DaVinci PDEX Plan Net
1.0.0 - STU1

DaVinci PDEX Plan Net, published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 1.0.0). This version is based on the current content of https://github.com/HL7/davinci-pdex-plan-net/ and changes regularly. See the Directory of published versions

Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Behavior: Capability Statements

The following artifacts define the specific capabilities that different types of systems are expected to have in order to comply with this implementation guide. Systems conforming to this implementation guide are expected to declare conformance to one or more of the following capability statements.

Plan-Net CapabilityStatement

This Section describes the expected capabilities of the Plan-Net Server actor which is responsible for providing responses to the queries submitted by the Plan-Net Requestors. The complete list of FHIR profiles, RESTful operations, and search parameters supported by Plan-Net Servers are defined. Systems implementing this capability statement should meet the CMS FInal Rule requirement for provider directory access. Plan-Net Clients can use the required capabilities to access necessary data based on their local use cases and other contextual requirements.

Behavior: Search Parameters

These define the properties by which a RESTful server can be searched. They can also be used for sorting and including related resources.

Plannet_sp_endpoint_organization

Select Endpoints managed by the specified organization

Plannet_sp_healthcareservice_category

Select HealthcareServices providing the specified category of services

Plannet_sp_healthcareservice_coverage_area

Select services available in a region described by the specified location

Plannet_sp_healthcareservice_endpoint

Select HealthcareServices with the specified endpoint

Plannet_sp_healthcareservice_location

Select HealthcareServices available at the specified location

Plannet_sp_healthcareservice_name

Select HealthcareServices with the specified name

Plannet_sp_healthcareservice_organization

Select HealthcareServices provided by the specified organization

Plannet_sp_healthcareservice_type

Select HealthcareServices of the specified type

Plannet_sp_healthcareservice_specialty

Select services associated with the specified specialty

Plannet_sp_insuranceplan_administered_by

Select products that are administered by the specified organization

Plannet_sp_insuranceplan_coverage_area

Select products that are offered in the specified location

Plannet_sp_insuranceplan_identifier

Select products with the specified identifier

Plannet_sp_insuranceplan_name

Select products with the specified name

Plannet_sp_insuranceplan_owned_by

Select products that are owned by the specified organization

Plannet_sp_insuranceplan_plan_type

Select plans of the specified type

Plannet_sp_insuranceplan_type

Select insurance plans of the specified type

Plannet_sp_location_address_postalcode

Select Locations with the specified address

Plannet_sp_location_address_state

Select Locations with the specified address.state

Plannet_sp_location_address_city

Select Locations with the specified address.city

Plannet_sp_location_address

Select Locations with the specified address

VhDir_sp_location_endpoint

Select Locations with the specified endpoint

Plannet_sp_location_organization

Select Locations managed by the specified organization

Plannet_sp_location_partof

Select Locations that are part of the specified location

Plannet_sp_location_type

Select Locations of the specified type

Plannet_sp_organization_address

Select organizations with the specified address (matches any of the string elements of an address)

Plannet_sp_network_coverage_area

Select health insurance provider networks available in a region described by the specified location

Plannet_sp_organization_endpoint

Select Organizations with the specified endpoint

Plannet_sp_organization_name

Select Organizations with the specified name

Plannet_sp_organization_partof

Select Organizations that are part of the specified organization

Plannet_sp_organization_type

Select Organizations of the specified type

VhDir_sp_organizationaffiliation_endpoint

Select OrganizationAffiliations with the specified endpoint

Plannet_sp_organizationaffiliation_location

Select OrganizationAffiliations available at the specified location

Plannet_sp_organizationaffiliation_network

Select roles where the organization is a member of the specified health insurance provider network

Plannet_sp_organizationaffiliation_participating_organization

Select roles filled by the specified organization

Plannet_sp_organizationaffiliation_primary_organization

Select roles offered by the specified organization

Plannet_sp_organizationaffiliation_role

Select OrganizationAffiliations with the specified role

Plannet_sp_organizationaffiliation_service

Select OrganizationAffiliations providing the specified service

Plannet_sp_organizationaffiliation_specialty

Select OrganizationAffiliations associated with the specified specialty

Plannet_sp_practitioner_family_name

Select Practitioners with the specified family name

Plannet_sp_practitioner_given_name

Select Practitioners with the specified given name

Plannet_sp_practitioner_name

Select Practitioners with the specified name (matches against any of the elements in the HumanName data type)

Plannet_sp_practitionerrole_endpoint

Select PractitionerRoles with the specified endpoint

Plannet_sp_practitionerrole_location

Select PractitionerRoles available at the specified location

Plannet_sp_practitionerrole_network

Select roles where the practitioner is a member of the specified health insurance provider network

Plannet_sp_practitionerrole_organization

Select PractitionerRoles available at the specified organization

Plannet_sp_practitionerrole_practitioner

Select roles filled by the specified practitioner

Plannet_sp_practitionerrole_role

Select PractitionerRoles with the specified role

Plannet_sp_practitionerrole_service

Select PractitionerRoles providing the specified service

Plannet_sp_practitionerrole_specialty

Select PractitionerRoles associated with the specified specialty

Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide

Plan-Net Endpoint

The technical details of an endpoint that can be used for electronic services, such as a portal or FHIR REST services, messaging or operations, or DIRECT messaging.

