{
  "resourceType": "StructureDefinition",
  "id": "InsurancePlan",
  "meta": {
    "lastUpdated": "2021-01-01T21:58:31.578+00:00"
  },
  "extension": [
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-category",
      "valueString": "Financial.General"
    },
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
      "valueCode": "trial-use"
    },
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
      "valueInteger": 0
    },
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-security-category",
      "valueCode": "business"
    },
    {
      "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode": "pa"
    },
    {
      "url": "http://hl7.org/fhir/build/StructureDefinition/entered-in-error-status",
      "valueCode": ".status = retired"
    }
  ],
  "url": "http://hl7.org/fhir/StructureDefinition/InsurancePlan",
  "version": "4.6.0",
  "name": "InsurancePlan",
  "status": "draft",
  "date": "2021-01-01T21:58:31+00:00",
  "publisher": "Health Level Seven International (Patient Administration)",
  "contact": [
    {
      "telecom": [
        {
          "system": "url",
          "value": "http://hl7.org/fhir"
        }
      ]
    },
    {
      "telecom": [
        {
          "system": "url",
          "value": "http://www.hl7.org/Special/committees/pafm/index.cfm"
        }
      ]
    }
  ],
  "description": "Details of a Health Insurance product/plan provided by an organization.",
  "fhirVersion": "4.6.0",
  "mapping": [
    {
      "identity": "w5",
      "uri": "http://hl7.org/fhir/fivews",
      "name": "FiveWs Pattern Mapping"
    },
    {
      "identity": "rim",
      "uri": "http://hl7.org/v3",
      "name": "RIM Mapping"
    }
  ],
  "kind": "resource",
  "abstract": false,
  "type": "InsurancePlan",
  "baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource",
  "derivation": "specialization",
  "differential": {
    "element": [
      {
        "id": "InsurancePlan",
        "path": "InsurancePlan",
        "short": "Details of a Health Insurance product/plan provided by an organization",
        "definition": "Details of a Health Insurance product/plan provided by an organization.",
        "min": 0,
        "max": "*",
        "constraint": [
          {
            "key": "ipn-1",
            "severity": "error",
            "human": "The organization SHALL at least have a name or an identifier, and possibly more than one",
            "expression": "(identifier.count() + name.count()) > 0",
            "xpath": "count(f:identifier | f:name) > 0",
            "source": "http://hl7.org/fhir/StructureDefinition/InsurancePlan"
          }
        ],
        "mapping": [
          {
            "identity": "w5",
            "map": "administrative.entity"
          }
        ]
      },
      {
        "id": "InsurancePlan.identifier",
        "path": "InsurancePlan.identifier",
        "short": "Business Identifier for Product",
        "definition": "Business identifiers assigned to this health insurance product which remain constant as the resource is updated and propagates from server to server.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Identifier"
          }
        ],
        "condition": [
          "ipn-1"
        ],
        "isSummary": true,
        "mapping": [
          {
            "identity": "w5",
            "map": "FiveWs.identifier"
          },
          {
            "identity": "rim",
            "map": ".scopes[Role](classCode=IDENT)"
          }
        ]
      },
      {
        "id": "InsurancePlan.status",
        "path": "InsurancePlan.status",
        "short": "draft | active | retired | unknown",
        "definition": "The current state of the health insurance product.",
        "requirements": "Need a flag to indicate a record is no longer to be used and should generally be hidden for the user in the UI.",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "code"
          }
        ],
        "meaningWhenMissing": "Default interpretation is active.",
        "isModifier": true,
        "isModifierReason": "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",
        "isSummary": true,
        "binding": {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
              "valueString": "PublicationStatus"
            },
            {
              "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
              "valueBoolean": true
            }
          ],
          "strength": "required",
          "description": "The lifecycle status of an artifact.",
          "valueSet": "http://hl7.org/fhir/ValueSet/publication-status"
        },
        "mapping": [
          {
            "identity": "w5",
            "map": "FiveWs.status"
          },
          {
            "identity": "rim",
            "map": ".status"
          }
        ]
      },
      {
        "id": "InsurancePlan.type",
        "path": "InsurancePlan.type",
        "short": "Kind of product",
        "definition": "The kind of health insurance product.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ],
        "isSummary": true,
        "binding": {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
              "valueString": "InsurancePlanType"
            }
          ],
          "strength": "example",
          "description": "Used to categorize the product/plan.",
          "valueSet": "http://hl7.org/fhir/ValueSet/insuranceplan-type"
        },
        "mapping": [
          {
            "identity": "w5",
            "map": "FiveWs.class"
          },
          {
            "identity": "rim",
            "map": ".code"
          }
        ]
      },
      {
        "id": "InsurancePlan.name",
        "path": "InsurancePlan.name",
        "short": "Official name",
        "definition": "Official name of the health insurance product as designated by the owner.",
        "comment": "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.",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "string"
          }
        ],
        "condition": [
          "ipn-1"
        ],
        "isSummary": true,
        "mapping": [
          {
            "identity": "rim",
            "map": ".name"
          }
        ]
      },
      {
        "id": "InsurancePlan.alias",
        "extension": [
          {
            "url": "http://hl7.org/fhir/build/StructureDefinition/committee-notes",
            "valueString": "This is used in many registries, and is often very important in searching."
