FHIR CI-Build

This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions icon

8.36 Resource InsuranceProduct - Content

Patient Administration icon

Work Group

Maturity Level: 1

Trial Use

Security Category: Business

Compartments: No defined compartments

A product is a discrete package of health insurance coverage benefits that are offered under a particular network, by an organization (payer) and additional information about the offering, such as who it is owned and administered by, a coverage area, contact information, etc.

8.36.1 Scope and Usage

Insurance offerings will be fully described by the combination of both InsurancePlan (the costs) and InsuranceProduct (the benefits). A given payer’s products typically differ by network type and/or coverage benefits.

An InsurancePlan pairs the health insurance coverage benefits under an InsuranceProduct with the particular cost sharing structure offered to a consumer. A given InsuranceProduct may comprise multiple InsurancePlans.

8.36.2 Boundaries and Relationships

Insurance Product describes a list of covered benefits and networks as well as details about who administers the product and applicable coverage areas.

InsurancePlan describes the costs to the subscriber or beneficiary associated with benefits, as well as additional information about the offering, such as who administers the plan, a coverage area, contact information, etc. The specific benefits covered by the plan are described in the InsuranceProduct referenced in InsurancePlan.product.

A Coverage resource establishes the link between an InsurancePlan and a beneficiary and optionally a subscriber.

8.36.3 References to this Resource

Resource References: InsurancePlan and itself

8.36.4 Resource Content

Structure

Name	Flags	Card.	Type	Description & Constraints
InsuranceProduct	TU		DomainResource	Details of a Health Insurance product provided by an organization + Rule: The organization SHALL at least have a name or an identifier, and possibly more than one Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
identifier	Σ C	0..*	Identifier	Business Identifier for Product
status	?!Σ	0..1	code	draft \| active \| retired \| unknown Binding: PublicationStatus (Required)
type	Σ	0..*	CodeableConcept	Kind of product Binding: Insurance Plan Type (Example)
name	Σ C	0..1	string	Official name
alias		0..*	string	Alternate names
period		0..1	Period	When the product is available
ownedBy	Σ	0..1	Reference(Organization)	Product issuer
administeredBy	Σ	0..1	Reference(Organization)	Product administrator
coverageArea	Σ	0..*	Reference(Location)	Where product applies
contact		0..*	ExtendedContactDetail	Official contact details relevant to the health insurance product
endpoint		0..*	Reference(Endpoint)	Technical endpoint
network		0..*	Reference(Organization)	What networks are Included
coverage		0..*	BackboneElement	Coverage details
type		1..1	CodeableConcept	Classification of Coverage
network		0..*	Reference(Organization)	What networks provide coverage
benefit		1..*	BackboneElement	List of benefits
type		1..1	CodeableConcept	Classification of benefit provided
requirement		0..1	string	Referral requirements
limit		0..*	BackboneElement	Limits on the provided benefits
value		0..1	Quantity	Maximum value allowed
code		0..1	CodeableConcept	Benefit limit details
related		0..*	BackboneElement	Associated insurance product
product		0..1	Reference(InsuranceProduct)	Related Product reference
relationship		0..1	CodeableConcept	Relationship of this product to the related product
period		0..1	Period	Period that this Relationship is valid
Documentation for this format

See the Extensions for this resource

XML Template

<InsuranceProduct xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- I 0..* Identifier Business Identifier for Product --></identifier>
 <status value="[code]"/><!-- 0..1 draft | active | retired | unknown -->
 <type><!-- 0..* CodeableConcept Kind of product --></type>
 <name value="[string]"/><!-- I 0..1 Official name -->
 <alias value="[string]"/><!-- 0..* Alternate names -->
 <period><!-- 0..1 Period When the product is available --></period>
 <ownedBy><!-- 0..1 Reference(Organization) Product issuer --></ownedBy>
 <administeredBy><!-- 0..1 Reference(Organization) Product administrator --></administeredBy>
 <coverageArea><!-- 0..* Reference(Location) Where product applies --></coverageArea>
 <contact><!-- 0..* ExtendedContactDetail Official contact details relevant to the health insurance product --></contact>
 <endpoint><!-- 0..* Reference(Endpoint) Technical endpoint --></endpoint>
 <network><!-- 0..* Reference(Organization) What networks are Included --></network>
 <coverage>  <!-- 0..* Coverage details -->
  <type><!-- 1..1 CodeableConcept Classification of Coverage --></type>
  <network><!-- 0..* Reference(Organization) What networks provide coverage --></network>
  <benefit>  <!-- 1..* List of benefits -->
   <type><!-- 1..1 CodeableConcept Classification of benefit provided --></type>
   <requirement value="[string]"/><!-- 0..1 Referral requirements -->
   <limit>  <!-- 0..* Limits on the provided benefits -->
    <value><!-- 0..1 Quantity Maximum value allowed --></value>
    <code><!-- 0..1 CodeableConcept Benefit limit details --></code>
   </limit>
  </benefit>
 </coverage>
 <related>  <!-- 0..* Associated insurance product -->
  <product><!-- 0..1 Reference(InsuranceProduct) Related Product reference --></product>
  <relationship><!-- 0..1 CodeableConcept Relationship of this product to the related product --></relationship>
  <period><!-- 0..1 Period Period that this Relationship is valid --></period>
 </related>
</InsuranceProduct>

