National Directory of Healthcare Providers & Services (NDH) Implementation Guide
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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

Resource Profile: NDH InsurancePlan Profile

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:2.999.1.2.3.4.42.43

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.

Background & scope

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

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 Σ 0..1 Meta Metadata about the resource
.... lastUpdated Σ 1..1 instant When the resource version last changed
... 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 BindingsPurpose
AllLanguages Max Binding
.... 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 SΣC 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 ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... assigner Σ 0..1 Reference(NDH Organization Profile) Organization that issued id (may be just text)
... status ?!SΣ 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 (extensible)
... name SΣC 0..1 string Official name
... alias 0..* string Alternate names
... period 0..1 Period When the product is available
... ownedBy Σ 0..1 Reference(NDH Organization Profile) Plan issuer
... administeredBy Σ 0..1 Reference(NDH Organization Profile) Product administrator
... coverageArea SΣ 0..* Reference(NDH Location Profile) Where product applies
... contact 0..* BackboneElement Contact for the product
.... modifierExtension ?!Σ 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 S 0..* Reference(NDH Network Profile) 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
Binding: Insurance Coverage Type (extensible)
.... network S 0..* Reference(NDH Network Profile) What networks provide coverage
.... benefit 1..* BackboneElement List of benefits
..... modifierExtension ?!Σ 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 ?!Σ 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 Σ 0..* Reference(NDH Location Profile) Where product applies
.... network 0..* Reference(NDH Network Profile) What networks provide coverage

doco Documentation for this format

Terminology Bindings

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 v7.2
InsurancePlan.coverage.​type Base extensible Insurance Coverage Type 📦1.0.0 THO v7.2
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 v7.2

Constraints

Id Grade Path(s) Description Expression
dom-2 error InsurancePlan If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error InsurancePlan If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice InsurancePlan A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
ipn-1 error InsurancePlan The organization SHALL at least have a name or an idendtifier, and possibly more than one (identifier.count() + name.count()) > 0
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()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
.... 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)
.... 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 S 1..1 code draft | active | retired | unknown
Fixed Value: active
... type S 1..1 CodeableConcept Product Type
Binding: Insurance Product Type (extensible)
... name S 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 S 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 S 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 S 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

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
InsurancePlan.type Base extensible Insurance Product Type 📦1.0.0 THO v7.2
InsurancePlan.coverage.​type Base extensible Insurance Coverage Type 📦1.0.0 THO v7.2
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 v7.2

Constraints

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()
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 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
... 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
.... 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 SΣC 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 ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... type Σ 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 Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ 0..1 string The value that is unique
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(NDH Organization Profile) Organization that issued id (may be just text)
... status ?!SΣ 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 (extensible)
... name SΣC 0..1 string Official name
... alias 0..* string Alternate names
... period 0..1 Period When the product is available
... ownedBy Σ 0..1 Reference(NDH Organization Profile) Plan issuer
... administeredBy Σ 0..1 Reference(NDH Organization Profile) Product administrator
... coverageArea SΣ 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 ?!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(NDH Endpoint Profile) Technical endpoint
... network S 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 ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Type of coverage
Binding: Insurance Coverage Type (extensible)
.... network S 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 ?!Σ 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 ?!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
..... 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 ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type Σ 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 Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 0..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 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 Σ 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 ?!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

doco Documentation for this format

Terminology Bindings

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 v7.2
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 v7.2
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 v7.2
InsurancePlan.plan.specificCost.​benefit.cost.applicability Base required Benefit cost applicability 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error InsurancePlan If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error InsurancePlan If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice InsurancePlan A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
ipn-1 error InsurancePlan The organization SHALL at least have a name or an idendtifier, and possibly more than one (identifier.count() + name.count()) > 0
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()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 Σ 0..1 Meta Metadata about the resource
.... lastUpdated Σ 1..1 instant When the resource version last changed
... 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 BindingsPurpose
AllLanguages Max Binding
.... 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 SΣC 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 ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... assigner Σ 0..1 Reference(NDH Organization Profile) Organization that issued id (may be just text)
... status ?!SΣ 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 (extensible)
... name SΣC 0..1 string Official name
... alias 0..* string Alternate names
... period 0..1 Period When the product is available
... ownedBy Σ 0..1 Reference(NDH Organization Profile) Plan issuer
... administeredBy Σ 0..1 Reference(NDH Organization Profile) Product administrator
... coverageArea SΣ 0..* Reference(NDH Location Profile) Where product applies
... contact 0..* BackboneElement Contact for the product
.... modifierExtension ?!Σ 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 S 0..* Reference(NDH Network Profile) 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
Binding: Insurance Coverage Type (extensible)
.... network S 0..* Reference(NDH Network Profile) What networks provide coverage
.... benefit 1..* BackboneElement List of benefits
..... modifierExtension ?!Σ 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 ?!Σ 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 Σ 0..* Reference(NDH Location Profile) Where product applies
.... network 0..* Reference(NDH Network Profile) What networks provide coverage

