This page is part of the FHIR Implementation Guide for ABDM (v6.0.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

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Resource Profile: StructureDefinition/InsurancePlan

InsurancePlan represents the product that can be offered to the customer. It 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. It provides the details of a contractual arrangement between an individual or entity (the policyholder) and an insurance provider. A plan describes the Health coverage issued to you directly (individual plan) or through an employer, union, or other group sponsor (employer group plan) that provides coverage for certain health care costs. It pairs the health insurance coverage benefits under a product with the particular cost sharing structure offered to a consumer.

Usage:

• Use this Resource Profile: InsurancePlanBundle
• Examples for this Resource Profile: Active Assure Silver

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from InsurancePlan

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan		0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization
claim-exclusion		0..*	(Complex)	Excluded coverage details within a health insurance product. It outlines services, treatments or conditions not covered. e.g. pre-existing disease, specific disease/procedure wating period etc. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion
claim-supportingInfoRequirement		0..*	(Complex)	Essential documentation necessary for a health insurance product during claim processing. e.g. proof of identity, proof of address URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-SupportingInfoRequirement
identifier	S	1..1	Identifier	Identifier provided by payer to uniquely identify the product covering a list of combinations offered to consumers under this particular insurance plan.
status	S	1..1	code	draft | active | retired | unknown
type	S	1..1	CodeableConcept	Type of product that indicates the predominant type. Binding: InsurancePlan Type (example): The valueset is created by referring the Health Insurance Data Reporting Manual provided by the Insurance Information Bureau of India (IIB). For more information, visit IIB's official website: https://iib.gov.in or access the manual directly at: https://healthapp.iib.gov.in/IIB/datamanuals/hidmanual08.pdf.
coding		0..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
text	S	0..1	string	Plain text representation of the concept
name	S	1..1	string	Official name of the product
alias	S	0..*	string	Alternate names
period	S	1..1	Period	When the product is available
ownedBy	S	1..1	Reference(Organization)	Plan issuer
administeredBy	S	0..1	Reference(Organization)	Product administrator
coverageArea	S	0..*	Reference(Location)	Where product applies
contact	S	0..*	BackboneElement	Contact for the product
network	S	0..*	Reference(Organization)	Network included in the health insurance product.
coverage	S	1..*	BackboneElement	Coverage details for e.g. In-Patient Hospitalization, Day Care etc.
claim-condition		0..*	(Complex)	Outlines specific conditions and criteria that may be required to successfully claim benefits under a coverage within a insurance product. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition
claim-supportingInfoRequirement		0..*	(Complex)	Essential documentation necessary for a health insurance product during claim processing. e.g. proof of identity, proof of address URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-SupportingInfoRequirement
type		1..1	CodeableConcept	Type of coverage Binding: Coverage Type (example)
coding		0..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
text	S	0..1	string	Plain text representation of the concept
benefit	S	1..*	BackboneElement	List of benefits e.g. consultation, oxygen, robotic surgery etc.
claim-condition		0..*	(Complex)	Outlines specific conditions and criteria that may be required to successfully claim benefits under a coverage within a insurance product. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition
type		1..1	CodeableConcept	Type of benefit Binding: Benefit Type (example)
coding		0..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
text	S	0..1	string	Plain text representation of the concept
plan	S	0..*	BackboneElement	Cost sharing details for the plan offered to a consumer.
claim-exclusion		0..*	(Complex)	Excluded coverage details within a plan. It outlines services, treatments or conditions not covered. e.g. pre-existing disease, specific disease/procedure waiting period etc. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion
type	S	1..1	CodeableConcept	Type of plan Binding: Plan Type (example)
coding		0..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
text	S	0..1	string	Plain text representation of the concept
coverageArea	S	0..*	Reference(Location)	Where product applies
network		0..*	Reference(Organization)	What networks provide coverage
generalCost	S	0..*	BackboneElement	Sum insured amount associated with the plan.
specificCost	S	0..*	BackboneElement	Specific costs
category	S	1..1	CodeableConcept	General category of benefit Binding: Benefit Category (example)
coding		0..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
text	S	0..1	string	Plain text representation of the concept
benefit
type		1..1	CodeableConcept	Type of specific benefit Binding: ProductorService (example)
coding		0..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
text	S	0..1	string	Plain text representation of the concept
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
InsurancePlan.type	example	InsurancePlanType (a valid code from InsurancePlan Type) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-insuranceplan-type from this IG
InsurancePlan.coverage.type	example	CoverageType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-coverage-type from this IG
InsurancePlan.coverage.benefit.type	example	BenefitType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefit-type from this IG
