HL7 FHIR® Validated Healthcare Directory Implementation Guide STU 1

Validated Healthcare Directory, published by HL7 International - Patient Admistration Working Group. This is not an authorized publication; it is the continuous build for version 0.2.0). This version is based on the current content of https://github.com/HL7/VhDir/ and changes regularly. See the Directory of published versions

JSON Format: InsurancePlan-insuranceplan1

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{
  "resourceType" : "InsurancePlan",
  "id" : "insuranceplan1",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: insuranceplan1</p><p><b>identifier</b>: HIOS product ID = 1234567891 (OFFICIAL)</p><p><b>status</b>: active</p><p><b>type</b>: Bronze <span style=\"background: LightGoldenRodYellow\">(Details : {http://hl7.org/fhir/uv/vhdir/CodeSystem/payercharacteristics code 'bronze' = 'Bronze', given as 'Bronze'})</span></p><p><b>name</b>: Patriot PPO Standard</p><p><b>alias</b>: Patriot Plus</p><p><b>period</b>: Jun 6, 2018, 12:00:00 AM --&gt; Jan 1, 2019, 12:00:00 AM</p><p><b>ownedBy</b>: <a href=\"Organization-homeland.html\">Homeland Health Insurance. Generated Summary: id: homeland; active; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/organization-type ins}\">Health System</span>; name: Homeland Health Insurance</a></p><p><b>administeredBy</b>: <a href=\"Organization-homeland.html\">Homeland Health Insurance. Generated Summary: id: homeland; active; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/organization-type ins}\">Health System</span>; name: Homeland Health Insurance</a></p><p><b>coverageArea</b>: <a href=\"Location-wash-dc-metro.html\">Washington, DC metro area. Generated Summary: id: wash-dc-metro; status: active; name: Washington, DC metro area; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/location-physical-type area}\">Area</span></a></p><h3>Contacts</h3><table class=\"grid\"><tr><td>-</td><td><b>Purpose</b></td><td><b>Telecom</b></td></tr><tr><td>*</td><td>General information <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/contactentity-type code 'PATINF' = 'Patient', given as 'Patient'})</span></td><td>ph: 202-123-5555</td></tr></table><p><b>endpoint</b>: patriot plan endpoint hub</p><p><b>network</b>: </p><ul><li><a href=\"Organization-patriotppo.html\">Patriot Preferred Provider Network. Generated Summary: id: patriotppo; Healthcare.gov Network ID = DCN001 (SECONDARY); active; <span title=\"Codes: {http://hl7.org/fhir/uv/vhdir/CodeSystem/network-type ppo}\">PPO</span>; name: Patriot Preferred Provider Network; alias: Patriot PPO</a></li><li><a href=\"Organization-patriotdental.html\">Patriot Dental Provider Network. Generated Summary: id: patriotdental; active; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/organization-type pay}\">Health System</span>; name: Patriot Dental Provider Network</a></li></ul><blockquote><p><b>coverage</b></p><p><b>type</b>: Coverage related to medical inpatient, outpatient, diagnostic, and preventive care <span style=\"background: LightGoldenRodYellow\">(Details : {[not stated] code 'medical' = 'medical', given as 'Medical'})</span></p><p><b>network</b>: <a href=\"Organization-patriotppo.html\">Patriot Preferred Provider Network. Generated Summary: id: patriotppo; Healthcare.gov Network ID = DCN001 (SECONDARY); active; <span title=\"Codes: {http://hl7.org/fhir/uv/vhdir/CodeSystem/network-type ppo}\">PPO</span>; name: Patriot Preferred Provider Network; alias: Patriot PPO</a></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Primary care visit to treat an injury or illness <span style=\"background: LightGoldenRodYellow\">(Details : {[not stated] code '001' = '001', given as 'Primary care visit to treat an injury or illness'})</span></p><p><b>requirement</b>: N/A</p><h3>Limits</h3><table class=\"grid\"><tr><td>-</td><td><b>Code</b></td></tr><tr><td>*</td><td>unlimited <span style=\"background: LightGoldenRodYellow\">(Details )</span></td></tr></table></blockquote></blockquote><blockquote><p><b>coverage</b></p><p><b>type</b>: Coverage related to dental care <span style=\"background: LightGoldenRodYellow\">(Details : {[not stated] code 'dental' = 'dental', given as 'Dental'})</span></p><p><b>network</b>: <a href=\"Organization-patriotdental.html\">Patriot Dental Provider