Name Flags Card. Type Description & Constraints InsurancePlan 0..* InsurancePlan Details of a Health Insurance product/plan provided by an organization ownedBy 0..1 Reference(Organization) Plan issuer administeredBy 0..1 Reference(Organization) Product administrator network 0..* Reference(Organization) What networks are Included plan network 0..* Reference(Organization) What networks provide coverage Documentation for this format
National Resource Center for EHR Standards
This Profile 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.
Details of a Health Insurance product/plan provided by an organization
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
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()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
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()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
The organization SHALL at least have a name or an idendtifier, and possibly more than one
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
A set of rules under which this content was created
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The base language in which the resource is written.
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Text summary of the resource, for human interpretation
A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Additional content defined by implementations
May be used to represent additional information that is not part of the basic definition of the resource. 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.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it 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 is allowed to 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).
Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Business identifiers assigned to this health insurance product which remain constant as the resource is updated and propagates from server to server.
The current state of the health insurance product.
Need a flag to indicate a record is no longer to be used and should generally be hidden for the user in the UI.
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
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.
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.
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.
The period of time that the health insurance product is available.
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'.
An organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owner.
The geographic region in which a health insurance product's benefits apply.
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.
Need to keep track of assigned contact points within bigger organization.
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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.
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).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Indicates a purpose for which the contact can be reached.
Need to distinguish between multiple contact persons.
The purpose for which you would contact a contact party.
Need to be able to track the person by name.
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.
People have (primary) ways to contact them in some way such as phone, email.
Visiting or postal addresses for the contact
May need to keep track of a contact party's address for contacting, billing or reporting requirements.
The technical endpoints providing access to services operated for the health insurance product.
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.
Reference to the network included in the health insurance product.
Networks are represented as a hierarchy of organization resources.
Details about the coverage offered by the insurance product.
Type of coverage (Medical; Dental; Mental Health; Substance Abuse; Vision; Drug; Short Term; Long Term Care; Hospice; Home Health).
Reference to the network that providing the type of coverage.
Specific benefits under this type of coverage.
Type of benefit (primary care; speciality care; inpatient; outpatient).
The referral requirements to have access/coverage for this benefit.
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.”.
Use `CodeableConcept.text` element if the data is free (uncoded) text.
Business identifiers assigned to this health insurance plan which remain constant as the resource is updated and propagates from server to server.
Type of plan. For example, "Platinum" or "High Deductable".
The geographic region in which a health insurance plan's benefits apply.
Number of participants enrolled in the plan.
Additional information about the general costs associated with this plan.
Costs associated with the coverage provided by the product.
General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health).
List of the specific benefits under this category of benefit.
Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care).
List of the costs associated with a specific benefit.
Type of cost (copay; individual cap; family cap; coinsurance; deductible).
Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other).
Whether the cost applies to in-network or out-of-network providers.
Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA).
The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance).