Administration
This
page
is
part
of
the
FHIR
Specification
(v5.0.0:
R5
-
STU
v6.0.0-ballot2:
Release
6
Ballot
(2nd
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
a
Health
Insurance
product/plan
provided
by
about
an
organization.
insurance
plan.
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.
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
|
|
|
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-ballot2
generated
on
Sun,
Mar
26,
2023
15:25+1100.
Mon,
Aug
12,
2024
16:58+0800.
Links:
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|
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|
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|
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|
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|
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to
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|
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|
|
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