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Provide Member Services

Learning Objectives

After completing this unit, you’ll be able to:
  • Browse the console.
  • Verify a member.
  • Create a case.

Start the Morning Providing Great Service

Makana Health is a health insurance payer with about 5 million members. It’s committed to giving those members the best possible healthcare services. So far, Makana is doing a great job. Their secret weapon? Committed member services agents. And Erica Joyner is one of the best. She makes sure that every member knows what Makana can do for them, which is a lot—everything from answering questions about plans and coverage to tracking billing and claims. Erica’s excited to use Health Cloud for Payers because it makes it easier for her to help her members.

Erica grabs her morning latte, sits down at her desk, and logs in to her Health Cloud for Payers console.

 Health Cloud for Payers console, open member cases (1), today’s events (2), and patient CSAT index. In the footer icons for phone (3), member verification (4), macros, omni-channel, open cases, history, and quip documents

She views open member cases (1), then scrolls down to view today’s events (2). Her first call of the morning arrives. She clicks the softphone icon at the bottom of her screen (3).

A member named Charles Green is on the line. Erica clicks Member Verification (4) to open up her verification script. The script prompts her to ask Charles for his member ID and date of birth. After he confirms, she opens his member record.

Answer Member Questions

While Erica refers to the member record for Charles in her console, Charles asks if he’s close to reaching his out-of-pocket maximum. Erica looks at the top of his health record.

Member record for Charles Green showing benefit usage as Low, Out-of-pocket expenses as $4,372 of $5,000.

She tells Charles that he’s spent $4,372 out of his $5,000 yearly out-of-pocket maximum. He asks about his last claim from his physical therapist. Erica sees that the claim hasn’t been paid or was rejected. It’s still open, so she opens a case to follow up and find out what’s going on. Let’s see what she does.

  1. Click General Inquiry. The contact name, Charles Green, is already filled in.
  2. Enter the Subject. Erica enters: Claim status for physical therapy.
  3. Enter description. Erica enters: Charles had physical therapy twice last month and wants to know if it’s approved before he goes back again.
  4. Click Save.

A new case is created. Erica sends an escalation note to the escalation processing group and tells Charles to call tomorrow about the status of his physical therapy claim. She clicks Member Details to make sure that she has the latest phone number and knows the best times to contact Charles.

Before Charles hangs up, she notices that he has member alerts about his health status.

Charles Green member record. Member Alerts & Notifications is highlighted with a warning that Charles didn’t pick up Glucophage (Metformin) refill. A second warning indicates that he hasn’t had a physical examination in more than a year.

She asks if he’d like to speak to his care coordinator to resolve them. Charles would like to, so Erica looks at the Member Details and discovers that the care coordinator for Charles is Richard Yang. She sends Richard a Chatter message to see if he’s available to talk to Charles. He is. After making sure there’s nothing else she can do for Charles, she transfers him to Richard.

Her coffee isn’t even cold, and Erica has checked her open cases and helped Charles Green. Not a bad start to the day.