers, fax numbers, mobile numbers, email addresses and web sites contact : ExtendedContactDetail [0..*] The technical endpoints providing access to services operated for the health insurance product endpoint : Reference [0..*] « Endpoint » Reference to the network included in the health insurance product network : Reference [0..*] « Organization » Contact Indicates a purpose for which the contact can be reached purpose : CodeableConcept [0..1] « null (Strength=Extensible) ContactEntityType + » A name associated with the contact name : HumanName [0..1] A contact detail (e.g. a telephone number or an email address) by which the party may be contacted telecom : ContactPoint [0..*] Visiting or postal addresses for the contact address : Address [0..1] Coverage Type of coverage (Medical; Dental; Mental Health; Substance Abuse; Vision; Drug; Short Term; Long Term Care; Hospice; Home Health) type : CodeableConcept [1..1] Reference to the network that providing the type of coverage network : Reference [0..*] « Organization » CoverageBenefit Type of benefit (primary care; speciality care; inpatient; outpatient) type : CodeableConcept [1..1] The referral requirements to have access/coverage for this benefit requirement : string [0..1] Limit The maximum amount of a service item a plan will pay for a covered benefit. For examples. wellness visits, or eyeglasses value : Quantity [0..1] The specific limit on the benefit code : CodeableConcept [0..1] Plan Business identifiers assigned to this health insurance plan which remain constant as the resource is updated and propagates from server to server identifier : Identifier [0..*] Type of plan. For example, "Platinum" or "High Deductable" type : CodeableConcept [0..1] The geographic region in which a health insurance plan's benefits apply coverageArea : Reference [0..*] « Location » Reference to the network that providing the type of coverage network : Reference [0..*] « Organization » GeneralCost Type of cost type : CodeableConcept [0..1] Number of participants enrolled in the plan groupSize : positiveInt [0..1] Value of the cost cost : Money [0..1] Additional information about the general costs associated with this plan comment : string [0..1] SpecificCost General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health) category : CodeableConcept [1..1] PlanBenefit Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care) type : CodeableConcept [1..1] Cost Type of cost (copay; individual cap; family cap; coinsurance; deductible) type : CodeableConcept [1..1] Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other) applicability : CodeableConcept [0..1] « null (Strength=Required) BenefitCostApplicability ! » Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA) qualifiers : CodeableConcept [0..*] The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance) value : Quantity [0..1] The contact for the health insurance product for a certain purpose contact [0..*] The specific limits on the benefit limit [0..*] Specific benefits under this type of coverage benefit [1..*] Details about the coverage offered by the insurance product coverage [0..*] Overall costs associated with the plan generalCost [0..*] List of the costs associated with a specific benefit cost [0..*] List of the specific benefits under this category of benefit benefit [0..*] Costs associated with the coverage provided by the product specificCost [0..*] Details about an insurance plan plan [0..*]

XML Template 

<InsurancePlan xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>

 <identifier><!-- I 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]"/><!-- I 0..1 Official name -->

 <alias value="[string]"/><!-- 0..* Alternate names -->
 <period><!-- 0..1 Period When the product is available --></period>
 <</ownedBy>

 <ownedBy><!-- 0..1 Reference(Organization) Product issuer --></ownedBy>

 <administeredBy><!-- 0..1 Reference(Organization) Product administrator --></administeredBy>
 <coverageArea><!-- 0..* Reference(Location) Where product applies --></coverageArea>
 <
  <</purpose>
  <</name>
  <</telecom>
  <</address>
 </contact>

 <contact><!-- 0..* ExtendedContactDetail Official contact details relevant to the health insurance plan/product --></contact>

