This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions
Patient Administration Work Group | Maturity Level: 1 | Trial Use | Security Category: Business | Compartments: No defined compartments |
InsurancePlan describes the costs to the subscriber or beneficiary associated with benefits, as well as additional information about the offering, such as who administers the plan, a coverage area, contact information, etc. The specific benefits covered by the plan are described in the InsuranceProduct
referenced in InsurancePlan.product
.
Insurance offerings will be fully described by the combination of both InsurancePlan (the costs) and InsuranceProduct (the benefits). However, some systems may only need to represent the InsurancePlan, so that Coverage resources can describe which plan is associated with a given beneficiary. In that case, there will be some other system that is responsible for tracking the benefits associated with the plan.
An InsurancePlan pairs the health insurance coverage benefits under an InsuranceProduct with the particular cost sharing structure offered to a consumer. A given InsuranceProduct may comprise multiple InsurancePlans.
InsuranceProduct describes a list of covered benefits and networks as well as details about who administers the product and applicable coverage areas.
InsurancePlan describes the costs to the subscriber or beneficiary associated with benefits, as well as additional information about the offering, such as who administers the plan, a coverage area, contact information, etc. The specific benefits covered by the plan are described in the InsuranceProduct referenced in InsurancePlan.product.
A Coverage resource establishes the link between an InsurancePlan and a beneficiary and optionally a subscriber.
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
InsurancePlan | TU | DomainResource | Plan details Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | |
identifier | Σ | 0..* | Identifier | Business Identifier for Plan |
type | 0..1 | CodeableConcept | Classification of Plan | |
product | Σ | 0..1 | Reference(InsuranceProduct) | The product that this plan is available under |
coverageArea | Σ | 0..* | Reference(Location) | Where product-plan applies |
network | 0..* | Reference(Organization) | What networks provide coverage | |
generalCost | 0..* | BackboneElement | Overall costs | |
type | 0..1 | CodeableConcept | Classification of specific cost | |
groupSize | 0..1 | positiveInt | Number of enrollees | |
cost | 0..1 | Money | Cost value | |
comment | 0..1 | string | Additional cost information | |
specificCost | 0..* | BackboneElement | Individual cost elements | |
category | 1..1 | CodeableConcept | General category of benefit | |
benefit | 0..* | BackboneElement | Benefits list | |
type | 1..1 | CodeableConcept | Classification of benefit provided | |
cost | 0..* | BackboneElement | List of the costs | |
type | 1..1 | CodeableConcept | Classification of specific cost | |
applicability | 0..1 | CodeableConcept | in-network | out-of-network | other Binding: Benefit Cost Applicability (Required) | |
qualifier | 0..* | CodeableConcept | Additional information about the cost | |
value | 0..1 | Quantity | The actual cost value | |
Documentation for this format |
See the Extensions for this resource
UML Diagram (Legend)
XML Template
<InsurancePlan xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier Business Identifier for Plan --></identifier> <type><!-- 0..1 CodeableConcept Classification of Plan --></type> <product><!-- 0..1 Reference(InsuranceProduct) The product that this plan is available under --></product> <coverageArea><!-- 0..* Reference(Location) Where product-plan applies --></coverageArea> <network><!-- 0..* Reference(Organization) What networks provide coverage --></network> <generalCost> <!-- 0..* Overall costs --> <type><!-- 0..1 CodeableConcept Classification of specific cost --></type> <groupSize value="[positiveInt]"/><!-- 0..1 Number of enrollees --> <cost><!-- 0..1 Money Cost value --></cost> <comment value="[string]"/><!