CoverageBenefit

Represents the benefits provided to a covered member by a purchaser’s plan.

Supported Calls

create(), delete(), describeLayout(), describeSObjects(), getDeleted(), getUpdated(), query(), retrieve(), search(), undelete(), update(), upsert()

Fields

BenefitNotes

Type: textarea
Properties: Create, Nillable, Update
Description: Additional information about the benefits available to the member under this plan’s coverage.

BenefitPeriodEndDate

Type: date
Properties: Create, Filter, Group, Nillable, Sort, Update
Description: Last day of the coverage benefit period.

BenefitPeriodStartDate

Type: date
Properties: Create, Filter, Group, Nillable, Sort, Update
Description: First day of the coverage benefit period.

CareBenefitVerifyRequestId

Type: reference
Properties: Create, Filter, Group, Nillable, Sort, Update
Description: The care benefit verify request associated with the coverage benefit.

This field is a relationship field.

This field is available in API version 61.0 and later with the Manage Pharmacy Benefits Verification permission set.
Relationship Name: CareBenefitVerifyRequest
Relationship Type: Lookup
Refers To: CareBenefitVerifyRequest

CoinsuranceNotes

Type: textarea
Properties: Create, Nillable, Update
Description: Additional information about the contribution the member makes towards treatment.

CopayNotes

Type: textarea
Properties: Create, Nillable, Update
Description: Additional information on the copayment amounts members contributes.

CoverageType

Type: picklist
Properties: Create, Filter, Group, Nillable, Sort, Update
Description: General category of service covered.
Possible values:
- Dental
- Medical
- Vision
- Home Health - This picklist value is available for the Home Health feature in API version 59.0 and later.
- Pharmacy - This picklist value is available for the Pharmacy Benefits Verification feature in API version 63.0 and later. See Activate Picklist Value for Coverage Benefit to activate this value.

DeductibleNotes

Type: textarea
Properties: Create, Nillable, Update
Description: Additional information about the member’s deductibles under this plan.

Disclaimer

Type: string
Properties: Create, Filter, Group, Nillable, Sort, Update
Description: Overall plan benefit disclaimers.

EmergencyDepartmentCopay

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member contributes towards emergency treatment.

FamilyInNetworkDeductibleApplied

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member has paid for health care provided by the health plan’s preferred providers for all family members.

FamilyInNetworkDeductibleLimit

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member is required to pay for health care provided by the health plan’s preferred providers for all family members. When this amount is reached, the plan starts to contribute towards treatment.

FamilyInNetworkDeductibleRemaining

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The remaining amount the member still has to pay for health care provided by the health plan’s preferred providers for all family members. When this amount is reached, the plan starts to contribute towards treatment.

FamilyInNetworkOutofPocketApplied

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount of the member has paid in this coverage year for health care provided by the health plan’s preferred providers for all family members. It includes deductibles, copayments, and coinsurance, but excludes premiums.

FamilyInNetworkOutofPocketLimit

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The most the member pays during the coverage year for health care provided by the health plan’s preferred providers for all family members. It includes deductibles, copayments, and coinsurance, but excludes premiums.

FamilyInNetworkOutofPocketRemaining

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The remaining amount for the member to pay during this coverage year for care provided by the plan’s preferred providers for all family members. When this amount is reached, the plan starts to contribute towards treatment. It includes deductibles, copayments, and coinsurance, but excludes premiums.

FamilyOutofNetworkDeductibleApplied

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member has paid for health care provided by non-preferred providers for all family members.

FamilyOutofNetworkDeductibleLimit

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The total amount the member has to pay for health care provided by non-preferred providers for all family members. When this amount is reached, the plan starts to contribute towards treatment.

FamilyOutofNetworkDeductibleRemaining

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member still has to pay for health care provided by non-preferred providers for all family members. When this amount is reached, the plan starts to contribute towards treatment.

FamilyOutofNetworkOutofPocketApplied

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount of the member has paid in this coverage year for health care provided by non-preferred providers for all family members. It includes deductibles, copayments, and coinsurance, but excludes premiums.

