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

XML Format: InsurancePlan-insuranceplan1

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<InsurancePlan xmlns="http://hl7.org/fhir">
<!--  describes a fictional Qualified Health Plan (QHP) in the Washington, DC metro area  -->
  <id value="insuranceplan1"/>
  <text>
    <status value="generated"/>
    <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>
  </text>
  <identifier>
  <!--  Official HIOS product ID assigned by CMS  -->
    <use value="official"/>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
        <code value="NIIP"/>
        <display value="National Insurance Payor Identifier (Payor)"/>
        <userSelected value="true"/>
      </coding>
      <text value="HIOS product ID"/>
    </type>
    <system value="https://www.cms.gov/CCIIO/"/>
    <value value="1234567891"/>
    <assigner>
      <display value="Centers for Medicare and Medicaid Services"/>
    </assigner>
  </identifier>
  <status value="active"/>
<!--  This record is active  -->
  <type>
    <coding>
      <system
              value="http://hl7.org/fhir/uv/vhdir/CodeSystem/payercharacteristics"/>
      <code value="bronze"/>
      <display value="Bronze"/>
    </coding>
  </type>
  <name value="Patriot PPO Standard"/>
<!--  Name of the product is Patriot PPO Standard  -->
  <alias value="Patriot Plus"/>
  <period>
    <start value="2018-06-06"/>
    <end value="2019-01-01"/>
  </period>
  <ownedBy>
  <!--  Reference to the owner of the product, Homeland Health Insurance  -->
    <reference value="Organization/homeland"/>
    <display value="Homeland Health Insurance"/>
  </ownedBy>
  <administeredBy>
    <reference value="Organization/homeland"/>
    <display value="Homeland Health Insurance"/>
  </administeredBy>
  <coverageArea>
  <!--  Reference to the product's coverage area, the Washington, DC metro area  -->
    <reference value="Location/wash-dc-metro"/>
    <display value="Washington, DC metro area"/>
  </coverageArea>
  <contact>
  <!--  Contact information for consumers  -->
    <purpose>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/contactentity-type"/>
        <code value="PATINF"/>
        <display value="Patient"/>
      </coding>
      <text value="General information"/>
    </purpose>
    <telecom>
      <system value="phone"/>
      <value value="202-123-5555"/>
    </telecom>
    <telecom>
      <system value="email"/>
      <value value="info@homelandinc.org"/>
    </telecom>
  </contact>
  <endpoint>
  <!--  A reference to the technical endpoints providing access to services operated for the health insurance product.
		<reference value=""/>  -->
    <display value="patriot plan endpoint hub"/>
  </endpoint>
  <network>
  <!--  A reference to the medical provider network associated with this product  -->
    <reference value="Organization/patriotppo"/>
    <display value="Patriot Preferred Provider Network"/>
  </network>
  <network>
  <!--  A reference to the dental provider network associated with this product  -->
    <reference value="Organization/patriotdental"/>
    <display value="Patriot Dental Provider Network"/>
  </network>
  <coverage>
  <!--  describes medical benefits  -->
    <type>
      <coding>
        <code value="medical"/>
        <display value="Medical"/>
      </coding>
      <text
            value="Coverage related to medical inpatient, outpatient, diagnostic, and preventive care"/>
    </type>
    <network>
      <reference value="Organization/patriotppo"/>
      <display value="Patriot Preferred Provider Network"/>
    </network>
    <benefit>
    <!--  basic primary care visit  -->
      <type>
        <coding>
          <code value="001"/>
          <display value="Primary care visit to treat an injury or illness"/>
        </coding>
      </type>
      <requirement value="N/A"/>
      <limit>
        <code>
          <text value="unlimited"/>
        </code>
      </limit>
    </benefit>
  </coverage>
  <coverage>
  <!--  describes dental benefits  -->
    <type>
      <coding>
        <code value="dental"/>
        <display value="Dental"/>
      </coding>
      <text value="Coverage related to dental care"/>
    </type>
    <network>
      <reference value="Organization/patriotdental"/>
      <display value="Patriot Dental Provider Network"/>
    </network>
  <!-- Specific benefits under this type of coverage. -->
    <benefit>
