FHIR CI-Build

This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions icon

Patient Administration icon Work GroupMaturity Level: 0 Trial UseSecurity Category: Business Compartments: Not linked to any defined compartments

Detailed Descriptions for the elements in the InsurancePlan resource.

InsurancePlan
Element IdInsurancePlan
Definition

Details of a Health Insurance product/plan provided by an organization.

Short DisplayDetails of a Health Insurance product/plan provided by an organization
Cardinality0..*
TypeDomainResource
Summaryfalse
Invariants
Defined on this element
ipn-1Rule The organization SHALL at least have a name or an identifier, and possibly more than one(identifier.count() + name.count()) > 0
InsurancePlan.identifier
Element IdInsurancePlan.identifier
Definition

Business identifiers assigned to this health insurance product which remain constant as the resource is updated and propagates from server to server.

Short DisplayBusiness Identifier for Product
NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..*
TypeIdentifier
Summarytrue
Invariants
Affect this element
ipn-1Rule The organization SHALL at least have a name or an identifier, and possibly more than one(identifier.count() + name.count()) > 0
InsurancePlan.status
Element IdInsurancePlan.status
Definition

The current state of the health insurance product.

Short Displaydraft | active | retired | unknown
Cardinality0..1
Terminology BindingPublicationStatus (Required)
Typecode
Is Modifiertrue (Reason: This element is labeled as a modifier because it is a status element that contains codes which means that the resource should not be treated as valid)
Meaning if MissingDefault interpretation is active.
Requirements

Need a flag to indicate a record is no longer to be used and should generally be hidden for the user in the UI.

Summarytrue
InsurancePlan.type
Element IdInsurancePlan.type
Definition

The kind of health insurance product.

Short DisplayKind of product
Cardinality0..*
Terminology BindingInsurancePlanType (Example)
TypeCodeableConcept
Summarytrue
InsurancePlan.name
Element IdInsurancePlan.name
Definition

Official name of the health insurance product as designated by the owner.

Short DisplayOfficial name
Cardinality0..1
Typestring
Summarytrue
Comments

If the name of the product/plan changes, consider putting the old name in the alias column so that it can still be located through searches.

Invariants
Affect this element
ipn-1Rule The organization SHALL at least have a name or an identifier, and possibly more than one(identifier.count() + name.count()) > 0
InsurancePlan.alias
Element IdInsurancePlan.alias
Definition

A list of alternate names that the product is known as, or was known as in the past.

Short DisplayAlternate names
Cardinality0..*
Typestring
Requirements

Over time products/plans go through many changes and can be known by different names.

For searching knowing previous names that the product/plan was known by can be very useful.

Summaryfalse
Comments

There are no dates associated with the alias/historic names, as this is not intended to track when names were used, but to assist in searching so that older names can still result in identifying the product/plan.

InsurancePlan.period
Element IdInsurancePlan.period
Definition

The period of time that the health insurance product is available.

Short DisplayWhen the product is available
Cardinality0..1
TypePeriod
Summaryfalse
InsurancePlan.ownedBy
Element IdInsurancePlan.ownedBy
Definition

The entity that is providing the health insurance product and underwriting the risk. This is typically an insurance carriers, other third-party payers, or health plan sponsors comonly referred to as 'payers'.

Short DisplayProduct issuer
Cardinality0..1
TypeReference(Organization)
Alternate NamesPayer
Summarytrue
InsurancePlan.administeredBy
Element IdInsurancePlan.administeredBy
Definition

An organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owner.

Short DisplayProduct administrator
Cardinality0..1
TypeReference(Organization)
Summarytrue
InsurancePlan.coverageArea
Element IdInsurancePlan.coverageArea
Definition

The geographic region in which a health insurance product's benefits apply.

Short DisplayWhere product applies
Cardinality0..*
TypeReference(Location)
Summarytrue
InsurancePlan.contact
Element IdInsurancePlan.contact
Definition

The contact details of communication devices available relevant to the specific Insurance Plan/Product. This can include addresses, phone numbers, fax numbers, mobile numbers, email addresses and web sites.

