National Directory of Healthcare Providers & Services (NDH) Implementation Guide
1.0.0-ballot - ballot United States of America flag

National Directory of Healthcare Providers & Services (NDH) Implementation Guide, published by HL7 International / Patient Administration. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-us-ndh/ and changes regularly. See the Directory of published versions

Resource Profile: NDH Base InsurancePlan Profile

Official URL: http://hl7.org/fhir/us/ndh/StructureDefinition/ndh-InsurancePlan Version: 1.0.0-ballot
Active as of 2024-06-17 Computable Name: NdhInsurancePlan

Copyright/Legal: HL7 International

An InsurancePlan 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 covered benefits. A plan pairs a product’s covered benefits with the particular cost sharing structure offered to a consumer. A given product may comprise multiple plans (i.e. each plan offers different cost sharing requirements for the same set of covered benefits). 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.

Background & scope

Each insurancePlan has a type which describe the product. An insurancePlan may offer its coverage benefits under a particular network. If an insurancePlan does not have a network, each plan of the insurancePlan must define a distinct plan type (InsurancePlace.plan.type).

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 insurance plan), and additional information about the offering, such as who own it, who administer it, coverage area, contact information, etc.

To change a network in an insurance plan, adjust the insurancePlan.period and genderate a fresh new insurance plan.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from InsurancePlan

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
network-or-NatlDirwork: If an insuranceplan does not define a network, then each plan must define one
plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type.
... meta
.... lastUpdated 1..1 instant When the resource version last changed
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... usage-restriction 0..* Reference(NDH Base Restriction) {c} Usage Restriction
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-usage-restriction
.... verification-status 0..1 CodeableConcept NDH Verification Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status
Binding: NDH Verification Status Value Set (extensible)
... identifier S 0..* Identifier Business Identifier for Product
.... Slices for extension Content/Rules for all slices
..... identifier-status 0..1 code NDH Identifier Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status
Binding: Identifier Status Value Set (required)
.... assigner 0..1 Reference(NDH Base Organization Profile) Organization that issued id (may be just text)
... type S 1..1 CodeableConcept Product Type
Binding: Insurance Product Type Value Set (extensible)
... name S 0..1 string Official name
... ownedBy 0..1 Reference(NDH Base Organization Profile) Plan issuer
... administeredBy 0..1 Reference(NDH Base Organization Profile) Product administrator
... coverageArea S 0..* Reference(NDH Base Location Profile) Where product applies
... contact
.... telecom
..... Slices for extension Content/Rules for all slices
...... contactpoint-availabletime 0..* (Complex) NDH Contactpoint Availabletime
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-contactpoint-availabletime
...... via-intermediary 0..1 Reference(NDH Base PractitionerRole | NDH Base OrganizationAffiliation Profile | NDH Base Location Profile | NDH Base Organization Profile) Via Intermediary
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-via-intermediary
... endpoint 0..* Reference(NDH Base Endpoint Profile) Technical endpoint
... network S 0..* Reference(NDH Base Network Profile) What networks are Included
... coverage
.... type 1..1 CodeableConcept Type of coverage
Binding: NDH Insurance Coverage Type Value Set (extensible)
.... network S 0..* Reference(NDH Base Network Profile) What networks provide coverage
.... benefit
..... type 1..1 CodeableConcept Type of benefit
Binding: NDH Benefit Type Value Set (extensible)
... plan 0..* BackboneElement Cost sharing details for the plan
.... identifier
..... Slices for extension Content/Rules for all slices
...... identifier-status 0..1 code NDH Identifier Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status
Binding: Identifier Status Value Set (required)
..... assigner 0..1 Reference(NDH Base Organization Profile) Organization that issued id (may be just text)
.... type 0..1 CodeableConcept Categorization of the cost sharing for the plan
Binding: Insurance Plan Type Value Set (extensible)
.... coverageArea 0..* Reference(NDH Base Location Profile) Where product applies
.... network 0..* Reference(NDH Base Network Profile) What networks provide coverage

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
InsurancePlan.typeextensibleInsuranceProductTypeVS (a valid code from Insurance Product Type Code System)
http://hl7.org/fhir/us/ndh/ValueSet/InsuranceProductTypeVS
from this IG
InsurancePlan.coverage.typeextensibleNdhCoverageTypeVS
http://hl7.org/fhir/us/ndh/ValueSet/NdhCoverageTypeVS
from this IG
InsurancePlan.coverage.benefit.typeextensibleNdhBenefitTypeVS
http://hl7.org/fhir/us/ndh/ValueSet/NdhBenefitTypeVS
from this IG
InsurancePlan.plan.typeextensibleInsurancePlanTypeVS (a valid code from Insurance Plan Type Code System)
http://hl7.org/fhir/us/ndh/ValueSet/InsurancePlanTypeVS
from this IG