FamilyOutofNetworkOutofPocketLimit

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The most the member pays during the coverage year for health care provided by non-preferred providers for all family members. It includes deductibles, copayments, and coinsurance, but excludes premiums.

FamilyOutofNetworkOutofPocketRemaining

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The remaining amount for the member to pay during this coverage period for health care provided by non-preferred providers for all family members. When this amount is reached, the plan starts to contribute towards treatment. It includes deductibles, copayments, and coinsurance, but excludes premiums.

FinalCoverageStatusCodeId

Type: reference
Properties: Create, Filter, Group, Nillable, Sort, Update
Description: The code that’s determined after considering the restrictions and other status types that apply to the coverage benefit.

This field is a relationship field.

This field is available in API version 61.0 and later with the Manage Pharmacy Benefits Verification permission set.
Relationship Name: FinalCoverageStatusCode
Relationship Type: Lookup
Refers To: CodeSet

FrequencyType

Type: picklist
Properties: Create, Filter, Group, Nillable, Restricted picklist, Sort, Update
Description: The frequency type of the coverage benefit associated with the home healthcare visit.

This field is available in API version 66.0 and later with the Home Health add-on license.
Possible values:
- Daily
- Fortnightly
- Monthly
- Quarterly
- Weekly
- Yearly

IndividualInNetworkDeductibleApplied

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member has paid for health care provided by the health plan’s preferred providers to the most costly family member.

IndividualInNetworkDeductibleLimit

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member has to pay for health care provided by the plan’s preferred providers for any family member. When this amount is reached, the plan starts to contribute towards treatment.

IndividualInNetworkDeductibleRemaining

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The remaining amount the member has to pay for care during the coverage year provided by the plan’s preferred providers for any family member. When this amount is reached, the plan starts to contribute towards treatment.

IndividualInNetworkOutofPocketApplied

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount of the member has paid in this coverage year for health care provided by the plan’s preferred providers to any one family member. It includes deductibles, copayments, and coinsurance, but excludes premiums.

IndividualInNetworkOutofPocketLimit

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The most the member pays during the coverage year for health care provided by the health plan’s preferred providers for any family member. It includes deductibles, copayments, and coinsurance, but excludes premiums.

IndividualInNetworkOutofPocketRemaining

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount remaining for the member to pay during the coverage year for care provided by the plan’s preferred providers for any family member. It includes deductibles, copayments, and coinsurance, but excludes premiums.

IndividualOutofNetworkDeductibleApplied

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member has paid for health care provided by non-preferred providers to the most costly family member.

IndividualOutofNetworkDeductibleLimit

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member has to pay for health care provided by non-preferred providers to any one family member. When this amount is reached, the plan starts to contribute towards treatment.

IndividualOutofNetworkDeductibleRemain

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The remaining amount the member has to pay for health care during the coverage year provided by non-preferred providers to any family member. When this amount is reached, the plan starts to contribute towards treatment.

IndividualOutofNetworkOutofPocketApplied

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount of the member has paid in this coverage period for health care provided by non-preferred providers to any family members. It includes deductibles, copayments, and coinsurance, but excludes premiums.

IndividualOutofNetworkOutofPocketLimit

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The most the member pays during the coverage year for health care provided by non-preferred providers to any family member. It includes deductibles, copayments, and coinsurance, but excludes premiums.

IndividualOutofNetworkOutofPocketRemain

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount remaining for the member to pay during the coverage year for health care provided by non-preferred providers to any family member. It includes deductibles, copayments, and coinsurance, but excludes premiums.

InNetworkCoinsuranceAmount

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member contributes towards treatment undertaken by the health plan’s preferred providers.

InNetworkCoinsurancePercentage

Type: percent
Properties: Create, Filter, Nillable, Sort, Update
Description: The percentage of treatment cost the member pays for treatment undertaken by the health plan’s preferred providers.

InNetworkLifetimeMaximum

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member has to pay during lifetime coverage under this plan after which the provider covers all costs for treatment provided by its preferred providers. It includes deductibles, copayments, and coinsurance, but excludes premiums.

IsActive

Type: boolean
Properties: Create, Defaulted on create, Filter, Group, Sort, Update
Description: Specifies whether the coverage benefit is currently in force.
Default value: false

LastReferencedDate

Type: datetime
Properties: Filter, Nillable, Sort
Description: The timestamp for when the current user last viewed a record related to this record.