 <endpoint><!-- 0..* Reference(Endpoint) Technical endpoint --></endpoint>
 <network><!-- 0..* Reference(Organization) What networks are Included --></network>
 <coverage>  <!-- 0..* Coverage details -->
  <type><!-- 1..1 CodeableConcept Type of coverage --></type>
  <network><!-- 0..* Reference(Organization) What networks provide coverage --></network>
  <benefit>  <!-- 1..* List of benefits -->
   <type><!-- 1..1 CodeableConcept Type of benefit --></type>
   <requirement value="[string]"/><!-- 0..1 Referral requirements -->
   <limit>  <!-- 0..* Benefit limits -->
    <value><!-- 0..1 Quantity Maximum value allowed --></value>
    <code><!-- 0..1 CodeableConcept Benefit limit details --></code>
   </limit>
  </benefit>
 </coverage>
 <plan>  <!-- 0..* Plan details -->
  <identifier><!-- 0..* Identifier Business Identifier for Product --></identifier>
  <type><!-- 0..1 CodeableConcept Type of plan --></type>
  <coverageArea><!-- 0..* Reference(Location) Where product applies --></coverageArea>
  <network><!-- 0..* Reference(Organization) What networks provide coverage --></network>
  <generalCost>  <!-- 0..* Overall costs -->
   <type><!-- 0..1 CodeableConcept Type of cost --></type>
   <groupSize value="[positiveInt]"/><!-- 0..1 Number of enrollees -->
   <cost><!-- 0..1 Money Cost value --></cost>
   <comment value="[string]"/><!-- 0..1 Additional cost information -->
  </generalCost>
  <specificCost>  <!-- 0..* Specific costs -->
   <category><!-- 1..1 CodeableConcept General category of benefit --></category>
   <benefit>  <!-- 0..* Benefits list -->
    <type><!-- 1..1 CodeableConcept Type of specific benefit --></type>
    <cost>  <!-- 0..* List of the costs -->
     <type><!-- 1..1 CodeableConcept Type of cost --></type>
     <applicability><!-- 0..1 CodeableConcept in-network | out-of-network | other --></applicability>
     <qualifiers><!-- 0..* CodeableConcept Additional information about the cost --></qualifiers>
     <value><!-- 0..1 Quantity The actual cost value --></value>
    </cost>
   </benefit>
  </specificCost>
 </plan>
</InsurancePlan>

JSON Template 

{doco
  "resourceType" : "InsurancePlan",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "

  "identifier" : [{ Identifier }], // I Business Identifier for Product

  "status" : "<code>", // draft | active | retired | unknown
  "type" : [{ CodeableConcept }], // Kind of product
  "

  "name" : "<string>", // I Official name

  "alias" : ["<string>"], // Alternate names
  "period" : { Period }, // When the product is available
  "

  "ownedBy" : { Reference(Organization) }, // Product issuer

  "administeredBy" : { Reference(Organization) }, // Product administrator
  "coverageArea" : [{ Reference(Location) }], // Where product applies
  "
    "
    "
    "
    "
  }],

  "contact" : [{ ExtendedContactDetail }], // Official contact details relevant to the health insurance plan/product

  "endpoint" : [{ Reference(Endpoint) }], // Technical endpoint
  "network" : [{ Reference(Organization) }], // What networks are Included
  "coverage" : [{ // Coverage details
    "type" : { CodeableConcept }, // R!  Type of coverage
    "network" : [{ Reference(Organization) }], // What networks provide coverage
    "benefit" : [{ // R!  List of benefits
      "type" : { CodeableConcept }, // R!  Type of benefit
      "requirement" : "<string>", // Referral requirements
      "limit" : [{ // Benefit limits
        "value" : { Quantity }, // Maximum value allowed
        "code" : { CodeableConcept } // Benefit limit details
      }]
    }]
  }],
  "plan" : [{ // Plan details
    "identifier" : [{ Identifier }], // Business Identifier for Product
    "type" : { CodeableConcept }, // Type of plan
    "coverageArea" : [{ Reference(Location) }], // Where product applies
    "network" : [{ Reference(Organization) }], // What networks provide coverage
    "generalCost" : [{ // Overall costs
      "type" : { CodeableConcept }, // Type of cost
      "groupSize" : "<positiveInt>", // Number of enrollees
      "cost" : { Money }, // Cost value
      "comment" : "<string>" // Additional cost information
    }],
    "specificCost" : [{ // Specific costs
      "category" : { CodeableConcept }, // R!  General category of benefit
      "benefit" : [{ // Benefits list
        "type" : { CodeableConcept }, // R!  Type of specific benefit
        "cost" : [{ // List of the costs
          "type" : { CodeableConcept }, // R!  Type of cost
          "applicability" : { CodeableConcept }, // in-network | out-of-network | other
          "qualifiers" : [{ CodeableConcept }], // Additional information about the cost
          "value" : { Quantity } // The actual cost value
        }]
      }]
    }]
  }]
}

