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.

Select Endpoints managed by the specified organization

Select HealthcareServices providing the specified category of services

Select services available in a region described by the specified location

Select HealthcareServices based on the delivery method type

Select HealthcareServices with the specified endpoint

Select HealthcareServices available at the specified location

Select HealthcareServices with the specified name

Select HealthcareServices provided by the specified organization

Select services associated with the specified specialty

Select HealthcareServices of the specified type

Select products that are administered by the specified organization

Select products that are offered in the specified location

Select products with the specified identifier

Select products with the specified name

Select products that are owned by the specified organization

Select plans of the specified type

Select insurance plans of the specified type

Select Locations with the specified address

Select Locations with the specified address.city

Select Locations with the specified address

Select Locations with the specified address.state

Select Locations with the specified endpoint

Select Locations managed by the specified organization

Select Locations that are part of the specified location

Select Locations of the specified type

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

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

Select Organizations with the specified endpoint

Select Organizations with the specified name

Select Organizations that are part of the specified organization

Select Organizations of the specified type

Select OrganizationAffiliations with the specified endpoint

Select OrganizationAffiliations available at the specified location

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

Select roles filled by the specified organization

Select Organization Affiliations available in the specified period

Select roles offered by the specified organization

Select OrganizationAffiliations with the specified role

Select OrganizationAffiliations providing the specified service

Select OrganizationAffiliations associated with the specified specialty

Select Practitioners with the specified family name

Select Practitioners with the specified given name

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

Select PractitionerRoles with the specified endpoint

Select PractitionerRoles available at the specified location

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

Select PractitionerRoles available at the specified organization

Select PractitionerRoles available in the specified period

Select roles filled by the specified practitioner

Select PractitionerRoles with the specified role

Select PractitionerRoles providing the specified service

Select PractitionerRoles associated with the specified specialty

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.

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.

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.

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.

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.

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

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.

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

PractitionerRole typically describes details about a provider. When the provider is a practitioner, there may be a relationship to an organization. A provider renders services to patients at a location. Practitioner participation in healthcare provider insurance networks may be direct or through their role at an organization. PractitionerRole involves either the actual or potential (hence the optionality on Practitioner) of an individual to play this role on behalf of or under the auspices of an organization. The absence of a Practitioner resource does not imply that the Organization itself is playing the role of a Practitioner, instead it implies that that role has been established by the Organization and MAY apply that to a specific Practitioner.

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

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

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

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

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

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

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

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. While the role is constrained to participation in a single network where it describes the single role this practitioner is playing (e.g., internal medicine physician) this does not in any way prohibit the practitioner from seeing patients from any other network, they will however be 'out of network' for those patients.

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

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

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

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

Codes to identify if the practice is accepting new patients

Codes for documenting general categories of accommodations available.

Codes for documenting delivery methods.

Endpoint Connection Types

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

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

Broad categories of healthcare services being performed or delivered.

Valueset for HealthCareService type

Individual Specialties, Degrees, Licenses, and Certificates

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

Categories of cost-sharing used by plans.

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

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

Minimum Endpoint Connection Types

Single value describing networks.

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

Non-Individual Specialties, Degrees, Licenses, and Certificates

Categories of organizations based on criteria in provider directories.

Value Set for Organization Affiliation Roles

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.

The state indicating if a qualification is currently valid.

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

Specialties and Degree License and Certificates

Codes for virtual service delivery modalities.

Codes to identify if the practice is accepting new patients

General categories of accommodations available.

Categories of healthcare service delivery methods.

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

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

Broad categories of healthcare services being performed or delivered

Categories of cost-sharing used by plans

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

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

Codes For Organization Affiliation Role

Categories of organizations based on criteria in provider directories.

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

The state indicating if a qualification is currently valid.

Categories of virtual service delivery modalities.

Payer Organization

Endpoint for Acme of CT Portal

Acme of CT QHP Bronze Plan

Acme of CT QHP Gold Plan

Acme of CT Premium Premium Network

Acme of CT Standard Network

Practitioner role that doesn't refer to a specific practitioner

Organization that Manages 2 of PharmChain's pharmacies

Burr Clinic provides service to Hartford Hospital

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

Burr Clinic Services

HartfordCancerClinicLLC

Location1 of Cancer Clinic

Cancer Clinic Services

Connecticut HIE

Burr Clinic's affiliation with Conn HIE

Counselor Susie Smith

Susie Smith is a counselor via Telemedicine

Hamilton Clinic (a Division of Hartford Hospital)

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

Hamilton Clinic Services

Solo Practitioner Hans Solo

Location of Hans Solo's clinic

Hans Solo is a solo practitioner

Hans Solo Services

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

Hartford Orthopedic Services

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

Hartford General Hospital ER

Location1 of Hartford Hospital

Location2 of Hartford Hospital

Hartford General Hospital

Practitioner Dr Joe Smith

Dr Smith moonlighting as ER Doc at Hartford Hospital

Dr Smith Internal Medicine at Burr Clinic

Dr Smith Admitting Privileges at Hartford General

Organization that Provides Pharmacy Services

Organization Affiliation for PharmChain (Retail)

Organization Affiliation for PharmChain (Compounding)

Organization Affiliation for PharmChain (MailOrder)

Compound Pharmacy Service provided by PharmacyOrganization A

Mail Order Pharmacy Service provided by PharmacyOrganization A

Pharmacy Service provided by PharmChain

Location of Pharmacy1 in PharmChain's network

Location of Pharmacy2 in PharmChain's network

Location of Pharmacy3 in PharmChain's network

Location of Pharmacy4 in PharmChain's network

State of CT Area

Virtual Counseling Service