JSON Template

{
  "resourceType" : "InsuranceProduct",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // I Business Identifier for Product
  "status" : "<code>", // draft | active | retired | unknown
  "type" : [{ CodeableConcept }], // Kind of product
  "name" : "<string>", // I Official name
  "alias" : ["<string>"], // Alternate names
  "period" : { Period }, // When the product is available
  "ownedBy" : { Reference(Organization) }, // Product issuer
  "administeredBy" : { Reference(Organization) }, // Product administrator
  "coverageArea" : [{ Reference(Location) }], // Where product applies
  "contact" : [{ ExtendedContactDetail }], // Official contact details relevant to the health insurance product
  "endpoint" : [{ Reference(Endpoint) }], // Technical endpoint
  "network" : [{ Reference(Organization) }], // What networks are Included
  "coverage" : [{ // Coverage details
    "type" : { CodeableConcept }, // R!  Classification of Coverage
    "network" : [{ Reference(Organization) }], // What networks provide coverage
    "benefit" : [{ // R!  List of benefits
      "type" : { CodeableConcept }, // R!  Classification of benefit provided
      "requirement" : "<string>", // Referral requirements
      "limit" : [{ // Limits on the provided benefits
        "value" : { Quantity }, // Maximum value allowed
        "code" : { CodeableConcept } // Benefit limit details
      }]
    }]
  }],
  "related" : [{ // Associated insurance product
    "product" : { Reference(InsuranceProduct) }, // Related Product reference
    "relationship" : { CodeableConcept }, // Relationship of this product to the related product
    "period" : { Period } // Period that this Relationship is valid
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .


[ a fhir:InsuranceProduct;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* I Business Identifier for Product
  fhir:status [ code ] ; # 0..1 draft | active | retired | unknown
  fhir:type  ( [ CodeableConcept ] ... ) ; # 0..* Kind of product
  fhir:name [ string ] ; # 0..1 I Official name
  fhir:alias  ( [ string ] ... ) ; # 0..* Alternate names
  fhir:period [ Period ] ; # 0..1 When the product is available
  fhir:ownedBy [ Reference(Organization) ] ; # 0..1 Product issuer
  fhir:administeredBy [ Reference(Organization) ] ; # 0..1 Product administrator
  fhir:coverageArea  ( [ Reference(Location) ] ... ) ; # 0..* Where product applies
  fhir:contact  ( [ ExtendedContactDetail ] ... ) ; # 0..* Official contact details relevant to the health insurance product
  fhir:endpoint  ( [ Reference(Endpoint) ] ... ) ; # 0..* Technical endpoint
  fhir:network  ( [ Reference(Organization) ] ... ) ; # 0..* What networks are Included
  fhir:coverage ( [ # 0..* Coverage details
    fhir:type [ CodeableConcept ] ; # 1..1 Classification of Coverage
    fhir:network  ( [ Reference(Organization) ] ... ) ; # 0..* What networks provide coverage
    fhir:benefit ( [ # 1..* List of benefits
      fhir:type [ CodeableConcept ] ; # 1..1 Classification of benefit provided
      fhir:requirement [ string ] ; # 0..1 Referral requirements
      fhir:limit ( [ # 0..* Limits on the provided benefits
        fhir:value [ Quantity ] ; # 0..1 Maximum value allowed
        fhir:code [ CodeableConcept ] ; # 0..1 Benefit limit details
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:related ( [ # 0..* Associated insurance product
    fhir:product [ Reference(InsuranceProduct) ] ; # 0..1 Related Product reference
    fhir:relationship [ CodeableConcept ] ; # 0..1 Relationship of this product to the related product
    fhir:period [ Period ] ; # 0..1 Period that this Relationship is valid
  ] ... ) ;
]

