National Healthcare Directory Query
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National Healthcare Directory Query, published by HL7 International - Patient Administration Work 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-query/ and changes regularly. See the Directory of published versions

Resource Profile: National Directory Endpoint Qry Exchange InsurancePlan

Official URL: http://hl7.org/fhir/us/directory-query/StructureDefinition/NatlDirEndpointQry-InsurancePlan Version: 1.0.0-ballot
Active as of 2022-12-08 Computable Name: NatlDirEndpointQryInsurancePlan

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.

Usage:

Formal Views of Profile Content

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

This structure is derived from InsurancePlan

NameFlagsCard.TypeDescription & Constraintsdoco
.. InsurancePlan C0..*InsurancePlanDetails of a Health Insurance product/plan provided by an organization
network-or-NatlDirwork: If an insuranceplan does not define a network, then each plan must define one
plan-type-is-distinct: Each InsurancePlan.plan should have a distinct plan.type.
... meta
.... lastUpdated 1..1instantWhen the resource version last changed
... identifier S0..*IdentifierBusiness Identifier for Product
... status 1..1codedraft | active | retired | unknown
Fixed Value: active
... name S0..1stringOfficial name
... ownedBy S1..1Reference(National Directory Endpoint Qry Exchange Organization)Plan issuer
... administeredBy S1..1Reference(National Directory Endpoint Qry Exchange Organization)Product administrator
... coverageArea S0..*Reference(National Directory Endpoint Qry Exchange Location)Where product applies
... endpoint 0..*Reference(National Directory Endpoint Qry Exchange Endpoint)Technical endpoint
... network S0..*Reference(National Directory Endpoint Qry Exchange Network)What networks are Included
... coverage
.... network S0..*Reference(Organization)What networks provide coverage
.... benefit
..... type S1..1CodeableConceptType of benefit
... plan 0..*BackboneElementCost sharing details for the plan
.... type 0..1CodeableConceptCategorization of the cost sharing for the plan
Binding: Insurance Plan Type Value Set (extensible)
.... coverageArea 0..*Reference(National Directory Endpoint Qry Exchange Location)Where product applies
.... network 0..*Reference(National Directory Endpoint Qry Exchange Network)What networks provide coverage

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
InsurancePlan.typeextensibleInsuranceProductTypeVS (a valid code from Insurance Product Type Code System)
InsurancePlan.plan.typeextensibleInsurancePlanTypeVS (a valid code from Insurance Plan Type Code System)

Constraints

IdGradePath(s)DetailsRequirements
network-or-NatlDirworkerrorInsurancePlanIf an insuranceplan does not define a network, then each plan must define one
: network.exists() or plan.network.exists.allTrue()
plan-type-is-distincterrorInsurancePlanEach InsurancePlan.plan should have a distinct plan.type.
: plan.type.coding.code.isDistinct()

 

Other representations of profile: CSV, Excel, Schematron