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Patient Administration Work GroupMaturity Level: 0 Draft Compartments: Not linked to any defined compartments

Detailed Descriptions for the elements in the ProductPlan resource.

ProductPlan
Element IdProductPlan
Definition

Details of a Health Insurance product/plan provided by an organization.

Control1..1
InvariantsDefined on this element
ppn-1: The organization SHALL at least have a name or an id, and possibly more than one (expression : (identifier.count() + name.count()) > 0, xpath: count(f:identifier | f:name) > 0)
ProductPlan.identifier
Element IdProductPlan.identifier
Definition

Business identifiers assigned to this health insurance product which remain constant as the resource is updated and propagates from server to server.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Summarytrue
InvariantsAffect this element
ppn-1: The organization SHALL at least have a name or an id, and possibly more than one (expression : (identifier.count() + name.count()) > 0, xpath: count(f:identifier | f:name) > 0)
ProductPlan.status
Element IdProductPlan.status
Definition

The current state of the health insurance product.

Control0..1
Terminology BindingPublicationStatus (Required)
Typecode
Is Modifiertrue (Reason: This element is labeled as a modifier because it is a status element that contains codes which means that the resource should not be treated as valid)
Meaning if MissingDefault interpretation is active.
Requirements

Need a flag to indicate a record is no longer to be used and should generally be hidden for the user in the UI.

Summarytrue
ProductPlan.type
Element IdProductPlan.type
Definition

The kind of health insurance product.

Control0..*
Terminology BindingProductPlanType (Example)
TypeCodeableConcept
Summarytrue
ProductPlan.name
Element IdProductPlan.name
Definition

Official name of the health insurance product as designated by the owner.

Control0..1
Typestring
Summarytrue
Comments

If the name of the product/plan changes, consider putting the old name in the alias column so that it can still be located through searches.

InvariantsAffect this element
ppn-1: The organization SHALL at least have a name or an id, and possibly more than one (expression : (identifier.count() + name.count()) > 0, xpath: count(f:identifier | f:name) > 0)
ProductPlan.alias
Element IdProductPlan.alias
Definition

A list of alternate names that the product is known as, or was known as in the past.

Control0..*
Typestring
Requirements

Over time products/plans go through many changes and can be known by different names.

For searching knowing previous names that the product/plan was known by can be very useful.

Comments

There are no dates associated with the alias/historic names, as this is not intended to track when names were used, but to assist in searching so that older names can still result in identifying the product/plan.

ProductPlan.period
Element IdProductPlan.period
Definition

The period of time that the health insurance product is available.

Control0..1
TypePeriod
ProductPlan.ownedBy
Element IdProductPlan.ownedBy
Definition

The entity that is providing the health insurance product and underwriting the risk. This is typically an insurance carriers, other third-party payers, or health plan sponsors comonly referred to as 'payers'.

Control0..1
TypeReference(Organization)
Alternate NamesPayer
Summarytrue
ProductPlan.administeredBy
Element IdProductPlan.administeredBy
Definition

An organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owner.

Control0..1
TypeReference(Organization)
Summarytrue
ProductPlan.coverageArea
Element IdProductPlan.coverageArea
Definition

The geographic region in which a health insurance product's benefits apply.

Control0..*
TypeReference(Location)
Summarytrue
ProductPlan.contact
Element IdProductPlan.contact
Definition

The contact for the health insurance product for a certain purpose.

Control0..*
Requirements

Need to keep track of assigned contact points within bigger organization.

Comments

Where multiple contacts for the same purpose are provided there is a standard extension that can be used to determine which one is the preferred contact to use.

ProductPlan.contact.purpose
Element IdProductPlan.contact.purpose
Definition

Indicates a purpose for which the contact can be reached.

Control0..1
Terminology BindingContactEntityType (Extensible)
TypeCodeableConcept
Requirements

Need to distinguish between multiple contact persons.

ProductPlan.contact.name
Element IdProductPlan.contact.name
Definition

A name associated with the contact.

Control0..1
TypeHumanName
Requirements

Need to be able to track the person by name.

ProductPlan.contact.telecom
Element IdProductPlan.contact.telecom
Definition

A contact detail (e.g. a telephone number or an email address) by which the party may be contacted.

Control0..*
TypeContactPoint
Requirements

People have (primary) ways to contact them in some way such as phone, email.

ProductPlan.contact.address
Element IdProductPlan.contact.address
Definition

Visiting or postal addresses for the contact.

Control0..1
TypeAddress
Requirements

May need to keep track of a contact party's address for contacting, billing or reporting requirements.

ProductPlan.endpoint
Element IdProductPlan.endpoint
Definition

The technical endpoints providing access to services operated for the health insurance product.

Control0..*
TypeReference(Endpoint)
Requirements

Organizations have multiple systems that provide various services and need to be able to define the technical connection details for how to connect to them, and for what purpose.

ProductPlan.network
Element IdProductPlan.network
Definition

Reference to the network included in the health insurance product.

Control0..*
TypeReference(Organization)
Comments

Networks are represented as a hierarchy of organization resources.

ProductPlan.coverage
Element IdProductPlan.coverage
Definition

Details about the coverage offered by the insurance product.