Constraints

IdGradePath(s)DetailsRequirements
network-or-NatlDirworkerrorInsurancePlanIf an insuranceplan does not define a network, then each plan must define one
: network.exists() or coverage.network.exists() or plan.network.exists()
plan-type-is-distincterrorInsurancePlanEach InsurancePlan.plan should have a distinct plan.type.
: plan.type.coding.code.isDistinct()
NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
ipn-1: The organization SHALL at least have a name or an idendtifier, and possibly more than one
network-or-NatlDirwork: If an insuranceplan does not define a network, then each plan must define one
plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type.
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... usage-restriction 0..* Reference(NDH Base Restriction) {c} Usage Restriction
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-usage-restriction
.... verification-status 0..1 CodeableConcept NDH Verification Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status
Binding: NDH Verification Status Value Set (extensible)
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
.... Slices for extension Content/Rules for all slices
..... identifier-status 0..1 code NDH Identifier Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status
Binding: Identifier Status Value Set (required)
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... assigner Σ 0..1 Reference(NDH Base Organization Profile) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code draft | active | retired | unknown
Binding: PublicationStatus (required): The lifecycle status of an artifact.


Fixed Value: active
... type SΣ 1..1 CodeableConcept Product Type
Binding: Insurance Product Type Value Set (extensible)
... name SΣC 0..1 string Official name
... ownedBy Σ 0..1 Reference(NDH Base Organization Profile) Plan issuer
... administeredBy Σ 0..1 Reference(NDH Base Organization Profile) Product administrator
... coverageArea SΣ 0..* Reference(NDH Base Location Profile) Where product applies
... endpoint 0..* Reference(NDH Base Endpoint Profile) Technical endpoint
... network S 0..* Reference(NDH Base Network Profile) What networks are Included
... coverage 0..* BackboneElement Coverage details
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Type of coverage
Binding: NDH Insurance Coverage Type Value Set (extensible)
.... network S 0..* Reference(NDH Base Network Profile) What networks provide coverage
.... benefit 1..* BackboneElement List of benefits
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 1..1 CodeableConcept Type of benefit
Binding: NDH Benefit Type Value Set (extensible)
... plan 0..* BackboneElement Cost sharing details for the plan
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 0..1 CodeableConcept Categorization of the cost sharing for the plan
Binding: Insurance Plan Type Value Set (extensible)
.... coverageArea Σ 0..* Reference(NDH Base Location Profile) Where product applies
.... network 0..* Reference(NDH Base Network Profile) What networks provide coverage

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
InsurancePlan.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
InsurancePlan.statusrequiredFixed Value: active
http://hl7.org/fhir/ValueSet/publication-status|4.0.1
from the FHIR Standard
InsurancePlan.typeextensibleInsuranceProductTypeVS (a valid code from Insurance Product Type Code System)
http://hl7.org/fhir/us/ndh/ValueSet/InsuranceProductTypeVS
from this IG
InsurancePlan.coverage.typeextensibleNdhCoverageTypeVS
http://hl7.org/fhir/us/ndh/ValueSet/NdhCoverageTypeVS
from this IG
InsurancePlan.coverage.benefit.typeextensibleNdhBenefitTypeVS
http://hl7.org/fhir/us/ndh/ValueSet/NdhBenefitTypeVS
from this IG
InsurancePlan.plan.typeextensibleInsurancePlanTypeVS (a valid code from Insurance Plan Type Code System)
http://hl7.org/fhir/us/ndh/ValueSet/InsurancePlanTypeVS
from this IG

