Implementation Guide
23.1.0 - R4 APIs

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Logical Model: Profile - Athena Custom PatientInsurance

Official URL: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-patientInsurance-profile Version: 23.1.0
Active as of 2023-03-01 Computable Name: PatientInsurance

The patientInsurance describes a health insurance offering comprised of a list of covered benefits (i.e. the product), costs associated with those benefits (i.e. the plan), and additional information about the offering, such as who it is owned and administered by, a coverage area, contact information, etc..


This custom PatientInsurance is part of the set of resource profiles supported by the API Server used with the athenaPractice 23.0.0. This is not a FHIR Conformant Resource. It further describes read and search capabilities of these products.
Note: Create and Update operations are NOT supported for this resource.

Overview

A financial tool for tracking value accrued for a particular purpose. In the healthcare field, used to track insurance for a patient, guarantor details and etc

Scope and Usage

PatientInsurance describes a health insurance offering comprised of a list of covered benefits (i.e. the product), costs associated with those benefits (i.e. the plan), and additional inform action about the offering, such as who it is owned and administered by, a coverage area, patient contact information, etc. All elements listed in the differential profile view are Supported, which means that the API Server is capable of supplying these fields from the product database when they have been populated via the product or its APIs.

Source

PatientInsurance resource contains information about insurance plan/product associated with the patient and guarantor information. This information is extracted from Guarantor, PatientProfile, InsuranceCarriers, InsuranceGroup, Doctorfacility tables.

Example

Example for the athena-patientInsurance-profile Profile.

PatientInsurance Example

Usage:

  • This Logical Model Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-patientInsurance-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid Σ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
.... reference 0..1 string Reference to the Patient
.... display 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... insuranceCarrier 0..1 Reference(Organization) Insurance carrier refernce
.... reference 0..1 string Insurance Carrier Id refering to Organization
.... display 0..1 string Insurance carrier Name
... patientSameAsGuarantor 0..1 unsignedInt Patient relationship with Guarantor
... guarantor 0..1 Reference(guarantor) Reference to RelatedPerson
.... reference 0..1 string GuarantorId refering to Related person
.... display 0..1 string Guarantor Name
... orderForClaims 0..1 decimal Number of Claim orders
... inActive 0..1 boolean Insurance status
... insuredID 0..1 string Insured ID for the Insurance.
... practitioner 0..1 Reference(Practitioner) Practitioner reference for insurance.
.... reference 0..1 string DoctorId refering to Practitioner
.... display 0..1 string Practitioner Name
... facility 0..1 string Facility associated to insurance plan
... financialClass 0..1 string Financial Class description
... insuranceGroup 0..1 string Insurance Group

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-patientInsurance-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid Σ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
.... reference ΣC 0..1 string Reference to the Patient
.... display Σ 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... insuranceCarrier C 0..1 Reference(Organization) Insurance carrier refernce
ref-1: SHALL have a contained resource if a local reference is provided
.... reference ΣC 0..1 string Insurance Carrier Id refering to Organization
.... display Σ 0..1 string Insurance carrier Name
... patientSameAsGuarantor 0..1 unsignedInt Patient relationship with Guarantor
... guarantor C 0..1 Reference(guarantor) Reference to RelatedPerson
ref-1: SHALL have a contained resource if a local reference is provided
.... reference ΣC 0..1 string GuarantorId refering to Related person
.... display Σ 0..1 string Guarantor Name
... orderForClaims 0..1 decimal Number of Claim orders
... inActive 0..1 boolean Insurance status
... insuredID 0..1 string Insured ID for the Insurance.
... practitioner C 0..1 Reference(Practitioner) Practitioner reference for insurance.
ref-1: SHALL have a contained resource if a local reference is provided
.... reference ΣC 0..1 string DoctorId refering to Practitioner
.... display Σ 0..1 string Practitioner Name
... facility 0..1 string Facility associated to insurance plan
... financialClass 0..1 string Financial Class description
... insuranceGroup 0..1 string Insurance Group

