Modeling Provider Networks
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
Connecting Insurance Plans to Networks
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
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.