Path | Short | Definition | Comments |
---|---|---|---|
Details of a Health Insurance product/plan provided by an organization | Details of a Health Insurance product/plan provided by an organization. | ||
identifier | Business Identifier for Product | Business identifiers assigned to this health insurance product which remain constant as the resource is updated and propagates from server to server. | |
status | draft | active | retired | unknown | The current state of the health insurance product. | |
type | Kind of product | The kind of health insurance product. | |
name | Official name | Official name of the health insurance product as designated by the owner. | 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. |
alias | Alternate names | A list of alternate names that the product is known as, or was known as in the past. | 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. |
period | When the product is available | The period of time that the health insurance product is available. | |
ownedBy | Plan issuer | 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'. | |
administeredBy | Product administrator | An organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owner. | |
coverageArea | Where product applies | The geographic region in which a health insurance product's benefits apply. | |
contact | Contact for the product | The contact for the health insurance product for a certain purpose. | Where multiple contacts for the same purpose are provided there is a standard extension that can be used to determine which one is the preferred contact to use. |
contact.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
contact.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
contact.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
contact.purpose | The type of contact | Indicates a purpose for which the contact can be reached. | |
contact.name | A name associated with the contact | A name associated with the contact. | |
contact.telecom | Contact details (telephone, email, etc.) for a contact | A contact detail (e.g. a telephone number or an email address) by which the party may be contacted. | |
contact.address | Visiting or postal addresses for the contact | Visiting or postal addresses for the contact. | |
endpoint | Technical endpoint | The technical endpoints providing access to services operated for the health insurance product. | |
network | What networks are Included | Reference to the network included in the health insurance product. | Networks are represented as a hierarchy of organization resources. |
coverage | Coverage details | Details about the coverage offered by the insurance product. | |
coverage.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
coverage.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
coverage.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
coverage.type | Type of coverage | Type of coverage (Medical; Dental; Mental Health; Substance Abuse; Vision; Drug; Short Term; Long Term Care; Hospice; Home Health). | |
coverage.network | What networks provide coverage | Reference to the network that providing the type of coverage. | Networks are represented as a hierarchy of organization resources. |
coverage.benefit | List of benefits | Specific benefits under this type of coverage. | |
coverage.benefit.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
coverage.benefit.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
coverage.benefit.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
coverage.benefit.type | Type of benefit | Type of benefit (primary care; speciality care; inpatient; outpatient). | |
coverage.benefit.requirement | Referral requirements | The referral requirements to have access/coverage for this benefit. | |
coverage.benefit.limit | Benefit limits | The specific limits on the benefit. | |
coverage.benefit.limit.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
coverage.benefit.limit.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
coverage.benefit.limit.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
coverage.benefit.limit.value | Maximum value allowed | The maximum amount of a service item a plan will pay for a covered benefit. For examples. wellness visits, or eyeglasses. | May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”. |
coverage.benefit.limit.code | Benefit limit details | The specific limit on the benefit. | Use `CodeableConcept.text` element if the data is free (uncoded) text. |
plan | Plan details | Details about an insurance plan. | |
plan.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
plan.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
plan.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
plan.identifier | Business Identifier for Product | Business identifiers assigned to this health insurance plan which remain constant as the resource is updated and propagates from server to server. | |
plan.type | Type of plan | Type of plan. For example, "Platinum" or "High Deductable". | |
plan.coverageArea | Where product applies | The geographic region in which a health insurance plan's benefits apply. | |
plan.network | What networks provide coverage | Reference to the network that providing the type of coverage. | Networks are represented as a hierarchy of organization resources. |
plan.generalCost | Overall costs | Overall costs associated with the plan. | |
plan.generalCost.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
plan.generalCost.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
plan.generalCost.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
plan.generalCost.type | Type of cost | Type of cost. | |
plan.generalCost.groupSize | Number of enrollees | Number of participants enrolled in the plan. | |
plan.generalCost.cost | Cost value | Value of the cost. | |
plan.generalCost.comment | Additional cost information | Additional information about the general costs associated with this plan. | |
plan.specificCost | Specific costs | Costs associated with the coverage provided by the product. | |
plan.specificCost.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
plan.specificCost.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
plan.specificCost.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
plan.specificCost.category | General category of benefit | General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health). | |
plan.specificCost.benefit | Benefits list | List of the specific benefits under this category of benefit. | |
plan.specificCost.benefit.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
plan.specificCost.benefit.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
plan.specificCost.benefit.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
plan.specificCost.benefit.type | Type of specific benefit | Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care). | |
plan.specificCost.benefit.cost | List of the costs | List of the costs associated with a specific benefit. | |
plan.specificCost.benefit.cost.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
plan.specificCost.benefit.cost.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
plan.specificCost.benefit.cost.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
plan.specificCost.benefit.cost.type | Type of cost | Type of cost (copay; individual cap; family cap; coinsurance; deductible). | |
plan.specificCost.benefit.cost.applicability | in-network | out-of-network | other | Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other). | |
plan.specificCost.benefit.cost.qualifiers | Additional information about the cost | Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA). | |
plan.specificCost.benefit.cost.value | The actual cost value | The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance). |
A product is a discrete package of health insurance coverage benefits that are offered under a particular network type. A given payer’s products typically differ by network type and/or coverage benefits. A plan pairs the health insurance coverage benefits under a product with the particular cost sharing structure offered to a consumer. A given product may comprise multiple plans.
InsurancePlan describes a health insurance offering comprised of a list of covered benefits (i.e. the product), costs associated with those benefits (i.e. the plan), and additional information about the offering, such as who it is owned and administered by, a coverage area, contact information, etc.
address | 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 | A city specified in an address | InsurancePlan.contact.address.city |
address-country | A country specified in an address | InsurancePlan.contact.address.country |
address-postalcode | A postal code specified in an address | InsurancePlan.contact.address.postalCode |
address-state | A state specified in an address | InsurancePlan.contact.address.state |
address-use | A use code specified in an address | InsurancePlan.contact.address.use |
administered-by | Product administrator | InsurancePlan.administeredBy |
endpoint | Technical endpoint | InsurancePlan.endpoint |
identifier | Any identifier for the organization (not the accreditation issuer's identifier) | InsurancePlan.identifier |
name | A portion of the organization's name or alias | name | alias |
owned-by | An organization of which this organization forms a part | InsurancePlan.ownedBy |
phonetic | A portion of the organization's name using some kind of phonetic matching algorithm | InsurancePlan.name |
status | Is the Organization record active | InsurancePlan.status |
type | A code for the type of organization | InsurancePlan.type |