Network. Generated Summary: id: patriotdental; active; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/organization-type pay}\">Health System</span>; name: Patriot Dental Provider Network</a></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Periodic oral checkup <span style=\"background: LightGoldenRodYellow\">(Details : {[not stated] code '052' = '052', given as 'Basic Dental Care – Adult'})</span></p><p><b>requirement</b>: N/A</p><h3>Limits</h3><table class=\"grid\"><tr><td>-</td><td><b>Value</b></td><td><b>Code</b></td></tr><tr><td>*</td><td>2 visit/yr<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {visit}/a = '{visit}/a')</span></td><td>biannual oral checkup <span style=\"background: LightGoldenRodYellow\">(Details )</span></td></tr></table></blockquote></blockquote><blockquote><p><b>plan</b></p><p><b>identifier</b>: HIOS plan ID = 123456789101112 (OFFICIAL)</p><p><b>type</b>: Bronze <span style=\"background: LightGoldenRodYellow\">(Details : {[not stated] code 'bronze' = 'bronze', given as 'Bronze'})</span></p><p><b>coverageArea</b>: <a href=\"Location-wash-dc-metro.html\">Washington, DC metro area. Generated Summary: id: wash-dc-metro; status: active; name: Washington, DC metro area; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/location-physical-type area}\">Area</span></a></p><p><b>network</b>: <a href=\"Organization-patriotdental.html\">Patriot Dental Provider Network. Generated Summary: id: patriotdental; active; <span title=\"Codes: {http://terminology.hl7.org/CodeSystem/organization-type pay}\">Health System</span>; name: Patriot Dental Provider Network</a></p><h3>GeneralCosts</h3><table class=\"grid\"><tr><td>-</td><td><b>Type</b></td><td><b>GroupSize</b></td><td><b>Cost</b></td><td><b>Comment</b></td></tr><tr><td>*</td><td>Deductible <span style=\"background: LightGoldenRodYellow\">(Details : {[not stated] code 'deductible' = 'deductible', given as 'Deductible'})</span></td><td>1</td><td/><td>Includes all prescription and medical costs for in-network providers</td></tr></table><blockquote><p><b>specificCost</b></p><p><b>category</b>: Medical <span style=\"background: LightGoldenRodYellow\">(Details : {[not stated] code 'medical' = 'medical', given as 'Medical'})</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Primary care visit to treat an injury or illness <span style=\"background: LightGoldenRodYellow\">(Details : {[not stated] code '001' = '001', given as 'Primary care visit to treat an injury or illness'})</span></p><h3>Costs</h3><table class=\"grid\"><tr><td>-</td><td><b>Type</b></td><td><b>Applicability</b></td><td><b>Qualifiers</b></td><td><b>Value</b></td></tr><tr><td>*</td><td>Copay <span style=\"background: LightGoldenRodYellow\">(Details : {[not stated] code 'copay' = 'copay', given as 'Copay'})</span></td><td>In Network <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/applicability code 'in-network' = 'In Network', given as 'In Network'})</span></td><td>in-network preferred provider <span style=\"background: LightGoldenRodYellow\">(Details )</span></td><td>50 dollars<span style=\"background: LightGoldenRodYellow\"> (Details: urn:iso:std:iso:4217 code USD = 'United States dollar')</span></td></tr></table></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: Dental <span style=\"background: LightGoldenRodYellow\">(Details : {[not stated] code 'dental' = 'dental', given as 'Dental'})</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: Basic Dental Care – Adult <span style=\"background: LightGoldenRodYellow\">(Details : {[not stated] code '052' = '052', given as 'Basic Dental Care – Adult'})</span></p><h3>Costs</h3><table class=\"grid\"><tr><td>-</td><td><b>Type</b></td><td><b>Applicability</b></td><td><b>Qualifiers</b></td><td><b>Value</b></td></tr><tr><td>*</td><td>Coinsurance <span style=\"background: LightGoldenRodYellow\">(Details : {[not stated] code 'coinsurance' = 'coinsurance', given as 'Coinsurance'})</span></td><td>In Network <span style=\"background: LightGoldenRodYellow\">(Details : {http://terminology.hl7.org/CodeSystem/applicability code 'in-network' = 'In Network', given as 'In Network'})</span></td><td>in-network provider <span style=\"background: LightGoldenRodYellow\">(Details )</span></td><td>10 percent</td></tr></table></blockquote></blockquote></blockquote></div>"