Turtle Template 

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
      fhir:
      fhir:
      fhir:
        fhir:
        fhir:
      ], ...;
    ], ...;
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
      fhir:
      fhir:
      fhir:
      fhir:
    ], ...;
    fhir:
      fhir:
      fhir:
        fhir:
        fhir:
          fhir:
          fhir:
          fhir:
          fhir:
        ], ...;
      ], ...;
    ], ...;
  ], ...;

  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* I Business Identifier for Product
  fhir:status [ code ] ; # 0..1 draft | active | retired | unknown
  fhir:type  ( [ CodeableConcept ] ... ) ; # 0..* Kind of product
  fhir:name [ string ] ; # 0..1 I Official name
  fhir:alias  ( [ string ] ... ) ; # 0..* Alternate names
  fhir:period [ Period ] ; # 0..1 When the product is available
  fhir:ownedBy [ Reference(Organization) ] ; # 0..1 Product issuer
  fhir:administeredBy [ Reference(Organization) ] ; # 0..1 Product administrator
  fhir:coverageArea  ( [ Reference(Location) ] ... ) ; # 0..* Where product applies
  fhir:contact  ( [ ExtendedContactDetail ] ... ) ; # 0..* Official contact details relevant to the health insurance plan/product
  fhir:endpoint  ( [ Reference(Endpoint) ] ... ) ; # 0..* Technical endpoint
  fhir:network  ( [ Reference(Organization) ] ... ) ; # 0..* What networks are Included
  fhir:coverage ( [ # 0..* Coverage details
    fhir:type [ CodeableConcept ] ; # 1..1 Type of coverage
    fhir:network  ( [ Reference(Organization) ] ... ) ; # 0..* What networks provide coverage
    fhir:benefit ( [ # 1..* List of benefits
      fhir:type [ CodeableConcept ] ; # 1..1 Type of benefit
      fhir:requirement [ string ] ; # 0..1 Referral requirements
      fhir:limit ( [ # 0..* Benefit limits
        fhir:value [ Quantity ] ; # 0..1 Maximum value allowed
        fhir:code [ CodeableConcept ] ; # 0..1 Benefit limit details
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:plan ( [ # 0..* Plan details
    fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business Identifier for Product
    fhir:type [ CodeableConcept ] ; # 0..1 Type of plan
    fhir:coverageArea  ( [ Reference(Location) ] ... ) ; # 0..* Where product applies
    fhir:network  ( [ Reference(Organization) ] ... ) ; # 0..* What networks provide coverage
    fhir:generalCost ( [ # 0..* Overall costs
      fhir:type [ CodeableConcept ] ; # 0..1 Type of 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:specificCost ( [ # 0..* Specific costs
      fhir:category [ CodeableConcept ] ; # 1..1 General category of benefit
      fhir:benefit ( [ # 0..* Benefits list
        fhir:type [ CodeableConcept ] ; # 1..1 Type of specific benefit
        fhir:cost ( [ # 0..* List of the costs
          fhir:type [ CodeableConcept ] ; # 1..1 Type of cost
          fhir:applicability [ CodeableConcept ] ; # 0..1 in-network | out-of-network | other
          fhir:qualifiers  ( [ CodeableConcept ] ... ) ; # 0..* Additional information about the cost
          fhir:value [ Quantity ] ; # 0..1 The actual cost value
        ] ... ) ;
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;

]

Changes since from both R4 and R4B

InsurancePlan
InsurancePlan.contact
  • No Changes Type changed from BackboneElement to ExtendedContactDetail
InsurancePlan.contact.purpose
  • Deleted (-> InsurancePlan.contact.purpose)
InsurancePlan.contact.name
  • Deleted (-> InsurancePlan.contact.name)
InsurancePlan.contact.telecom
  • Deleted (-> InsurancePlan.contact.telecom)
InsurancePlan.contact.address
  • Deleted (-> InsurancePlan.contact.address)

See the Full Difference for further information

This analysis is available for R4 as XML or JSON . Conversions between R3 and R4 for R4B as XML or JSON .

