Modeling a member's health plan coverage
Key Takeaway
A member's coverage is a chain: a Member Plan on the person account points to the Purchaser Plan, and Coverage Benefit records related to the Member Plan hold what that member's plan covers.
In Agentforce Health, a member's health plan coverage is a chain of records. The member is a person account. A Member Plan links that person to the Purchaser Plan they bought from a payer. Coverage Benefit records then spell out what that member's plan covers. You need this chain to be right because features such as Benefits Verification, Utilization Management, and Claims all read the same coverage data.
Person accounts and business accounts
Always model members and patients as person accounts, because you can't fully use Agentforce Health functionality otherwise. One person account record can represent the same person as both a patient and a member.
Organizations on the insurance side are modeled as business accounts. The payer, the purchaser, and the purchaser group are each a business account record.