National Directory of Healthcare Providers & Services (NDH) Implementation Guide
2.0.0-current - ci-build
National Directory of Healthcare Providers & Services (NDH) Implementation Guide
2.0.0-current - ci-build
National Directory of Healthcare Providers & Services (NDH) Implementation Guide, published by HL7 International / Patient Administration. This guide is not an authorized publication; it is the continuous build for version 2.0.0-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-us-ndh/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/us/ndh/StructureDefinition/ndh-InsurancePlan | Version: 2.0.0-current | ||||
| Standards status: Trial-use | Maturity Level: 4 | Computable Name: NdhInsurancePlan | |||
| Other Identifiers: OID:2.16.840.1.113883.4.642.40.43.42.43 | |||||
This profile enables NDH to publish normalized insurance product and plan details, including coverage, network relationships, and administration, so users can compare options and accurately match plans to participating providers and service areas; it adds verification and identifier-status extensions and uses ValueSet bindings to normalize product type, coverage type, benefit type, and plan type classifications.
Each insurancePlan has a type which describe the product. An insurancePlan may offer its coverage benefits under a particular network. If an insurancePlan does not have a network, each plan of the insurancePlan must define a distinct plan type (InsurancePlace.plan.type).
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 insurance plan), and additional information about the offering, such as who own it, who administer it, coverage area, contact information, etc.
To change a network in an insurance plan, adjust the insurancePlan.period and generate a fresh new insurance plan.
Usages:
You can also check for usages in the FHIR IG Statistics
Description Differentials, Snapshots, and other representations.
| Name | Flags | Card. | Type | Description & Constraints Filter:  | ||||
|---|---|---|---|---|---|---|---|---|
  InsurancePlan |
C | 0..* | InsurancePlan | Details of a Health Insurance product/plan provided by an organization Constraints: ipn-1, network-or-NatlDirwork, plan-type-is-distinct | ||||
  meta |
0..1 | Meta | Metadata about the resource | |||||
   lastUpdated |
1..1 | instant | When the resource version last changed | |||||
 implicitRules |
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.
| |||||
 Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
  extension:verification-status |
0..1 | CodeableConcept | NDH Verification Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status Binding: NDH Verification Status Value Set (extensible) | |||||
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| identifier |
C | 0..* | Identifier | Business Identifier for Product | ||||
 Slices for extension |
Content/Rules for all slices | |||||||
| extension:identifier-status |
0..1 | code | NDH Identifier Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status Binding: Identifier Status Value Set (required) | |||||
| use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||
 assigner |
0..1 | Reference(NDH Organization Profile) | Organization that issued id (may be just text) | |||||
| status |
1..1 | code | draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact. Fixed Value: active (no extensions allowed) | |||||
| type |
1..1 | CodeableConcept | Product Type Binding: Insurance Product Type (extensible) | |||||
| name |
C | 0..1 | string | Official name | ||||
| alias |
0..* | string | Alternate names | |||||
| period |
0..1 | Period | When the product is available | |||||
| ownedBy |
0..1 | Reference(NDH Organization Profile) | Plan issuer | |||||
| administeredBy |
0..1 | Reference(NDH Organization Profile) | Product administrator | |||||
| coverageArea |
0..* | Reference(NDH Location Profile) | Where product applies | |||||
| contact |
0..* | BackboneElement | Contact for the product | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| name |
0..1 | HumanName | A name associated with the contact | |||||
| telecom |
0..* | ContactPoint | Contact details (telephone, email, etc.) for a contact | |||||
| endpoint |
0..* | Reference(NDH Endpoint Profile) | Technical endpoint | |||||
| network |
0..* | Reference(NDH Network Profile) | What networks are Included | |||||
| coverage |
0..* | BackboneElement | Coverage details | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
1..1 | CodeableConcept | Type of coverage Binding: Insurance Coverage Type (extensible) | |||||
| network |
0..* | Reference(NDH Network Profile) | What networks provide coverage | |||||
 benefit |
1..* | BackboneElement | List of benefits | |||||
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