doco Documentation for this format

Terminology Bindings

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 v7.2
InsurancePlan.coverage.​type Base extensible Insurance Coverage Type 📦1.0.0 THO v7.2
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 v7.2

Constraints

Id Grade Path(s) Description Expression
dom-2 error InsurancePlan If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error InsurancePlan If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice InsurancePlan A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
ipn-1 error InsurancePlan The organization SHALL at least have a name or an idendtifier, and possibly more than one (identifier.count() + name.count()) > 0
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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
.... 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)
.... 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 S 1..1 code draft | active | retired | unknown
Fixed Value: active
... type S 1..1 CodeableConcept Product Type
Binding: Insurance Product Type (extensible)
... name S 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 S 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 S 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 S 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

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
InsurancePlan.type Base extensible Insurance Product Type 📦1.0.0 THO v7.2
InsurancePlan.coverage.​type Base extensible Insurance Coverage Type 📦1.0.0 THO v7.2
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 v7.2

Constraints

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 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
... 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
.... 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 SΣC 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 ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... type Σ 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 Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ 0..1 string The value that is unique
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(NDH Organization Profile) Organization that issued id (may be just text)
... status ?!SΣ 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 (extensible)
... name SΣC 0..1 string Official name
... alias 0..* string Alternate names
... period 0..1 Period When the product is available
... ownedBy Σ 0..1 Reference(NDH Organization Profile) Plan issuer
... administeredBy Σ 0..1 Reference(NDH Organization Profile) Product administrator
... coverageArea SΣ 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 ?!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(NDH Endpoint Profile) Technical endpoint
... network S 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 ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Type of coverage
Binding: Insurance Coverage Type (extensible)
.... network S 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 ?!Σ 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 ?!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
..... 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 ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type Σ 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 Σ 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 0..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 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 Σ 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 ?!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

doco Documentation for this format

Terminology Bindings

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 v7.2
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 v7.2
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 v7.2
InsurancePlan.plan.specificCost.​benefit.cost.applicability Base required Benefit cost applicability 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error InsurancePlan If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error InsurancePlan If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error InsurancePlan If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice InsurancePlan A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
ipn-1 error InsurancePlan The organization SHALL at least have a name or an idendtifier, and possibly more than one (identifier.count() + name.count()) > 0
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()

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Search Parameters

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

Select products that are administered by the specified organization

 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

Any identifier for the organization (not the accreditation issuer's identifier)

 InsurancePlan.identifier
name string

A portion of the organization's name or alias

 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

Select plans of the specified type

 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 Search Parameter

_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.

Special Search Parameters

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.

InsurancePlan and Network relationship

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.

InsurancePlan type, network diagram

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).

InsurancePlantype 1..1Commercial PPOCommercial HDHPCommercial POSCommercial HMOCommercial EPOMedicaidMedicad HMOMedicare AdvantageMedicare Advantage HMOMedicare Part AMedicare Part BMedicare Pard DMedicare A/BQualified HealthPlanIndian Health SequenceFederal Employee ProgramVeterans Affais PlanDental Plan, Dental Plan HMOVision Plan, Vision Plan HMOnetwork 0..*ownedBy 1..1administeredBy 1..1coverage 0..*type 1..1MedicalDentalMental HealthSubstance Abuse...network 0..*benefit 1..*type 1..1Primary Care Visit to Treat an Injury or IllnessSpecialist Office VisitOther Practitioner Office Visit (Nurse, Physician Assistant)...plan 0..*type 0..1QHP PlantinumQHP GoldQHP SilverQHP BronzeQHP CatastrophicLow DeductibleHigh DeductibleCatastrophic PlancoverageArea 0..*network 0..*generalCost 0..*specificCost 0..*