Short DisplayOfficial contact details relevant to the health insurance plan/product
Cardinality0..*
TypeExtendedContactDetail
Requirements

Need to keep track of both simple contact details and also assigned contacts within larger organizations.

Summaryfalse
Comments

The address/telecom use code 'home' are not to be used.

InsurancePlan.endpoint
Element IdInsurancePlan.endpoint
Definition

The technical endpoints providing access to services operated for the health insurance product.

Short DisplayTechnical endpoint
Cardinality0..*
TypeReference(Endpoint)
Requirements

Organizations have multiple systems that provide various services and need to be able to define the technical connection details for how to connect to them, and for what purpose.

Summaryfalse
InsurancePlan.network
Element IdInsurancePlan.network
Definition

Reference to the network included in the health insurance product.

Short DisplayWhat networks are Included
Cardinality0..*
TypeReference(Organization)
Summaryfalse
Comments

Networks are represented as a hierarchy of organization resources.

InsurancePlan.coverage
Element IdInsurancePlan.coverage
Definition

Details about the coverage offered by the insurance product.

Short DisplayCoverage details
Cardinality0..*
Summaryfalse
InsurancePlan.coverage.type
Element IdInsurancePlan.coverage.type
Definition

Type of coverage (Medical; Dental; Mental Health; Substance Abuse; Vision; Drug; Short Term; Long Term Care; Hospice; Home Health).

Short DisplayType of coverage
Cardinality1..1
TypeCodeableConcept
Summaryfalse
InsurancePlan.coverage.network
Element IdInsurancePlan.coverage.network
Definition

Reference to the network that providing the type of coverage.

Short DisplayWhat networks provide coverage
Cardinality0..*
TypeReference(Organization)
Summaryfalse
Comments

Networks are represented as a hierarchy of organization resources.

InsurancePlan.coverage.benefit
Element IdInsurancePlan.coverage.benefit
Definition

Specific benefits under this type of coverage.

Short DisplayList of benefits
Cardinality1..*
Summaryfalse
InsurancePlan.coverage.benefit.type
Element IdInsurancePlan.coverage.benefit.type
Definition

Type of benefit (primary care; speciality care; inpatient; outpatient).

Short DisplayType of benefit
Cardinality1..1
TypeCodeableConcept
Summaryfalse
InsurancePlan.coverage.benefit.requirement
Element IdInsurancePlan.coverage.benefit.requirement
Definition

The referral requirements to have access/coverage for this benefit.

Short DisplayReferral requirements
Cardinality0..1
Typestring
Summaryfalse
InsurancePlan.coverage.benefit.limit
Element IdInsurancePlan.coverage.benefit.limit
Definition

The specific limits on the benefit.

Short DisplayBenefit limits
Cardinality0..*
Summaryfalse
InsurancePlan.coverage.benefit.limit.value
Element IdInsurancePlan.coverage.benefit.limit.value
Definition

The maximum amount of a service item a plan will pay for a covered benefit. For examples. wellness visits, or eyeglasses.

Short DisplayMaximum value allowed
Cardinality0..1
TypeQuantity
Summaryfalse
Comments

May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”.

InsurancePlan.coverage.benefit.limit.code
Element IdInsurancePlan.coverage.benefit.limit.code
Definition

The specific limit on the benefit.

Short DisplayBenefit limit details
Cardinality0..1
TypeCodeableConcept
Summaryfalse
Comments

Use CodeableConcept.text element if the data is free (uncoded) text.

InsurancePlan.plan
Element IdInsurancePlan.plan
Definition

Details about an insurance plan.

Short DisplayPlan details
Cardinality0..*
Summaryfalse
InsurancePlan.plan.identifier
Element IdInsurancePlan.plan.identifier
Definition

Business identifiers assigned to this health insurance plan which remain constant as the resource is updated and propagates from server to server.

Short DisplayBusiness Identifier for Product
NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..*
TypeIdentifier
Summarytrue
InsurancePlan.plan.type
Element IdInsurancePlan.plan.type
Definition

Type of plan. For example, "Platinum" or "High Deductable".