InsurancePlan.plan.type	example	PlanType (a valid code from Plan Type) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-plan-type from this IG
InsurancePlan.plan.specificCost.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
InsurancePlan.plan.specificCost.benefit.type	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan	C	0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
claim-exclusion		0..*	(Complex)	Excluded coverage details within a health insurance product. It outlines services, treatments or conditions not covered. e.g. pre-existing disease, specific disease/procedure wating period etc. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion
claim-supportingInfoRequirement		0..*	(Complex)	Essential documentation necessary for a health insurance product during claim processing. e.g. proof of identity, proof of address URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-SupportingInfoRequirement
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣC	1..1	Identifier	Identifier provided by payer to uniquely identify the product covering a list of combinations offered to consumers under this particular insurance plan.
status	?!SΣ	1..1	code	draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact.
type	SΣ	1..1	CodeableConcept	Type of product that indicates the predominant type. Binding: InsurancePlan Type (example): The valueset is created by referring the Health Insurance Data Reporting Manual provided by the Insurance Information Bureau of India (IIB). For more information, visit IIB's official website: https://iib.gov.in or access the manual directly at: https://healthapp.iib.gov.in/IIB/datamanuals/hidmanual08.pdf.
coding	Σ	0..1	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
text	SΣ	0..1	string	Plain text representation of the concept
name	SΣC	1..1	string	Official name of the product
alias	S	0..*	string	Alternate names
period	S	1..1	Period	When the product is available
ownedBy	SΣ	1..1	Reference(Organization)	Plan issuer
administeredBy	SΣ	0..1	Reference(Organization)	Product administrator
coverageArea	SΣ	0..*	Reference(Location)	Where product applies
contact	S	0..*	BackboneElement	Contact for the product
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
network	S	0..*	Reference(Organization)	Network included in the health insurance product.
coverage	S	1..*	BackboneElement	Coverage details for e.g. In-Patient Hospitalization, Day Care etc.
claim-condition		0..*	(Complex)	Outlines specific conditions and criteria that may be required to successfully claim benefits under a coverage within a insurance product. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition
claim-supportingInfoRequirement		0..*	(Complex)	Essential documentation necessary for a health insurance product during claim processing. e.g. proof of identity, proof of address URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-SupportingInfoRequirement
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of coverage Binding: Coverage Type (example)
coding	Σ	0..1	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
text	SΣ	0..1	string	Plain text representation of the concept
benefit	S	1..*	BackboneElement	List of benefits e.g. consultation, oxygen, robotic surgery etc.
claim-condition		0..*	(Complex)	Outlines specific conditions and criteria that may be required to successfully claim benefits under a coverage within a insurance product. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of benefit Binding: Benefit Type (example)
coding	Σ	0..1	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
text	SΣ	0..1	string	Plain text representation of the concept
plan	S	0..*	BackboneElement	Cost sharing details for the plan offered to a consumer.
claim-exclusion		0..*	(Complex)	Excluded coverage details within a plan. It outlines services, treatments or conditions not covered. e.g. pre-existing disease, specific disease/procedure waiting period etc. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Type of plan Binding: Plan Type (example)
coding	Σ	0..1	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
text	SΣ	0..1	string	Plain text representation of the concept
coverageArea	SΣ	0..*	Reference(Location)	Where product applies
network		0..*	Reference(Organization)	What networks provide coverage
generalCost	S	0..*	BackboneElement	Sum insured amount associated with the plan.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
specificCost	S	0..*	BackboneElement	Specific costs
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	General category of benefit Binding: Benefit Category (example)
coding	Σ	0..1	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
text	SΣ	0..1	string	Plain text representation of the concept
benefit		0..*	BackboneElement	Benefits list
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of specific benefit Binding: ProductorService (example)
coding	Σ	0..1	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
text	SΣ	0..1	string	Plain text representation of the concept
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
InsurancePlan.status	required	PublicationStatus http://hl7.org/fhir/ValueSet/publication-status|4.0.1 from the FHIR Standard
InsurancePlan.type	example	InsurancePlanType (a valid code from InsurancePlan Type) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-insuranceplan-type from this IG
InsurancePlan.coverage.type	example	CoverageType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-coverage-type from this IG
InsurancePlan.coverage.benefit.type	example	BenefitType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefit-type from this IG
InsurancePlan.plan.type	example	PlanType (a valid code from Plan Type) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-plan-type from this IG
InsurancePlan.plan.specificCost.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
InsurancePlan.plan.specificCost.benefit.type	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
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