-- 0..1 Additional cost information --> </generalCost> <specificCost> <!-- 0..* Individual cost elements --> <category><!-- 1..1 CodeableConcept General category of benefit --></category> <benefit> <!-- 0..* Benefits list --> <type><!-- 1..1 CodeableConcept Classification of benefit provided --></type> <cost> <!-- 0..* List of the costs --> <type><!-- 1..1 CodeableConcept Classification of specific cost --></type> <applicability><!-- 0..1 CodeableConcept in-network | out-of-network | other --></applicability> <qualifier><!-- 0..* CodeableConcept Additional information about the cost --></qualifier> <value><!-- 0..1 Quantity The actual cost value --></value> </cost> </benefit> </specificCost> </InsurancePlan>
JSON Template
{ "resourceType" : "InsurancePlan", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business Identifier for Plan "type" : { CodeableConcept }, // Classification of Plan "product" : { Reference(InsuranceProduct) }, // The product that this plan is available under "coverageArea" : [{ Reference(Location) }], // Where product-plan applies "network" : [{ Reference(Organization) }], // What networks provide coverage "generalCost" : [{ // Overall costs "type" : { CodeableConcept }, // Classification of specific cost "groupSize" : "<positiveInt>", // Number of enrollees "cost" : { Money }, // Cost value "comment" : "<string>" // Additional cost information }], "specificCost" : [{ // Individual cost elements "category" : { CodeableConcept }, // R! General category of benefit "benefit" : [{ // Benefits list "type" : { CodeableConcept }, // R! Classification of benefit provided "cost" : [{ // List of the costs "type" : { CodeableConcept }, // R! Classification of specific cost "applicability" : { CodeableConcept }, // in-network | out-of-network | other "qualifier" : [{ CodeableConcept }], // Additional information about the cost "value" : { Quantity } // The actual cost value }] }] }] }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ a fhir:InsurancePlan; fhir:nodeRole fhir:treeRoot; # if this is the parser root # from Resource: .id, .meta, .implicitRules, and .language # from DomainResource: .text, .contained, .extension, and .modifierExtension fhir:identifier ( [ Identifier ] ... ) ; # 0..* Business Identifier for Plan fhir:type [ CodeableConcept ] ; # 0..1 Classification of Plan fhir:product [ Reference(InsuranceProduct) ] ; # 0..1 The product that this plan is available under fhir:coverageArea ( [ Reference(Location) ] ... ) ; # 0..* Where product-plan applies fhir:network ( [ Reference(Organization) ] ... ) ; # 0..* What networks provide coverage fhir:generalCost ( [ # 0..* Overall costs fhir:type [ CodeableConcept ] ; # 0..1 Classification of specific cost fhir:groupSize [ positiveInt ] ; # 0..1 Number of enrollees fhir:cost [ Money ] ; # 0..1 Cost value fhir:comment [ string ] ; # 0..1 Additional cost information ] ... ) ; fhir:specificCost ( [ # 0..* Individual cost elements fhir:category [ CodeableConcept ] ; # 1..1 General category of benefit fhir:benefit ( [ # 0..* Benefits list fhir:type [ CodeableConcept ] ; # 1..1 Classification of benefit provided fhir:cost ( [ # 0..* List of the costs fhir:type [ CodeableConcept ] ; # 1..1 Classification of specific cost fhir:applicability [ CodeableConcept ] ; # 0..1 in-network | out-of-network | other fhir:qualifier ( [ CodeableConcept ] ... ) ; # 0..* Additional information about the cost fhir:value [ Quantity ] ; # 0..1 The actual cost value ] ... ) ; ] ... ) ; ] ... ) ; ]
Changes from both R4 and R4B
InsurancePlan | |
InsurancePlan.type |
|
InsurancePlan.product |
|
InsurancePlan.generalCost |
|
InsurancePlan.generalCost.type |
|
InsurancePlan.generalCost.groupSize |
|
InsurancePlan.generalCost.cost |
|
InsurancePlan.generalCost.comment |
|
InsurancePlan.specificCost |
|
InsurancePlan.specificCost.category |
|
InsurancePlan.specificCost.benefit |
|
InsurancePlan.specificCost.benefit.type |
|
InsurancePlan.specificCost.benefit.cost |
|
InsurancePlan.specificCost.benefit.cost.type |
|
InsurancePlan.specificCost.benefit.cost.applicability |