Plan-Net HealthcareService

The HealthCareService resource typically describes services offered by an organization/practitioner at a location. The resource may be used to encompass a variety of services covering the entire healthcare spectrum, including promotion, prevention, diagnostics, pharmacy, hospital and ambulatory care, home care, long-term care, and other health-related and community services.

Plan-Net InsurancePlan

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.

Plan-Net Location

A Location is the physical place where healthcare services are provided, practitioners are employed, organizations are based, etc. Locations can range in scope from a room in a building to a geographic region/area.

Plan-Net Network

A Network refers to a healthcare provider insurance network. A healthcare provider insurance network is an aggregation of organizations and individuals that deliver a set of services across a geography through health insurance products/plans. A network is typically owned by a payer.

In the PlanNet IG, individuals and organizations are represented as participants in a PLan-Net Network through the practitionerRole and Plan-Net-organizationAffiliation resources, respectively.

Plan-Net Organization

An organization is a formal or informal grouping of people or organizations with a common purpose, such as a company, institution, corporation, community group, or healthcare practice. Guidance: When the contact is a department name, rather than a human (e.g., patient help line), include a blank family and given name, and provide the department name in contact.name.text

Plan-Net OrganizationAffiliation

The OrganizationAffiliation resource describes relationships between two or more organizations, including the services one organization provides another, the location(s) where they provide services, the availability of those services, electronic endpoints, and other relevant information.

Plan-Net Practitioner

Practitioner is a person who is directly or indirectly involved in the provisioning of healthcare.

Plan-Net PractitionerRole

PractionerRole describes details about a provider, which can be a practitioner or an organization. When the provider is a practitioner, there may be a relationship to an organization. A provider renders services to patients at a location. When the provider is a practitioner, there may also be a relationship to an organization. Practitioner participation in healthcare provider insurance networks may be direct or through their role at an organization.

Structures: Extension Definitions

These define constraints on FHIR data types for systems conforming to this implementation guide

Accessibility

An extension to describe accessibility options offered by a practitioner or at a location.

Communication Proficiency

An extension to express a practitioner’s spoken proficiency with the language indicated in practitioner.communication.

Contactpoint Availabletime

An extension representing the days and times a contact point is available

Delivery Method

An extension describing the service delivery method. If service delivery is virtual, one or more delivery modalities should be specified.

Endpoint Usecase

EndpointUseCase is an enumeration of the specific use cases (service descriptions) supported by the endpoint

Location Reference

A reference to a Location resource (plannet-Location) defining the coverage area of a health insurance provider network

Network Reference

A reference to the healthcare provider insurance networks (plannet-Network) the practitioner participates in through their role

New Patients

New Patients indicates whether new patients are being accepted in general, or from a specific network.
This extension is included in the PractitionerRole, HealthcareService, and Location profiles.
This provides needed flexibility for specifying whether a provider accepts new patients by location and network.

Org Description

An extension to provide a human-readable description of an organization.

Practitioner Qualification

An extension to add status and whereValid elements to a practitioner’s qualifications.

Qualification

An extension to add qualifications for an organization (e.g. accreditation) or practitionerRole (e.g. registered to prescribe controlled substances).

Via Intermediary

A reference to an alternative point of contact (plannet-PractitionerRole, plannet-Organization, plannet-OrganizationAffiliation, or plannet-Location) for this organization

Terminology: Value Sets

These define sets of codes used by systems conforming to this implementation guide

Accepting Patients Codes

Codes to identify if the practice is accepting new patients

Accessibility

Codes for documenting general categories of accommodations available.

Delivery Methods

Codes for documenting delivery methods.

Endpoint Connection Types

Endpoint Connection Types

Endpoint Payload Types

Endpoint Payload Types are constrained to NA (Not Applicable) as part of this IG

Endpoint Usecases

Codes for documenting business use case by a general grouping by business area.

Healthcare Service Category

Broad categories of healthcare services being performed or delivered.

HealthcareService Types

Valueset for HealthCareService type

Individual and Group Specialties

Individual and Group Specialties from National Uniform Claim Committee (NUCC) Health Care Provider Taxonomy code set.

Individual Specialties, Degrees, Licenses, and Certificates

Individual Specialties, Degrees, Licenses, and Certificates

Insurance Plan Type

Categories of cost-sharing used by plans.

Insurance Product Type

A distinct package of health insurance coverage benefits that are offered using a particular product network type.

Language Proficiency

Codes for documenting spoken language proficiency based on the Interagency Language Roundtable scale of abilities to communicate in a language.

Minimum Endpoint Connection Types

Minimum Endpoint Connection Types

Network Type

Single value describing networks.

Non-Individual Specialties

Non-Individual Specialties from National Uniform Claim Committee (NUCC) Health Care Provider Taxonomy code set.

Non-Individual Specialties, Degrees, Licenses, and Certificates

Non-Individual Specialties, Degrees, Licenses, and Certificates

Organization Type

Categories of organizations based on criteria in provider directories.