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
ref-1errorathena-patientInsurance-profile.patient, athena-patientInsurance-profile.insuranceCarrier, athena-patientInsurance-profile.guarantor, athena-patientInsurance-profile.practitionerSHALL have a contained resource if a local reference is provided
: reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-patientInsurance-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid Σ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Reference to the Patient
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... insuranceCarrier C 0..1 Reference(Organization) Insurance carrier refernce
ref-1: SHALL have a contained resource if a local reference is provided
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Insurance Carrier Id refering to Organization
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Insurance carrier Name
... patientSameAsGuarantor 0..1 unsignedInt Patient relationship with Guarantor
... guarantor C 0..1 Reference(guarantor) Reference to RelatedPerson
ref-1: SHALL have a contained resource if a local reference is provided
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string GuarantorId refering to Related person
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Guarantor Name
... orderForClaims 0..1 decimal Number of Claim orders
... inActive 0..1 boolean Insurance status
... insuredID 0..1 string Insured ID for the Insurance.
... practitioner C 0..1 Reference(Practitioner) Practitioner reference for insurance.
ref-1: SHALL have a contained resource if a local reference is provided
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string DoctorId refering to Practitioner
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Practitioner Name
... facility 0..1 string Facility associated to insurance plan
... financialClass 0..1 string Financial Class description
... insuranceGroup 0..1 string Insurance Group

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
athena-patientInsurance-profile.patient.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
athena-patientInsurance-profile.insuranceCarrier.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
athena-patientInsurance-profile.guarantor.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
athena-patientInsurance-profile.practitioner.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
ref-1errorathena-patientInsurance-profile.patient, athena-patientInsurance-profile.insuranceCarrier, athena-patientInsurance-profile.guarantor, athena-patientInsurance-profile.practitionerSHALL have a contained resource if a local reference is provided
: reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

This structure is derived from Base

Summary

Mandatory: 0 element(3 nested mandatory elements)
Must-Support: 2 elements

Structures

This structure refers to these other structures:

  • Unable to summarise profile http://hl7.org/fhir/StructureDefinition/guarantor (no profile found)

Differential View

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-patientInsurance-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid Σ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
.... reference 0..1 string Reference to the Patient
.... display 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... insuranceCarrier 0..1 Reference(Organization) Insurance carrier refernce
.... reference 0..1 string Insurance Carrier Id refering to Organization
.... display 0..1 string Insurance carrier Name
... patientSameAsGuarantor 0..1 unsignedInt Patient relationship with Guarantor
... guarantor 0..1 Reference(guarantor) Reference to RelatedPerson
.... reference 0..1 string GuarantorId refering to Related person
.... display 0..1 string Guarantor Name
... orderForClaims 0..1 decimal Number of Claim orders
... inActive 0..1 boolean Insurance status
... insuredID 0..1 string Insured ID for the Insurance.
... practitioner 0..1 Reference(Practitioner) Practitioner reference for insurance.
.... reference 0..1 string DoctorId refering to Practitioner
.... display 0..1 string Practitioner Name
... facility 0..1 string Facility associated to insurance plan
... financialClass 0..1 string Financial Class description
... insuranceGroup 0..1 string Insurance Group

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-patientInsurance-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid Σ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
.... reference ΣC 0..1 string Reference to the Patient
.... display Σ 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... insuranceCarrier C 0..1 Reference(Organization) Insurance carrier refernce
ref-1: SHALL have a contained resource if a local reference is provided
.... reference ΣC 0..1 string Insurance Carrier Id refering to Organization
.... display Σ 0..1 string Insurance carrier Name
... patientSameAsGuarantor 0..1 unsignedInt Patient relationship with Guarantor
... guarantor C 0..1 Reference(guarantor) Reference to RelatedPerson
ref-1: SHALL have a contained resource if a local reference is provided
.... reference ΣC 0..1 string GuarantorId refering to Related person
.... display Σ 0..1 string Guarantor Name
... orderForClaims 0..1 decimal Number of Claim orders
... inActive 0..1 boolean Insurance status
... insuredID 0..1 string Insured ID for the Insurance.
... practitioner C 0..1 Reference(Practitioner) Practitioner reference for insurance.
ref-1: SHALL have a contained resource if a local reference is provided
.... reference ΣC 0..1 string DoctorId refering to Practitioner
.... display Σ 0..1 string Practitioner Name
... facility 0..1 string Facility associated to insurance plan
... financialClass 0..1 string Financial Class description
... insuranceGroup 0..1 string Insurance Group