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan	C	0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
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 Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
claim-exclusion		0..*	(Complex)	Excluded coverage details within a health insurance product. It outlines services, treatments or conditions not covered. e.g. pre-existing disease, specific disease/procedure wating period etc. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion
claim-supportingInfoRequirement		0..*	(Complex)	Essential documentation necessary for a health insurance product during claim processing. e.g. proof of identity, proof of address URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-SupportingInfoRequirement
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣC	1..1	Identifier	Identifier provided by payer to uniquely identify the product covering a list of combinations offered to consumers under this particular insurance plan.
status	?!SΣ	1..1	code	draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact.
type	SΣ	1..1	CodeableConcept	Type of product that indicates the predominant type. Binding: InsurancePlan Type (example): The valueset is created by referring the Health Insurance Data Reporting Manual provided by the Insurance Information Bureau of India (IIB). For more information, visit IIB's official website: https://iib.gov.in or access the manual directly at: https://healthapp.iib.gov.in/IIB/datamanuals/hidmanual08.pdf.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
name	SΣC	1..1	string	Official name of the product
alias	S	0..*	string	Alternate names
period	S	1..1	Period	When the product is available
ownedBy	SΣ	1..1	Reference(Organization)	Plan issuer
administeredBy	SΣ	0..1	Reference(Organization)	Product administrator
coverageArea	SΣ	0..*	Reference(Location)	Where product applies
contact	S	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(Endpoint)	Technical endpoint
network	S	0..*	Reference(Organization)	Network included in the health insurance product.
coverage	S	1..*	BackboneElement	Coverage details for e.g. In-Patient Hospitalization, Day Care etc.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
claim-condition		0..*	(Complex)	Outlines specific conditions and criteria that may be required to successfully claim benefits under a coverage within a insurance product. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition
claim-supportingInfoRequirement		0..*	(Complex)	Essential documentation necessary for a health insurance product during claim processing. e.g. proof of identity, proof of address URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-SupportingInfoRequirement
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of coverage Binding: Coverage Type (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
network		0..*	Reference(Organization)	What networks provide coverage
benefit	S	1..*	BackboneElement	List of benefits e.g. consultation, oxygen, robotic surgery etc.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
claim-condition		0..*	(Complex)	Outlines specific conditions and criteria that may be required to successfully claim benefits under a coverage within a insurance product. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of benefit Binding: Benefit Type (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
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	S	0..*	BackboneElement	Cost sharing details for the plan offered to a consumer.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
claim-exclusion		0..*	(Complex)	Excluded coverage details within a plan. It outlines services, treatments or conditions not covered. e.g. pre-existing disease, specific disease/procedure waiting period etc. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
identifier	Σ	0..*	Identifier	Business Identifier for Product
type	S	1..1	CodeableConcept	Type of plan Binding: Plan Type (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
coverageArea	SΣ	0..*	Reference(Location)	Where product applies
network		0..*	Reference(Organization)	What networks provide coverage
generalCost	S	0..*	BackboneElement	Sum insured amount associated with 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
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	S	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	S	1..1	CodeableConcept	General category of benefit Binding: Benefit Category (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
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 Binding: ProductorService (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
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
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
InsurancePlan.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
InsurancePlan.status	required	PublicationStatus http://hl7.org/fhir/ValueSet/publication-status|4.0.1 from the FHIR Standard
InsurancePlan.type	example	InsurancePlanType (a valid code from InsurancePlan Type) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-insuranceplan-type from this IG
InsurancePlan.contact.purpose	extensible	ContactEntityType http://hl7.org/fhir/ValueSet/contactentity-type from the FHIR Standard
InsurancePlan.coverage.type	example	CoverageType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-coverage-type from this IG
InsurancePlan.coverage.benefit.type	example	BenefitType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefit-type from this IG
InsurancePlan.plan.type	example	PlanType (a valid code from Plan Type) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-plan-type from this IG
InsurancePlan.plan.specificCost.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
InsurancePlan.plan.specificCost.benefit.type	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
InsurancePlan.plan.specificCost.benefit.cost.applicability	required	BenefitCostApplicability http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1 from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
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

This structure is derived from InsurancePlan

Summary

Mandatory: 7 elements (19 nested mandatory elements)
Must-Support: 25 elements

Structures

This structure refers to these other structures:

• Organization (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization)

