Insurance plan response, coverage-based

The shape a private insurer or its TPA sends, and the generic shape on the exchange. An indemnity policy lists benefits with money limits, and the hospital bills against those limits rather than against a package price.

The bundle​

Elements​

NRCeS profile: InsurancePlan.

Claim-Condition flags​

Supporting-information requirements​

10 of the requirements link a questionnaire through documentationUrl.

Exclusions​

Questionnaires​

Rules​

1. One structure per benefit​

Everything about a benefit, its conditions and required documents, hangs off coverage[].benefit[], with its money cap in limit[]. plan[].specificCost[] carries the cost per benefit category.

2. Conditions are prose​

The Claim-Condition extension on a benefit carries a sentence, such as a window after discharge, with the number in limit[] as a value, a comparator and a unit.

3. Benefit types are the insurer's vocabulary​

No closed value set is published for indemnity benefit types. Ask the insurer for its list before building a picker.

4. Requirements by stage​

Supporting-info requirements name the stage they apply to, preauthorisation, discharge or claim, in the extension url.

5. Exclusions​

Waiting periods, pre-existing-condition rules and excluded procedures are Claim-Exclusion extensions on the plan, each with a category and a statement.

6. What the screen caps​

The amount, against the benefit's limit. Submission is blocked by an amount over the limit or a missing mandatory document.

PMJAY​

PMJAY does not send this shape. Its plan is package-based; see the previous chapter.