Constraints

IdGradePath(s)DetailsRequirements
network-or-NatlDirworkerrorInsurancePlanIf an insuranceplan does not define a network, then each plan must define one
: network.exists() or coverage.network.exists() or plan.network.exists()
plan-type-is-distincterrorInsurancePlanEach InsurancePlan.plan should have a distinct plan.type.
: plan.type.coding.code.isDistinct()
NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
ipn-1: The organization SHALL at least have a name or an idendtifier, and possibly more than one
network-or-NatlDirwork: If an insuranceplan does not define a network, then each plan must define one
plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type.
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 1..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... usage-restriction 0..* Reference(NDH Base Restriction) {c} Usage Restriction
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-usage-restriction
.... verification-status 0..1 CodeableConcept NDH Verification Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status
Binding: NDH Verification Status Value Set (extensible)
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣC 0..* Identifier Business Identifier for Product
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... identifier-status 0..1 code NDH Identifier Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status
Binding: Identifier Status Value Set (required)
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

.... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ 0..1 string The value that is unique
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(NDH Base Organization Profile) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code draft | active | retired | unknown
Binding: PublicationStatus (required): The lifecycle status of an artifact.


Fixed Value: active
... type SΣ 1..1 CodeableConcept Product Type
Binding: Insurance Product Type Value Set (extensible)
... name SΣC 0..1 string Official name
... alias 0..* string Alternate names
... period 0..1 Period When the product is available
... ownedBy Σ 0..1 Reference(NDH Base Organization Profile) Plan issuer
... administeredBy Σ 0..1 Reference(NDH Base Organization Profile) Product administrator
... coverageArea SΣ 0..* Reference(NDH Base Location Profile) Where product applies
... contact 0..* BackboneElement Contact for the product
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... purpose 0..1 CodeableConcept The type of contact
Binding: ContactEntityType (extensible): The purpose for which you would contact a contact party.

.... name 0..1 HumanName A name associated with the contact
.... telecom 0..* ContactPoint Contact details (telephone, email, etc.) for a contact
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... contactpoint-availabletime 0..* (Complex) NDH Contactpoint Availabletime
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-contactpoint-availabletime
...... via-intermediary 0..1 Reference(NDH Base PractitionerRole | NDH Base OrganizationAffiliation Profile | NDH Base Location Profile | NDH Base Organization Profile) Via Intermediary
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-via-intermediary
..... system ΣC 0..1 code phone | fax | email | pager | url | sms | other
Binding: ContactPointSystem (required): Telecommunications form for contact point.

..... value Σ 0..1 string The actual contact point details
..... use ?!Σ 0..1 code home | work | temp | old | mobile - purpose of this contact point
Binding: ContactPointUse (required): Use of contact point.

..... rank Σ 0..1 positiveInt Specify preferred order of use (1 = highest)
..... period Σ 0..1 Period Time period when the contact point was/is in use
.... address 0..1 Address Visiting or postal addresses for the contact
... endpoint 0..* Reference(NDH Base Endpoint Profile) Technical endpoint
... network S 0..* Reference(NDH Base Network Profile) What networks are Included
... coverage 0..* BackboneElement Coverage details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Type of coverage
Binding: NDH Insurance Coverage Type Value Set (extensible)
.... network S 0..* Reference(NDH Base Network Profile) What networks provide coverage
.... benefit 1..* BackboneElement List of benefits
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 1..1 CodeableConcept Type of benefit
Binding: NDH Benefit Type Value Set (extensible)
..... requirement 0..1 string Referral requirements
..... limit 0..* BackboneElement Benefit limits
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... value 0..1 Quantity Maximum value allowed
...... code 0..1 CodeableConcept Benefit limit details
... plan 0..* BackboneElement Cost sharing details for the plan
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... identifier Σ 0..* Identifier Business Identifier for Product
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... identifier-status 0..1 code NDH Identifier Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status
Binding: Identifier Status Value Set (required)
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

..... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 0..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(NDH Base Organization Profile) Organization that issued id (may be just text)
.... type 0..1 CodeableConcept Categorization of the cost sharing for the plan
Binding: Insurance Plan Type Value Set (extensible)
.... coverageArea Σ 0..* Reference(NDH Base Location Profile) Where product applies
.... network 0..* Reference(NDH Base Network Profile) What networks provide coverage
.... generalCost 0..* BackboneElement Overall costs
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... 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
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept General category of benefit
..... benefit 0..* BackboneElement Benefits list
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type 1..1 CodeableConcept Type of specific benefit
...... cost 0..* BackboneElement List of the costs
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
....... type 1..1 CodeableConcept Type of cost
....... applicability 0..1 CodeableConcept in-network | out-of-network | other
Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.