OrganizationAffiliation Roles

Value Set for Organization Affiliation Roles

PractitionerRole Code

Codes for the capabilities that an individual, group, or organization is acknowledged to have in a payer network, including general codes from the HL7 PractitionerRole Code System.

Qualification Status

The state indicating if a qualification is currently valid.

Specialties

Specialties value set based on National Uniform Claim Committee (NUCC) Health Care Provider Taxonomy code set.

Specialties, Degrees, Licenses, and Certificates

Specialties and Degree License and Certificates

Virtual Modalities

Codes for virtual service delivery modalities .

Terminology: Code Systems

These define new code systems used by systems conforming to this implementation guide

Accepting Patients Codes

Codes to identify if the practice is accepting new patients

Accessibility

General categories of accommodations available.

Delivery Methods

Categories of healthcare service delivery methods.

Endpoint Connection Types (additional)

Extension codes for http://terminology.hl7.org/CodeSystem/endpoint-connection-type

Endpoint Payload Types

Endpoint Payload Types are constrained to NA (Not Applicable) as part of this IG

Healthcare Service Category

Broad categories of healthcare services being performed or delivered

Insurance Plan Type

Categories of cost-sharing used by plans

Insurance Product Type

A distinct package of health insurance coverage benefits that are offered using a particular product network type.

Language Proficiency

Codes for documenting spoken language proficiency based on the Interagency Language Roundtable scale of abilities to communicate in a language.

Organization Type

Categories of organizations based on criteria in provider directories.

Organization Affiliation Role

Codes For Organization Affiliation Role

Provider Role Codes

A capability that an individual, group, or organization is acknowledged to have in a payer network.

Qualification Status

The state indicating if a qualification is currently valid.

Virtual Modalities

Categories of virtual service delivery modalities.

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like

Acme

Payer Organization

AcmeOfCTPortalEndpoint

Endpoint for Acme of CT Portal

AcmeQHPBronze

Acme of CT QHP Bronze Plan

AcmeQHPGold

Acme of CT QHP Gold Plan

AcmeofCTPremNet

Acme of CT Premium Premium Network

AcmeofCTStdNet

Acme of CT Standard Network

AnonRole

Practitioner role that doesn’t refer to a specific practitioner

BigBox

Organization that Manages 2 of PharmChain’s pharmacies

BurrClinic

Burr Clinic provides service to Hartford Hospital

BurrClinicAffil

Burr Clinic’s affiliation with Acme of CT Provider Network and Hartford General Hospital

BurrClinicServices

Burr Clinic Services

CancerClinic

HartfordCancerClinicLLC

CancerClinicLoc

Location1 of Cancer Clinic

CancerClinicService

Cancer Clinic Services

ConnHIE

Connecticut HIE

ConnHIEAffil

Burr Clinic’s affiliation with Conn HIE

Counselor

Counselor Susie Smith

CounselorRole1

Susie Smith is a counselor via Telemedicine

HamiltonClinic

Hamilton Clinic (a Division of Hartford Hospital)

HamiltonClinicAffil

Hamilton Clinic’s affiliation with Acme of CT Provider Network and Hartford General Hospital

HamiltonClinicServices

Hamilton Clinic Services

HansSolo

Solo Practitioner Hans Solo

HansSoloClinic

Location of Hans Solo’s clinic

HansSoloRole1

Hans Solo is a solo practitioner

HansSoloService

Hans Solo Services

HartfordOrthopedicAffil

Hartford Orthopedic Services affiliation with Acme of CT Provider Network and Hartford General Hospital

HartfordOrthopedicServices

Hartford Orthopedic Services

HartfordOrthopedics

Hartford Orthpedic Services is a group providing Orthpods for Acme of CT at Hartford General Hospital

HospERService

Hartford General Hospital ER

HospLoc1

Location1 of Hartford Hospital

HospLoc2

Location2 of Hartford Hospital

Hospital

Hartford General Hospital

JoeSmith

Practitioner Dr Joe Smith

JoeSmithRole1

Dr Smith moonlighting as ER Doc at Hartford Hospital

JoeSmithRole2

Dr Smith Internal Medicine at Burr Clinic

JoeSmithRole3

Dr Smith Admitting Privileges at Hartford General

PharmChain

Organization that Provides Pharmacy Services

PharmChainAffil1

Organization Affiliation for PharmChain (Retail)

PharmChainAffil2

Organization Affiliation for PharmChain (Compounding)

PharmChainAffil3

Organization Affiliation for PharmChain (MailOrder)

PharmChainCompService

Compound Pharmacy Service provided by PharmacyOrganization A

PharmChainMailService

Mail Order Pharmacy Service provided by PharmacyOrganization A

PharmChainRetailService

Pharmacy Service provided by PharmChain

PharmLoc1

Location of Pharmacy1 in PharmChain’s network

PharmLoc2

Location of Pharmacy2 in PharmChain’s network

PharmLoc3

Location of Pharmacy3 in PharmChain’s network

PharmLoc4

Location of Pharmacy4 in PharmChain’s network

StateOfCTLocation

State of CT Area

VirtualCounselService

Virtual Counseling Service