Extensions

This structure refers to these extensions:

• https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion
• https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-SupportingInfoRequirement
• https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition

Differential View

This structure is derived from InsurancePlan

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan		0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization
claim-exclusion		0..*	(Complex)	Excluded coverage details within a health insurance product. It outlines services, treatments or conditions not covered. e.g. pre-existing disease, specific disease/procedure wating period etc. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion
claim-supportingInfoRequirement		0..*	(Complex)	Essential documentation necessary for a health insurance product during claim processing. e.g. proof of identity, proof of address URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-SupportingInfoRequirement
identifier	S	1..1	Identifier	Identifier provided by payer to uniquely identify the product covering a list of combinations offered to consumers under this particular insurance plan.
status	S	1..1	code	draft | active | retired | unknown
type	S	1..1	CodeableConcept	Type of product that indicates the predominant type. Binding: InsurancePlan Type (example): The valueset is created by referring the Health Insurance Data Reporting Manual provided by the Insurance Information Bureau of India (IIB). For more information, visit IIB's official website: https://iib.gov.in or access the manual directly at: https://healthapp.iib.gov.in/IIB/datamanuals/hidmanual08.pdf.
coding		0..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
text	S	0..1	string	Plain text representation of the concept
name	S	1..1	string	Official name of the product
alias	S	0..*	string	Alternate names
period	S	1..1	Period	When the product is available
ownedBy	S	1..1	Reference(Organization)	Plan issuer
administeredBy	S	0..1	Reference(Organization)	Product administrator
coverageArea	S	0..*	Reference(Location)	Where product applies
contact	S	0..*	BackboneElement	Contact for the product
network	S	0..*	Reference(Organization)	Network included in the health insurance product.
coverage	S	1..*	BackboneElement	Coverage details for e.g. In-Patient Hospitalization, Day Care etc.
claim-condition		0..*	(Complex)	Outlines specific conditions and criteria that may be required to successfully claim benefits under a coverage within a insurance product. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition
claim-supportingInfoRequirement		0..*	(Complex)	Essential documentation necessary for a health insurance product during claim processing. e.g. proof of identity, proof of address URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-SupportingInfoRequirement
type		1..1	CodeableConcept	Type of coverage Binding: Coverage Type (example)
coding		0..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
text	S	0..1	string	Plain text representation of the concept
benefit	S	1..*	BackboneElement	List of benefits e.g. consultation, oxygen, robotic surgery etc.
claim-condition		0..*	(Complex)	Outlines specific conditions and criteria that may be required to successfully claim benefits under a coverage within a insurance product. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition
type		1..1	CodeableConcept	Type of benefit Binding: Benefit Type (example)
coding		0..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
text	S	0..1	string	Plain text representation of the concept
plan	S	0..*	BackboneElement	Cost sharing details for the plan offered to a consumer.
claim-exclusion		0..*	(Complex)	Excluded coverage details within a plan. It outlines services, treatments or conditions not covered. e.g. pre-existing disease, specific disease/procedure waiting period etc. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion
type	S	1..1	CodeableConcept	Type of plan Binding: Plan Type (example)
coding		0..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
text	S	0..1	string	Plain text representation of the concept
coverageArea	S	0..*	Reference(Location)	Where product applies
network		0..*	Reference(Organization)	What networks provide coverage
generalCost	S	0..*	BackboneElement	Sum insured amount associated with the plan.
specificCost	S	0..*	BackboneElement	Specific costs
category	S	1..1	CodeableConcept	General category of benefit Binding: Benefit Category (example)
coding		0..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
text	S	0..1	string	Plain text representation of the concept
benefit
type		1..1	CodeableConcept	Type of specific benefit Binding: ProductorService (example)
coding		0..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
text	S	0..1	string	Plain text representation of the concept
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
InsurancePlan.type	example	InsurancePlanType (a valid code from InsurancePlan Type) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-insuranceplan-type from this IG
InsurancePlan.coverage.type	example	CoverageType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-coverage-type from this IG
InsurancePlan.coverage.benefit.type	example	BenefitType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefit-type from this IG
InsurancePlan.plan.type	example	PlanType (a valid code from Plan Type) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-plan-type from this IG
InsurancePlan.plan.specificCost.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
InsurancePlan.plan.specificCost.benefit.type	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan	C	0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