Structure

purpose 0..1 CodeableConcept The type of contact ContactEntityType ( Extensible )
Name Flags Card. Type Description & Constraints doco
. . 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, identifier, and possibly more than one

Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier Σ I C 0..* Identifier Business Identifier for Product

. . . status ?! Σ 0..1 code draft | active | retired | unknown
Binding: PublicationStatus ( Required )
. . . type Σ 0..* CodeableConcept Kind of product
Binding: InsurancePlanType Insurance Plan Type ( Example )

. . . alias 0..* string Alternate names

. . . period 0..1 Period When the product is available
. . . ownedBy Σ 0..1 Reference ( Organization ) Plan Product issuer
. . . administeredBy Σ 0..1 Reference ( Organization ) Product administrator
. . . coverageArea Σ 0..* Reference ( Location ) Where product applies
contact 0..* BackboneElement Contact for the product
. . . name contact 0..1 0..* HumanName ExtendedContactDetail A name associated with the Official contact telecom 0..* ContactPoint Contact details (telephone, email, etc.) for a contact relevant to the health insurance plan/product
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
Binding: BenefitCostApplicability Benefit Cost Applicability ( Required )
. . . . . . . qualifiers 0..* CodeableConcept Additional information about the cost

. . . . . . . value 0..1 Quantity The actual cost value

doco Documentation for this format icon

See the Extensions for this resource

UML Diagram ( Legend )

InsurancePlan ( DomainResource ) Business identifiers assigned to this health insurance product which remain constant as the resource is updated and propagates from server to server identifier : Identifier [0..*] « This element has or is affected by some invariants C » The current state of the health insurance product (this element modifies the meaning of other elements) status : code [0..1] « null (Strength=Required) PublicationStatus ! » The kind of health insurance product type : CodeableConcept [0..*] « null (Strength=Example) InsurancePlanType ?? » Official name of the health insurance product as designated by the owner name : string [0..1] « This element has or is affected by some invariants C » A list of alternate names that the product is known as, or was known as in the past alias : string [0..*] The period of time that the health insurance product is available period : Period [0..1] The entity that is providing the health insurance product and underwriting the risk. This is typically an insurance carriers, other third-party payers, or health plan sponsors comonly referred to as 'payers' ownedBy : Reference [0..1] « Organization » An organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owner administeredBy : Reference [0..1] « Organization » The geographic region in which a health insurance product's benefits apply coverageArea : Reference [0..*] « Location » The contact details of communication devices available relevant to the specific Insurance Plan/Product. This can include addresses, phone numbers, fax numbers, mobile numbers, email addresses and web sites contact : ExtendedContactDetail [0..*] The technical endpoints providing access to services operated for the health insurance product endpoint : Reference [0..*] « Endpoint » Reference to the network included in the health insurance product network : Reference [0..*] « Organization » Contact Indicates a purpose for which the contact can be reached purpose : CodeableConcept [0..1] « null (Strength=Extensible) ContactEntityType + » A name associated with the contact name : HumanName [0..1] A contact detail (e.g. a telephone number or an email address) by which the party may be contacted telecom : ContactPoint [0..*] Visiting or postal addresses for the contact address : Address [0..1] Coverage Type of coverage (Medical; Dental; Mental Health; Substance Abuse; Vision; Drug; Short Term; Long Term Care; Hospice; Home Health) type : CodeableConcept [1..1] Reference to the network that providing the type of coverage network : Reference [0..*] « Organization » CoverageBenefit Type of benefit (primary care; speciality care; inpatient; outpatient) type : CodeableConcept [1..1] The referral requirements to have access/coverage for this benefit requirement : string [0..1] Limit The maximum amount of a service item a plan will pay for a covered benefit. For examples. wellness visits, or eyeglasses value : Quantity [0..1] The specific limit on the benefit code : CodeableConcept [0..1] Plan Business identifiers assigned to this health insurance plan which remain constant as the resource is updated and propagates from server to server identifier : Identifier [0..*] Type of plan. For example, "Platinum" or "High Deductable" type : CodeableConcept [0..1] The geographic region in which a health insurance plan's benefits apply coverageArea : Reference [0..*] « Location » Reference to the network that providing the type of coverage network : Reference [0..*] « Organization » GeneralCost Type of cost type : CodeableConcept [0..1] Number of participants enrolled in the plan groupSize : positiveInt [0..1] Value of the cost cost : Money [0..1] Additional information about the general costs associated with this plan comment : string [0..1] SpecificCost General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health) category : CodeableConcept [1..1] PlanBenefit Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care) type : CodeableConcept [1..1] Cost Type of cost (copay; individual cap; family cap; coinsurance; deductible) type : CodeableConcept [1..1] Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other) applicability : CodeableConcept [0..1] « null (Strength=Required) BenefitCostApplicability ! » Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA) qualifiers : CodeableConcept [0..*] The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance) value : Quantity [0..1] The contact for the health insurance product for a certain purpose contact [0..*] The specific limits on the benefit limit [0..*] Specific benefits under this type of coverage benefit [1..*] Details about the coverage offered by the insurance product coverage [0..*] Overall costs associated with the plan generalCost [0..*] List of the costs associated with a specific benefit cost [0..*] List of the specific benefits under this category of benefit benefit [0..*] Costs associated with the coverage provided by the product specificCost [0..*] Details about an insurance plan plan [0..*]