Short DisplayType of plan
Cardinality0..1
TypeCodeableConcept
Summaryfalse
InsurancePlan.plan.coverageArea
Element IdInsurancePlan.plan.coverageArea
Definition

The geographic region in which a health insurance plan's benefits apply.

Short DisplayWhere product applies
Cardinality0..*
TypeReference(Location)
Summarytrue
InsurancePlan.plan.network
Element IdInsurancePlan.plan.network
Definition

Reference to the network that providing the type of coverage.

Short DisplayWhat networks provide coverage
Cardinality0..*
TypeReference(Organization)
Summaryfalse
Comments

Networks are represented as a hierarchy of organization resources.

InsurancePlan.plan.generalCost
Element IdInsurancePlan.plan.generalCost
Definition

Overall costs associated with the plan.

Short DisplayOverall costs
Cardinality0..*
Summaryfalse
InsurancePlan.plan.generalCost.type
Element IdInsurancePlan.plan.generalCost.type
Definition

Type of cost.

Short DisplayType of cost
Cardinality0..1
TypeCodeableConcept
Summaryfalse
InsurancePlan.plan.generalCost.groupSize
Element IdInsurancePlan.plan.generalCost.groupSize
Definition

Number of participants enrolled in the plan.

Short DisplayNumber of enrollees
Cardinality0..1
TypepositiveInt
Summaryfalse
InsurancePlan.plan.generalCost.cost
Element IdInsurancePlan.plan.generalCost.cost
Definition

Value of the cost.

Short DisplayCost value
Cardinality0..1
TypeMoney
Summaryfalse
InsurancePlan.plan.generalCost.comment
Element IdInsurancePlan.plan.generalCost.comment
Definition

Additional information about the general costs associated with this plan.

Short DisplayAdditional cost information
Cardinality0..1
Typestring
Summaryfalse
InsurancePlan.plan.specificCost
Element IdInsurancePlan.plan.specificCost
Definition

Costs associated with the coverage provided by the product.

Short DisplaySpecific costs
Cardinality0..*
Summaryfalse
InsurancePlan.plan.specificCost.category
Element IdInsurancePlan.plan.specificCost.category
Definition

General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health).

Short DisplayGeneral category of benefit
Cardinality1..1
TypeCodeableConcept
Summaryfalse
InsurancePlan.plan.specificCost.benefit
Element IdInsurancePlan.plan.specificCost.benefit
Definition

List of the specific benefits under this category of benefit.

Short DisplayBenefits list
Cardinality0..*
Summaryfalse
InsurancePlan.plan.specificCost.benefit.type
Element IdInsurancePlan.plan.specificCost.benefit.type
Definition

Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care).

Short DisplayType of specific benefit
Cardinality1..1
TypeCodeableConcept
Summaryfalse
InsurancePlan.plan.specificCost.benefit.cost
Element IdInsurancePlan.plan.specificCost.benefit.cost
Definition

List of the costs associated with a specific benefit.

Short DisplayList of the costs
Cardinality0..*
Summaryfalse
InsurancePlan.plan.specificCost.benefit.cost.type
Element IdInsurancePlan.plan.specificCost.benefit.cost.type
Definition

Type of cost (copay; individual cap; family cap; coinsurance; deductible).

Short DisplayType of cost
Cardinality1..1
TypeCodeableConcept
Summaryfalse
InsurancePlan.plan.specificCost.benefit.cost.applicability
Element IdInsurancePlan.plan.specificCost.benefit.cost.applicability
Definition

Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other).

Short Displayin-network | out-of-network | other
Cardinality0..1
Terminology BindingBenefitCostApplicability (Required)
TypeCodeableConcept
Summaryfalse
InsurancePlan.plan.specificCost.benefit.cost.qualifiers
Element IdInsurancePlan.plan.specificCost.benefit.cost.qualifiers
Definition

Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA).

Short DisplayAdditional information about the cost
Cardinality0..*
TypeCodeableConcept
Summaryfalse
InsurancePlan.plan.specificCost.benefit.cost.value
Element IdInsurancePlan.plan.specificCost.benefit.cost.value
Definition

The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance).

Short DisplayThe actual cost value
Cardinality0..1
TypeQuantity
Summaryfalse