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: Payer Provider Network Query InsurancePlan Profile

Official URL: http://hl7.org/fhir/us/ndh/StructureDefinition/ndhPn-ldapi-InsurancePlan Version: 1.0.0-ballot
Active as of 2024-11-25 Computable Name: NdhPnLdApiInsurancePlan

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.

Usage:

Formal Views of Profile Content

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

This structure is derived from NdhInsurancePlan

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan NdhInsurancePlan
... identifier
.... type S 0..1 CodeableConcept Description of identifier
.... value S 0..1 string The value that is unique
.... assigner S 0..1 Reference(Payer Provider Network Query Organization Profile) Organization that issued id (may be just text)
... alias S 0..* string Alternate names
... period S 0..1 Period When the product is available
... administeredBy S 1..1 Reference(Payer Provider Network Query Organization Profile) Product administrator
... coverageArea 0..* Reference(Payer Provider Network Query Location Profile) Where product applies
... contact S 0..* BackboneElement Contact for the product
.... name S 0..1 HumanName A name associated with the contact
..... text S 0..1 string Text representation of the full name
.... telecom S 0..* ContactPoint Contact details (telephone, email, etc.) for a contact
..... system S 0..1 code phone | fax | email | pager | url | sms | other
..... value S 0..1 string The actual contact point details
... endpoint S 0..* Reference(Payer Provider Network Local Directory API Endpoint Profile) Technical endpoint
... network 0..* Reference(Payer Provider Network Query Network Profile) What networks are Included
... coverage
.... network 0..* Reference(Payer Provider Network Query Network Profile) What networks provide coverage
... plan
.... type S 0..1 CodeableConcept Categorization of the cost sharing for the plan
.... coverageArea S 0..* Reference(Payer Provider Network Query Location Profile) Where product applies
.... network 0..* Reference(Payer Provider Network Query Network Profile) What networks provide coverage

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C 0..* NdhInsurancePlan 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 Content/Rules for all slices
.... 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: rofessional Credential Status (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 SΣ 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.

.... value SΣ 0..1 string The value that is unique
Example General: 123456
.... assigner SΣ 0..1 Reference(Payer Provider Network Query 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 (extensible)
... name SΣC 0..1 string Official name
... alias S 0..* string Alternate names
... period S 0..1 Period When the product is available
... ownedBy SΣ 1..1 Reference(Payer Provider Network Query Organization Profile) Plan issuer
... administeredBy SΣ 1..1 Reference(Payer Provider Network Query Organization Profile) Product administrator
... coverageArea SΣ 0..* Reference(Payer Provider Network Query Location Profile) Where product applies
... contact S 0..* BackboneElement Contact for the product
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... name S 0..1 HumanName A name associated with the contact
..... use ?!Σ 0..1 code usual | official | temp | nickname | anonymous | old | maiden
Binding: NameUse (required): The use of a human name.

..... text SΣ 0..1 string Text representation of the full name
.... telecom S 0..* ContactPoint Contact details (telephone, email, etc.) for a contact
..... 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
..... system SΣC 0..1 code phone | fax | email | pager | url | sms | other
Binding: ContactPointSystem (required): Telecommunications form for contact point.

..... value SΣ 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.

... endpoint S 0..* Reference(Payer Provider Network Local Directory API Endpoint Profile) Technical endpoint
... network S 0..* Reference(Payer Provider Network Query 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: Insurance Coverage Type (extensible)
.... network S 0..* Reference(Payer Provider Network Query 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 S 0..1 CodeableConcept Categorization of the cost sharing for the plan
Binding: Insuranceplan Plan Type (extensible)
.... coverageArea SΣ 0..* Reference(Payer Provider Network Query Location Profile) Where product applies
.... network 0..* Reference(Payer Provider Network Query 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.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.typeextensibleInsuranceProductType
http://terminology.hl7.org/ValueSet/insurance-product-type
InsurancePlan.contact.name.userequiredNameUse
http://hl7.org/fhir/ValueSet/name-use|4.0.1
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.typeextensibleInsuranceCoverageType
http://terminology.hl7.org/ValueSet/insurance-coverage-type
InsurancePlan.coverage.benefit.typeextensibleNdhBenefitTypeVS
http://hl7.org/fhir/us/ndh/ValueSet/NdhBenefitTypeVS
from this IG
InsurancePlan.plan.typeextensibleInsuranceplanPlanType
http://terminology.hl7.org/ValueSet/insuranceplan-plan-type
NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C 0..* NdhInsurancePlan 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: rofessional Credential Status (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 SΣ 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 SΣ 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 SΣ 0..1 Reference(Payer Provider Network Query 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 (extensible)
... name SΣC 0..1 string Official name
... alias S 0..* string Alternate names
... period S 0..1 Period When the product is available
... ownedBy SΣ 1..1 Reference(Payer Provider Network Query Organization Profile) Plan issuer
... administeredBy SΣ 1..1 Reference(Payer Provider Network Query Organization Profile) Product administrator
... coverageArea SΣ 0..* Reference(Payer Provider Network Query Location Profile) Where product applies
... contact S 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 S 0..1 HumanName A name associated with the contact
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | nickname | anonymous | old | maiden
Binding: NameUse (required): The use of a human name.

