Payer Plans

Datasets

Part of the Drug Formulary feed, built to Da Vinci PDex US Drug Formulary STU 2.1.0. The feed's data conventions apply.

A payer plan is one Payer Insurance Plan (InsurancePlan). The profile nests several repeating structures, and every one that may repeat is its own dataset here: the root file carries what occurs once per plan, and each child file carries one repeating element, keyed back to its parent. This mirrors the profile's slices one to one.

A repeating element is carried one of two ways. A structure with fields of its own is a child dataset, one row per occurrence. A repeating reference, code or short text with no fields of its own is a ;-separated list column on its parent row. Free-text lists such as aliases must not contain ; inside a value; a value that needs one goes in a single-value column or its own row.

Repeating references and codes that carry no fields of their own stay as ;-separated lists on their parent row: network_ids, coverage_area_ids, formulary_ids, plan_aliases.

payer_plans

One row per plan: the elements of the InsurancePlan that occur once.

• plan_id becomes the plan's first identifier, under the identifier namespace fixed for your engagement. Further identifiers, such as the CMS contract-plan-segment, are rows in plan_identifiers.
• A plan is complete only with its children. The profile requires at least one drug coverage and at least one drug plan with a cost table, so a payer_plans row with no plan_drug_coverages row or no drug_plans row is reported and not published.
• Plan-Net defines ownedBy as "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 commonly referred to as 'payers'."
• Plan-Net defines administeredBy as "an organization which administer other services such as underwriting, customer service and/or claims processing on behalf of the health insurance product owner."
• is_deleted on the plan retracts the whole tree. Child rows have their own is_deleted for dropping one contact, one cost cell or one identifier from the plan; a child row absent from the snapshot is dropped the same way when the plan is next built.

How the datasets become the resource

Every column maps to an element of the IG's own profiles; the feed defines no extensions. The one element the profile leaves optional and this feed does not collect is endpoint.

These resources are served by Patient Access.