Control0..*
ProductPlan.coverage.type
Element IdProductPlan.coverage.type
Definition

Type of coverage (Medical; Dental; Mental Health; Substance Abuse; Vision; Drug; Short Term; Long Term Care; Hospice; Home Health).

Control1..1
TypeCodeableConcept
ProductPlan.coverage.network
Element IdProductPlan.coverage.network
Definition

Reference to the network that providing the type of coverage.

Control0..*
TypeReference(Organization)
Comments

Networks are represented as a hierarchy of organization resources.

ProductPlan.coverage.benefit
Element IdProductPlan.coverage.benefit
Definition

Specific benefits under this type of coverage.

Control1..*
ProductPlan.coverage.benefit.type
Element IdProductPlan.coverage.benefit.type
Definition

Type of benefit (primary care; speciality care; inpatient; outpatient).

Control1..1
TypeCodeableConcept
ProductPlan.coverage.benefit.requirement
Element IdProductPlan.coverage.benefit.requirement
Definition

The referral requirements to have access/coverage for this benefit.

Control0..1
Typestring
ProductPlan.coverage.benefit.limit
Element IdProductPlan.coverage.benefit.limit
Definition

The specific limits on the benefit.

Control0..*
ProductPlan.coverage.benefit.limit.value
Element IdProductPlan.coverage.benefit.limit.value
Definition

The maximum amount of a service item a plan will pay for a covered benefit. For examples. wellness visits, or eyeglasses.

Control0..1
TypeQuantity
Comments

May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”.

ProductPlan.coverage.benefit.limit.code
Element IdProductPlan.coverage.benefit.limit.code
Definition

The specific limit on the benefit.

Control0..1
TypeCodeableConcept
Comments

Use CodeableConcept.text element if the data is free (uncoded) text.

ProductPlan.plan
Element IdProductPlan.plan
Definition

Details about an insurance plan.

Control0..*
ProductPlan.plan.identifier
Element IdProductPlan.plan.identifier
Definition

Business identifiers assigned to this health insurance plan which remain constant as the resource is updated and propagates from server to server.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Summarytrue
ProductPlan.plan.type
Element IdProductPlan.plan.type
Definition

Type of plan. For example, "Platinum" or "High Deductable".

Control0..1
TypeCodeableConcept
ProductPlan.plan.coverageArea
Element IdProductPlan.plan.coverageArea
Definition

The geographic region in which a health insurance plan's benefits apply.

Control0..*
TypeReference(Location)
Summarytrue
ProductPlan.plan.network
Element IdProductPlan.plan.network
Definition

Reference to the network that providing the type of coverage.

Control0..*
TypeReference(Organization)
Comments

Networks are represented as a hierarchy of organization resources.

ProductPlan.plan.generalCost
Element IdProductPlan.plan.generalCost
Definition

Overall costs associated with the plan.

Control0..*
ProductPlan.plan.generalCost.type
Element IdProductPlan.plan.generalCost.type
Definition

Type of cost.

Control0..1
TypeCodeableConcept
ProductPlan.plan.generalCost.groupSize
Element IdProductPlan.plan.generalCost.groupSize
Definition

Number of participants enrolled in the plan.

Control0..1
TypepositiveInt
ProductPlan.plan.generalCost.cost
Element IdProductPlan.plan.generalCost.cost
Definition

Value of the cost.

Control0..1
TypeMoney
ProductPlan.plan.generalCost.comment
Element IdProductPlan.plan.generalCost.comment
Definition

Additional information about the general costs associated with this plan.

Control0..1
Typestring
ProductPlan.plan.specificCost
Element IdProductPlan.plan.specificCost
Definition

Costs associated with the coverage provided by the product.

Control0..*
ProductPlan.plan.specificCost.category
Element IdProductPlan.plan.specificCost.category
Definition

General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health).

Control1..1
TypeCodeableConcept
ProductPlan.plan.specificCost.benefit
Element IdProductPlan.plan.specificCost.benefit
Definition

List of the specific benefits under this category of benefit.

Control0..*
ProductPlan.plan.specificCost.benefit.type
Element IdProductPlan.plan.specificCost.benefit.type
Definition

Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care).

Control1..1
TypeCodeableConcept
ProductPlan.plan.specificCost.benefit.cost
Element IdProductPlan.plan.specificCost.benefit.cost
Definition

List of the costs associated with a specific benefit.

Control0..*
ProductPlan.plan.specificCost.benefit.cost.type
Element IdProductPlan.plan.specificCost.benefit.cost.type
Definition

Type of cost (copay; individual cap; family cap; coinsurance; deductible).

Control1..1
TypeCodeableConcept
ProductPlan.plan.specificCost.benefit.cost.applicability
Element IdProductPlan.plan.specificCost.benefit.cost.applicability
Definition

Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other).

Control0..1
Terminology BindingBenefitCostApplicability (Required)
TypeCodeableConcept
ProductPlan.plan.specificCost.benefit.cost.qualifiers
Element IdProductPlan.plan.specificCost.benefit.cost.qualifiers
Definition

Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA).

Control0..*
TypeCodeableConcept
ProductPlan.plan.specificCost.benefit.cost.value
Element IdProductPlan.plan.specificCost.benefit.cost.value
Definition

The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance).

Control0..1
TypeQuantity