XML Template 

<InsurancePlan xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>

 <identifier><!-- I 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]"/><!-- I 0..1 Official name -->

 <alias value="[string]"/><!-- 0..* Alternate names -->
 <period><!-- 0..1 Period When the product is available --></period>
 <</ownedBy>

 <ownedBy><!-- 0..1 Reference(Organization) Product issuer --></ownedBy>

 <administeredBy><!-- 0..1 Reference(Organization) Product administrator --></administeredBy>
 <coverageArea><!-- 0..* Reference(Location) Where product applies --></coverageArea>
 <
  <</purpose>
  <</name>
  <</telecom>
  <</address>
 </contact>

 <contact><!-- 0..* ExtendedContactDetail Official contact details relevant to the health insurance plan/product --></contact>

 <endpoint><!-- 0..* Reference(Endpoint) Technical endpoint --></endpoint>
 <network><!-- 0..* Reference(Organization) What networks are Included --></network>
 <coverage>  <!-- 0..* Coverage details -->
  <type><!-- 1..1 CodeableConcept Type of coverage --></type>
  <network><!-- 0..* Reference(Organization) What networks provide coverage --></network>
  <benefit>  <!-- 1..* List of benefits -->
   <type><!-- 1..1 CodeableConcept Type of benefit --></type>
   <requirement value="[string]"/><!-- 0..1 Referral requirements -->
   <limit>  <!-- 0..* Benefit limits -->
    <value><!-- 0..1 Quantity Maximum value allowed --></value>
    <code><!-- 0..1 CodeableConcept Benefit limit details --></code>
   </limit>
  </benefit>
 </coverage>
 <plan>  <!-- 0..* Plan details -->
  <identifier><!-- 0..* Identifier Business Identifier for Product --></identifier>
  <type><!-- 0..1 CodeableConcept Type of plan --></type>
  <coverageArea><!-- 0..* Reference(Location) Where product applies --></coverageArea>
  <network><!-- 0..* Reference(Organization) What networks provide coverage --></network>
  <generalCost>  <!-- 0..* Overall costs -->
   <type><!-- 0..1 CodeableConcept Type of cost --></type>
   <groupSize value="[positiveInt]"/><!-- 0..1 Number of enrollees -->
   <cost><!-- 0..1 Money Cost value --></cost>
   <comment value="[string]"/><!-- 0..1 Additional cost information -->
  </generalCost>
  <specificCost>  <!-- 0..* Specific costs -->
   <category><!-- 1..1 CodeableConcept General category of benefit --></category>
   <benefit>  <!-- 0..* Benefits list -->
    <type><!-- 1..1 CodeableConcept Type of specific benefit --></type>
    <cost>  <!-- 0..* List of the costs -->
     <type><!-- 1..1 CodeableConcept Type of cost --></type>
     <applicability><!-- 0..1 CodeableConcept in-network | out-of-network | other --></applicability>
     <qualifiers><!-- 0..* CodeableConcept Additional information about the cost --></qualifiers>
     <value><!-- 0..1 Quantity The actual cost value --></value>
    </cost>
   </benefit>
  </specificCost>
 </plan>
</InsurancePlan>