  },
  "identifier" : [
    {
      "use" : "official",
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
            "code" : "NIIP",
            "display" : "National Insurance Payor Identifier (Payor)",
            "userSelected" : true
          }
        ],
        "text" : "HIOS product ID"
      },
      "system" : "https://www.cms.gov/CCIIO/",
      "value" : "1234567891",
      "assigner" : {
        "display" : "Centers for Medicare and Medicaid Services"
      }
    }
  ],
  "status" : "active",
  "type" : [
    {
      "coding" : [
        {
          "system" : "http://hl7.org/fhir/uv/vhdir/CodeSystem/payercharacteristics",
          "code" : "bronze",
          "display" : "Bronze"
        }
      ]
    }
  ],
  "name" : "Patriot PPO Standard",
  "alias" : [
    "Patriot Plus"
  ],
  "period" : {
    "start" : "2018-06-06",
    "end" : "2019-01-01"
  },
  "ownedBy" : {
    "reference" : "Organization/homeland",
    "display" : "Homeland Health Insurance"
  },
  "administeredBy" : {
    "reference" : "Organization/homeland",
    "display" : "Homeland Health Insurance"
  },
  "coverageArea" : [
    {
      "reference" : "Location/wash-dc-metro",
      "display" : "Washington, DC metro area"
    }
  ],
  "contact" : [
    {
      "purpose" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/contactentity-type",
            "code" : "PATINF",
            "display" : "Patient"
          }
        ],
        "text" : "General information"
      },
      "telecom" : [
        {
          "system" : "phone",
          "value" : "202-123-5555"
        },
        {
          "system" : "email",
          "value" : "info@homelandinc.org"
        }
      ]
    }
  ],
  "endpoint" : [
    {
      "display" : "patriot plan endpoint hub"
    }
  ],
  "network" : [
    {
      "reference" : "Organization/patriotppo",
      "display" : "Patriot Preferred Provider Network"
    },
    {
      "reference" : "Organization/patriotdental",
      "display" : "Patriot Dental Provider Network"
    }
  ],
  "coverage" : [
    {
      "type" : {
        "coding" : [
          {
            "code" : "medical",
            "display" : "Medical"
          }
        ],
        "text" : "Coverage related to medical inpatient, outpatient, diagnostic, and preventive care"
      },
      "network" : [
        {
          "reference" : "Organization/patriotppo",
          "display" : "Patriot Preferred Provider Network"
        }
      ],
      "benefit" : [
        {
          "type" : {
            "coding" : [
              {
                "code" : "001",
                "display" : "Primary care visit to treat an injury or illness"
              }
            ]
          },
          "requirement" : "N/A",
          "limit" : [
            {
              "code" : {
                "text" : "unlimited"
              }
            }
          ]
        }
      ]
    },
    {
      "type" : {
        "coding" : [
          {
            "code" : "dental",
            "display" : "Dental"
          }
        ],
        "text" : "Coverage related to dental care"
      },
      "network" : [
        {
          "reference" : "Organization/patriotdental",
          "display" : "Patriot Dental Provider Network"
        }
      ],
      "benefit" : [
        {
          "type" : {
            "coding" : [
              {
                "code" : "052",
                "display" : "Basic Dental Care – Adult"
              }
            ],
            "text" : "Periodic oral checkup"
          },
          "requirement" : "N/A",
          "limit" : [
            {
              "value" : {
                "value" : 2,
                "unit" : "visit/yr",
                "system" : "http://unitsofmeasure.org",
                "code" : "{visit}/a"
              },
              "code" : {
                "text" : "biannual oral checkup"
              }
            }
          ]
        }
      ]
    }
  ],
  "plan" : [
    {
      "identifier" : [
        {
          "use" : "official",
          "type" : {
            "coding" : [
              {
                "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
                "code" : "NIIP",
                "display" : "National Insurance Payor Identifier (Payor)",
                "userSelected" : true