claim-exclusion		0..*	(Complex)	Excluded coverage details within a health insurance product. It outlines services, treatments or conditions not covered. e.g. pre-existing disease, specific disease/procedure wating period etc. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion
claim-supportingInfoRequirement		0..*	(Complex)	Essential documentation necessary for a health insurance product during claim processing. e.g. proof of identity, proof of address URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-SupportingInfoRequirement
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣC	1..1	Identifier	Identifier provided by payer to uniquely identify the product covering a list of combinations offered to consumers under this particular insurance plan.
status	?!SΣ	1..1	code	draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact.
type	SΣ	1..1	CodeableConcept	Type of product that indicates the predominant type. Binding: InsurancePlan Type (example): The valueset is created by referring the Health Insurance Data Reporting Manual provided by the Insurance Information Bureau of India (IIB). For more information, visit IIB's official website: https://iib.gov.in or access the manual directly at: https://healthapp.iib.gov.in/IIB/datamanuals/hidmanual08.pdf.
coding	Σ	0..1	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
text	SΣ	0..1	string	Plain text representation of the concept
name	SΣC	1..1	string	Official name of the product
alias	S	0..*	string	Alternate names
period	S	1..1	Period	When the product is available
ownedBy	SΣ	1..1	Reference(Organization)	Plan issuer
administeredBy	SΣ	0..1	Reference(Organization)	Product administrator
coverageArea	SΣ	0..*	Reference(Location)	Where product applies
contact	S	0..*	BackboneElement	Contact for the product
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
network	S	0..*	Reference(Organization)	Network included in the health insurance product.
coverage	S	1..*	BackboneElement	Coverage details for e.g. In-Patient Hospitalization, Day Care etc.
claim-condition		0..*	(Complex)	Outlines specific conditions and criteria that may be required to successfully claim benefits under a coverage within a insurance product. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition
claim-supportingInfoRequirement		0..*	(Complex)	Essential documentation necessary for a health insurance product during claim processing. e.g. proof of identity, proof of address URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-SupportingInfoRequirement
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of coverage Binding: Coverage Type (example)
coding	Σ	0..1	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
text	SΣ	0..1	string	Plain text representation of the concept
benefit	S	1..*	BackboneElement	List of benefits e.g. consultation, oxygen, robotic surgery etc.
claim-condition		0..*	(Complex)	Outlines specific conditions and criteria that may be required to successfully claim benefits under a coverage within a insurance product. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of benefit Binding: Benefit Type (example)
coding	Σ	0..1	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
text	SΣ	0..1	string	Plain text representation of the concept
plan	S	0..*	BackboneElement	Cost sharing details for the plan offered to a consumer.
claim-exclusion		0..*	(Complex)	Excluded coverage details within a plan. It outlines services, treatments or conditions not covered. e.g. pre-existing disease, specific disease/procedure waiting period etc. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	S	1..1	CodeableConcept	Type of plan Binding: Plan Type (example)
coding	Σ	0..1	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
text	SΣ	0..1	string	Plain text representation of the concept
coverageArea	SΣ	0..*	Reference(Location)	Where product applies
network		0..*	Reference(Organization)	What networks provide coverage
generalCost	S	0..*	BackboneElement	Sum insured amount associated with the plan.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
specificCost	S	0..*	BackboneElement	Specific costs
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	General category of benefit Binding: Benefit Category (example)
coding	Σ	0..1	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
text	SΣ	0..1	string	Plain text representation of the concept
benefit		0..*	BackboneElement	Benefits list
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of specific benefit Binding: ProductorService (example)
coding	Σ	0..1	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
text	SΣ	0..1	string	Plain text representation of the concept
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
InsurancePlan.status	required	PublicationStatus http://hl7.org/fhir/ValueSet/publication-status|4.0.1 from the FHIR Standard
InsurancePlan.type	example	InsurancePlanType (a valid code from InsurancePlan Type) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-insuranceplan-type from this IG
InsurancePlan.coverage.type	example	CoverageType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-coverage-type from this IG
InsurancePlan.coverage.benefit.type	example	BenefitType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefit-type from this IG
InsurancePlan.plan.type	example	PlanType (a valid code from Plan Type) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-plan-type from this IG
InsurancePlan.plan.specificCost.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
InsurancePlan.plan.specificCost.benefit.type	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
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

