type: resource-definitionsresource: InsuranceProduct

InsuranceProduct Definitions

InsuranceProduct

Details of a Health Insurance product provided by an organization

Definition: A product is a discrete package of health insurance coverage benefits that are offered under a particular network, by an organization (payer) and additional information about the offering, such as who it is owned and administered by, a coverage area, contact information, etc.

Cardinality: 0..*

Constraints: ipn-1 | error | The organization SHALL at least have a name or an identifier, and possibly more than one | (identifier.count() + name.count()) > 0

Mappings: w5=administrative.entity

InsuranceProduct.identifier

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.

Conditions: ipn-1

Cardinality: 0..*

Type: Identifier

Summary: true

Mappings: w5=FiveWs.identifier; rim=.scopesRole

InsuranceProduct.status

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.

Meaning if Missing: Default interpretation is active.

Cardinality: 0..1

Type: code

Binding: required:publication-status

Summary: true

Is Modifier: true (Reason: 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)

Mappings: w5=FiveWs.status; rim=.status

InsuranceProduct.type

Kind of product

Definition: The kind of health insurance product.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:insuranceproduct-type

Summary: true

Mappings: w5=FiveWs.class; rim=.code

InsuranceProduct.name

Official name

Definition: Official name of the health insurance product as designated by the owner.

Comments: If the name of the product changes, consider putting the old name in the alias column so that it can still be located through searches.

Conditions: ipn-1

Cardinality: 0..1

Type: string

Summary: true

Mappings: rim=.name

InsuranceProduct.alias

Alternate names

Definition: A list of alternate names that the product is known as, or was known as in the past.

Comments: 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.

Requirements: Over time products go through many changes and can be known by different names.

For searching knowing previous names that the product was known by can be very useful.

Cardinality: 0..*

Type: string

Mappings: rim=.name

InsuranceProduct.period

When the product is available

Definition: The period of time that the health insurance product is available.

Cardinality: 0..1

Type: Period

InsuranceProduct.ownedBy

Product 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'.

Aliases: Payer

Cardinality: 0..1

Type: Reference(Organization)

Summary: true

InsuranceProduct.administeredBy

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.

Cardinality: 0..1

Type: Reference(Organization)

Summary: true

InsuranceProduct.coverageArea

Where product applies

Definition: The geographic region in which a health insurance product's benefits apply.

Cardinality: 0..*

Type: Reference(Location)

Summary: true

InsuranceProduct.contact

Official contact details relevant to the health insurance product

Definition: The contact details of communication devices available relevant to the specific Insurance Product. This can include addresses, phone numbers, fax numbers, mobile numbers, email addresses and web sites.

Comments: 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.

Cardinality: 0..*

Type: ExtendedContactDetail

Mappings: rim=.contactParty

InsuranceProduct.endpoint

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.

Cardinality: 0..*

Type: Reference(Endpoint)

Mappings: rim=n/a

InsuranceProduct.network

What networks are Included

Definition: Reference to the network included in the health insurance product.

Comments: Networks are represented as a hierarchy of organization resources.

Cardinality: 0..*

Type: Reference(Organization)

InsuranceProduct.coverage

Coverage details

Definition: Details about the coverage offered by the insurance product.

Cardinality: 0..*

Type: BackboneElement

InsuranceProduct.coverage.type

Classification of Coverage

Definition: Type of coverage (Medical; Dental; Mental Health; Substance Abuse; Vision; Drug; Short Term; Long Term Care; Hospice; Home Health).

Cardinality: 1..1

Type: CodeableConcept

InsuranceProduct.coverage.network

What networks provide coverage

Definition: Reference to the network that providing the type of coverage.

Comments: Networks are represented as a hierarchy of organization resources.

Cardinality: 0..*

Type: Reference(Organization)

InsuranceProduct.coverage.benefit

List of benefits

Definition: Specific benefits under this type of coverage.

Cardinality: 1..*

Type: BackboneElement

InsuranceProduct.coverage.benefit.type

Classification of benefit provided

Definition: Type of benefit (primary care; specialty care; inpatient; outpatient).

Cardinality: 1..1

Type: CodeableConcept

InsuranceProduct.coverage.benefit.requirement

Referral requirements

Definition: The referral requirements to have access/coverage for this benefit.

Cardinality: 0..1

Type: string

InsuranceProduct.coverage.benefit.limit

Limits on the provided benefits

Definition: The specific limits on the benefit.

Cardinality: 0..*

Type: BackboneElement

InsuranceProduct.coverage.benefit.limit.value

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.

Comments: May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”.

Cardinality: 0..1

Type: Quantity

InsuranceProduct.coverage.benefit.limit.code

Benefit limit details

Definition: The specific limit on the benefit.

Comments: Use CodeableConcept.text element if the data is free (uncoded) text.

Cardinality: 0..1

Type: CodeableConcept

InsuranceProduct.related

Associated insurance product

Definition: Another product that is related to this product. Often used to create relationships to parents or families of products.

Cardinality: 0..*

Type: BackboneElement

InsuranceProduct.related.product

InsuranceProduct.related.relationship

Relationship of this product to the related product

Definition: The relationship of this product to the related product. an example would be 'sub-plan' where this product is a sub-plan of the related.product.

Comments: Use CodeableConcept.text element if the data is free (uncoded) text.

Cardinality: 0..1

Type: CodeableConcept

InsuranceProduct.related.period

Period that this Relationship is valid

Definition: Period of time that the product relationship is valid. The start and/or end dates can be empty if this is an open ended relationship.

Cardinality: 0..1

Type: Period