          }
        ],
        "path": "InsurancePlan.alias",
        "short": "Alternate names",
        "definition": "A list of alternate names that the product is known as, or was known as in the past.",
        "comment": "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.",
        "requirements": "Over time products/plans go through many changes and can be known by different names.\n\nFor searching knowing previous names that the product/plan was known by can be very useful.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "string"
          }
        ],
        "mapping": [
          {
            "identity": "rim",
            "map": ".name"
          }
        ]
      },
      {
        "id": "InsurancePlan.period",
        "path": "InsurancePlan.period",
        "short": "When the product is available",
        "definition": "The period of time that the health insurance product is available.",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Period"
          }
        ]
      },
      {
        "id": "InsurancePlan.ownedBy",
        "path": "InsurancePlan.ownedBy",
        "short": "Plan issuer",
        "definition": "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'.",
        "alias": [
          "Payer"
        ],
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/Organization"
            ]
          }
        ],
        "isSummary": true
      },
      {
        "id": "InsurancePlan.administeredBy",
        "path": "InsurancePlan.administeredBy",
        "short": "Product administrator",
        "definition": "An organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owner.",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/Organization"
            ]
          }
        ],
        "isSummary": true
      },
      {
        "id": "InsurancePlan.coverageArea",
        "path": "InsurancePlan.coverageArea",
        "short": "Where product applies",
        "definition": "The geographic region in which a health insurance product's benefits apply.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/Location"
            ]
          }
        ],
        "isSummary": true
      },
      {
        "id": "InsurancePlan.contact",
        "path": "InsurancePlan.contact",
        "short": "Official contact details relevant to the health insurance plan/product",
        "definition": "The contact details of communication devices available relevant to the specific Insurance Plan/Product. This can include addresses, phone numbers, fax numbers, mobile numbers, email addresses and web sites.",
        "comment": "The address/telecom use code 'home' are not to be used.",
        "requirements": "Need to keep track of both simple contact details and also assigned contacts within larger organizations.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "ExtendedContactDetail"
          }
        ],
        "mapping": [
          {
            "identity": "rim",
            "map": ".contactParty"
          }
        ]
      },
      {
        "id": "InsurancePlan.endpoint",
        "path": "InsurancePlan.endpoint",
        "short": "Technical endpoint",
        "definition": "The technical endpoints providing access to services operated for the health insurance product.",
        "requirements": "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.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/Endpoint"
            ]
          }
        ],
        "mapping": [
          {
            "identity": "rim",
            "map": "n/a"
          }
        ]
      },
      {
        "id": "InsurancePlan.network",
        "path": "InsurancePlan.network",
        "short": "What networks are Included",
        "definition": "Reference to the network included in the health insurance product.",
        "comment": "Networks are represented as a hierarchy of organization resources.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/Organization"
            ]
          }
        ]
      },
      {
        "id": "InsurancePlan.coverage",
        "path": "InsurancePlan.coverage",
        "short": "Coverage details",
        "definition": "Details about the coverage offered by the insurance product.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "BackboneElement"
          }
        ]
      },
      {
        "id": "InsurancePlan.coverage.type",
        "path": "InsurancePlan.coverage.type",
        "short": "Type of coverage",
        "definition": "Type of coverage  (Medical; Dental; Mental Health; Substance Abuse; Vision; Drug; Short Term; Long Term Care; Hospice; Home Health).",
        "min": 1,
        "max": "1",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "InsurancePlan.coverage.network",
        "path": "InsurancePlan.coverage.network",
        "short": "What networks provide coverage",
        "definition": "Reference to the network that providing the type of coverage.",
        "comment": "Networks are represented as a hierarchy of organization resources.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/Organization"
            ]
          }
        ]
      },
      {
        "id": "InsurancePlan.coverage.benefit",
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
            "valueString": "CoverageBenefit"
          }
        ],
        "path": "InsurancePlan.coverage.benefit",
        "short": "List of benefits",
        "definition": "Specific benefits under this type of coverage.",
        "min": 1,
        "max": "*",
        "type": [
          {
            "code": "BackboneElement"
          }
        ]
      },
      {
        "id": "InsurancePlan.coverage.benefit.type",
        "path": "InsurancePlan.coverage.benefit.type",
        "short": "Type of benefit",
        "definition": "Type of benefit (primary care; speciality care; inpatient; outpatient).",
        "min": 1,
        "max": "1",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "InsurancePlan.coverage.benefit.requirement",
        "path": "InsurancePlan.coverage.benefit.requirement",
        "short": "Referral requirements",
        "definition": "The referral requirements to have access/coverage for this benefit.",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "string"
          }
        ]
      },
      {
        "id": "InsurancePlan.coverage.benefit.limit",
        "path": "InsurancePlan.coverage.benefit.limit",
        "short": "Benefit limits",
        "definition": "The specific limits on the benefit.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "BackboneElement"
          }
        ]
      },
      {
        "id": "InsurancePlan.coverage.benefit.limit.value",
        "path": "InsurancePlan.coverage.benefit.limit.value",
        "short": "Maximum value allowed",
        "definition": "The maximum amount of a service item a plan will pay for a covered benefit.  For examples. wellness visits, or eyeglasses.",
        "comment": "May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”.",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Quantity"
          }
        ]
      },
      {
        "id": "InsurancePlan.coverage.benefit.limit.code",
        "path": "InsurancePlan.coverage.benefit.limit.code",
        "short": "Benefit limit details",
        "definition": "The specific limit on the benefit.",
        "comment": "Use `CodeableConcept.text` element if the data is free (uncoded) text.",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "InsurancePlan.plan",
        "path": "InsurancePlan.plan",
        "short": "Plan details",
        "definition": "Details about an insurance plan.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "BackboneElement"
          }
        ]
      },
      {
        "id": "InsurancePlan.plan.identifier",
        "path": "InsurancePlan.plan.identifier",
        "short": "Business Identifier for Product",
        "definition": "Business identifiers assigned to this health insurance plan which remain constant as the resource is updated and propagates from server to server.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Identifier"
          }
        ],
        "isSummary": true,
        "mapping": [
          {
            "identity": "w5",
            "map": "FiveWs.identifier"
          },
          {
            "identity": "rim",
            "map": ".scopes[Role](classCode=IDENT)"
          }
        ]
      },
      {
        "id": "InsurancePlan.plan.type",
        "path": "InsurancePlan.plan.type",
        "short": "Type of plan",
        "definition": "Type of plan. For example, \"Platinum\" or \"High Deductable\".",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "InsurancePlan.plan.coverageArea",
        "path": "InsurancePlan.plan.coverageArea",
        "short": "Where product applies",
        "definition": "The geographic region in which a health insurance plan's benefits apply.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/Location"
            ]
          }
        ],
        "isSummary": true
      },
      {
        "id": "InsurancePlan.plan.network",
        "path": "InsurancePlan.plan.network",
        "short": "What networks provide coverage",
        "definition": "Reference to the network that providing the type of coverage.",
        "comment": "Networks are represented as a hierarchy of organization resources.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/Organization"
            ]
          }
        ]
      },
      {
        "id": "InsurancePlan.plan.generalCost",
        "path": "InsurancePlan.plan.generalCost",
        "short": "Overall costs",
        "definition": "Overall costs associated with the plan.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "BackboneElement"
          }
        ]
      },
      {
        "id": "InsurancePlan.plan.generalCost.type",