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
InsurancePlan	C	0..*	InsurancePlan	Details of a Health Insurance product/plan provided by an organization
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
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 Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
claim-exclusion		0..*	(Complex)	Excluded coverage details within a health insurance product. It outlines services, treatments or conditions not covered. e.g. pre-existing disease, specific disease/procedure wating period etc. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion
claim-supportingInfoRequirement		0..*	(Complex)	Essential documentation necessary for a health insurance product during claim processing. e.g. proof of identity, proof of address URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-SupportingInfoRequirement
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣC	1..1	Identifier	Identifier provided by payer to uniquely identify the product covering a list of combinations offered to consumers under this particular insurance plan.
status	?!SΣ	1..1	code	draft | active | retired | unknown Binding: PublicationStatus (required): The lifecycle status of an artifact.
type	SΣ	1..1	CodeableConcept	Type of product that indicates the predominant type. Binding: InsurancePlan Type (example): The valueset is created by referring the Health Insurance Data Reporting Manual provided by the Insurance Information Bureau of India (IIB). For more information, visit IIB's official website: https://iib.gov.in or access the manual directly at: https://healthapp.iib.gov.in/IIB/datamanuals/hidmanual08.pdf.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
name	SΣC	1..1	string	Official name of the product
alias	S	0..*	string	Alternate names
period	S	1..1	Period	When the product is available
ownedBy	SΣ	1..1	Reference(Organization)	Plan issuer
administeredBy	SΣ	0..1	Reference(Organization)	Product administrator
coverageArea	SΣ	0..*	Reference(Location)	Where product applies
contact	S	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(Endpoint)	Technical endpoint
network	S	0..*	Reference(Organization)	Network included in the health insurance product.
coverage	S	1..*	BackboneElement	Coverage details for e.g. In-Patient Hospitalization, Day Care etc.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
claim-condition		0..*	(Complex)	Outlines specific conditions and criteria that may be required to successfully claim benefits under a coverage within a insurance product. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition
claim-supportingInfoRequirement		0..*	(Complex)	Essential documentation necessary for a health insurance product during claim processing. e.g. proof of identity, proof of address URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-SupportingInfoRequirement
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of coverage Binding: Coverage Type (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
network		0..*	Reference(Organization)	What networks provide coverage
benefit	S	1..*	BackboneElement	List of benefits e.g. consultation, oxygen, robotic surgery etc.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
claim-condition		0..*	(Complex)	Outlines specific conditions and criteria that may be required to successfully claim benefits under a coverage within a insurance product. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Type of benefit Binding: Benefit Type (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
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	S	0..*	BackboneElement	Cost sharing details for the plan offered to a consumer.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
claim-exclusion		0..*	(Complex)	Excluded coverage details within a plan. It outlines services, treatments or conditions not covered. e.g. pre-existing disease, specific disease/procedure waiting period etc. URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
identifier	Σ	0..*	Identifier	Business Identifier for Product
type	S	1..1	CodeableConcept	Type of plan Binding: Plan Type (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
coverageArea	SΣ	0..*	Reference(Location)	Where product applies
network		0..*	Reference(Organization)	What networks provide coverage
generalCost	S	0..*	BackboneElement	Sum insured amount associated with 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
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	S	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	S	1..1	CodeableConcept	General category of benefit Binding: Benefit Category (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
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 Binding: ProductorService (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
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
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
InsurancePlan.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
InsurancePlan.status	required	PublicationStatus http://hl7.org/fhir/ValueSet/publication-status|4.0.1 from the FHIR Standard
InsurancePlan.type	example	InsurancePlanType (a valid code from InsurancePlan Type) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-insuranceplan-type from this IG
InsurancePlan.contact.purpose	extensible	ContactEntityType http://hl7.org/fhir/ValueSet/contactentity-type from the FHIR Standard
InsurancePlan.coverage.type	example	CoverageType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-coverage-type from this IG
InsurancePlan.coverage.benefit.type	example	BenefitType https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefit-type from this IG
InsurancePlan.plan.type	example	PlanType (a valid code from Plan Type) https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-plan-type from this IG
InsurancePlan.plan.specificCost.category	example	BenefitCategory https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-benefitcategory from this IG
InsurancePlan.plan.specificCost.benefit.type	example	ProductorService https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice from this IG
InsurancePlan.plan.specificCost.benefit.cost.applicability	required	BenefitCostApplicability http://hl7.org/fhir/ValueSet/insuranceplan-applicability|4.0.1 from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
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

This structure is derived from InsurancePlan

Summary

Mandatory: 7 elements (19 nested mandatory elements)
Must-Support: 25 elements

Structures

This structure refers to these other structures:

• Organization (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization)

Extensions

This structure refers to these extensions:

• https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion
• https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-SupportingInfoRequirement
• https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition