InsurancePlan

Overview

The InsurancePlan API empowers healthcare developers to seamlessly manage and retrieve insurance plan information, providing a standardized interface for efficient integration of coverage details into clinical workflows. By leveraging this API, developers can optimize insurance verification, streamline billing processes, and ensure accurate and up-to-date coverage information for improved patient care and administrative efficiency.

Use Cases

Provider Directories - Maintain real-time list of health plans offered, with networks, coverage details.
Member Management - Check eligibility, enroll members to requested plans.
Premium payments - Record payment transactions associated with correct insurance plans.
Claim submissions - Submit to correct plan claims forms, documentation as needed.
Plan recommendation - Suggest plans based on the patient's qualifying demographics, needs.
Plan comparison - Provide the differences between plans on offerings to assist selection.
Population analytics - Stratify patient population stats by subscribing plans.
Value-based care - Track outcome metrics by plans under risk-contracted arrangements.
Patient portals - Present subscribed health plan details and documentation to members.
Interoperability - Exchange InsurancePlan data between payer and provider systems.

EHR Data Model

EHR	Supported?	Mapped Source Object
Athena	✅	Insurance package, Case Policy Insurance Package
Elation	✅	Insurance Plan
Epic	✅	N/A

Object Definition

{
  "resourceType": "InsurancePlan",
  "id": "example",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: example</p><p><b>name</b>: foo</p></div>"
  },
  "name": "foo",
  "meta": {
    "tag": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code": "HTEST",
        "display": "test health data"
      }
    ]
  }
}

Data Fields

Data Field	Type	Description
resourceType	InsurancePlan	This is a InsurancePlan resource
id	id	The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
meta	Meta	The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
implicitRules	uri	A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
language	code	The base language in which the resource is written.
text	Narrative	A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
contained	BackboneElement	These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
extension	Extension	May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
identifier	Identifier	Business identifiers assigned to this health insurance product which remain constant as the resource is updated and propagates from server to server.
status	code	The current state of the health insurance product.
type	CodeableConcept	The kind of health insurance product.
name	string	Official name of the health insurance product as designated by the owner.
alias	string	A list of alternate names that the product is known as, or was known as in the past.
period	Period	The period of time that the health insurance product is available.
ownedBy	Reference	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'.
administeredBy	Reference	An organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owner.
coverageArea	Reference	The geographic region in which a health insurance product's benefits apply.
contact	BackboneElement	The contact for the health insurance product for a certain purpose.
contact.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
contact.extension	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
contact.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
contact.purpose	CodeableConcept	Indicates a purpose for which the contact can be reached.
contact.name	HumanName	A name associated with the contact.
contact.telecom	ContactPoint	A contact detail (e.g. a telephone number or an email address) by which the party may be contacted.
contact.address	Address	Visiting or postal addresses for the contact.
endpoint	Reference	The technical endpoints providing access to services operated for the health insurance product.
network	Reference	Reference to the network included in the health insurance product.
coverage	BackboneElement	Details about the coverage offered by the insurance product.
coverage.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
coverage.extension	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
coverage.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
coverage.type	CodeableConcept	Type of coverage (Medical; Dental; Mental Health; Substance Abuse; Vision; Drug; Short Term; Long Term Care; Hospice; Home Health).
coverage.network	Reference	Reference to the network that providing the type of coverage.
coverage.benefit	BackboneElement	Specific benefits under this type of coverage.
coverage.benefit.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
coverage.benefit.extension	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
coverage.benefit.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
coverage.benefit.type	CodeableConcept	Type of benefit (primary care; speciality care; inpatient; outpatient).
coverage.benefit.requirement	string	The referral requirements to have access/coverage for this benefit.
coverage.benefit.limit	BackboneElement	The specific limits on the benefit.
coverage.benefit.limit.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
coverage.benefit.limit.extension	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
coverage.benefit.limit.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
coverage.benefit.limit.value	Quantity	The maximum amount of a service item a plan will pay for a covered benefit. For examples. wellness visits, or eyeglasses.
coverage.benefit.limit.code	CodeableConcept	The specific limit on the benefit.
plan	BackboneElement	Details about an insurance plan.
plan.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
plan.extension	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
plan.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
plan.identifier	Identifier	Business identifiers assigned to this health insurance plan which remain constant as the resource is updated and propagates from server to server.
plan.type	CodeableConcept	Type of plan. For example, "Platinum" or "High Deductable".
plan.coverageArea	Reference	The geographic region in which a health insurance plan's benefits apply.
plan.network	Reference	Reference to the network that providing the type of coverage.
plan.generalCost	BackboneElement	Overall costs associated with the plan.
plan.generalCost.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
plan.generalCost.extension	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
plan.generalCost.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
plan.generalCost.type	CodeableConcept	Type of cost.
plan.generalCost.groupSize	positiveInt	Number of participants enrolled in the plan.
plan.generalCost.cost	Money	Value of the cost.
plan.generalCost.comment	string	Additional information about the general costs associated with this plan.
plan.specificCost	BackboneElement	Costs associated with the coverage provided by the product.
plan.specificCost.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
plan.specificCost.extension	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
plan.specificCost.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
plan.specificCost.category	CodeableConcept	General category of benefit (Medical; Dental; Vision; Drug; Mental Health; Substance Abuse; Hospice, Home Health).
plan.specificCost.benefit	BackboneElement	List of the specific benefits under this category of benefit.
plan.specificCost.benefit.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
plan.specificCost.benefit.extension	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
plan.specificCost.benefit.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
plan.specificCost.benefit.type	CodeableConcept	Type of specific benefit (preventative; primary care office visit; speciality office visit; hospitalization; emergency room; urgent care).
plan.specificCost.benefit.cost	BackboneElement	List of the costs associated with a specific benefit.
plan.specificCost.benefit.cost.id	string	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
plan.specificCost.benefit.cost.extension	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
plan.specificCost.benefit.cost.modifierExtension	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
plan.specificCost.benefit.cost.type	CodeableConcept	Type of cost (copay; individual cap; family cap; coinsurance; deductible).
plan.specificCost.benefit.cost.applicability	CodeableConcept	Whether the cost applies to in-network or out-of-network providers (in-network; out-of-network; other).
plan.specificCost.benefit.cost.qualifiers	CodeableConcept	Additional information about the cost, such as information about funding sources (e.g. HSA, HRA, FSA, RRA).
plan.specificCost.benefit.cost.value	Quantity	The actual cost value. (some of the costs may be represented as percentages rather than currency, e.g. 10% coinsurance).

Extensions

Name	URL

InsurancePlan

Overview

Use Cases

EHR Data Model

Object Definition

Data Fields

Extensions

Operations & APIs

InsurancePlan-GET

InsurancePlan-POST

InsurancePlan ID-GET

InsurancePlan ID-PUT

InsurancePlan ID-DELETE