        "path": "InsurancePlan.plan.generalCost.type",
        "short": "Type of cost",
        "definition": "Type of cost.",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "InsurancePlan.plan.generalCost.groupSize",
        "path": "InsurancePlan.plan.generalCost.groupSize",
        "short": "Number of enrollees",
        "definition": "Number of participants enrolled in the plan.",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "positiveInt"
          }
        ]
      },
      {
        "id": "InsurancePlan.plan.generalCost.cost",
        "path": "InsurancePlan.plan.generalCost.cost",
        "short": "Cost value",
        "definition": "Value of the cost.",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Money"
          }
        ]
      },
      {
        "id": "InsurancePlan.plan.generalCost.comment",
        "path": "InsurancePlan.plan.generalCost.comment",
        "short": "Additional cost information",
        "definition": "Additional information about the general costs associated with this plan.",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "string"
          }
        ]
      },
      {
        "id": "InsurancePlan.plan.specificCost",
        "path": "InsurancePlan.plan.specificCost",
        "short": "Specific costs",
        "definition": "Costs associated with the coverage provided by the product.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "BackboneElement"
          }
        ]
      },
      {
        "id": "InsurancePlan.plan.specificCost.category",
        "path": "InsurancePlan.plan.specificCost.category",
        "short": "General category of benefit",
        "definition": "General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health).",
        "min": 1,
        "max": "1",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "InsurancePlan.plan.specificCost.benefit",
        "extension": [
          {
            "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
            "valueString": "PlanBenefit"
          }
        ],
        "path": "InsurancePlan.plan.specificCost.benefit",
        "short": "Benefits list",
        "definition": "List of the specific benefits under this category of benefit.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "BackboneElement"
          }
        ]
      },
      {
        "id": "InsurancePlan.plan.specificCost.benefit.type",
        "path": "InsurancePlan.plan.specificCost.benefit.type",
        "short": "Type of specific benefit",
        "definition": "Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care).",
        "min": 1,
        "max": "1",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "InsurancePlan.plan.specificCost.benefit.cost",
        "path": "InsurancePlan.plan.specificCost.benefit.cost",
        "short": "List of the costs",
        "definition": "List of the costs associated with a specific benefit.",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "BackboneElement"
          }
        ]
      },
      {
        "id": "InsurancePlan.plan.specificCost.benefit.cost.type",
        "path": "InsurancePlan.plan.specificCost.benefit.cost.type",
        "short": "Type of cost",
        "definition": "Type of cost (copay; individual cap; family cap; coinsurance; deductible).",
        "min": 1,
        "max": "1",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "InsurancePlan.plan.specificCost.benefit.cost.applicability",
        "path": "InsurancePlan.plan.specificCost.benefit.cost.applicability",
        "short": "in-network | out-of-network | other",
        "definition": "Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other).",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ],
        "binding": {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
              "valueString": "BenefitCostApplicability"
            }
          ],
          "strength": "required",
          "description": "Whether the cost applies to in-network or out-of-network providers.",
          "valueSet": "http://hl7.org/fhir/ValueSet/insuranceplan-applicability"
        }
      },
      {
        "id": "InsurancePlan.plan.specificCost.benefit.cost.qualifiers",
        "path": "InsurancePlan.plan.specificCost.benefit.cost.qualifiers",
        "short": "Additional information about the cost",
        "definition": "Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA).",
        "min": 0,
        "max": "*",
        "type": [
          {
            "code": "CodeableConcept"
          }
        ]
      },
      {
        "id": "InsurancePlan.plan.specificCost.benefit.cost.value",
        "path": "InsurancePlan.plan.specificCost.benefit.cost.value",
        "short": "The actual cost value",
        "definition": "The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance).",
        "min": 0,
        "max": "1",
        "type": [
          {
            "code": "Quantity"
          }
        ]
      }
    ]
  }
}