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Pega Customer Service for Healthcare case types

In the context of a customer service application, case types define the work that your customer is asking you to perform. The Pega® Customer Service for Healthcare application components that you install determine which case types are available for your use.

Cases that you can modify in App Studio are marked with an asterisk (*).

The following Pega Customer Service case types are available in Member Services, Provider Services, and Patient Relationship Management.

Cases available in Pega Customer Service

The following Pega Customer Service case types are automatically available in Member and Provider Services. You can add other Pega Customer Service cases for your use.

CaseDescription

Complaint or Compliment *

Enter a complaint or compliment regarding an account, product, or other issue that distributes the feedback according to the feedback type and recipient (potentially into the back office).

General Service Request

Address a customer issue when there are no service request types that are more suitable for handling the situation. Customer service representatives (CSRs) can select the location to route the service request to facilitate resolution.

Schedule Activity *

Schedule an activity, such as a follow-up conference call for a customer, including the start and end dates, topic, and location. You can specify an owner or route the activity to a work queue.

Send Correspondence *

Send correspondence to a customer (contact or account holder) by using email.

Update Contact Profile *

Update contact profile information such as first, middle, and last name, date of birth, verification settings, such as social security number and security questions, and marketing preferences.

Cases available in Member Services

Cases that you can modify in App Studio are marked with an asterisk (*).

Case

Description

Add Newborn *

Enter and process information about newborns that are added to a policy.

Claims Inquiry *

Respond to claims-related questions by using information such as claim status, information about out-of-pocket costs, and service history. The case type creates the follow-up work that is needed based on the context of the interaction.

Coordination of Benefits *

Collect policy information when members are covered by multiple plans.This coordinates benefit coverage and improves claims accuracy.

Create Business Lead

Create a sales lead for a business during a customer service interaction and route it to a sales representative.

Create Individual Lead

Create a sales lead for a consumer during a customer service interaction and route it to a sales representative.

Create Individual Opportunity

Add, view, and modify sales opportunities during a customer service interaction.

Exercise Member Data RightsUnder the General Data Protection Regulations (GDPR) legislation, customers have the right to access their personal data, have the data corrected if it is inaccurate or incomplete, request the removal of data, and request to suppress the data.

Find Provider *

Search for provider organizations or individual practitioners that are based on criteria such as plan and location.

Make Offer

Upsell or cross-sell to the customer with an offer that is generated by Pega Marketing.

Medicare Inquiry *

Qualify inbound inquiries about Medicare plans by using a series of industry-standard, qualifying questions and then presenting Medicare plans that are available to the customer.

Offer Negotiator

Negotiate a retention offer with a customer. Enables you to bundle multiple products together to create a custom retention offer and provide guidance to stay within a budget for each offer.

Order ID Card *

Request identification cards for members.

Sales Negotiator

Negotiate a sale by upselling or cross-selling. CSRs can upsell or cross-sell bundled products to retain and increase business with a customer.

Schedule Activity *

Schedule an activity, such as a follow-up conference call for a customer. Includes the start and end dates, topic, and location. You can specify an owner or route the activity to a work queue.

Schedule Appointment

CSRs can facilitate interactions between customers and sales representatives by scheduling appointments on the sales representative's behalf. CSRs can view available appointment times on the Microsoft Outlook calendars of the sales representatives.

Schedule Correspondence *

Send correspondence to a customer (contact or account holder) by using email.

Suggested Offers

Select and present cross-sell and other offers to a customer.

Update Contact Profile *

Update the contact profile information, such as first, middle, and last name, date of birth, verification settings, such as social security number and security questions, and marketing preferences.

Update PCP *

Update a member’s primary care provider (PCP).

Review Member Benefits *

Review the member’s plan and product eligibility information, including information on specific benefit coverage.

Cases available in Provider Services

Cases that you can modify in App Studio are marked with an asterisk (*).

Case

Description

Appeal a Prior Authorization Denial *

Initiate and process the appeal of a previously denied authorization (pre-certification) request on behalf of the member for whom the service was requested.

Authorization Intake

The Authorization intake case type is used to receive and process authorization requests from providers. This case is specific to provider services.

Claims Inquiry *

Respond to claims-related questions by using information such as claim status, out-of-pocket costs, and service history. The case type creates the follow-up work that is needed based on the context of the interaction.

Co-browsing Session

Collaborate in real time with a customer through sharing a browser session and providing guidance on how to navigate a website. The co-browse case maintains a history of the co-browse session, including a recording of the session (when the co-browsing recording feature is enabled) that can be viewed as part of the customer history.

Coordination of Benefits *

Collect policy information when members are covered by multiple plans. This coordinates benefit coverage and improves claims accuracy.

Manage AppointmentA case type for canceling appointments or rescheduling appointments for a different time or with a different provider.
Medical Appointment SchedulingA case type for scheduling new appointments. Schedulers and other representatives can schedule new appointments for different medical services while interacting with the patients or with an authorized contact on the patient's behalf.

Offer Negotiator

Negotiate a retention offer with a customer. This case type enables you to bundle multiple products together to create a custom retention offer and provide guidance to stay within a set budget for each offer.

Request Prior Authorization

A decision that is made by your health insurer or plan that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. This case enables your physician to obtain approval from your health insurance plan for treatment. A prior authorization is a technique for minimizing costs, wherein benefits are only paid if the medical care has been pre-approved by the insurance company.

Schedule Appointment

CSRs can facilitate interactions between customers and sales representatives by scheduling appointments on behalf of the sales representative. CSRs can view available appointment times on the Microsoft Outlook calendars of the sales representatives.

Suggested Offers

Select and present cross-sell and other offers to a customer.

Update Contact Profile

Update contact profile information, such as first, middle, and last name, date of birth, verification settings, such as social security number and security questions, and marketing preferences.

Update NPI

Update or correct a provider’s National Provider Identifier (NPI) number.

Update Practitioner Address *

Submit a request to update practitioner addresses.

Update Hospital Admitting Privileges

Update the list of hospitals at which a practitioner holds admitting privileges.

Update Practitioner Business Affiliations

Update a practitioner's relationship with the business entities (hospitals and clinics) with which they are associated.

Update Practitioner Languages

Update the languages that are spoken by a practitioner.

Update Practitioner Licenses

Update the license-related information that is held by a practitioner, such as a state-issued medical licenses, Drug Enforcement Administration (DEA) number, and Medicare and Medicaid numbers.

Update Practitioner Specialties

Update the type of provider and the specialties that are recorded for the practitioner.

View Benefits

Review the member’s plan and product eligibility information, including information on specific benefit coverage.

Cases provided in Patient Relationship Management

Pega has enhanced its Patient Relationship Management solution by bundling and adding capabilities to Pega Customer Service for Healthcare and Pega Care Management with the Program referral and Visit case types.

CaseDescription
Manage AppointmentA case type for canceling appointments or rescheduling appointments for a different time or with a different provider.
Medical Appointment SchedulingA case type for scheduling new appointments. Schedulers and other representatives can schedule new appointments for different medical services while interacting with the patients or with an authorized contact on the patient's behalf.

Program Referral

A case type for enrolling a member into a program. After the member consents, a care manager chooses the appropriate program for the member based on the assessment.

VisitA visit is a meeting between care managers and patients. Certain steps in this case are performed only in the CM Care Manager portal in the Care Management application, but coordinators can set up these meetings in the Interaction portal. Scheduling work is queued from and creates follow-up work in the CM Care Manager portal.

Published March 22, 2018 — Updated March 22, 2019


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