National Healthcare Directory Exchange
1.0.0-ballot - ballot

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

## Resource Profile: National Directory InsurancePlan

Official URL: http://hl7.org/fhir/us/directory-exchange/StructureDefinition/NatlDirEx-InsurancePlan | Version: 1.0.0-ballot
Active as of 2022-12-08 | Computable Name: NatlDirExInsurancePlan

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 | S Σ C | 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 | S Σ | 1..1 | CodeableConcept | Product Type Binding: Insurance Product Type Value Set (extensible)
name | S Σ C | 0..1 | string | Official name
ownedBy | S Σ | 1..1 | Reference(National Directory Endpoint Qry Exchange Organization) | Plan issuer
administeredBy | S Σ | 1..1 | Reference(National Directory Endpoint Qry Exchange Organization) | Product administrator
coverageArea | S Σ | 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 | S Σ C | 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 | S Σ | 1..1 | CodeableConcept | Product Type Binding: Insurance Product Type Value Set (extensible)
name | S Σ C | 0..1 | string | Official name
alias |  | 0..* | string | Alternate names
period |  | 0..1 | Period | When the product is available
ownedBy | S Σ | 1..1 | Reference(National Directory Endpoint Qry Exchange Organization) | Plan issuer
administeredBy | S Σ | 1..1 | Reference(National Directory Endpoint Qry Exchange Organization) | Product administrator
coverageArea | S Σ | 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 | S Σ C | 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 | S Σ | 1..1 | CodeableConcept | Product Type Binding: Insurance Product Type Value Set (extensible)
name | S Σ C | 0..1 | string | Official name
ownedBy | S Σ | 1..1 | Reference(National Directory Endpoint Qry Exchange Organization) | Plan issuer
administeredBy | S Σ | 1..1 | Reference(National Directory Endpoint Qry Exchange Organization) | Product administrator
coverageArea | S Σ | 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 | S Σ C | 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 | S Σ | 1..1 | CodeableConcept | Product Type Binding: Insurance Product Type Value Set (extensible)
name | S Σ C | 0..1 | string | Official name
alias |  | 0..* | string | Alternate names
period |  | 0..1 | Period | When the product is available
ownedBy | S Σ | 1..1 | Reference(National Directory Endpoint Qry Exchange Organization) | Plan issuer
administeredBy | S Σ | 1..1 | Reference(National Directory Endpoint Qry Exchange Organization) | Product administrator
coverageArea | S Σ | 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