FHIR Implementation Guide for ABDM
6.5.0 - active
FHIR Implementation Guide for ABDM
6.5.0 - active
This page is part of the FHIR Implementation Guide for ABDM (v6.5.0: 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
{
"resourceType" : "InsurancePlan",
"id" : "example-01",
"meta" : {
"versionId" : "1",
"profile" : [
🔗 "https://nrces.in/ndhm/fhir/r4/StructureDefinition/InsurancePlan"
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: InsurancePlan example-01</b></p><a name=\"example-01\"> </a><a name=\"hcexample-01\"> </a><a name=\"example-01-hi-IN\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">version: 1</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-InsurancePlan.html\">InsurancePlan</a></p></div><blockquote><p><b>ClaimSupportingInfoRequirement</b></p><ul><li>category: <span title=\"Codes:{https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-supportinginfo-category POI}\">Proof of identity</span></li><li>code: <span title=\"Codes:{https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-identifier-type-code ADN}\">Adhaar number</span></li></ul></blockquote><blockquote><p><b>ClaimSupportingInfoRequirement</b></p><ul><li>category: <span title=\"Codes:{https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-supportinginfo-category POA}\">Proof of address</span></li><li>code: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0203 PPN}\">Passport number</span></li></ul></blockquote><blockquote><p><b>ClaimExclusion</b></p><ul><li>category: <span title=\"Codes:{http://snomed.info/sct 277011002}\">Pre-existing disease in renal transplant</span></li><li>statement: Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded untit the expiry of 48 months</li></ul></blockquote><blockquote><p><b>ClaimExclusion</b></p><ul><li>category: <span title=\"Codes:\">Specified disease</span></li><li>statement: Expenses related to the treatment of a listed conditions, surgeries/treatments shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with us.</li><li>item: <span title=\"Codes:{http://snomed.info/sct 86077009}\">Operation for glaucoma</span></li></ul></blockquote><p><b>identifier</b>: <code>https://irdai.gov.in</code>/761234556546</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-insuranceplan-type 01}\">Hospitalisation Indemnity Policy</span></p><p><b>name</b>: Active Assure Silver</p><p><b>period</b>: 2023-09-10 --> 2024-09-10</p><p><b>ownedBy</b>: <a href=\"Organization-example-02.html\">Organization XYZ Insurance Co. Ltd.</a></p><p><b>administeredBy</b>: <a href=\"Organization-example-02.html\">Organization XYZ Insurance Co. Ltd.</a></p><blockquote><p><b>coverage</b></p><blockquote><p><b>ClaimCondition</b></p><ul><li>claim-condition: The Hospitalization is medically necessary and follows the written advice of a Medical Practitioner</li></ul></blockquote><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 737481003}\">Inpatient care management (procedure)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 309904001}\">Intensive care unit (environment)</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 87612001}\">Blood</span></p></blockquote><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 24099007}\">Oxygen (substance)</span></p></blockquote></blockquote><blockquote><p><b>coverage</b></p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 710967003}\">Management of health status after discharge from hospital (procedure)</span></p><blockquote><p><b>benefit</b></p><blockquote><p><b>ClaimCondition</b></p><ul><li>claim-condition: Medical Expenses incurred up to 90 days after discharge from the hospital</li></ul></blockquote><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 710967003}\">Management of health status after discharge from hospital (procedure)</span></p><h3>Limits</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td></tr><tr><td style=\"display: none\">*</td><td><=90 day</td></tr></table></blockquote></blockquote><blockquote><p><b>coverage</b></p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 409972000}\">Pre-hospital care (situation)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 409972000}\">Pre-hospital care (situation)</span></p><h3>Limits</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td></tr><tr><td style=\"display: none\">*</td><td><=60 day</td></tr></table></blockquote></blockquote><blockquote><p><b>coverage</b></p><blockquote><p><b>ClaimCondition</b></p><ul><li>claim-condition: We have accepted a claim for In-patient Hospitalization under Section C.I.(a) above for the same Illness/ Injur</li></ul></blockquote><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 49122002}\">Ambulance, device (physical object)</span></p><h3>Benefits</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Type</b></td></tr><tr><td style=\"display: none\">*</td><td/><td><span title=\"Codes:{http://snomed.info/sct 49122002}\">Ambulance, device (physical object)</span></td></tr></table></blockquote><blockquote><p><b>coverage</b></p><blockquote><p><b>ClaimCondition</b></p><ul><li>claim-condition: The Medical Expenses are incurred, including for any procedure which requires a period of specialized observation or care after completion of the procedure undertaken by an Insured Person as Day Care Treatment</li></ul></blockquote><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 737850002}\">Day care case management</span></p><h3>Benefits</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://snomed.info/sct 737850002}\">Day care case management</span></td></tr></table></blockquote><blockquote><p><b>coverage</b></p><blockquote><p><b>ClaimCondition</b></p><ul><li>claim-condition: The donation conforms to The Transplantation of Human Organs Act 1994 and the organ is for the use of the Insured Person</li></ul></blockquote><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 105461009}\">Organ donor</span></p><h3>Benefits</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Extension</b></td><td><b>Type</b></td></tr><tr><td style=\"display: none\">*</td><td/><td><span title=\"Codes:{http://snomed.info/sct 105461009}\">Organ donor</span></td></tr></table></blockquote><blockquote><p><b>plan</b></p><p><b>identifier</b>: Active Assure Silver\u00a0(use:\u00a0official,\u00a0)</p><p><b>type</b>: <span title=\"Codes:{https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-plan-type 01}\">Individual</span></p><blockquote><p><b>generalCost</b></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>200000</td><td>Indian rupee</td></tr></table></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://snomed.info/sct 49122002}\">Ambulance, device (physical object)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 49122002}\">Ambulance, device (physical object)</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:\">fullcoverage</span></td><td>2000 INR</td></tr></table></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://snomed.info/sct 224663004}\">Single room (environment)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 224663004}\">Single room (environment)</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:\">fullcoverage</span></td><td>2000 INR</td></tr></table></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://snomed.info/sct 309904001}\">Intensive care unit (environment)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 309904001}\">Intensive care unit (environment)</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:\">fullcoverage</span></td><td>4000 INR</td></tr></table></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://snomed.info/sct 60689008}\">Home care of patient</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 60689008}\">Home care of patient</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:\">fullcoverage</span></td><td>20000 INR</td></tr></table></blockquote></blockquote></blockquote><blockquote><p><b>plan</b></p><p><b>identifier</b>: Active Assure Silver\u00a0(use:\u00a0official,\u00a0)</p><p><b>type</b>: <span title=\"Codes:{https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-plan-type 01}\">Individual</span></p><blockquote><p><b>generalCost</b></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>700000</td><td>Indian rupee</td></tr></table></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://snomed.info/sct 49122002}\">Ambulance, device (physical object)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 49122002}\">Ambulance, device (physical object)</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:\">fullcoverage</span></td><td>2000 INR</td></tr></table></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://snomed.info/sct 224663004}\">Single room (environment)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 224663004}\">Single room (environment)</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:\">fullcoverage</span></td><td>7000 INR</td></tr></table></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://snomed.info/sct 309904001}\">Intensive care unit (environment)</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 309904001}\">Intensive care unit (environment)</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:\">fullcoverage</span></td><td>14000 INR</td></tr></table></blockquote></blockquote><blockquote><p><b>specificCost</b></p><p><b>category</b>: <span title=\"Codes:{http://snomed.info/sct 60689008}\">Home care of patient</span></p><blockquote><p><b>benefit</b></p><p><b>type</b>: <span title=\"Codes:{http://snomed.info/sct 60689008}\">Home care of patient</span></p><h3>Costs</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Type</b></td><td><b>Value</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:\">fullcoverage</span></td><td>70000 INR</td></tr></table></blockquote></blockquote></blockquote></div>"
},
"extension" : [
{
"extension" : [
{
"url" : "category",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-supportinginfo-category",
"code" : "POI",
"display" : "Proof of identity"
}
]
}
},
{
"url" : "code",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-identifier-type-code",
"code" : "ADN",
"display" : "Adhaar number"
}
]
}
}
],
"url" : "https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-SupportingInfoRequirement"
},
{
"extension" : [
{
"url" : "category",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-supportinginfo-category",
"code" : "POA",
"display" : "Proof of address"
}
]
}
},
{
"url" : "code",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
"code" : "PPN",
"display" : "Passport number"
}
]
}
}
],
"url" : "https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-SupportingInfoRequirement"
},
{
"extension" : [
{
"url" : "category",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "277011002",
"display" : "Pre-existing disease in renal transplant"
}
]
}
},
{
"url" : "statement",
"valueString" : "Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded untit the expiry of 48 months"
}
],
"url" : "https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion"
},
{
"extension" : [
{
"url" : "category",
"valueCodeableConcept" : {
"text" : "Specified disease"
}
},
{
"url" : "statement",
"valueString" : "Expenses related to the treatment of a listed conditions, surgeries/treatments shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with us."