1..1 | CodeableConcept | Type of benefit Binding: Benefit Type Value Set (extensible) | |||||
| plan |
0..* | BackboneElement | Cost sharing details for the plan | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
0..1 | CodeableConcept | Categorization of the cost sharing for the plan Binding: Insuranceplan Plan Type (extensible) | |||||
| coverageArea |
0..* | Reference(NDH Location Profile) | Where product applies | |||||
| network |
0..* | Reference(NDH Network Profile) | What networks provide coverage | |||||
| Documentation for this format | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| InsurancePlan.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| InsurancePlan.identifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| InsurancePlan.status | Base | required | PublicationStatus | 📍4.0.1 | FHIR Std. |
| InsurancePlan.type | Base | extensible | Insurance Product Type | 📦1.0.0 | THO v7.4 |
| InsurancePlan.coverage.type | Base | extensible | Insurance Coverage Type | 📦1.0.0 | THO v7.4 |
| InsurancePlan.coverage.benefit.type | Base | extensible | Benefit Type Value Set | 📦2.0.0-current | This IG |
| InsurancePlan.plan.type | Base | extensible | Insuranceplan Plan Type | 📦1.0.0 | THO v7.4 |
| Id | Grade | Path(s) | Description | Expression |
| network-or-NatlDirwork | error | InsurancePlan | If an insuranceplan does not define a network, then each plan must define one |
network.exists() or coverage.network.exists() or plan.network.exists()
|
| plan-type-is-distinct | error | InsurancePlan | Each InsurancePlan.plan should have a distinct plan.type. |
plan.type.coding.code.isDistinct()
|
This structure is derived from InsurancePlan
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| InsurancePlan |
C | 0..* | InsurancePlan | Details of a Health Insurance product/plan provided by an organization Constraints: network-or-NatlDirwork, plan-type-is-distinct |
 meta |
0..1 | Meta | Metadata about the resource | |
| lastUpdated |
1..1 | instant | When the resource version last changed | |
| language |
0..1 | code | Language of the resource content | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| extension:verification-status |
0..1 | CodeableConcept | NDH Verification Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status Binding: NDH Verification Status Value Set (extensible) | |
| identifier |
0..* | Identifier | Business Identifier for Product | |
| Slices for extension |
Content/Rules for all slices | |||
| extension:identifier-status |
0..1 | code | NDH Identifier Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status Binding: Identifier Status Value Set (required) | |
| assigner |
0..1 | Reference(NDH Organization Profile) | Organization that issued id (may be just text) | |
| status |
1..1 | code | draft | active | retired | unknown Fixed Value: active (no extensions allowed) | |
| type |
1..1 | CodeableConcept | Product Type Binding: Insurance Product Type (extensible) | |
| name |
0..1 | string | Official name | |
| alias |
0..* | string | Alternate names | |
| period |
0..1 | Period | When the product is available | |
| ownedBy |
0..1 | Reference(NDH Organization Profile) | Plan issuer | |
| administeredBy |
0..1 | Reference(NDH Organization Profile) | Product administrator | |
| coverageArea |
0..* | Reference(NDH Location Profile) | Where product applies | |
| contact |
0..* | BackboneElement | Contact for the product | |
| name |
0..1 | HumanName | A name associated with the contact | |
| telecom |
0..* | ContactPoint | Contact details (telephone, email, etc.) for a contact | |
| endpoint |
0..* | Reference(NDH Endpoint Profile) | Technical endpoint | |
| network |
0..* | Reference(NDH Network Profile) | What networks are Included | |
| coverage |
0..* | BackboneElement | Coverage details | |
| type |
1..1 | CodeableConcept | Type of coverage Binding: Insurance Coverage Type (extensible) | |
| network |
0..* | Reference(NDH Network Profile) | What networks provide coverage | |
| benefit |
||||
| type |
1..1 | CodeableConcept | Type of benefit Binding: Benefit Type Value Set (extensible) | |
| plan |
0..* | BackboneElement | Cost sharing details for the plan | |
| identifier |
||||
| Slices for extension |
Content/Rules for all slices | |||
| extension:identifier-status |
0..1 | code | NDH Identifier Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status Binding: Identifier Status Value Set (required) | |
| assigner |
0..1 | Reference(NDH Organization Profile) | Organization that issued id (may be just text) | |
| type |
0..1 | CodeableConcept | Categorization of the cost sharing for the plan Binding: Insuranceplan Plan Type (extensible) | |
| coverageArea |
0..* | Reference(NDH Location Profile) | Where product applies | |
| network |