JSON Template 

{doco
  "resourceType" : "InsurancePlan",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "

  "identifier" : [{ Identifier }], // I Business Identifier for Product

  "status" : "<code>", // draft | active | retired | unknown
  "type" : [{ CodeableConcept }], // Kind of product
  "

  "name" : "<string>", // I Official name

  "alias" : ["<string>"], // Alternate names
  "period" : { Period }, // When the product is available
  "

  "ownedBy" : { Reference(Organization) }, // Product issuer

  "administeredBy" : { Reference(Organization) }, // Product administrator
  "coverageArea" : [{ Reference(Location) }], // Where product applies
  "
    "
    "
    "
    "
  }],

  "contact" : [{ ExtendedContactDetail }], // Official contact details relevant to the health insurance plan/product

  "endpoint" : [{ Reference(Endpoint) }], // Technical endpoint
  "network" : [{ Reference(Organization) }], // What networks are Included
  "coverage" : [{ // Coverage details
    "type" : { CodeableConcept }, // R!  Type of coverage
    "network" : [{ Reference(Organization) }], // What networks provide coverage
    "benefit" : [{ // R!  List of benefits
      "type" : { CodeableConcept }, // R!  Type of benefit
      "requirement" : "<string>", // Referral requirements
      "limit" : [{ // Benefit limits
        "value" : { Quantity }, // Maximum value allowed
        "code" : { CodeableConcept } // Benefit limit details
      }]
    }]
  }],
  "plan" : [{ // Plan details
    "identifier" : [{ Identifier }], // Business Identifier for Product
    "type" : { CodeableConcept }, // Type of plan
    "coverageArea" : [{ Reference(Location) }], // Where product applies
    "network" : [{ Reference(Organization) }], // What networks provide coverage
    "generalCost" : [{ // Overall costs
      "type" : { CodeableConcept }, // Type of cost
      "groupSize" : "<positiveInt>", // Number of enrollees
      "cost" : { Money }, // Cost value
      "comment" : "<string>" // Additional cost information
    }],
    "specificCost" : [{ // Specific costs
      "category" : { CodeableConcept }, // R!  General category of benefit
      "benefit" : [{ // Benefits list
        "type" : { CodeableConcept }, // R!  Type of specific benefit
        "cost" : [{ // List of the costs
          "type" : { CodeableConcept }, // R!  Type of cost
          "applicability" : { CodeableConcept }, // in-network | out-of-network | other
          "qualifiers" : [{ CodeableConcept }], // Additional information about the cost
          "value" : { Quantity } // The actual cost value
        }]
      }]
    }]
  }]
}

Turtle Template 

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


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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
  ], ...;
  fhir:
  fhir:
  fhir:
    fhir:
    fhir:
    fhir:
      fhir:
      fhir:
      fhir:
        fhir:
        fhir:
      ], ...;
    ], ...;
  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
      fhir:
      fhir:
      fhir:
      fhir:
    ], ...;
    fhir:
      fhir:
      fhir:
        fhir:
        fhir:
          fhir:
          fhir:
          fhir:
          fhir:
        ], ...;
      ], ...;
    ], ...;
  ], ...;

