Modeling Provider Networks
Introduction
Understanding how to effectively track and manage physician networks is crucial for digital health companies aiming to offer affordable and convenient care. This guide will provide an in-depth explanation on:
- Modeling an insurance provider network offered by a payer.
- Associating an individual or organizational provider with an insurance network.
- Modeling an insurance product or plan offered by a payer.
Defining the Network
A critical first step is to define the insurance network. A network is a group of doctors, hospitals and care providers that the health insurance company contracts with to provide medical services.
In FHIR, an insurance network is modeled using the Organization resource. This resource represents the many-to-many relationship between insurance plans and provider networks.
The Da Vinci PDEX Plan Net (PDEX) specifies a unique profile of Organization to represent a provider network. In this profile, the partOf attribute is mandatory, necessitating the creation of an Organization resource for each payer.
Connecting Providers to Networks
To link individual Practitioners to the network, the PractitionerRole resource is used. For every network affiliation, there should be a corresponding PractitionerRole. The PDEX extends the PractitionerRole resource with a network attribute to reference the network. For instance, a single practitioner operating in two different organizations can each point to the same Acme Bronze network.
Organizational providers (e.g. "Cancer Specialists of Springfield"), are modeled as Organization resources. The OrganizationAffiliation resource is used to link the provider to the network through the OrganizationAffiliation.network attribute.
Connecting Insurance Plans to Networks
The InsurancePlan resource represents a health insurance offering by a payer. It consists of a list of covered benefits (InsurancePlan.coverage), costs associated with those benefits (InsurancePlan.plan), and additional details about the offering. The InsurancePlan.plan attribute describes the cost-sharing agreement between the payer and the patient.
There can be multiple InsurancePlan.plan entries. This is because the same insurance product may have different costs for beneficiaries, depending on whether the provider is in-network or out-of-network.
A plan can be associated with multiple networks, and a network can be associated with many plans. You can specify the InsurancePlan.network attribute and/or the InsurancePlan.network attribute that applies to all cost-sharing plans. If the InsurancePlan.network attribute is not provided, each cost-sharing plan must provide at least one network in the InsurancePlan.plan.network attribute.
References
As a private sector collaboration Da Vinci PDEX Payer Network guide is being implemented by Payers. See the following reference APIs for examples
For information about how to represent provider directories, see our guides on Provider Organizations and Provider Credentials.