$schema: https://json-schema.org/draft/2020-12/schema $id: https://raw.githubusercontent.com/api-evangelist/aetna/refs/heads/main/vocabulary/aetna-vocabulary.yaml title: Aetna Vocabulary description: Controlled vocabulary and taxonomy for Aetna health insurance APIs and data concepts. version: '1.0.0' provider: Aetna domains: - Health Insurance - Healthcare Interoperability - Patient Data Access - Provider Administration concepts: - name: ExplanationOfBenefit abbreviation: EOB definition: >- A FHIR resource representing a claim submission or adjudication result including services provided, amounts billed, and insurance payment details. standard: HL7 FHIR R4 related: - Claim - Coverage - Patient - name: Coverage definition: >- A FHIR resource describing health insurance coverage including subscriber information, plan details, network, and benefit period. standard: HL7 FHIR R4 related: - Patient - ExplanationOfBenefit - name: Patient definition: >- A FHIR resource representing an individual receiving healthcare services. In the payer context, refers to a health plan member. standard: HL7 FHIR R4 - name: Practitioner definition: >- A FHIR resource representing a healthcare provider including physicians, nurses, and other licensed professionals. standard: HL7 FHIR R4 related: - PractitionerRole - Organization - Location - name: PractitionerRole definition: >- A FHIR resource representing the roles a practitioner plays at an organization including specialty, network status, and contact details. standard: HL7 FHIR R4 - name: MedicationKnowledge definition: >- A FHIR resource representing formulary drug information including drug tier, cost-sharing requirements, and coverage limitations. standard: HL7 FHIR R4 / DaVinci PDEX Drug Formulary - name: InsurancePlan definition: >- A FHIR resource describing a health insurance product including plan type, coverage area, networks, and contact information. standard: HL7 FHIR R4 / DaVinci Plan-Net - name: SMART on FHIR definition: >- An open, standards-based technology platform enabling applications to access healthcare data securely using OAuth 2.0 and FHIR APIs. standard: SMART App Launch Framework - name: CMS-9115-F label: CMS Interoperability and Patient Access Final Rule definition: >- A CMS regulation requiring health insurers to implement FHIR-based APIs for patient data access, provider directory, drug formulary, and payer-to-payer data exchange. effective: '2021-01-01' - name: EDI 837 definition: >- HIPAA standard electronic transaction for submitting healthcare claims and encounter information from providers to payers. standard: ASC X12 837 - name: EDI 270/271 definition: >- HIPAA standard electronic transactions for healthcare eligibility benefit inquiry (270) and response (271). standard: ASC X12 270/271 - name: EDI 276/277 definition: >- HIPAA standard electronic transactions for healthcare claim status request (276) and response (277). standard: ASC X12 276/277 - name: EDI 835 definition: >- HIPAA standard electronic transaction for healthcare payment and remittance advice from payer to provider. standard: ASC X12 835 - name: Drug Formulary definition: >- A list of prescription drugs covered by a health plan, organized by tier with associated cost-sharing requirements and coverage restrictions. - name: Prior Authorization abbreviation: PA definition: >- A requirement that a provider obtain approval from the health plan before delivering specific services or prescribing certain medications. - name: Network definition: >- The group of doctors, hospitals, pharmacies, and other healthcare providers that have contracted with a health plan to provide services at negotiated rates. - name: Deductible definition: >- The amount a member must pay for covered health care services before the insurance plan starts to pay. - name: Copayment abbreviation: Copay definition: >- A fixed amount a member pays for a covered health care service, usually at the time of service. - name: Coinsurance definition: >- The member's share of costs for a covered health care service, calculated as a percentage of the allowed amount for the service. workflows: - name: Patient Data Access description: Member authorizes third-party app via SMART on FHIR to access health records through FHIR R4 Patient Access API. steps: - Member registers or logs in to the third-party application - App redirects member to Aetna authorization server - Member grants consent for data access scopes - App receives authorization code and exchanges for access token - App queries FHIR Patient Access API with bearer token - Member health data returned as FHIR resources - name: Provider Eligibility Verification description: Provider verifies member eligibility and benefits before delivering care using EDI 270/271. steps: - Provider submits EDI 270 eligibility inquiry via Availity - Aetna processes inquiry and returns EDI 271 response - Response includes coverage details, deductible status, and copay information - Provider confirms in-network status and expected member cost-sharing - name: Electronic Claims Submission description: Provider submits claims electronically via EDI 837 and receives remittance via EDI 835. steps: - Provider prepares EDI 837 claim file with service details - Claim submitted to Aetna via Availity EDI gateway - Aetna adjudicates claim and issues EDI 835 remittance advice - Provider applies payment and posts explanation of benefits personas: - name: Health Plan Member description: Individual covered by Aetna health insurance seeking access to personal health data. - name: Healthcare Provider description: Physician, hospital, or clinic submitting claims and verifying eligibility via EDI. - name: Health App Developer description: Third-party developer building SMART on FHIR applications for member health data access. - name: Benefits Administrator description: Employer or broker managing group health plan enrollments and coverage.