..... text SΣ 0..1 string Text representation of the full name
..... family Σ 0..1 string Family name (often called 'Surname')
..... given Σ 0..* string Given names (not always 'first'). Includes middle names
This repeating element order: Given Names appear in the correct order for presenting the name
..... prefix Σ 0..* string Parts that come before the name
This repeating element order: Prefixes appear in the correct order for presenting the name
..... suffix Σ 0..* string Parts that come after the name
This repeating element order: Suffixes appear in the correct order for presenting the name
..... period Σ 0..1 Period Time period when name was/is in use
.... telecom S 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 SΣC 0..1 code phone | fax | email | pager | url | sms | other
Binding: ContactPointSystem (required): Telecommunications form for contact point.

..... value SΣ 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 S 0..* Reference(Payer Provider Network Local Directory API Endpoint Profile) Technical endpoint
... network S 0..* Reference(Payer Provider Network Query 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: Insurance Coverage Type (extensible)
.... network S 0..* Reference(Payer Provider Network Query 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: rofessional Credential Status (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 S 0..1 CodeableConcept Categorization of the cost sharing for the plan
Binding: Insuranceplan Plan Type (extensible)
.... coverageArea SΣ 0..* Reference(Payer Provider Network Query Location Profile) Where product applies
.... network 0..* Reference(Payer Provider Network Query 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.typeextensibleInsuranceProductType
http://terminology.hl7.org/ValueSet/insurance-product-type
InsurancePlan.contact.purposeextensibleContactEntityType
http://hl7.org/fhir/ValueSet/contactentity-type
from the FHIR Standard
InsurancePlan.contact.name.userequiredNameUse
http://hl7.org/fhir/ValueSet/name-use|4.0.1
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.typeextensibleInsuranceCoverageType
http://terminology.hl7.org/ValueSet/insurance-coverage-type
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.typeextensibleInsuranceplanPlanType
http://terminology.hl7.org/ValueSet/insuranceplan-plan-type
InsurancePlan.plan.specificCost.benefit.cost.applicabilityrequiredBenefitCostApplicability
http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1
from the FHIR Standard

Differential View

This structure is derived from NdhInsurancePlan

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan NdhInsurancePlan
... identifier
.... type S 0..1 CodeableConcept Description of identifier
.... value S 0..1 string The value that is unique
.... assigner S 0..1 Reference(Payer Provider Network Query Organization Profile) Organization that issued id (may be just text)
... alias S 0..* string Alternate names
... period S 0..1 Period When the product is available
... administeredBy S 1..1 Reference(Payer Provider Network Query Organization Profile) Product administrator
... coverageArea 0..* Reference(Payer Provider Network Query Location Profile) Where product applies
... contact S 0..* BackboneElement Contact for the product
.... name S 0..1 HumanName A name associated with the contact
..... text S 0..1 string Text representation of the full name
.... telecom S 0..* ContactPoint Contact details (telephone, email, etc.) for a contact
..... system S 0..1 code phone | fax | email | pager | url | sms | other
..... value S 0..1 string The actual contact point details
... endpoint S 0..* Reference(Payer Provider Network Local Directory API Endpoint Profile) Technical endpoint
... network 0..* Reference(Payer Provider Network Query Network Profile) What networks are Included
... coverage
.... network 0..* Reference(Payer Provider Network Query Network Profile) What networks provide coverage
... plan
.... type S 0..1 CodeableConcept Categorization of the cost sharing for the plan
.... coverageArea S 0..* Reference(Payer Provider Network Query Location Profile) Where product applies
.... network 0..* Reference(Payer Provider Network Query Network Profile) What networks provide coverage

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C 0..* NdhInsurancePlan 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 Content/Rules for all slices
.... 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: rofessional Credential Status (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 SΣ 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.

.... value SΣ 0..1 string The value that is unique
Example General: 123456
.... assigner SΣ 0..1 Reference(Payer Provider Network Query 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 (extensible)
... name SΣC 0..1 string Official name
... alias S 0..* string Alternate names
... period S 0..1 Period When the product is available
... ownedBy SΣ 1..1 Reference(Payer Provider Network Query Organization Profile) Plan issuer
... administeredBy SΣ 1..1 Reference(Payer Provider Network Query Organization Profile) Product administrator
... coverageArea SΣ 0..* Reference(Payer Provider Network Query Location Profile) Where product applies
... contact S 0..* BackboneElement Contact for the product
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... name S 0..1 HumanName A name associated with the contact
..... use ?!Σ 0..1 code usual | official | temp | nickname | anonymous | old | maiden
Binding: NameUse (required): The use of a human name.