LastViewedDate

Type: datetime
Properties: Filter, Nillable, Sort
Description: The timestamp for when the current user last viewed this record. If this value is null, it’s possible that this record was referenced (LastReferencedDate) and not viewed.

LifetimeMaximumNotes

Type: textarea
Properties: Create, Nillable, Update
Description: Additional information on the lifetime maximum payments the member Will be expected to make.

MemberId

Type: reference
Properties: Create, Filter, Group, Nillable, Sort, Update
Description: The ID of the member receiving these benefits.

MemberPlanId

Type: reference
Properties: Create, Filter, Group, Sort
Description: The ID of the member plan receiving these benefits.

Name

Type: string
Properties: Create, Filter, Group, Sort, Update
Description: Name of these coverage benefits.

OutcomeStatusCodeId

Type: reference
Properties: Create, Filter, Group, Nillable, Sort, Update
Description: The outcome code set associated with the coverage benefit.

This field is a relationship field.

This field is available in API version 61.0 and later with the Manage Pharmacy Benefits Verification permission set.
Relationship Name: OutcomeStatusCode
Relationship Type: Lookup
Refers To: CodeSet

OutofNetworkCoinsuranceAmount

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member contributes towards treatment undertaken by non-preferred providers.

OutofNetworkCoinsurancPercentage

Type: percent
Properties: Create, Filter, Nillable, Sort, Update
Description: The percentage of treatment cost the member pays for treatment undertaken by non-preferred providers.

OutofNetworkLifetimeMaximum

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member has to pay during lifetime coverage under this plan after which the plan provider covers all costs for treatment provided by its non-preferred providers. It includes deductibles, copayments, and coinsurance, but excludes premiums.

OutofPocketNotes

Type: textarea
Properties: Create, Nillable, Update
Description: Additional information about the out-of-pocket payment the member makes.

OwnerId

Type: reference
Properties: Create, Defaulted on create, Filter, Group, Sort, Update
Description: The ID of the user who owns this record.

PharmaCopayAmount

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member contributes towards the pharma products.

This field is available in API version 62.0 and later with the Manage Financial Assistance Program permission set.

PrimaryCareCopay

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member contributes towards primary care treatment.

SourceSystem

Type: string
Properties: Create, Filter, Group, Nillable, Sort, Update
Description: The name of the system this benefits record was obtained from.

SourceSystemIdentifier

Type: string
Properties: Create, Filter, Group, Nillable, Sort, Update
Description: The ID of this benefits record on its source system.

SourceSystemModified

Type: date
Properties: Create, Filter, Group, Nillable, Sort, Update
Description: The date on which these benefits were last changed on their source system.

SpecialistCopay

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member contributes towards specialist consultations.

StatusCodeId

Type: reference
Properties: Create, Filter, Group, Nillable, Sort, Update
Description: The status code set associated with the coverage benefit.

This field is a relationship field.

This field is available in API version 61.0 and later with the Manage Pharmacy Benefits Verification permission set.
Relationship Name: StatusCode
Relationship Type: Lookup
Refers To: CodeSet

TotalBenefitAmount

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The total amount of the coverage benefit associated with the home healthcare visit.

This field is available in API version 66.0 and later with the Home Health add-on license.

UrgentCareCopay

Type: currency
Properties: Create, Filter, Nillable, Sort, Update
Description: The amount the member contributes towards urgent care.

VerificationDate

Type: dateTime
Properties: Create, Filter, Nillable, Sort, Update
Description: Date on which the benefit was verified.

Associated Objects

This object has these associated objects. If the API version isn’t specified, they’re available in the same API versions as this object. Otherwise, they’re available in the specified API version and later.

CoverageBenefitChangeEvent (API version 59.0): Change events are available for the object.
CoverageBenefitFeed: Feed tracking is available for the object.
CoverageBenefitHistory: History is available for tracked fields of the object.
CoverageBenefitOwnerSharingRule: Sharing rules are available for the object.
CoverageBenefitShare: Sharing is available for the object.