....... qualifiers 0..* CodeableConcept Additional information about the cost
....... value 0..1 Quantity The actual cost value

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
InsurancePlan.meta.securityextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
InsurancePlan.meta.tagexampleCommonTags
http://hl7.org/fhir/ValueSet/common-tags
from the FHIR Standard
InsurancePlan.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
InsurancePlan.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
InsurancePlan.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
InsurancePlan.statusrequiredFixed Value: active
http://hl7.org/fhir/ValueSet/publication-status|4.0.1
from the FHIR Standard
InsurancePlan.typeextensibleInsuranceProductTypeVS (a valid code from Insurance Product Type Code System)
http://hl7.org/fhir/us/ndh/ValueSet/InsuranceProductTypeVS
from this IG
InsurancePlan.contact.purposeextensibleContactEntityType
http://hl7.org/fhir/ValueSet/contactentity-type
from the FHIR Standard
InsurancePlan.contact.telecom.systemrequiredContactPointSystem
http://hl7.org/fhir/ValueSet/contact-point-system|4.0.1
from the FHIR Standard
InsurancePlan.contact.telecom.userequiredContactPointUse
http://hl7.org/fhir/ValueSet/contact-point-use|4.0.1
from the FHIR Standard
InsurancePlan.coverage.typeextensibleNdhCoverageTypeVS
http://hl7.org/fhir/us/ndh/ValueSet/NdhCoverageTypeVS
from this IG
InsurancePlan.coverage.benefit.typeextensibleNdhBenefitTypeVS
http://hl7.org/fhir/us/ndh/ValueSet/NdhBenefitTypeVS
from this IG
InsurancePlan.plan.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
InsurancePlan.plan.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
InsurancePlan.plan.typeextensibleInsurancePlanTypeVS (a valid code from Insurance Plan Type Code System)
http://hl7.org/fhir/us/ndh/ValueSet/InsurancePlanTypeVS
from this IG
InsurancePlan.plan.specificCost.benefit.cost.applicabilityrequiredBenefitCostApplicability
http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
network-or-NatlDirworkerrorInsurancePlanIf an insuranceplan does not define a network, then each plan must define one
: network.exists() or coverage.network.exists() or plan.network.exists()
plan-type-is-distincterrorInsurancePlanEach InsurancePlan.plan should have a distinct plan.type.
: plan.type.coding.code.isDistinct()

Differential View

This structure is derived from InsurancePlan

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
network-or-NatlDirwork: If an insuranceplan does not define a network, then each plan must define one
plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type.
... meta
.... lastUpdated 1..1 instant When the resource version last changed
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... usage-restriction 0..* Reference(NDH Base Restriction) {c} Usage Restriction
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-usage-restriction
.... verification-status 0..1 CodeableConcept NDH Verification Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status
Binding: NDH Verification Status Value Set (extensible)
... identifier S 0..* Identifier Business Identifier for Product
.... Slices for extension Content/Rules for all slices
..... identifier-status 0..1 code NDH Identifier Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status
Binding: Identifier Status Value Set (required)
.... assigner 0..1 Reference(NDH Base Organization Profile) Organization that issued id (may be just text)
... type S 1..1 CodeableConcept Product Type
Binding: Insurance Product Type Value Set (extensible)
... name S 0..1 string Official name
... ownedBy 0..1 Reference(NDH Base Organization Profile) Plan issuer
... administeredBy 0..1 Reference(NDH Base Organization Profile) Product administrator
... coverageArea S 0..* Reference(NDH Base Location Profile) Where product applies
... contact
.... telecom
..... Slices for extension Content/Rules for all slices
...... contactpoint-availabletime 0..* (Complex) NDH Contactpoint Availabletime
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-contactpoint-availabletime
...... via-intermediary 0..1 Reference(NDH Base PractitionerRole | NDH Base OrganizationAffiliation Profile | NDH Base Location Profile | NDH Base Organization Profile) Via Intermediary
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-via-intermediary
... endpoint 0..* Reference(NDH Base Endpoint Profile) Technical endpoint
... network S 0..* Reference(NDH Base Network Profile) What networks are Included
... coverage
.... type 1..1 CodeableConcept Type of coverage
Binding: NDH Insurance Coverage Type Value Set (extensible)
.... network S 0..* Reference(NDH Base Network Profile) What networks provide coverage
.... benefit
..... type 1..1 CodeableConcept Type of benefit
Binding: NDH Benefit Type Value Set (extensible)
... plan 0..* BackboneElement Cost sharing details for the plan
.... identifier
..... Slices for extension Content/Rules for all slices
...... identifier-status 0..1 code NDH Identifier Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status
Binding: Identifier Status Value Set (required)
..... assigner 0..1 Reference(NDH Base Organization Profile) Organization that issued id (may be just text)
.... type 0..1 CodeableConcept Categorization of the cost sharing for the plan
Binding: Insurance Plan Type Value Set (extensible)
.... coverageArea 0..* Reference(NDH Base Location Profile) Where product applies
.... network 0..* Reference(NDH Base Network Profile) What networks provide coverage