              }
            ],
            "text" : "HIOS plan ID"
          },
          "system" : "https://www.cms.gov/CCIIO/",
          "value" : "123456789101112",
          "assigner" : {
            "display" : "Centers for Medicare and Medicaid Services"
          }
        }
      ],
      "type" : {
        "coding" : [
          {
            "code" : "bronze",
            "display" : "Bronze"
          }
        ],
        "text" : "Bronze"
      },
      "coverageArea" : [
        {
          "reference" : "Location/wash-dc-metro",
          "display" : "Washington, DC metro area"
        }
      ],
      "network" : [
        {
          "reference" : "Organization/patriotdental",
          "display" : "Patriot Dental Provider Network"
        }
      ],
      "generalCost" : [
        {
          "type" : {
            "coding" : [
              {
                "code" : "deductible",
                "display" : "Deductible"
              }
            ],
            "text" : "Deductible"
          },
          "groupSize" : 1,
          "cost" : {
            "value" : 6200,
            "currency" : "USD"
          },
          "comment" : "Includes all prescription and medical costs for in-network providers"
        }
      ],
      "specificCost" : [
        {
          "category" : {
            "coding" : [
              {
                "code" : "medical",
                "display" : "Medical"
              }
            ]
          },
          "benefit" : [
            {
              "type" : {
                "coding" : [
                  {
                    "code" : "001",
                    "display" : "Primary care visit to treat an injury or illness"
                  }
                ]
              },
              "cost" : [
                {
                  "type" : {
                    "coding" : [
                      {
                        "code" : "copay",
                        "display" : "Copay"
                      }
                    ]
                  },
                  "applicability" : {
                    "coding" : [
                      {
                        "system" : "http://terminology.hl7.org/CodeSystem/applicability",
                        "code" : "in-network",
                        "display" : "In Network"
                      }
                    ]
                  },
                  "qualifiers" : [
                    {
                      "text" : "in-network preferred provider"
                    }
                  ],
                  "value" : {
                    "value" : 50,
                    "unit" : "dollars",
                    "system" : "urn:iso:std:iso:4217",
                    "code" : "USD"
                  }
                }
              ]
            }
          ]
        },
        {
          "category" : {
            "coding" : [
              {
                "code" : "dental",
                "display" : "Dental"
              }
            ]
          },
          "benefit" : [
            {
              "type" : {
                "coding" : [
                  {
                    "code" : "052",
                    "display" : "Basic Dental Care – Adult"
                  }
                ]
              },
              "cost" : [
                {
                  "type" : {
                    "coding" : [
                      {
                        "code" : "coinsurance",
                        "display" : "Coinsurance"
                      }
                    ]
                  },
                  "applicability" : {
                    "coding" : [
                      {
                        "system" : "http://terminology.hl7.org/CodeSystem/applicability",
                        "code" : "in-network",
                        "display" : "In Network"
                      }
                    ]
                  },
                  "qualifiers" : [
                    {
                      "text" : "in-network provider"
                    }
                  ],
                  "value" : {
                    "value" : 10,
                    "unit" : "percent"
                  }
                }
              ]
            }
          ]
        }
      ]
    }
  ]
}