|
InsurancePlan.specificCost.benefit.cost.qualifier |
|
InsurancePlan.specificCost.benefit.cost.value |
|
InsurancePlan.status |
|
InsurancePlan.name |
|
InsurancePlan.alias |
|
InsurancePlan.period |
|
InsurancePlan.ownedBy |
|
InsurancePlan.administeredBy |
|
InsurancePlan.contact |
|
InsurancePlan.endpoint |
|
InsurancePlan.coverage |
|
InsurancePlan.plan |
|
See the Full Difference for further information
This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
InsurancePlan | TU | DomainResource | Plan details Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | |
identifier | Σ | 0..* | Identifier | Business Identifier for Plan |
type | 0..1 | CodeableConcept | Classification of Plan | |
product | Σ | 0..1 | Reference(InsuranceProduct) | The product that this plan is available under |
coverageArea | Σ | 0..* | Reference(Location) | Where product-plan applies |
network | 0..* | Reference(Organization) | What networks provide coverage | |
generalCost | 0..* | BackboneElement | Overall costs | |
type | 0..1 | CodeableConcept | Classification of specific cost | |
groupSize | 0..1 | positiveInt | Number of enrollees | |
cost | 0..1 | Money | Cost value | |
comment | 0..1 | string | Additional cost information | |
specificCost | 0..* | BackboneElement | Individual cost elements | |
category | 1..1 | CodeableConcept | General category of benefit | |
benefit | 0..* | BackboneElement | Benefits list | |
type | 1..1 | CodeableConcept | Classification of benefit provided | |
cost | 0..* | BackboneElement | List of the costs | |
type | 1..1 | CodeableConcept | Classification of specific cost | |
applicability | 0..1 | CodeableConcept | in-network | out-of-network | other Binding: Benefit Cost Applicability (Required) | |
qualifier | 0..* | CodeableConcept | Additional information about the cost | |
value | 0..1 | Quantity | The actual cost value | |
Documentation for this format |
See the Extensions for this resource
XML Template
<InsurancePlan xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier Business Identifier for Plan --></identifier> <type><!-- 0..1 CodeableConcept Classification of Plan --></type> <product><!-- 0..1 Reference(InsuranceProduct) The product that this plan is available under --></product> <coverageArea><!-- 0..* Reference(Location) Where product-plan applies --></coverageArea> <network><!-- 0..* Reference(Organization) What networks provide coverage --></network> <generalCost> <!-- 0..* Overall costs --> <type><!-- 0..1 CodeableConcept Classification of specific cost --></type> <groupSize value="[positiveInt]"/><!-- 0..1 Number of enrollees --> <cost><!-- 0..1 Money Cost value --></cost> <comment value="[string]"/><!-- 0..1 Additional cost information --> </generalCost> <specificCost> <!-- 0..* Individual cost elements --> <category><!-- 1..1 CodeableConcept General category of benefit --></category> <benefit> <!-- 0..* Benefits list --> <type><!-- 1..1 CodeableConcept Classification of benefit provided --></type> <cost> <!-- 0..* List of the costs --> <type><!-- 1..1 CodeableConcept Classification of specific cost --></type> <applicability><!-- 0..1 CodeableConcept in-network | out-of-network | other --></applicability> <qualifier><!-- 0..* CodeableConcept Additional information about the cost --></qualifier> <value><!-- 0..1 Quantity The actual cost value --></value> </cost> </benefit> </specificCost> </InsurancePlan>
JSON Template
{ "resourceType" : "InsurancePlan", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business Identifier for Plan "type" : { CodeableConcept }, // Classification of Plan "product" : { Reference(InsuranceProduct) }, // The product that this plan is available under "coverageArea" : [{ Reference(Location) }], // Where product-plan applies "network" : [{ Reference(Organization) }], // What networks provide coverage "generalCost" : [{ // Overall costs "type" : { CodeableConcept }, // Classification of specific cost "groupSize" : "<positiveInt>", // Number of enrollees "cost" : { Money }, // Cost value "comment" : "<string>" // Additional cost information }], "specificCost" : [{ // Individual cost elements "category" : { CodeableConcept }, // R! General category of benefit "benefit" : [{ // Benefits list "type" : { CodeableConcept }, // R! Classification of benefit provided "cost" : [{ // List of the costs "type" : { CodeableConcept }, // R! Classification of specific cost "applicability" : { CodeableConcept }, // in-network | out-of-network | other "qualifier" : [{ CodeableConcept }], // Additional information about the cost "value" : { Quantity } // The actual cost value }] }] }] }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ a fhir:InsurancePlan; fhir:nodeRole fhir:treeRoot; # if this is the parser root # from Resource: .id, .meta, .implicitRules, and .language # from DomainResource: .text, .contained, .extension, and .modifierExtension fhir:identifier ( [ Identifier ] ... ) ; # 0..* Business Identifier for Plan fhir:type [ CodeableConcept ] ; # 0..1 Classification of Plan fhir:product [ Reference(InsuranceProduct) ] ; # 0..1 The product that this plan is available under fhir:coverageArea ( [ Reference(Location) ] ... ) ; # 0..* Where product-plan applies fhir:network ( [ Reference(Organization) ] ... ) ; # 0..* What networks provide coverage fhir:generalCost ( [ # 0..* Overall costs fhir:type [ CodeableConcept ] ; # 0..1 Classification of specific cost fhir:groupSize [ positiveInt ] ; # 0..1 Number of enrollees fhir:cost [ Money ] ; # 0..1 Cost value fhir:comment [ string ] ; # 0..1 Additional cost information ] ... ) ; fhir:specificCost ( [ # 0..* Individual cost elements fhir:category [ CodeableConcept ] ; # 1..1 General category of benefit fhir:benefit ( [ # 0..* Benefits list fhir:type [ CodeableConcept ] ; # 1..1 Classification of benefit provided fhir:cost ( [ # 0..* List of the costs fhir:type [ CodeableConcept ] ; # 1..1 Classification of specific cost fhir:applicability [ CodeableConcept ] ; # 0..1 in-network | out-of-network | other fhir:qualifier ( [ CodeableConcept ] ... ) ; # 0..* Additional information about the cost fhir:value [ Quantity ] ; # 0..1 The actual cost value ] ... ) ; ] ... ) ; ] ... ) ; ]
Changes from both R4 and R4B
InsurancePlan | |
InsurancePlan.type |
|
InsurancePlan.product |
|
InsurancePlan.generalCost |
|
InsurancePlan.generalCost.type |
|
InsurancePlan.generalCost.groupSize |
|
InsurancePlan.generalCost.cost |
|
InsurancePlan.generalCost.comment |
|
InsurancePlan.specificCost |
|
InsurancePlan.specificCost.category |
|
InsurancePlan.specificCost.benefit |
|
InsurancePlan.specificCost.benefit.type |
|
InsurancePlan.specificCost.benefit.cost |
|
InsurancePlan.specificCost.benefit.cost.type |
|
InsurancePlan.specificCost.benefit.cost.applicability |
|
InsurancePlan.specificCost.benefit.cost.qualifier |
|
InsurancePlan.specificCost.benefit.cost.value |
|
InsurancePlan.status |
|
InsurancePlan.name |
|
InsurancePlan.alias |
|
InsurancePlan.period |
|
InsurancePlan.ownedBy |
|
InsurancePlan.administeredBy |
|
InsurancePlan.contact |
|
InsurancePlan.endpoint |
|
InsurancePlan.coverage |
|
InsurancePlan.plan |
|
See the Full Difference for further information
This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.
Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis
Path | ValueSet | Type | Documentation |
---|---|---|---|
InsurancePlan.specificCost.benefit.cost.applicability | BenefitCostApplicability | Required | Whether the cost applies to in-network or out-of-network providers. |
Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.
Name | Type | Description | Expression | In Common |
coverage-area | reference | Location(s) insurance product is intended for/available to | InsurancePlan.coverageArea (Location) |
|
identifier | token | External identifiers for this item | InsurancePlan.identifier | |
network | reference | The product this plan is available to | InsurancePlan.network (Organization) |
|
product | reference | The product this plan is available to | InsurancePlan.product (InsuranceProduct) |
|
type | token | A code for the type of insurance plan | InsurancePlan.type |