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
ref-1errorathena-patientInsurance-profile.patient, athena-patientInsurance-profile.insuranceCarrier, athena-patientInsurance-profile.guarantor, athena-patientInsurance-profile.practitionerSHALL have a contained resource if a local reference is provided
: reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. athena-patientInsurance-profile 0..* Base Instances of this logical model are not marked to be the target of a Reference
... id SΣ 1..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... pid Σ 1..1 integer PID is internal numeric value used in the Chart module and clinical data. This will be the same as the resource id in the Patient resource.
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Reference to the Patient
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Patient name
... patientProfileId SΣ 1..1 unsignedInt Patient specific id for practice management data including financial information
... insuranceCarrier C 0..1 Reference(Organization) Insurance carrier refernce
ref-1: SHALL have a contained resource if a local reference is provided
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Insurance Carrier Id refering to Organization
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Insurance carrier Name
... patientSameAsGuarantor 0..1 unsignedInt Patient relationship with Guarantor
... guarantor C 0..1 Reference(guarantor) Reference to RelatedPerson
ref-1: SHALL have a contained resource if a local reference is provided
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string GuarantorId refering to Related person
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Guarantor Name
... orderForClaims 0..1 decimal Number of Claim orders
... inActive 0..1 boolean Insurance status
... insuredID 0..1 string Insured ID for the Insurance.
... practitioner C 0..1 Reference(Practitioner) Practitioner reference for insurance.
ref-1: SHALL have a contained resource if a local reference is provided
.... @id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string DoctorId refering to Practitioner
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Practitioner Name
... facility 0..1 string Facility associated to insurance plan
... financialClass 0..1 string Financial Class description
... insuranceGroup 0..1 string Insurance Group

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
athena-patientInsurance-profile.patient.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
athena-patientInsurance-profile.insuranceCarrier.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
athena-patientInsurance-profile.guarantor.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
athena-patientInsurance-profile.practitioner.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
ref-1errorathena-patientInsurance-profile.patient, athena-patientInsurance-profile.insuranceCarrier, athena-patientInsurance-profile.guarantor, athena-patientInsurance-profile.practitionerSHALL have a contained resource if a local reference is provided
: reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

This structure is derived from Base

Summary

Mandatory: 0 element(3 nested mandatory elements)
Must-Support: 2 elements

Structures

This structure refers to these other structures:

  • Unable to summarise profile http://hl7.org/fhir/StructureDefinition/guarantor (no profile found)

 

Other representations of profile: CSV, Excel

Notes:

Supported Interactions

The Interactions supported by this resource are listed below.

Search Parameters

Search parameters are executed as specified in the HL7 FHIR RESTful API implementation definition. To search for PatientInsurance resources, an application shall perform an HTTP GET, specifying the query parameters associated with the resource.

GET [base]/customresource/PatientInsurance?{search-parameters}

Where:

Name Description
[base] Specifies the base URL of the FHIR Server, e.g., https://ap22sandbox.athenahealth.com/demoAPIServer
_id (token) The ID of the resource
patientProfileId known id of the patient.
patient (reference) Who the sensitivity is for
[_include] Specifies the supported hl7 resources include which are defined as reference in examples. Note: The Patient, RelatedPerson, Organization and Practitioner resources are supported via the _include parameter.
HTTP Response Codes

The following HTTP response codes are returned by this API call:

200 OK The query was performed and any results found are contained within the body of the HTTP response. Note: The search API will return 200 OK when the query itself is successful, regardless of whether or not any matching results were found.
401 Unauthorized Authorization is required for this request, and either the Authorization header is missing or the supplied user credentials in the Authorization header are not valid or have expired. The body of the HTTP response will contain an OperationOutcome resource that indicates that Authorization is required.
500 Server Error The server may return other error codes to indicate other error conditions. The body of the HTTP response will contain an OperationOutcome resource that indicates the nature of the error.