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Coverage Inquiry

The Coverage Inquiry Microjourney™ in Pega Customer Service™ for Healthcare preemptively notifies health plan members about potential coverage issues and identifies the next steps to prevent care interruptions.

This use case includes Pega decisioning capabilities that identify opportunities for action, as well as a mobile self-service case type.

* License to use Pega Customer Decision Hub™ is required.

The Coverage Inquiry Microjourney is available through self-service channels.

Self-service example: members can reply to secure notifications from their health plans.


Health plan members want easy, convenient service. Digital channels, such as your mobile application or website, make your outreach efforts more successful with features such as:

  1. Personalized coverage information
  2. Member options
  3. Progress indicator
  4. Service expectations

App Studio provides personas, stages and steps, and data objects in one window.


Personas help you to group users according to the cases they work on, the channels they can access, and the responsibilities they have within a process.

Stages and Steps

Stages and steps show the visual path of the business process. The image below details the stages and steps of this particular Microjourney.

Data Objects

Data objects organize and store data that your Microjourney requires. These categories of data have fields, field mappings, and connections to data sources.

Personas in this Microjourney.


The insurance subscriber who uses health plan benefits to address personal medical issues. “Health literacy” and visibility into out-of-pocket expenses may be low.

Customer service representative

The representative who follows up on member requests, for example by researching issues or coordinating with providers.

Stages and Steps

You can identify preemptive outreach opportunities by using Pega Event Strategy Manager. For more information, see Coverage Inquiry Microjourney

After those opportunities have been identified, the Coverage Inquiry Microjourney performs the outreach. It includes the following stages.

  1. Member Input: provides outreach through email and self-service. This can be extended to assisted-service channels.
  2. Notify Provider: provides outreach, coordination, and internal routing. Healthcare organizations can extend this stage to conform to their workflows.
  3. Resolve: provides outreach to the member to resolve the issue through email or by extending outreach to assisted self-service channels.


  1. Member: Confirms whether assistance is needed.
  2. CSR: Follows up again with member to resolve the issue.

Data Objects/Models

Information used by the outreach and subsequent follow-up activity, such as coverage details, is created in and retrieved from the Benefit Issues data type.

  1. The Member Input stage retrieves information from the Benefit Issues data type.

Additional Information

See this article for more information about implementing the Coverage Inquiry Microjourney.

Start this Microjourney implementation.

Find more details and step-by-step instructions on implementation below.

Get documentation

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