The View Benefits Microjourney in Pega Customer Service for Healthcare enables healthcare organizations to easily and consistently address the high volume of plan benefit questions they receive. Successful resolution of these inquiries is critical to improving customer satisfaction and first-call resolution rates. Agents can quickly access critical, personalized information, whether it is for a simple eligibility check or a complex scenario that requires multiple types of coverage information, such as cost share responsibilities, claims, and limits.
The View Benefits Microjourney is available through assisted-service channels.
Assisted service example: Members can speak or chat with customer service representatives about their plan benefits and statuses
When members and providers understand plan benefits, it leads not only to a better customer experience but also lower costs, better outcomes, and fewer follow-ups. Enable agents to skillfully resolve the wide range of inquiries they receive, such as:
- A member or provider checks a member’s cost-share responsibilities for an upcoming service, such as whether a deductible applies or what copayment a doctor's office should collect
- A member or provider checks whether a member is covered for a benefit or whether they have visits remaining in the benefit year
- A member seeks to understand the cost impact of a provider selection, for example, in-network versus out-of-network or if their network is tiered
- A provider checks whether an authorization is required for a procedure
View Benefits example
- Coverage information by network type
- Cost share statuses
- Usage accumulation
- See claims by benefit
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 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 consumer is a health plan member inquiring about their coverage.
The provider or an employee verifies health plan members’ benefit eligibility and cost-share responsibilities for scheduling and billing purposes.
Customer service representative
The customer service representative (CSR) addresses plan benefit inquiries from members and providers.
Stages and Steps
This Microjourney includes the following stages:
- The Verify stage is skipped by default, but can be extended to filter which customers can be serviced by View Benefits. For example, privacy rules can be referenced to prevent inappropriate disclosures.
- The Intake stage collects information necessary for fulfilling customers’ requests. In this Microjourney, it includes a member search for provider services use cases only.
- The Process stage delivers the requested information, and includes benefit selection, coverage information, related claims, and a review step.
- The Resolve stage includes the steps to complete the inquiry and a step to email a summary to the customer. The process can also be extended to include routing for other channels, such as mail.
- Customer Service Representative: answers coverage questions for members and providers
- Plan: retrieves a member’s plan
- Member: retrieves information about a member
- Benefit coverage: retrieves a member’s coverage information about a particular benefit
- Accumulators – Header (Benefits): retrieves cost-share accumulations
- Claims: retrieves claims that are associated with the benefit in question
See this article for more information about implementing the View Benefits Microjourney.