0..* | Reference(NDH Network Profile) | What networks provide coverage | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| InsurancePlan.type | Base | extensible | Insurance Product Type | 📦1.0.0 | THO v7.4 |
| InsurancePlan.coverage.type | Base | extensible | Insurance Coverage Type | 📦1.0.0 | THO v7.4 |
| InsurancePlan.coverage.benefit.type | Base | extensible | Benefit Type Value Set | 📦2.0.0-current | This IG |
| InsurancePlan.plan.type | Base | extensible | Insuranceplan Plan Type | 📦1.0.0 | THO v7.4 |
| Id | Grade | Path(s) | Description | Expression |
| network-or-NatlDirwork | error | InsurancePlan | If an insuranceplan does not define a network, then each plan must define one |
network.exists() or coverage.network.exists() or plan.network.exists()
|
| plan-type-is-distinct | error | InsurancePlan | Each InsurancePlan.plan should have a distinct plan.type. |
plan.type.coding.code.isDistinct()
|
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| InsurancePlan |
C | 0..* | InsurancePlan | Details of a Health Insurance product/plan provided by an organization Constraints: ipn-1, network-or-NatlDirwork, plan-type-is-distinct | ||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
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 |
0..1 | id | Version specific identifier | |||||
| lastUpdated |
1..1 | instant | When the resource version last changed | |||||
| source |
0..1 | uri | Identifies where the resource comes from | |||||
| profile |
0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | |||||
| security |
0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | |||||
| tag |
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 |
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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| extension:verification-status |
0..1 | CodeableConcept | NDH Verification Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status Binding: NDH Verification Status Value Set (extensible) | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| identifier |
C | 0..* | Identifier | Business Identifier for Product | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| extension:identifier-status |
0..1 | code | NDH Identifier Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status Binding: Identifier Status Value Set (required) | |||||
| use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||
| type |
0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | |||||
| system |
0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | |||||
| value |
0..1 | string | The value that is unique Example General: 123456 | |||||
| period |
0..1 | Period | Time period when id is/was valid for use | |||||
| assigner |
0..1 | Reference(NDH Organization Profile) | Organization that issued id (may be just text) | |||||
| status |
1..1 | code | draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact. Fixed Value: active (no extensions allowed) | |||||
| type |
1..1 | CodeableConcept | Product Type Binding: Insurance Product Type (extensible) | |||||
| name |
C | 0..1 | string | Official name | ||||
| alias |
0..* | string | Alternate names | |||||
| period |
0..1 | Period | When the product is available | |||||
| ownedBy |
0..1 | Reference(NDH Organization Profile) | Plan issuer | |||||
| administeredBy |
0..1 | Reference(NDH Organization Profile) | Product administrator | |||||
| coverageArea |
0..* | Reference(NDH Location Profile) | 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 |
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(NDH Endpoint Profile) | Technical endpoint | |||||
| network |
0..* | Reference(NDH Network Profile) | 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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
1..1 | CodeableConcept | Type of coverage Binding: Insurance Coverage Type (extensible) | |||||
| network |
0..* | Reference(NDH Network Profile) | 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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
1..1 | CodeableConcept | Type of benefit Binding: Benefit Type Value Set (extensible) | |||||
| 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 |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| identifier |
0..* | Identifier | Business Identifier for Product | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| extension:identifier-status |
0..1 | code | NDH Identifier Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status Binding: Identifier Status Value Set (required) | |||||
| use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||
| type |
0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | |||||
| system |
0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | |||||
| value |
0..1 | string | The value that is unique Example General: 123456 | |||||