  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* I Business Identifier for Product
  fhir:status [ code ] ; # 0..1 draft | active | retired | unknown
  fhir:type  ( [ CodeableConcept ] ... ) ; # 0..* Kind of product
  fhir:name [ string ] ; # 0..1 I Official name
  fhir:alias  ( [ string ] ... ) ; # 0..* Alternate names
  fhir:period [ Period ] ; # 0..1 When the product is available
  fhir:ownedBy [ Reference(Organization) ] ; # 0..1 Product issuer
  fhir:administeredBy [ Reference(Organization) ] ; # 0..1 Product administrator
  fhir:coverageArea  ( [ Reference(Location) ] ... ) ; # 0..* Where product applies
  fhir:contact  ( [ ExtendedContactDetail ] ... ) ; # 0..* Official contact details relevant to the health insurance plan/product
  fhir:endpoint  ( [ Reference(Endpoint) ] ... ) ; # 0..* Technical endpoint
  fhir:network  ( [ Reference(Organization) ] ... ) ; # 0..* What networks are Included
  fhir:coverage ( [ # 0..* Coverage details
    fhir:type [ CodeableConcept ] ; # 1..1 Type of coverage
    fhir:network  ( [ Reference(Organization) ] ... ) ; # 0..* What networks provide coverage
    fhir:benefit ( [ # 1..* List of benefits
      fhir:type [ CodeableConcept ] ; # 1..1 Type of benefit
      fhir:requirement [ string ] ; # 0..1 Referral requirements
      fhir:limit ( [ # 0..* Benefit limits
        fhir:value [ Quantity ] ; # 0..1 Maximum value allowed
        fhir:code [ CodeableConcept ] ; # 0..1 Benefit limit details
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:plan ( [ # 0..* Plan details
    fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business Identifier for Product
    fhir:type [ CodeableConcept ] ; # 0..1 Type of plan
    fhir:coverageArea  ( [ Reference(Location) ] ... ) ; # 0..* Where product applies
    fhir:network  ( [ Reference(Organization) ] ... ) ; # 0..* What networks provide coverage
    fhir:generalCost ( [ # 0..* Overall costs
      fhir:type [ CodeableConcept ] ; # 0..1 Type of 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:specificCost ( [ # 0..* Specific costs
      fhir:category [ CodeableConcept ] ; # 1..1 General category of benefit
      fhir:benefit ( [ # 0..* Benefits list
        fhir:type [ CodeableConcept ] ; # 1..1 Type of specific benefit
        fhir:cost ( [ # 0..* List of the costs
          fhir:type [ CodeableConcept ] ; # 1..1 Type of cost
          fhir:applicability [ CodeableConcept ] ; # 0..1 in-network | out-of-network | other
          fhir:qualifiers  ( [ CodeableConcept ] ... ) ; # 0..* Additional information about the cost
          fhir:value [ Quantity ] ; # 0..1 The actual cost value
        ] ... ) ;
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;

]

Changes since Release 4 from both R4 and R4B

InsurancePlan
InsurancePlan.contact
  • No Changes Type changed from BackboneElement to ExtendedContactDetail
InsurancePlan.contact.purpose
  • Deleted (-> InsurancePlan.contact.purpose)
InsurancePlan.contact.name
  • Deleted (-> InsurancePlan.contact.name)
InsurancePlan.contact.telecom
  • Deleted (-> InsurancePlan.contact.telecom)
InsurancePlan.contact.address
  • Deleted (-> InsurancePlan.contact.address)

See the Full Difference for further information

This analysis is available for R4 as XML or JSON . Conversions between R3 and R4 for R4B as XML or JSON .

 

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

8.31.4.1 8.34.4.1 Terminology Bindings

InsurancePlan.contact.purpose
Path Definition ValueSet Type Reference Documentation
InsurancePlan.status PublicationStatus Required PublicationStatus

The lifecycle status of an artifact.

InsurancePlan.type Example InsurancePlanType Extensible Example ContactEntityType

This example value set defines a set of codes that can be used to indicate a type of insurance plan.

InsurancePlan.plan.specificCost.benefit.cost.applicability BenefitCostApplicability Required BenefitCostApplicability

Whether the cost applies to in-network or out-of-network providers.

8.31.4.2 8.34.4.2 Constraints

id UniqueKey Level Location Description Expression
ipn-1 img  ipn-1 Rule (base) The organization SHALL at least have a name or an idendtifier, identifier, and possibly more than one (identifier.count() + name.count()) > 0

8.31.5 8.34.5 Notes:

8.31.6 8.34.6 Search Parameters

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
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 string A city specified in an address InsurancePlan.contact.address.city
address-country string A country specified in an address InsurancePlan.contact.address.country
address-postalcode string A postal code specified in an address InsurancePlan.contact.address.postalCode
address-state string A state specified in an address InsurancePlan.contact.address.state
address-use 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 InsurancePlan.name | alias InsurancePlan.alias
owned-by reference An organization of which this organization forms a part InsurancePlan.ownedBy
( Organization )
phonetic string A portion of the organization's name using some kind of phonetic matching algorithm InsurancePlan.name
status token Is the Organization record active InsurancePlan.status
type token A code for the type of organization InsurancePlan.type