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
InsurancePlan.typeextensibleInsuranceProductTypeVS (a valid code from Insurance Product Type Code System)
http://hl7.org/fhir/us/ndh/ValueSet/InsuranceProductTypeVS
from this IG
InsurancePlan.coverage.typeextensibleNdhCoverageTypeVS
http://hl7.org/fhir/us/ndh/ValueSet/NdhCoverageTypeVS
from this IG
InsurancePlan.coverage.benefit.typeextensibleNdhBenefitTypeVS
http://hl7.org/fhir/us/ndh/ValueSet/NdhBenefitTypeVS
from this IG
InsurancePlan.plan.typeextensibleInsurancePlanTypeVS (a valid code from Insurance Plan Type Code System)
http://hl7.org/fhir/us/ndh/ValueSet/InsurancePlanTypeVS
from this IG

Constraints

IdGradePath(s)DetailsRequirements
network-or-NatlDirworkerrorInsurancePlanIf an insuranceplan does not define a network, then each plan must define one
: network.exists() or coverage.network.exists() or plan.network.exists()
plan-type-is-distincterrorInsurancePlanEach InsurancePlan.plan should have a distinct plan.type.
: plan.type.coding.code.isDistinct()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
ipn-1: The organization SHALL at least have a name or an idendtifier, and possibly more than one
network-or-NatlDirwork: If an insuranceplan does not define a network, then each plan must define one
plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type.
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... usage-restriction 0..* Reference(NDH Base Restriction) {c} Usage Restriction
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-usage-restriction
.... verification-status 0..1 CodeableConcept NDH Verification Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status
Binding: NDH Verification Status Value Set (extensible)
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
.... Slices for extension Content/Rules for all slices
..... identifier-status 0..1 code NDH Identifier Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status
Binding: Identifier Status Value Set (required)
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... assigner Σ 0..1 Reference(NDH Base Organization Profile) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code draft | active | retired | unknown
Binding: PublicationStatus (required): The lifecycle status of an artifact.


Fixed Value: active
... type SΣ 1..1 CodeableConcept Product Type
Binding: Insurance Product Type Value Set (extensible)
... name SΣC 0..1 string Official name
... ownedBy Σ 0..1 Reference(NDH Base Organization Profile) Plan issuer
... administeredBy Σ 0..1 Reference(NDH Base Organization Profile) Product administrator
... coverageArea SΣ 0..* Reference(NDH Base Location Profile) Where product applies
... endpoint 0..* Reference(NDH Base Endpoint Profile) Technical endpoint
... network S 0..* Reference(NDH Base Network Profile) What networks are Included
... coverage 0..* BackboneElement Coverage details
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Type of coverage
Binding: NDH Insurance Coverage Type Value Set (extensible)
.... network S 0..* Reference(NDH Base Network Profile) What networks provide coverage
.... benefit 1..* BackboneElement List of benefits
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 1..1 CodeableConcept Type of benefit
Binding: NDH Benefit Type Value Set (extensible)
... plan 0..* BackboneElement Cost sharing details for the plan
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 0..1 CodeableConcept Categorization of the cost sharing for the plan
Binding: Insurance Plan Type Value Set (extensible)
.... coverageArea Σ 0..* Reference(NDH Base Location Profile) Where product applies
.... network 0..* Reference(NDH Base Network Profile) What networks provide coverage

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
InsurancePlan.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
InsurancePlan.statusrequiredFixed Value: active
http://hl7.org/fhir/ValueSet/publication-status|4.0.1
from the FHIR Standard
InsurancePlan.typeextensibleInsuranceProductTypeVS (a valid code from Insurance Product Type Code System)
http://hl7.org/fhir/us/ndh/ValueSet/InsuranceProductTypeVS
from this IG
InsurancePlan.coverage.typeextensibleNdhCoverageTypeVS
http://hl7.org/fhir/us/ndh/ValueSet/NdhCoverageTypeVS
from this IG
InsurancePlan.coverage.benefit.typeextensibleNdhBenefitTypeVS
http://hl7.org/fhir/us/ndh/ValueSet/NdhBenefitTypeVS
from this IG
InsurancePlan.plan.typeextensibleInsurancePlanTypeVS (a valid code from Insurance Plan Type Code System)
http://hl7.org/fhir/us/ndh/ValueSet/InsurancePlanTypeVS
from this IG

