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).

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.

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.

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