..... text SΣ 0..1 string Text representation of the full name
.... telecom S 0..* ContactPoint Contact details (telephone, email, etc.) for a contact
..... 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
..... system SΣC 0..1 code phone | fax | email | pager | url | sms | other
Binding: ContactPointSystem (required): Telecommunications form for contact point.

..... value SΣ 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.

... endpoint S 0..* Reference(Payer Provider Network Local Directory API Endpoint Profile) Technical endpoint
... network S 0..* Reference(Payer Provider Network Query 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: Insurance Coverage Type (extensible)
.... network S 0..* Reference(Payer Provider Network Query 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 S 0..1 CodeableConcept Categorization of the cost sharing for the plan
Binding: Insuranceplan Plan Type (extensible)
.... coverageArea SΣ 0..* Reference(Payer Provider Network Query Location Profile) Where product applies
.... network 0..* Reference(Payer Provider Network Query 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.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.typeextensibleInsuranceProductType
http://terminology.hl7.org/ValueSet/insurance-product-type
InsurancePlan.contact.name.userequiredNameUse
http://hl7.org/fhir/ValueSet/name-use|4.0.1
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.typeextensibleInsuranceCoverageType
http://terminology.hl7.org/ValueSet/insurance-coverage-type
InsurancePlan.coverage.benefit.typeextensibleNdhBenefitTypeVS
http://hl7.org/fhir/us/ndh/ValueSet/NdhBenefitTypeVS
from this IG
InsurancePlan.plan.typeextensibleInsuranceplanPlanType
http://terminology.hl7.org/ValueSet/insuranceplan-plan-type

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C 0..* NdhInsurancePlan 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: rofessional Credential Status (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 SΣ 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 SΣ 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 SΣ 0..1 Reference(Payer Provider Network Query 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 (extensible)
... name SΣC 0..1 string Official name
... alias S 0..* string Alternate names
... period S 0..1 Period When the product is available
... ownedBy SΣ 1..1 Reference(Payer Provider Network Query Organization Profile) Plan issuer
... administeredBy SΣ 1..1 Reference(Payer Provider Network Query Organization Profile) Product administrator
... coverageArea SΣ 0..* Reference(Payer Provider Network Query Location Profile) Where product applies
... contact S 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 S 0..1 HumanName A name associated with the contact
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | nickname | anonymous | old | maiden
Binding: NameUse (required): The use of a human name.

..... text SΣ 0..1 string Text representation of the full name
..... family Σ 0..1 string Family name (often called 'Surname')
..... given Σ 0..* string Given names (not always 'first'). Includes middle names
This repeating element order: Given Names appear in the correct order for presenting the name
..... prefix Σ 0..* string Parts that come before the name
This repeating element order: Prefixes appear in the correct order for presenting the name
..... suffix Σ 0..* string Parts that come after the name
This repeating element order: Suffixes appear in the correct order for presenting the name
..... period Σ 0..1 Period Time period when name was/is in use
.... telecom S 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 SΣC 0..1 code phone | fax | email | pager | url | sms | other
Binding: ContactPointSystem (required): Telecommunications form for contact point.

..... value SΣ 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 S 0..* Reference(Payer Provider Network Local Directory API Endpoint Profile) Technical endpoint
... network S 0..* Reference(Payer Provider Network Query 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: Insurance Coverage Type (extensible)
.... network S 0..* Reference(Payer Provider Network Query 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: rofessional Credential Status (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 S 0..1 CodeableConcept Categorization of the cost sharing for the plan
Binding: Insuranceplan Plan Type (extensible)
.... coverageArea SΣ 0..* Reference(Payer Provider Network Query Location Profile) Where product applies
.... network 0..* Reference(Payer Provider Network Query 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.typeextensibleInsuranceProductType
http://terminology.hl7.org/ValueSet/insurance-product-type
InsurancePlan.contact.purposeextensibleContactEntityType
http://hl7.org/fhir/ValueSet/contactentity-type
from the FHIR Standard
InsurancePlan.contact.name.userequiredNameUse
http://hl7.org/fhir/ValueSet/name-use|4.0.1
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.typeextensibleInsuranceCoverageType
http://terminology.hl7.org/ValueSet/insurance-coverage-type
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.typeextensibleInsuranceplanPlanType
http://terminology.hl7.org/ValueSet/insuranceplan-plan-type
InsurancePlan.plan.specificCost.benefit.cost.applicabilityrequiredBenefitCostApplicability
http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1
from the FHIR Standard

 

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