Constraints

IdGradePath(s)DetailsRequirements
network-or-NatlDirworkerrorInsurancePlanIf an insuranceplan does not define a network, then each plan must define one
: network.exists() or coverage.network.exists() or plan.network.exists()
plan-type-is-distincterrorInsurancePlanEach InsurancePlan.plan should have a distinct plan.type.
: plan.type.coding.code.isDistinct()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization
ipn-1: The organization SHALL at least have a name or an idendtifier, and possibly more than one
network-or-NatlDirwork: If an insuranceplan does not define a network, then each plan must define one
plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type.
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 1..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... usage-restriction 0..* Reference(NDH Base Restriction) {c} Usage Restriction
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-usage-restriction
.... verification-status 0..1 CodeableConcept NDH Verification Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status
Binding: NDH Verification Status Value Set (extensible)
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣC 0..* Identifier Business Identifier for Product
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... identifier-status 0..1 code NDH Identifier Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status
Binding: Identifier Status Value Set (required)
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

.... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ 0..1 string The value that is unique
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(NDH Base Organization Profile) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code draft | active | retired | unknown
Binding: PublicationStatus (required): The lifecycle status of an artifact.


Fixed Value: active
... type SΣ 1..1 CodeableConcept Product Type
Binding: Insurance Product Type Value Set (extensible)
... name SΣC 0..1 string Official name
... alias 0..* string Alternate names
... period 0..1 Period When the product is available
... ownedBy Σ 0..1 Reference(NDH Base Organization Profile) Plan issuer
... administeredBy Σ 0..1 Reference(NDH Base Organization Profile) Product administrator
... coverageArea SΣ 0..* Reference(NDH Base Location Profile) Where product applies
... contact 0..* BackboneElement Contact for the product
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... purpose 0..1 CodeableConcept The type of contact
Binding: ContactEntityType (extensible): The purpose for which you would contact a contact party.

.... name 0..1 HumanName A name associated with the contact
.... telecom 0..* ContactPoint Contact details (telephone, email, etc.) for a contact
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... contactpoint-availabletime 0..* (Complex) NDH Contactpoint Availabletime
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-contactpoint-availabletime
...... via-intermediary 0..1 Reference(NDH Base PractitionerRole | NDH Base OrganizationAffiliation Profile | NDH Base Location Profile | NDH Base Organization Profile) Via Intermediary
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-via-intermediary
..... system ΣC 0..1 code phone | fax | email | pager | url | sms | other
Binding: ContactPointSystem (required): Telecommunications form for contact point.

..... value Σ 0..1 string The actual contact point details
..... use ?!Σ 0..1 code home | work | temp | old | mobile - purpose of this contact point
Binding: ContactPointUse (required): Use of contact point.

..... rank Σ 0..1 positiveInt Specify preferred order of use (1 = highest)
..... period Σ 0..1 Period Time period when the contact point was/is in use
.... address 0..1 Address Visiting or postal addresses for the contact
... endpoint 0..* Reference(NDH Base Endpoint Profile) Technical endpoint
... network S 0..* Reference(NDH Base Network Profile) What networks are Included
... coverage 0..* BackboneElement Coverage details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Type of coverage
Binding: NDH Insurance Coverage Type Value Set (extensible)
.... network S 0..* Reference(NDH Base Network Profile) What networks provide coverage
.... benefit 1..* BackboneElement List of benefits
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type 1..1 CodeableConcept Type of benefit
Binding: NDH Benefit Type Value Set (extensible)
..... requirement 0..1 string Referral requirements
..... limit 0..* BackboneElement Benefit limits
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... value 0..1 Quantity Maximum value allowed
...... code 0..1 CodeableConcept Benefit limit details
... plan 0..* BackboneElement Cost sharing details for the plan
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... identifier Σ 0..* Identifier Business Identifier for Product
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... identifier-status 0..1 code NDH Identifier Status
URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status
Binding: Identifier Status Value Set (required)
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

