Customer Service for Healthcare Microjourneys
These Microjourneys™ provide seamless workflows and a modern user experience for healthcare providers and health plan members, improving efficiency and patient satisfaction.
Featured Microjourneys
CUSTOMER SERVICE FOR HEALTHCARE
Schedule Medical Appointment
This use case can be implemented by healthcare organizations to schedule, reschedule, or cancel appointments for medical services while interacting with patients, or with an authorized contact on the patient's behalf.
Overview | Configuration
CUSTOMER SERVICE FOR HEALTHCARE
Coverage Inquiry
This use case utilizes Pega decisioning capabilities* to identify preemptive opportunities and a mobile self-service case type to address them with members. Overview | Configuration
CUSTOMER SERVICE FOR HEALTHCARE
View Benefits
This use case enables healthcare organizations to easily and consistently address the high volume of plan benefit questions they receive.
Overview | Configuration
Additional Microjourneys
Member / Patient Services
View Benefits
Review the member’s plan and product eligibility information including information on specific benefit coverage.
Claims Inquiry
Responds to claims-related questions by using information such as claim status, information about out-of-pocket costs, and service history. The Microjourney creates follow-up work based on the context of the interaction.
Find Provider
Searches for provider organizations or individual practitioners based on criteria such as plan and location.
Update PCP
Updates member’s primary care provider (PCP).
Authorization Inquiry
Respond to customer questions about authorization statuses.
Add Child Dependent
Enter and process information about newborns and adopted children added to a policy. For information, see Add Child Dependent Microjourney.
Order ID Card
Request identification cards for members. For information, see Order ID Card Microjourney.
Coordination of Benefits
Collect policy information when members are covered by multiple plans. This coordinates benefit coverage and improves claims accuracy.
Update Contact Profile
Update contact profile information such as first, middle, and last name, date of birth, and marketing communication preferences.
Patient Assistance
Enables patients or providers on their behalf to request enrollment into a financial assistance program for medications or a medical procedure.
Reminder Management
Send medical appointment reminders to patients for scheduled medical appointments.
Welcome Member
Engages and educates new health plan members in self-service channels. It promotes benefits and programs and captures care team information.
Start Co-Browse
Collaborate in real-time with a customer by sharing a browser session and providing visual guidance on how to navigate a web site.
Create Lead‡
Create a sales lead during a customer service interaction and route to a sales rep.
Create Opportunity‡
Add, view, and modify sales opportunities during a customer service interaction.
Medicare Inquiry
Qualify inbound Medicare inquiries, present available plans, and route follow-up work.
Exercise Data Rights
Support customer requests to exercise their GDPR rights by making a request for data.
Log General Service Request
Create an ad hoc case to log a general customer request.
Send Correspondence
Send correspondence via email to a customer (contact or account holder).
Schedule Activity‡
Schedule a sales-related activity such as a follow-up conference call for a customer, including the start/end date, topic, location and route follow-up work.
Schedule Appointment
Facilitate interactions between customers and sales reps by scheduling appointments on the sales reps’ behalf.
Provider Services
View Benefits
Review the member’s plan and product eligibility information including information on specific benefit coverage.
Claims Inquiry
Respond to claims related questions using information such as claim status, out-of-pocket costs, and service history, and route follow-up work.
Authorization Intake
Receives and processes authorization requests from providers.
Authorization Inquiry
Respond to customer questions about authorization statuses.
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 theservice was requested.
Update Practitioner Address
Collect and route updates to practitioners’ 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, clinics etc.) with which they are associated.
Update Practitioner Languages
Update the languages spoken by a practitioner.
Update Practitioner Licenses
Update the license related information held by a practitioner, such as a state-issued medical licenses, DEA number, and Medicare and Medicaid numbers.
Update Practitioner Specialties
Update the type of provider and the specialties recorded for the practitioner.
Update NPI
Update or correct a provider’s NPI (National Provider Identifier) number.
Update Contact Profile
Update contact profile information such as first, middle, and last name, date of birth, and marketing communication preferences.
Patient Assistance
Enables patients or providers on their behalf to request enrollment into a financial assistance program for medications or a medical procedure.
Coordination of Benefits
Collect policy information when members are covered by multiple plans. This coordinates benefit coverage and improves claims accuracy. Providers can submit on behalf of members.
Start Co-Browse
Collaborate in real-time with a customer by sharing a browser session and providing visual guidance on how to navigate a web site.
Log General Service Request
Create an ad hoc case to log a general customer request.
Send Correspondence
Send correspondence via email to a customer (contact or account holder).
Schedule Activity ‡
Schedule a sales-related activity such as a follow-up conference call for a customer, including the start/end date, topic, location and route follow-up work.
‡Requires Pega Sales Automation for Healthcare license.