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  1. FHIR Specification Feedback
  2. FHIR-19432

InsurancePlan.identifier use for plan and group number

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    • Icon: Change Request Change Request
    • Resolution: Persuasive with Modification
    • Icon: Medium Medium
    • FHIR Core (FHIR)
    • STU3
    • Patient Administration
    • InsurancePlan
    • 8.36.7
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      InsurancePlan is intended to be used by a payer to publish their products to consumers for browsing.  It isn't specific enough to be used for the charging or service-level billing scenarios.  In that context, we expect you'd use Coverage to represent the patient's insurance details, including the group and plan numbers (which would be in Coverage.class).  Note that there is an outstanding tracker to make some updates to Coverage.class:  https://jira.hl7.org/browse/FHIR-24641

       

      There are three different options we've considered:
      1. Adding guidance to use InsurancePlan.identifier, with an identifier.type of (Group or Plan)
      2. Create new .group and .plan properties
      3. Do what Coverage does.
      4. InsurancePlan.businessIdentifiers

       

      Given the refactor of InsurancePlan in FHIR-24827, we will adopt the approach to use the (post-refactor) InsurancePlan.identifier to include both group and plan IDs.  See the example structure below:

      We will make some updates to the InsurancePlan.identifier definition and comments to clarify this intent.

       

      InsurancePlan.identifier 

      Definition    
      Identifiers, such as the plan ID and/or group ID associated with the insurance plan.

      Comments:

      In some markets, the combination of a plan ID and a group ID are needed to uniquely identify an InsurancePlan.  For example, if a single plan (Bronze) is offered to two employer groups (Boilermakers and Aviation), you would represent that using two InsurancePlan resources, as shown below:

      InsurancePlan.identifier  0..*  (Boilermakers)   InsurancePlan/bm
           [0].value = 1234   (bronze plan)
           [0].type = Plan
           [0].system = https://insurance-payer.com/plan-numbers

           [1].value = Boilermakers
           [1].type = Group
           [1].system = https:// insurance-payer.com /group-numbers

      InsurancePlan.identifier  0..*  (Aviation)   InsurancePlan/av
           [0].value = 1234  (bronze plan)
           [0].type = Plan
           [0].system = https:// insurance-payer.com /plan-numbers

           [1].value = Aviation
           [1].type = Group
           [1].system = https:// insurance-payer.com /group-numbers

      Show
      InsurancePlan is intended to be used by a payer to publish their products to consumers for browsing.  It isn't specific enough to be used for the charging or service-level billing scenarios.  In that context, we expect you'd use Coverage to represent the patient's insurance details, including the group and plan numbers (which would be in Coverage.class).  Note that there is an outstanding tracker to make some updates to Coverage.class:  https://jira.hl7.org/browse/FHIR-24641   There are three different options we've considered: 1. Adding guidance to use InsurancePlan.identifier, with an identifier.type of (Group or Plan) 2. Create new .group and .plan properties 3. Do what Coverage does. 4. InsurancePlan.businessIdentifiers   Given the refactor of InsurancePlan in FHIR-24827 , we will adopt the approach to use the (post-refactor) InsurancePlan.identifier to include both group and plan IDs.  See the example structure below: We will make some updates to the InsurancePlan.identifier definition and comments to clarify this intent.   InsurancePlan.identifier   Definition     Identifiers, such as the plan ID and/or group ID associated with the insurance plan. Comments: In some markets, the combination of a plan ID and a group ID are needed to uniquely identify an InsurancePlan.  For example, if a single plan (Bronze) is offered to two employer groups (Boilermakers and Aviation), you would represent that using two InsurancePlan resources, as shown below: InsurancePlan.identifier  0..*  (Boilermakers)   InsurancePlan/bm       [0] .value = 1234   (bronze plan)       [0] .type = Plan       [0] .system = https://insurance-payer.com/plan-numbers       [1] .value = Boilermakers       [1] .type = Group       [1] .system = https:// insurance-payer.com /group-numbers InsurancePlan.identifier  0..*  (Aviation)   InsurancePlan/av       [0] .value = 1234  (bronze plan)       [0] .type = Plan       [0] .system = https:// insurance-payer.com /plan-numbers       [1] .value = Aviation       [1] .type = Group       [1] .system = https:// insurance-payer.com /group-numbers
    • Brian Postlethwaite / Sonja Ziegler : 5-0-0
    • Clarification
    • Non-substantive

    Description

      In the US domain, most commercial insurance coverage is identified by the combination of a plan number and group number. In HL7 V2 terms that would correspond to the IN1-2 and IN1-8 fields. Practitioners have to know both numbers to determine whether a particular service is covered for a patient. I assume both numbers should go in the InsurancePlan.identifier element but the documentation is rather vague. Could we please make that explicit by giving some examples at the end of the definition? It could be something like "Identifiers may include plan number, group number, or other values assigned to a particular set of coverage rather than to an individual person or organization." And we should also include those IN1-2 and IN1-8 mappings on the Mappings tab.

      Also assuming that InsurancePlan.identifier is the correct place for plan number and group number then we probably will also need a vocabulary proposal to enhance the identifier-type value set with additional Identifier types for plan number and group number.

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            nradov Nick Radov
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