..... system Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 0..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(NDH Base Organization Profile) Organization that issued id (may be just text)
.... type 0..1 CodeableConcept Categorization of the cost sharing for the plan
Binding: Insurance Plan Type Value Set (extensible)
.... coverageArea Σ 0..* Reference(NDH Base Location Profile) Where product applies
.... network 0..* Reference(NDH Base Network Profile) What networks provide coverage
.... generalCost 0..* BackboneElement Overall costs
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... 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
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept General category of benefit
..... benefit 0..* BackboneElement Benefits list
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... type 1..1 CodeableConcept Type of specific benefit
...... cost 0..* BackboneElement List of the costs
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
....... type 1..1 CodeableConcept Type of cost
....... applicability 0..1 CodeableConcept in-network | out-of-network | other
Binding: BenefitCostApplicability (required): Whether the cost applies to in-network or out-of-network providers.

....... qualifiers 0..* CodeableConcept Additional information about the cost
....... value 0..1 Quantity The actual cost value

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
InsurancePlan.meta.securityextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
InsurancePlan.meta.tagexampleCommonTags
http://hl7.org/fhir/ValueSet/common-tags
from the FHIR Standard
InsurancePlan.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
InsurancePlan.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
InsurancePlan.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
InsurancePlan.statusrequiredFixed Value: active
http://hl7.org/fhir/ValueSet/publication-status|4.0.1
from the FHIR Standard
InsurancePlan.typeextensibleInsuranceProductTypeVS (a valid code from Insurance Product Type Code System)
http://hl7.org/fhir/us/ndh/ValueSet/InsuranceProductTypeVS
from this IG
InsurancePlan.contact.purposeextensibleContactEntityType
http://hl7.org/fhir/ValueSet/contactentity-type
from the FHIR Standard
InsurancePlan.contact.telecom.systemrequiredContactPointSystem
http://hl7.org/fhir/ValueSet/contact-point-system|4.0.1
from the FHIR Standard
InsurancePlan.contact.telecom.userequiredContactPointUse
http://hl7.org/fhir/ValueSet/contact-point-use|4.0.1
from the FHIR Standard
InsurancePlan.coverage.typeextensibleNdhCoverageTypeVS
http://hl7.org/fhir/us/ndh/ValueSet/NdhCoverageTypeVS
from this IG
InsurancePlan.coverage.benefit.typeextensibleNdhBenefitTypeVS
http://hl7.org/fhir/us/ndh/ValueSet/NdhBenefitTypeVS
from this IG
InsurancePlan.plan.identifier.userequiredIdentifierUse
http://hl7.org/fhir/ValueSet/identifier-use|4.0.1
from the FHIR Standard
InsurancePlan.plan.identifier.typeextensibleIdentifier Type Codes
http://hl7.org/fhir/ValueSet/identifier-type
from the FHIR Standard
InsurancePlan.plan.typeextensibleInsurancePlanTypeVS (a valid code from Insurance Plan Type Code System)
http://hl7.org/fhir/us/ndh/ValueSet/InsurancePlanTypeVS
from this IG
InsurancePlan.plan.specificCost.benefit.cost.applicabilityrequiredBenefitCostApplicability
http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
network-or-NatlDirworkerrorInsurancePlanIf an insuranceplan does not define a network, then each plan must define one
: network.exists() or coverage.network.exists() or plan.network.exists()
plan-type-is-distincterrorInsurancePlanEach InsurancePlan.plan should have a distinct plan.type.
: plan.type.coding.code.isDistinct()

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Search Parameters

Search Parameter defined by the NDH IG

SearchParameter Name Type Example
coverage-area reference GET [base]/InsurancePlan?coverage-area.contains=41.809006\|-71.41177
coverage-benefit-type token GET [base]/InsurancePlan?coverage-benefit-type=pcpov
coverage-type token GET [base]/InsurancePlan?coverage-type=medical
coverage-network reference GET [base]/InsurancePlan?coverage-network.type=ntwk&coverage-network.address-state=CT
network reference GET [base]/InsurancePlan?network.type=ntwk&network.address-state=CT
plan-network reference `GET [base]/InsurancePlan?plan-network.type=ntwk&plan-network.address-state=CT
plan-type token `GET [base]/InsurancePlan?plan-type=gold
verification-status token GET [base]/InsurancePlan?verification-status=complete

Search Parameter defined by FHIR Search Parameter Registry and used by the NDH IG

Since there is no direct individual url for each Search Parameter defined by FHIR Serach Parameter Registry, we have provided the following links for you to access more information about them.

