| Interoperability Standards Platform (ISP)

Data related to an individual’s insurance coverage for health care.

Data Element

Plan Name

Description

Name of the health plan benefit offering assigned to the Plan Identifier.

Submitted By: Mark Roberts / Leavitt Partners
Data Element Information
Use Case Description(s)
Use Case Description	Administrative and financial transactions are a critical part of health care provisioning and management. There is a need for health care consumers to get access this health data to be able to make better care decisions and manage their health care journey. Making Health Insurance Coverage data available to consumers will enable them to have greater visibility into the costs associated with their health care, identify potential errors, and enable them to plan for their future health care needs taking financial costs into account. Consumer-directed exchange occurs when a consumer or an authorized caregiver invokes their HIPAA Individual Right of Access (45 CFR 164.524) and requests their digital health information (adjudicated claims and encounter data) from a HIPAA covered entity (CE) – health insurance company or payers via an application or other third-party data steward.
Estimate the breadth of applicability of the use case(s) for this data element	All health care insurers (>1,800), third-party application developers, and all consumers of the health care system (>320M)
Link to use case project page	http://hl7.org/fhir/us/carin-bb/
Healthcare Aims	Improving patient experience of care (quality and/or satisfaction) Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s)	NUBC, CPT, HCPCS, HIPPS, ICD-9, ICD-10, DRGs, NDC, POS, NCPDP codes, and X12 codes. http://hl7.org/fhir/us/carin-bb/artifacts.html#5
Additional Specifications	HL7® FHIR® US Core Implementation Guide v3.1.1 based on FHIR R4
Current Use	Extensively used in production environments
Supporting Artifacts	This was part of the CMS Patient Access and Interoperability Rules, which went into effect July 1, 2021. CMS has suggested that industry consider using the CARIN for Blue Button Implementation Guide for the Patient Access API. https://www.cms.gov/about-cms/health-informatics-and-interoperability-group/faqs
Extent of exchange	5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Supporting Artifacts	While it is not known how many consumers have requested this data electronically, this information is communicated broadly today through other forms. This data is now being required to be communicated electronically through the CMS Patient Access API for which the regulation has suggested that industry consider using the CARIN for Blue Button Implementation Guide for the Patient Access API, we expect this data will be exchanged broadly throughout the health care sector. https://www.cms.gov/about-cms/health-informatics-and-interoperability-group/faqs
Potential Challenges
Restrictions on Standardization (e.g. proprietary code)	Some codes, but not all, are linked to proprietary code standards that may require a license.
Restrictions on Use (e.g. licensing, user fees)	Licensed Industry Standard Code Systems This IG includes value set bindings to code systems that reference industry standard codes which require implementers to purchase a license before the coded concepts can be used. The following information summarizes the set of licensed Code Systems required by this IG and provides links to the information about where to go to obtain a license: • AMA CPT: The CPT procedure and modifier codes are owned by the American Medical Association. • X12: CARC (Claim Adjustment Reason Codes are owned by X12.. • NUBC: The NUBC secretariat is the American Hospital Association.. • NUCC: National Uniform Claim Committee (NUCC) is presently maintaining the Taxonomy code set. The codes are free and publically available for download and use. If the use however is “For commercial use, including sales or licensing, a license must be obtained”. It would be appropriate for an app developer to file the license form just like they would for any other code set; however, there is no fee. • NCPDP: Retail Pharmacy data standards are defined by the NCPDP . • 3M APR-DRG: AP-DRGs and APR-DRGs are owned by 3M. Use of AP-DRGs and APR-DRGs require a license. Code Systems Not Requiring Licenses This IG includes value set bindings to code systems that are industry standard codes available for use without licenses. The following information summarizes the set of Code Systems required by this IG that are available for use: • ICD-CM Diagnosis Codes (ICD-10-CM): International Statistical Classification of Diseases and Related Health Problems (ICD). This IG will use version 10. The ICD-10-CM code set is maintained by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC) for use in the United States. It is based on ICD-10, which was developed by the World Health Organization (WHO) and is used internationally a medical classification. • ICD-Procedure Codes (ICD-PCS): The ICD-10-PCS code set is owned by CMS.. • DRGs.:MS-DRGs are owned by CMS. MS-DRGs are used for the Medicare population. • HCPCS Level II Procedure and Modifier Codes: Primarily include non-physician products, supplies, and procedures not included in CPT. They are owned by CMS and are available for use. • NDC (National Drug Codes): The US Federal Drug Administration (FDA) Data Standards Council assigns the first 5 digits of the 11 digit code.. • RARCCodes: The RARC codes are owned by CMS.
Privacy and Security Concerns	This data, like any patient data should be exchanged securely. Current processes exist, governed by CMS and ONC, to securely transfer this data.
Estimate of Overall Burden	The data elements in this class are already held by health care payers, anticipated burden of collection of data would be negligible. The CMS rule and Patient Access API already require CMS covered payers to share this data electronically. Many payers covered by the CMS rule have or are already considering making this data available in the same fashion for other lines of business.

ASTP Evaluation Details Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1 Maturity - Current Standards	Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2 Maturity - Current Use	Level 1 - Data element is captured, stored, or accessed in at least one production EHR or HIT module.
Criterion #3 Maturity - Current Exchange	Level 1 - Data element is electronically exchanged between two production EHRs or other HIT modules using available interoperability standards.
Criterion #4 Use Case(s) - Breadth of Applicability	Level 2 - Use cases apply to most care settings or specialties.

Comment

Submitted by rdillaire on 2025-05-12

CMS-CCSQ Supports Plan Name for USCDI v6

Recommendation: CMS CCSQ recommends advancing the Medicare Patient Identifier element to Level 2 and inclusion of the Coverage Period, Group Name, Payer Name, Plan Name, and Medicare Patient Identifier data elements in final USCDI v6.

Rationale: Inclusion of these common health insurance data elements for nationwide interoperability is essential for such use cases as value-based care, including affordability for lower-income individuals, and enabling patients to determine costs and affordability up front. This Health Insurance Information data class is associated with the overall primary and secondary coverage for the individual. In some cases, it may be different from the benefit used for a particular encounter or claim (e.g., worker's comp benefits). While these data elements are already included in the latest Fast Healthcare Interoperability Resources (FHIR) US Core and Consolidated Clinical Document Architecture (CDA) implementation guides (IGs) referenced in the Health, Data, Technology, and Interoperability-1 Final Rules (HTI-1), the implementation community can benefit from more clarity on how to consistently populate these fields—in particular Payer Name and Group Name—as there is variation between what a typical insurance card shows versus what is best used on real-time eligibility (RTE) queries with health plans.