Structure

Name	Flags	Card.	Type	Description & Constraints
InsuranceProduct	TU		DomainResource	Details of a Health Insurance product provided by an organization + Rule: The organization SHALL at least have a name or an identifier, and possibly more than one Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
identifier	Σ C	0..*	Identifier	Business Identifier for Product
status	?!Σ	0..1	code	draft \| active \| retired \| unknown Binding: PublicationStatus (Required)
type	Σ	0..*	CodeableConcept	Kind of product Binding: Insurance Plan Type (Example)
name	Σ C	0..1	string	Official name
alias		0..*	string	Alternate names
period		0..1	Period	When the product is available
ownedBy	Σ	0..1	Reference(Organization)	Product issuer
administeredBy	Σ	0..1	Reference(Organization)	Product administrator
coverageArea	Σ	0..*	Reference(Location)	Where product applies
contact		0..*	ExtendedContactDetail	Official contact details relevant to the health insurance product
endpoint		0..*	Reference(Endpoint)	Technical endpoint
network		0..*	Reference(Organization)	What networks are Included
coverage		0..*	BackboneElement	Coverage details
type		1..1	CodeableConcept	Classification of Coverage
network		0..*	Reference(Organization)	What networks provide coverage
benefit		1..*	BackboneElement	List of benefits
type		1..1	CodeableConcept	Classification of benefit provided
requirement		0..1	string	Referral requirements
limit		0..*	BackboneElement	Limits on the provided benefits
value		0..1	Quantity	Maximum value allowed
code		0..1	CodeableConcept	Benefit limit details
related		0..*	BackboneElement	Associated insurance product
product		0..1	Reference(InsuranceProduct)	Related Product reference
relationship		0..1	CodeableConcept	Relationship of this product to the related product
period		0..1	Period	Period that this Relationship is valid
Documentation for this format

See the Extensions for this resource

UML Diagram (Legend)

XML Template

<InsuranceProduct xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- I 0..* Identifier Business Identifier for Product --></identifier>
 <status value="[code]"/><!-- 0..1 draft | active | retired | unknown -->
 <type><!-- 0..* CodeableConcept Kind of product --></type>
 <name value="[string]"/><!-- I 0..1 Official name -->
 <alias value="[string]"/><!-- 0..* Alternate names -->
 <period><!-- 0..1 Period When the product is available --></period>
 <ownedBy><!-- 0..1 Reference(Organization) Product issuer --></ownedBy>
 <administeredBy><!-- 0..1 Reference(Organization) Product administrator --></administeredBy>
 <coverageArea><!-- 0..* Reference(Location) Where product applies --></coverageArea>
 <contact><!-- 0..* ExtendedContactDetail Official contact details relevant to the health insurance product --></contact>
 <endpoint><!-- 0..* Reference(Endpoint) Technical endpoint --></endpoint>
 <network><!-- 0..* Reference(Organization) What networks are Included --></network>
 <coverage>  <!-- 0..* Coverage details -->
  <type><!-- 1..1 CodeableConcept Classification of Coverage --></type>
  <network><!-- 0..* Reference(Organization) What networks provide coverage --></network>
  <benefit>  <!-- 1..* List of benefits -->
   <type><!-- 1..1 CodeableConcept Classification of benefit provided --></type>
   <requirement value="[string]"/><!-- 0..1 Referral requirements -->
   <limit>  <!-- 0..* Limits on the provided benefits -->
    <value><!-- 0..1 Quantity Maximum value allowed --></value>
    <code><!-- 0..1 CodeableConcept Benefit limit details --></code>
   </limit>
  </benefit>
 </coverage>
 <related>  <!-- 0..* Associated insurance product -->
  <product><!-- 0..1 Reference(InsuranceProduct) Related Product reference --></product>
  <relationship><!-- 0..1 CodeableConcept Relationship of this product to the related product --></relationship>
  <period><!-- 0..1 Period Period that this Relationship is valid --></period>
 </related>
</InsuranceProduct>

JSON Template

{
  "resourceType" : "InsuranceProduct",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // I Business Identifier for Product
  "status" : "<code>", // draft | active | retired | unknown
  "type" : [{ CodeableConcept }], // Kind of product
  "name" : "<string>", // I Official name
  "alias" : ["<string>"], // Alternate names
  "period" : { Period }, // When the product is available
  "ownedBy" : { Reference(Organization) }, // Product issuer
  "administeredBy" : { Reference(Organization) }, // Product administrator
  "coverageArea" : [{ Reference(Location) }], // Where product applies
  "contact" : [{ ExtendedContactDetail }], // Official contact details relevant to the health insurance product
  "endpoint" : [{ Reference(Endpoint) }], // Technical endpoint
  "network" : [{ Reference(Organization) }], // What networks are Included
  "coverage" : [{ // Coverage details
    "type" : { CodeableConcept }, // R!  Classification of Coverage
    "network" : [{ Reference(Organization) }], // What networks provide coverage
    "benefit" : [{ // R!  List of benefits
      "type" : { CodeableConcept }, // R!  Classification of benefit provided
      "requirement" : "<string>", // Referral requirements
      "limit" : [{ // Limits on the provided benefits
        "value" : { Quantity }, // Maximum value allowed
        "code" : { CodeableConcept } // Benefit limit details
      }]
    }]
  }],
  "related" : [{ // Associated insurance product
    "product" : { Reference(InsuranceProduct) }, // Related Product reference
    "relationship" : { CodeableConcept }, // Relationship of this product to the related product
    "period" : { Period } // Period that this Relationship is valid
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .


[ a fhir:InsuranceProduct;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* I Business Identifier for Product
  fhir:status [ code ] ; # 0..1 draft | active | retired | unknown
  fhir:type  ( [ CodeableConcept ] ... ) ; # 0..* Kind of product
  fhir:name [ string ] ; # 0..1 I Official name
  fhir:alias  ( [ string ] ... ) ; # 0..* Alternate names
  fhir:period [ Period ] ; # 0..1 When the product is available
  fhir:ownedBy [ Reference(Organization) ] ; # 0..1 Product issuer
  fhir:administeredBy [ Reference(Organization) ] ; # 0..1 Product administrator
  fhir:coverageArea  ( [ Reference(Location) ] ... ) ; # 0..* Where product applies
  fhir:contact  ( [ ExtendedContactDetail ] ... ) ; # 0..* Official contact details relevant to the health insurance product
  fhir:endpoint  ( [ Reference(Endpoint) ] ... ) ; # 0..* Technical endpoint
  fhir:network  ( [ Reference(Organization) ] ... ) ; # 0..* What networks are Included
  fhir:coverage ( [ # 0..* Coverage details
    fhir:type [ CodeableConcept ] ; # 1..1 Classification of Coverage
    fhir:network  ( [ Reference(Organization) ] ... ) ; # 0..* What networks provide coverage
    fhir:benefit ( [ # 1..* List of benefits
      fhir:type [ CodeableConcept ] ; # 1..1 Classification of benefit provided
      fhir:requirement [ string ] ; # 0..1 Referral requirements
      fhir:limit ( [ # 0..* Limits on the provided benefits
        fhir:value [ Quantity ] ; # 0..1 Maximum value allowed
        fhir:code [ CodeableConcept ] ; # 0..1 Benefit limit details
      ] ... ) ;
    ] ... ) ;
  ] ... ) ;
  fhir:related ( [ # 0..* Associated insurance product
    fhir:product [ Reference(InsuranceProduct) ] ; # 0..1 Related Product reference
    fhir:relationship [ CodeableConcept ] ; # 0..1 Relationship of this product to the related product
    fhir:period [ Period ] ; # 0..1 Period that this Relationship is valid
  ] ... ) ;
]

Changes from both R4 and R4B

This resource did not exist in Release R4

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

8.36.4.1 Terminology Bindings

Path	ValueSet	Type	Documentation
InsuranceProduct.status	PublicationStatus	Required	The lifecycle status of an artifact.
InsuranceProduct.type	InsurancePlanType	Example	This example value set defines a set of codes that can be used to indicate a type of insurance plan.

Path

ValueSet

Type

Documentation

InsuranceProduct.status

PublicationStatus

Required

The lifecycle status of an artifact.

InsuranceProduct.type

InsurancePlanType

Example

This example value set defines a set of codes that can be used to indicate a type of insurance plan.

8.36.4.2 Constraints

UniqueKey

Level

Location

Description

Expression

ipn-1

Rule

(base)

The organization SHALL at least have a name or an identifier, and possibly more than one

(identifier.count() + name.count()) > 0

8.36.5 Notes:

8.36.6 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name	Type	Description	Expression	In Common
administered-by	reference	Product administrator	InsuranceProduct.administeredBy (Organization)
contact-address	string	A server defined search that may match any of the string fields in the Address, including line, city, district, state, country, postalCode, and/or text	InsuranceProduct.contact.address
contact-address-city	string	A city specified in an address	InsuranceProduct.contact.address.city
contact-address-country	string	A country specified in an address	InsuranceProduct.contact.address.country
contact-address-postalcode	string	A postal code specified in an address	InsuranceProduct.contact.address.postalCode
contact-address-state	string	A state specified in an address	InsuranceProduct.contact.address.state
contact-address-use	token	A use code specified in an address	InsuranceProduct.contact.address.use
endpoint	reference	The endpoint(s) applicable to this product	InsuranceProduct.endpoint (Endpoint)
identifier	token	Any identifier for the product (not the accreditation issuer's identifier)	InsuranceProduct.identifier
name	string	A portion of the insurance product's name or alias	InsuranceProduct.name \| InsuranceProduct.alias
owned-by	reference	The issuer of the insurance product	InsuranceProduct.ownedBy (Organization)
phonetic	string	A portion of the product's name using some kind of phonetic matching algorithm	InsuranceProduct.name
status	token	Is the Product record active	InsuranceProduct.status
type	token	A code for the type of insurance product	InsuranceProduct.type