National Healthcare Directory Exchange, published by HL7 Patient Administration Working Group. This is not an authorized publication; it is the continuous build for version 1.0.0-ballot). This version is based on the current content of https://github.com/HL7/fhir-directory-exchange/ and changes regularly. See the Directory of published versions

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Resource Profile: National Directory 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).

Usage:

• Examples for this Resource Profile: Acme of CT QHP Bronze, Acme of CT QHP Gold

Formal Views of Profile Content

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

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from NatlDirEndpointQryInsurancePlan

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan		0..*	NatlDirEndpointQryInsurancePlan	Details of a Health Insurance product/plan provided by an organization
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan	C	0..*	NatlDirEndpointQryInsurancePlan	Details of a Health Insurance product/plan provided by an organization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣC	0..*	Identifier	Business Identifier for Product
status	?!Σ	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 Value Set (extensible)
name	SΣC	0..1	string	Official name
ownedBy	SΣ	1..1	Reference(National Directory Endpoint Qry Exchange Organization)	Plan issuer
administeredBy	SΣ	1..1	Reference(National Directory Endpoint Qry Exchange Organization)	Product administrator
coverageArea	SΣ	0..*	Reference(National Directory Endpoint Qry Exchange Location)	Where product applies
network	S	0..*	Reference(National Directory Endpoint Qry Exchange Network)	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
network	S	0..*	Reference(Organization)	What networks provide coverage
benefit		1..*	BackboneElement	List of benefits
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Type of benefit
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
InsurancePlan.status	required	Fixed Value: active
InsurancePlan.type	extensible	InsuranceProductTypeVS

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan	C	0..*	NatlDirEndpointQryInsurancePlan	Details of a Health Insurance product/plan provided by an organization
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
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣC	0..*	Identifier	Business Identifier for Product
status	?!Σ	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 Value Set (extensible)
name	SΣC	0..1	string	Official name
alias		0..*	string	Alternate names
period		0..1	Period	When the product is available
ownedBy	SΣ	1..1	Reference(National Directory Endpoint Qry Exchange Organization)	Plan issuer
administeredBy	SΣ	1..1	Reference(National Directory Endpoint Qry Exchange Organization)	Product administrator
coverageArea	SΣ	0..*	Reference(National Directory Endpoint Qry Exchange Location)	Where product applies
contact		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		0..1	HumanName	A name associated with the contact
telecom		0..*	ContactPoint	Contact details (telephone, email, etc.) for a contact
address		0..1	Address	Visiting or postal addresses for the contact
endpoint		0..*	Reference(National Directory Endpoint Qry Exchange Endpoint)	Technical endpoint
network	S	0..*	Reference(National Directory Endpoint Qry Exchange Network)	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
network	S	0..*	Reference(Organization)	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	S	1..1	CodeableConcept	Type of benefit
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
type		0..1	CodeableConcept	Categorization of the cost sharing for the plan Binding: Insurance Plan Type Value Set (extensible)
coverageArea	Σ	0..*	Reference(National Directory Endpoint Qry Exchange Location)	Where product applies
network		0..*	Reference(National Directory Endpoint Qry Exchange Network)	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
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
InsurancePlan.meta.security	extensible	All Security Labels
InsurancePlan.meta.tag	example	CommonTags
InsurancePlan.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
InsurancePlan.status	required	Fixed Value: active
InsurancePlan.type	extensible	InsuranceProductTypeVS
InsurancePlan.contact.purpose	extensible	ContactEntityType
InsurancePlan.plan.type	extensible	InsurancePlanTypeVS
InsurancePlan.plan.specificCost.benefit.cost.applicability	required	BenefitCostApplicability

This structure is derived from NatlDirEndpointQryInsurancePlan

Summary

Differential View

This structure is derived from NatlDirEndpointQryInsurancePlan

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan		0..*	NatlDirEndpointQryInsurancePlan	Details of a Health Insurance product/plan provided by an organization
Documentation for this format

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan	C	0..*	NatlDirEndpointQryInsurancePlan	Details of a Health Insurance product/plan provided by an organization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣC	0..*	Identifier	Business Identifier for Product
status	?!Σ	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 Value Set (extensible)
name	SΣC	0..1	string	Official name
ownedBy	SΣ	1..1	Reference(National Directory Endpoint Qry Exchange Organization)	Plan issuer
administeredBy	SΣ	1..1	Reference(National Directory Endpoint Qry Exchange Organization)	Product administrator
coverageArea	SΣ	0..*	Reference(National Directory Endpoint Qry Exchange Location)	Where product applies
network	S	0..*	Reference(National Directory Endpoint Qry Exchange Network)	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
network	S	0..*	Reference(Organization)	What networks provide coverage
benefit		1..*	BackboneElement	List of benefits
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Type of benefit
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
InsurancePlan.status	required	Fixed Value: active
InsurancePlan.type	extensible	InsuranceProductTypeVS

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan	C	0..*	NatlDirEndpointQryInsurancePlan	Details of a Health Insurance product/plan provided by an organization
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
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣC	0..*	Identifier	Business Identifier for Product
status	?!Σ	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 Value Set (extensible)
name	SΣC	0..1	string	Official name
alias		0..*	string	Alternate names
period		0..1	Period	When the product is available
ownedBy	SΣ	1..1	Reference(National Directory Endpoint Qry Exchange Organization)	Plan issuer
administeredBy	SΣ	1..1	Reference(National Directory Endpoint Qry Exchange Organization)	Product administrator
coverageArea	SΣ	0..*	Reference(National Directory Endpoint Qry Exchange Location)	Where product applies
contact		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		0..1	HumanName	A name associated with the contact
telecom		0..*	ContactPoint	Contact details (telephone, email, etc.) for a contact
address		0..1	Address	Visiting or postal addresses for the contact
endpoint		0..*	Reference(National Directory Endpoint Qry Exchange Endpoint)	Technical endpoint
network	S	0..*	Reference(National Directory Endpoint Qry Exchange Network)	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
network	S	0..*	Reference(Organization)	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	S	1..1	CodeableConcept	Type of benefit
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
type		0..1	CodeableConcept	Categorization of the cost sharing for the plan Binding: Insurance Plan Type Value Set (extensible)
coverageArea	Σ	0..*	Reference(National Directory Endpoint Qry Exchange Location)	Where product applies
network		0..*	Reference(National Directory Endpoint Qry Exchange Network)	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
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
InsurancePlan.meta.security	extensible	All Security Labels
InsurancePlan.meta.tag	example	CommonTags
InsurancePlan.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
InsurancePlan.status	required	Fixed Value: active
InsurancePlan.type	extensible	InsuranceProductTypeVS
InsurancePlan.contact.purpose	extensible	ContactEntityType
InsurancePlan.plan.type	extensible	InsurancePlanTypeVS
InsurancePlan.plan.specificCost.benefit.cost.applicability	required	BenefitCostApplicability

This structure is derived from NatlDirEndpointQryInsurancePlan

Summary

Other representations of profile: CSV, Excel, Schematron