    <!--  biannual oral checkup  -->
      <type>
        <coding>
          <code value="052"/>
          <display value="Basic Dental Care – Adult"/>
        </coding>
        <text value="Periodic oral checkup"/>
      </type>
      <requirement value="N/A"/>
      <limit>
        <value>
          <value value="2"/>
          <unit value="visit/yr"/>
          <system value="http://unitsofmeasure.org"/>
          <code value="{visit}/a"/>
        </value>
        <code>
          <text value="biannual oral checkup"/>
        </code>
      </limit>
    </benefit>
  </coverage>
  <plan>
  <!--  Information about the cost sharing features of the product  -->
    <identifier>
      <use value="official"/>
      <type>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
          <code value="NIIP"/>
          <display value="National Insurance Payor Identifier (Payor)"/>
          <userSelected value="true"/>
        </coding>
        <text value="HIOS plan ID"/>
      </type>
      <system value="https://www.cms.gov/CCIIO/"/>
      <value value="123456789101112"/>
      <assigner>
        <display value="Centers for Medicare and Medicaid Services"/>
      </assigner>
    </identifier>
    <type>
      <coding>
        <code value="bronze"/>
        <display value="Bronze"/>
      </coding>
      <text value="Bronze"/>
    </type>
    <coverageArea>
    <!--  Reference to the product's coverage area, the Washington, DC metro area  -->
      <reference value="Location/wash-dc-metro"/>
      <display value="Washington, DC metro area"/>
    </coverageArea>
    <network>
      <reference value="Organization/patriotdental"/>
      <display value="Patriot Dental Provider Network"/>
    </network>
    <generalCost>
    <!--  Describes the plan's deductible  -->
      <type>
        <coding>
          <code value="deductible"/>
          <display value="Deductible"/>
        </coding>
        <text value="Deductible"/>
      </type>
      <groupSize value="1"/>
      <cost>
        <value value="6200"/>
        <currency value="USD"/>
      </cost>
      <comment
               value="Includes all prescription and medical costs for in-network providers"/>
    </generalCost>
    <specificCost>
    <!--  Describes the costs associated with the medical coverage options  -->
      <category>
        <coding>
          <code value="medical"/>
          <display value="Medical"/>
        </coding>
      </category>
      <benefit>
      <!--  $50 copay for primary care visits with an in-network preferred provider  -->
        <type>
          <coding>
            <code value="001"/>
            <display value="Primary care visit to treat an injury or illness"/>
          </coding>
        </type>
        <cost>
          <type>
            <coding>
              <code value="copay"/>
              <display value="Copay"/>
            </coding>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <text value="in-network preferred provider"/>
          </qualifiers>
          <value>
            <value value="50"/>
            <unit value="dollars"/>
            <system value="urn:iso:std:iso:4217"/>
            <code value="USD"/>
          </value>
        </cost>
      </benefit>
    </specificCost>
    <specificCost>
    <!--  describes the costs associated with dental coverage  -->
      <category>
        <coding>
          <code value="dental"/>
          <display value="Dental"/>
        </coding>
      </category>
      <benefit>
      <!--  10% coinsurance for routine oral checkup with an in-network dental provider  -->
        <type>
          <coding>
            <code value="052"/>
            <display value="Basic Dental Care – Adult"/>
          </coding>
        </type>
        <cost>
          <type>
            <coding>
              <code value="coinsurance"/>
              <display value="Coinsurance"/>
            </coding>
          </type>
          <applicability>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/applicability"/>
              <code value="in-network"/>
              <display value="In Network"/>
            </coding>
          </applicability>
          <qualifiers>
            <text value="in-network provider"/>
          </qualifiers>
          <value>
            <value value="10"/>
            <unit value="percent"/>
          </value>
        </cost>
      </benefit>
    </specificCost>
  </plan>
</InsurancePlan>