},
{
"url" : "item",
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "86077009",
"display" : "Operation for glaucoma"
}
]
}
}
],
"url" : "https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Exclusion"
}
],
"identifier" : [
{
"system" : "https://irdai.gov.in",
"value" : "761234556546"
}
],
"status" : "active",
"type" : [
{
"coding" : [
{
"system" : "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-insuranceplan-type",
"code" : "01",
"display" : "Hospitalisation Indemnity Policy"
}
]
}
],
"name" : "Active Assure Silver",
"period" : {
"start" : "2023-09-10",
"end" : "2024-09-10"
},
"ownedBy" : {
🔗 "reference" : "Organization/example-02"
},
"administeredBy" : {
🔗 "reference" : "Organization/example-02"
},
"coverage" : [
{
"extension" : [
{
"extension" : [
{
"url" : "claim-condition",
"valueString" : "The Hospitalization is medically necessary and follows the written advice of a Medical Practitioner"
}
],
"url" : "https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition"
}
],
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "737481003",
"display" : "Inpatient care management (procedure)"
}
]
},
"benefit" : [
{
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "309904001",
"display" : "Intensive care unit (environment)"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "87612001",
"display" : "Blood"
}
]
}
},
{
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "24099007",
"display" : "Oxygen (substance)"
}
]
}
}
]
},
{
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "710967003",
"display" : "Management of health status after discharge from hospital (procedure)"
}
]
},
"benefit" : [
{
"extension" : [
{
"extension" : [
{
"url" : "claim-condition",
"valueString" : "Medical Expenses incurred up to 90 days after discharge from the hospital"
}
],
"url" : "https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition"
}
],
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "710967003",
"display" : "Management of health status after discharge from hospital (procedure)"
}
]
},
"limit" : [
{
"value" : {
"value" : 90,
"comparator" : "<=",
"unit" : "day"
}
}
]
}
]
},
{
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "409972000",
"display" : "Pre-hospital care (situation)"
}
]
},
"benefit" : [
{
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "409972000",
"display" : "Pre-hospital care (situation)"
}
]
},
"limit" : [
{
"value" : {
"value" : 60,
"comparator" : "<=",
"unit" : "day"
}
}
]
}
]
},
{
"extension" : [
{
"extension" : [
{
"url" : "claim-condition",
"valueString" : "We have accepted a claim for In-patient Hospitalization under Section C.I.(a) above for the same Illness/ Injur"
}
],
"url" : "https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition"
}
],
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "49122002",
"display" : "Ambulance, device (physical object)"
}
]
},
"benefit" : [
{
"extension" : [
{
"extension" : [
{
"url" : "claim-condition",
"valueString" : "Per policy limits is up to 10% of the Sum Insured."
}
],
"url" : "https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition"
}
],
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "49122002",
"display" : "Ambulance, device (physical object)"
}
]
}
}
]
},
{
"extension" : [
{
"extension" : [
{
"url" : "claim-condition",
"valueString" : "The Medical Expenses are incurred, including for any procedure which requires a period of specialized observation or care after completion of the procedure undertaken by an Insured Person as Day Care Treatment"
}
],
"url" : "https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition"
}
],
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "737850002",
"display" : "Day care case management"
}
]
},
"benefit" : [
{
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "737850002",
"display" : "Day care case management"
}
]
}
}
]
},
{
"extension" : [
{
"extension" : [
{
"url" : "claim-condition",
"valueString" : "The donation conforms to The Transplantation of Human Organs Act 1994 and the organ is for the use of the Insured Person"
}
],
"url" : "https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition"
}
],
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "105461009",
"display" : "Organ donor"
}
]
},
"benefit" : [
{
"extension" : [
{
"extension" : [
{
"url" : "claim-condition",
"valueString" : "This coverage is subject to a limit of 10% of the Sum Insured or Rupees One Lakh whichever is less."
}
],
"url" : "https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim-Condition"
}
],
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "105461009",
"display" : "Organ donor"
}
]
}
}
]
}
],
"plan" : [
{
"identifier" : [
{
"use" : "official",
"value" : "Active Assure Silver"
}
],
"type" : {
"coding" : [
{
"system" : "https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-plan-type",
"code" : "01",
"display" : "Individual"
}
]
},
"generalCost" : [
{
"cost" : {
"value" : 200000,
"currency" : "INR"
}
}
],
"specificCost" : [
{
"category" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "49122002",
"display" : "Ambulance, device (physical object)"
}
]
},
"benefit" : [
{
"type" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "49122002",
"display" : "Ambulance, device (physical object)"
}
]
},
"cost" : [
{
"type" : {
"coding" : [
{
"code" : "fullcoverage"
}
]
},
"value" : {
"value" : 2000,
"unit" : "INR"
}
}
]
}
]
},
{
"category" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "224663004",
"display" : "Single room (environment)"
}
]
},
"benefit" : [
{
"type" : {
"coding" : [
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