| period |
0..1 | Period | Time period when id is/was valid for use | |||||
| assigner |
0..1 | Reference(NDH Organization Profile) | Organization that issued id (may be just text) | |||||
| type |
0..1 | CodeableConcept | Categorization of the cost sharing for the plan Binding: Insuranceplan Plan Type (extensible) | |||||
| coverageArea |
0..* | Reference(NDH Location Profile) | Where product applies | |||||
| network |
0..* | Reference(NDH Network Profile) | 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 |
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 |
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 |
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 |
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 | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| InsurancePlan.meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std. |
| InsurancePlan.meta.tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std. |
| InsurancePlan.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| InsurancePlan.identifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| InsurancePlan.identifier.type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std. |
| InsurancePlan.status | Base | required | PublicationStatus | 📍4.0.1 | FHIR Std. |
| InsurancePlan.type | Base | extensible | Insurance Product Type | 📦1.0.0 | THO v7.4 |
| InsurancePlan.contact.purpose | Base | extensible | Contact entity type | 📍4.0.1 | FHIR Std. |
| InsurancePlan.coverage.type | Base | extensible | Insurance Coverage Type | 📦1.0.0 | THO v7.4 |
| InsurancePlan.coverage.benefit.type | Base | extensible | Benefit Type Value Set | 📦2.0.0-current | This IG |
| InsurancePlan.plan.identifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| InsurancePlan.plan.identifier.type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std. |
| InsurancePlan.plan.type | Base | extensible | Insuranceplan Plan Type | 📦1.0.0 | THO v7.4 |
| InsurancePlan.plan.specificCost.benefit.cost.applicability | Base | required | Benefit cost applicability | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| network-or-NatlDirwork | error | InsurancePlan | If an insuranceplan does not define a network, then each plan must define one |
network.exists() or coverage.network.exists() or plan.network.exists()
|
| plan-type-is-distinct | error | InsurancePlan | Each InsurancePlan.plan should have a distinct plan.type. |
plan.type.coding.code.isDistinct()
|
This structure is derived from InsurancePlan
Summary
Mandatory: 2 elements(1 nested mandatory element)
Must-Support: 7 elements
Fixed: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 4
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| InsurancePlan |
C | 0..* | InsurancePlan | Details of a Health Insurance product/plan provided by an organization Constraints: ipn-1, network-or-NatlDirwork, plan-type-is-distinct | ||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| lastUpdated |
1..1 | instant | When the resource version last changed | |||||
| implicitRules |
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.
| |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| extension:verification-status |
0..1 | CodeableConcept | NDH Verification Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status Binding: NDH Verification Status Value Set (extensible) | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| identifier |
C | 0..* | Identifier | Business Identifier for Product | ||||
| Slices for extension |
Content/Rules for all slices | |||||||
| extension:identifier-status |
0..1 | code | NDH Identifier Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status Binding: Identifier Status Value Set (required) | |||||
| use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||
| assigner |
0..1 | Reference(NDH Organization Profile) | Organization that issued id (may be just text) | |||||
| status |
1..1 | code | draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact. Fixed Value: active (no extensions allowed) | |||||
| type |
1..1 | CodeableConcept | Product Type Binding: Insurance Product Type (extensible) | |||||
| name |
C | 0..1 | string | Official name | ||||
| alias |
0..* | string | Alternate names | |||||
| period |
0..1 | Period | When the product is available | |||||
| ownedBy |
0..1 | Reference(NDH Organization Profile) | Plan issuer | |||||
| administeredBy |
0..1 | Reference(NDH Organization Profile) | Product administrator | |||||
| coverageArea |
0..* | Reference(NDH Location Profile) | Where product applies | |||||
| contact |
0..* | BackboneElement | Contact for the product | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| name |
0..1 | HumanName | A name associated with the contact | |||||
| telecom |
0..* | ContactPoint | Contact details (telephone, email, etc.) for a contact | |||||
| endpoint |
0..* | Reference(NDH Endpoint Profile) | Technical endpoint | |||||
| network |
0..* | Reference(NDH Network Profile) | What networks are Included | |||||
| coverage |
0..* | BackboneElement | Coverage details | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
1..1 | CodeableConcept | Type of coverage Binding: Insurance Coverage Type (extensible) | |||||
| network |
0..* | Reference(NDH Network Profile) | What networks provide coverage | |||||
| benefit |
1..* | BackboneElement | List of benefits | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
1..1 | CodeableConcept | Type of benefit Binding: Benefit Type Value Set (extensible) | |||||
| plan |
0..* | BackboneElement | Cost sharing details for the plan | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
0..1 | CodeableConcept | Categorization of the cost sharing for the plan Binding: Insuranceplan Plan Type (extensible) | |||||
| coverageArea |
0..* | Reference(NDH Location Profile) | Where product applies | |||||
| network |
0..* | Reference(NDH Network Profile) | What networks provide coverage | |||||
| Documentation for this format | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| InsurancePlan.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| InsurancePlan.identifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| InsurancePlan.status | Base | required | PublicationStatus | 📍4.0.1 | FHIR Std. |
| InsurancePlan.type | Base | extensible | Insurance Product Type | 📦1.0.0 | THO v7.4 |
| InsurancePlan.coverage.type | Base | extensible | Insurance Coverage Type | 📦1.0.0 | THO v7.4 |
| InsurancePlan.coverage.benefit.type | Base | extensible | Benefit Type Value Set | 📦2.0.0-current | This IG |
| InsurancePlan.plan.type | Base | extensible | Insuranceplan Plan Type | 📦1.0.0 | THO v7.4 |
| Id | Grade | Path(s) | Description | Expression |
| network-or-NatlDirwork | error | InsurancePlan | If an insuranceplan does not define a network, then each plan must define one |
network.exists() or coverage.network.exists() or plan.network.exists()
|
| plan-type-is-distinct | error | InsurancePlan | Each InsurancePlan.plan should have a distinct plan.type. |
plan.type.coding.code.isDistinct()
|
Differential View
This structure is derived from InsurancePlan
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| InsurancePlan |
C | 0..* | InsurancePlan | Details of a Health Insurance product/plan provided by an organization Constraints: network-or-NatlDirwork, plan-type-is-distinct |
| meta |
0..1 | Meta | Metadata about the resource | |
| lastUpdated |
1..1 | instant | When the resource version last changed | |
| language |
0..1 | code | Language of the resource content | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| extension:verification-status |
0..1 | CodeableConcept | NDH Verification Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status Binding: NDH Verification Status Value Set (extensible) | |
| identifier |
0..* | Identifier | Business Identifier for Product | |
| Slices for extension |
Content/Rules for all slices | |||
| extension:identifier-status |
0..1 | code | NDH Identifier Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status Binding: Identifier Status Value Set (required) | |
| assigner |
0..1 | Reference(NDH Organization Profile) | Organization that issued id (may be just text) | |
| status |
1..1 | code | draft | active | retired | unknown Fixed Value: active (no extensions allowed) | |
| type |
1..1 | CodeableConcept | Product Type Binding: Insurance Product Type (extensible) | |
| name |
0..1 | string | Official name | |
| alias |
0..* | string | Alternate names | |
| period |
0..1 | Period | When the product is available | |
| ownedBy |
0..1 | Reference(NDH Organization Profile) | Plan issuer | |
| administeredBy |
0..1 | Reference(NDH Organization Profile) | Product administrator | |
| coverageArea |
0..* | Reference(NDH Location Profile) | Where product applies | |
| contact |
0..* | BackboneElement | Contact for the product | |
| name |
0..1 | HumanName | A name associated with the contact | |
| telecom |
0..* | ContactPoint | Contact details (telephone, email, etc.) for a contact | |
| endpoint |
0..* | Reference(NDH Endpoint Profile) | Technical endpoint | |
| network |
0..* | Reference(NDH Network Profile) | What networks are Included | |
| coverage |
0..* | BackboneElement | Coverage details | |
| type |
1..1 | CodeableConcept | Type of coverage Binding: Insurance Coverage Type (extensible) | |
| network |
0..* | Reference(NDH Network Profile) | What networks provide coverage | |
| benefit |
||||
| type |
1..1 | CodeableConcept | Type of benefit Binding: Benefit Type Value Set (extensible) | |
| plan |
0..* | BackboneElement | Cost sharing details for the plan | |
| identifier |
||||
| Slices for extension |
Content/Rules for all slices | |||
| extension:identifier-status |
0..1 | code | NDH Identifier Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status Binding: Identifier Status Value Set (required) | |
| assigner |
0..1 | Reference(NDH Organization Profile) | Organization that issued id (may be just text) | |
| type |
0..1 | CodeableConcept | Categorization of the cost sharing for the plan Binding: Insuranceplan Plan Type (extensible) | |
| coverageArea |
0..* | Reference(NDH Location Profile) | Where product applies | |
| network |
0..* | Reference(NDH Network Profile) | What networks provide coverage | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| InsurancePlan.type | Base | extensible | Insurance Product Type | 📦1.0.0 | THO v7.4 |
| InsurancePlan.coverage.type | Base | extensible | Insurance Coverage Type | 📦1.0.0 | THO v7.4 |
| InsurancePlan.coverage.benefit.type | Base | extensible | Benefit Type Value Set | 📦2.0.0-current | This IG |
| InsurancePlan.plan.type | Base | extensible | Insuranceplan Plan Type | 📦1.0.0 | THO v7.4 |
| Id | Grade | Path(s) | Description | Expression |
| network-or-NatlDirwork | error | InsurancePlan | If an insuranceplan does not define a network, then each plan must define one |
network.exists() or coverage.network.exists() or plan.network.exists()
|
| plan-type-is-distinct | error | InsurancePlan | Each InsurancePlan.plan should have a distinct plan.type. |
plan.type.coding.code.isDistinct()
|
Snapshot ViewView
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| InsurancePlan |
C | 0..* | InsurancePlan | Details of a Health Insurance product/plan provided by an organization Constraints: ipn-1, network-or-NatlDirwork, plan-type-is-distinct | ||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
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 |
0..1 | id | Version specific identifier | |||||
| lastUpdated |
1..1 | instant | When the resource version last changed | |||||
| source |
0..1 | uri | Identifies where the resource comes from | |||||
| profile |
0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | |||||
| security |
0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | |||||
| tag |
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 |
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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| extension:verification-status |
0..1 | CodeableConcept | NDH Verification Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status Binding: NDH Verification Status Value Set (extensible) | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| identifier |
C | 0..* | Identifier | Business Identifier for Product | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| extension:identifier-status |
0..1 | code | NDH Identifier Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status Binding: Identifier Status Value Set (required) | |||||
| use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||
| type |
0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | |||||
| system |
0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | |||||
| value |
0..1 | string | The value that is unique Example General: 123456 | |||||
| period |
0..1 | Period | Time period when id is/was valid for use | |||||
| assigner |
0..1 | Reference(NDH Organization Profile) | Organization that issued id (may be just text) | |||||
| status |
1..1 | code | draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact. Fixed Value: active (no extensions allowed) | |||||
| type |
1..1 | CodeableConcept | Product Type Binding: Insurance Product Type (extensible) | |||||
| name |
C | 0..1 | string | Official name | ||||
| alias |
0..* | string | Alternate names | |||||
| period |
0..1 | Period | When the product is available | |||||
| ownedBy |
0..1 | Reference(NDH Organization Profile) | Plan issuer | |||||
| administeredBy |
0..1 | Reference(NDH Organization Profile) | Product administrator | |||||
| coverageArea |
0..* | Reference(NDH Location Profile) | 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 |
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(NDH Endpoint Profile) | Technical endpoint | |||||
| network |
0..* | Reference(NDH Network Profile) | 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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
1..1 | CodeableConcept | Type of coverage Binding: Insurance Coverage Type (extensible) | |||||
| network |
0..* | Reference(NDH Network Profile) | 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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| type |
1..1 | CodeableConcept | Type of benefit Binding: Benefit Type Value Set (extensible) | |||||
| 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 |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| identifier |
0..* | Identifier | Business Identifier for Product | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| extension:identifier-status |
0..1 | code | NDH Identifier Status URL: http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-identifier-status Binding: Identifier Status Value Set (required) | |||||
| use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||
| type |
0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | |||||
| system |
0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | |||||
| value |
0..1 | string | The value that is unique Example General: 123456 | |||||
| period |
0..1 | Period | Time period when id is/was valid for use | |||||
| assigner |
0..1 | Reference(NDH Organization Profile) | Organization that issued id (may be just text) | |||||
| type |
0..1 | CodeableConcept | Categorization of the cost sharing for the plan Binding: Insuranceplan Plan Type (extensible) | |||||
| coverageArea |
0..* | Reference(NDH Location Profile) | Where product applies | |||||
| network |
0..* | Reference(NDH Network Profile) | 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 |
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 |
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 |
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 |
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 | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| InsurancePlan.meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std. |
| InsurancePlan.meta.tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std. |
| InsurancePlan.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| InsurancePlan.identifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| InsurancePlan.identifier.type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std. |
| InsurancePlan.status | Base | required | PublicationStatus | 📍4.0.1 | FHIR Std. |
| InsurancePlan.type | Base | extensible | Insurance Product Type | 📦1.0.0 | THO v7.4 |
| InsurancePlan.contact.purpose | Base | extensible | Contact entity type | 📍4.0.1 | FHIR Std. |
| InsurancePlan.coverage.type | Base | extensible | Insurance Coverage Type | 📦1.0.0 | THO v7.4 |
| InsurancePlan.coverage.benefit.type | Base | extensible | Benefit Type Value Set | 📦2.0.0-current | This IG |
| InsurancePlan.plan.identifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std. |
| InsurancePlan.plan.identifier.type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std. |
| InsurancePlan.plan.type | Base | extensible | Insuranceplan Plan Type | 📦1.0.0 | THO v7.4 |
| InsurancePlan.plan.specificCost.benefit.cost.applicability | Base | required | Benefit cost applicability | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| network-or-NatlDirwork | error | InsurancePlan | If an insuranceplan does not define a network, then each plan must define one |
network.exists() or coverage.network.exists() or plan.network.exists()
|
| plan-type-is-distinct | error | InsurancePlan | Each InsurancePlan.plan should have a distinct plan.type. |
plan.type.coding.code.isDistinct()
|
This structure is derived from InsurancePlan
Summary
Mandatory: 2 elements(1 nested mandatory element)
Must-Support: 7 elements
Fixed: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 4
Other representations of profile: CSV, Excel, Schematron
| Name | Type | Description | Expression |
| address | string |
A server defined search that may match any of the string fields in the Address, including line, city, district, state, country, postalCode, and/or text |
InsurancePlan.contact.address
|
| address-city | string |
A city specified in an address |
InsurancePlan.contact.address.city
|
| address-country | string |
A country specified in an address |
InsurancePlan.contact.address.country
|
| address-postalcode | string |
A postal code specified in an address |
InsurancePlan.contact.address.postalCode
|
| address-state | string |
A state specified in an address |
InsurancePlan.contact.address.state
|
| address-use | token |
A use code specified in an address |
InsurancePlan.contact.address.use
|
| administered-by | reference |
Product administrator |
InsurancePlan.administeredBy
|
| coverage-area | reference |
Use this search parameter to find products that are offered in the specified location. Applies to InsurancePlan records. |
InsurancePlan.coverageArea
|
| coverage-benefit-type | token |
Use this search parameter to find products that are offered in the specified coverage benefit type. Applies to InsurancePlan records. |
InsurancePlan.coverage.benefit.type
|
| coverage-network | reference |
Use this search parameter to find products offering covered benefits through the specified coverage network. Applies to InsurancePlan records. |
InsurancePlan.coverage.network
|
| coverage-type | token |
Use this search parameter to find products that are offered in the specified coverage type. Applies to InsurancePlan records. |
InsurancePlan.coverage.type
|
| endpoint | reference |
Technical endpoint |
InsurancePlan.endpoint
|
| identifier | token |
Select products with the specified identifier |
InsurancePlan.identifier
|
| name | string |
Select products with the specified name |
name | alias
|
| network | reference |
Use this search parameter to find products that are offered in the specified network. Applies to InsurancePlan records. |
InsurancePlan.network
|
| owned-by | reference |
Select products that are owned by the specified organization |
InsurancePlan.ownedBy
|
| phonetic | string |
A portion of the organization's name using some kind of phonetic matching algorithm |
InsurancePlan.name
|
| plan-network | reference |
Use this search parameter to find products that are offered in the specified plan network. Applies to InsurancePlan records. |
InsurancePlan.plan.network
|
| plan-type | token |
Use this search parameter to find products that are offered in the specified plan type. Applies to InsurancePlan records. |
InsurancePlan.plan.type
|
| status | token |
Is the Organization record active |
InsurancePlan.status
|
| type | token |
Select insurance plans of the specified type |
InsurancePlan.type
|
| verification-status | token |
Use this search parameter to find records by verification standing to prioritize trusted and current directory data. Applies to Endpoint, HealthcareService, Organization, Location, Practitioner, PractitionerRole, InsurancePlan, OrganizationAffiliation, and Group records. |
extension('http://hl7.org/fhir/us/ndh/StructureDefinition/base-ext-verification-status').value
|
| _include | Example |
|---|---|
| InsurancePlan:administered-by | GET [base]/InsurancePlan?_include=InsurancePlan:administered-by |
| InsurancePlan:endpoint | GET [base]/InsurancePlan?_include=InsurancePlan:endpoint |
| InsurancePlan:owned-by | GET [base]/InsurancePlan?_include=InsurancePlan:owned-by |
| InsurancePlan:coverage-area | GET [base]/InsurancePlan?_include=InsurancePlan:coverage-area |
| InsurancePlan:coverage-network | GET [base]/InsurancePlan?_include=InsurancePlan:coverage-network |
| InsurancePlan:plan-network | GET [base]/InsurancePlan?_include=InsurancePlan:plan-network |
| InsurancePlan:network | GET [base]/InsurancePlan?_include=InsurancePlan:network |
If you only want to search for networks associated with an InsurancePlan, you can use the following approach: The primary resource in this context is the Organization, while the InsurancePlan resources serve as references to it. To accomplish this, the _revinclude feature is utilized. As the Network resource profile is derived from the Organization resource, the type=ntwk parameter must be included in your search.
GET [base]/Organization?type=ntwk&_revinclude=InsurancePlan:network
The relationship between InsurancePlans and Networks is many-to-many. A plan may be associated with multipe networks. The NDH model is having InsurancePlan reference networks.
The search parameters outlined above are straightforward for basic scenarios but have limitations in handling complex combination queries. To enhance these capabilities, employing the special search parameters _filter is recommended.
The Insurance Plan resource defines three levels of networks: the base level network, the coverage level network, and the plan level network. The base level network is intended to apply to all coverage and plans when appropriate. For example, if dental services are included in the base level network and are covered at the coverage level, they would apply. Networks at the coverage level are specific to that coverage and are in addition to the base level network. Networks at the plan level are specific to the particular plan and incorporate any networks defined at both the base level and the coverage level. For instance, in a Platinum plan, the network may include more expensive venues that are not covered in lower-priced plans.
A payer’s products typically differ by network type and/or covered benefits. A insurance plan pairs a product’s covered benefits with the particular cost sharing structure offered to a consumer. A given payer’s product may comprise multiple insurance plans (i.e. each insurance plan offers different cost sharing requirements for the same set of covered benefits).
IG © 2023+ HL7 International / Patient Administration.
Package hl7.fhir.us.ndh#2.0.0-current based on FHIR 4.0.1.
Generated
2026-10-19
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