SearchParameter Name Type Example
address string GET [base]/InsurancePlan?address=456 Main Street
address-city string GET [base]/InsurancePlan?address-city=Norwalk
address-country string GET [base]/InsurancePlan?address-country=USA
address-postalcode string GET [base]/InsurancePlan?address-postalcode=34997
address-state string GET [base]/InsurancePlan?address-state=FL
administered-by reference GET [base]/InsurancePlan?administered-by.name=HOPE INC
endpoint reference GET [base]/InsurancePlan?endpoint.connection-type=hl7-fhir-rest
identifier token GET [base]/InsurancePlan?identifier=12345
name string GET [base]/InsurancePlan?name=Florida Blue
owned-by reference GET [base]/InsurancePlan?owned-by.name=Florida Blue
status token GET [base]/InsurancePlan?status=active
type token GET [base]/InsurancePlan?type=commppo

_include Search Parameter

_include Example
InsurancePlan:administered-by GET [base]/InsurancePlan?_include=InsurancePlan:administered-by
InsurancePlan:endpoint GET [base]/InsurancePlan?_include=InsurancePlan:endpoint
InsurancePlan:owned-by GET [base]/InsurancePlan?_include=InsurancePlan:owned-by
InsurancePlan:coverage-area GET [base]/InsurancePlan?_include=InsurancePlan:coverage-area
InsurancePlan:coverage-network GET [base]/InsurancePlan?_include=InsurancePlan:coverage-network
InsurancePlan:plan-coverage-area GET [base]/InsurancePlan?_include=InsurancePlan:coverage-area
InsurancePlan:plan-network GET [base]/InsurancePlan?_include=InsurancePlan:plan-network
InsurancePlan:network GET [base]/InsurancePlan?_include=InsurancePlan:network

If you only want to search for networks associated with an InsurancePlan, you can use the following approach: The primary resource in this context is the Organization, while the InsurancePlan resources serve as references to it. To accomplish this, the _revinclude feature is utilized. As the Network resource profile is derived from the Organization resource, the type=ntwk parameter must be included in your search.

GET [base]/Organization?type=ntwk&_revinclude=InsurancePlan:network

The relationship between InsurancePlans and Networks is many-to-many. A plan may be associated with multipe networks. The NDH model is having InsurancePlan reference networks.

Special Search Parameters

The search parameters outlined above are straightforward for basic scenarios but have limitations in handling complex combination queries. To enhance these capabilities, employing the special search parameters _filter is recommended.

InsurancePlan and Network relationship

The Insurance Plan resource defines three levels of networks: the base level network, the coverage level network, and the plan level network. The base level network is intended to apply to all coverage and plans when appropriate. For example, if dental services are included in the base level network and are covered at the coverage level, they would apply. Networks at the coverage level are specific to that coverage and are in addition to the base level network. Networks at the plan level are specific to the particular plan and incorporate any networks defined at both the base level and the coverage level. For instance, in a Platinum plan, the network may include more expensive venues that are not covered in lower-priced plans.

InsurancePlan type, network diagram

A payer’s products typically differ by network type and/or covered benefits. A insurance plan pairs a product’s covered benefits with the particular cost sharing structure offered to a consumer. A given payer’s product may comprise multiple insurance plans (i.e. each insurance plan offers different cost sharing requirements for the same set of covered benefits).

InsurancePlantype 1..1Commercial PPOCommercial HDHPCommercial POSCommercial HMOCommercial EPOMedicaidMedicad HMOMedicare AdvantageMedicare Advantage HMOMedicare Part AMedicare Part BMedicare Pard DMedicare A/BQualified HealthPlanIndian Health SequenceFederal Employee ProgramVeterans Affais PlanDental Plan, Dental Plan HMOVision Plan, Vision Plan HMOnetwork 0..*ownedBy 1..1administeredBy 1..1coverage 0..*type 1..1MedicalDentalMental HealthSubstance Abuse...network 0..*benefit 1..*type 1..1Primary Care Visit to Treat an Injury or IllnessSpecialist Office VisitOther Practitioner Office Visit (Nurse, Physician Assistant)...plan 0..*type 0..1QHP PlantinumQHP GoldQHP SilverQHP BronzeQHP CatastrophicLow DeductibleHigh DeductibleCatastrophic PlancoverageArea 0..*network 0..*generalCost 0..*specificCost 0..*