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Scenarios for Managing Benefit Cases

These scenarios provide examples of benefit case management processes performed by agency employees, call center representatives and agency managers. Your agency may follow a different process according to its business requirements.

Referral Management

An intake agent at a Human Services Department receives a referral for rehabilitative services from a social services worker. The Human Services department employee also receives referral documents by mail from the individual's doctor and other social services specialists. The referral information includes the individual's personal information such as an address, the reason for the recommendation for services, and a brief description of the problem.

The intake agent creates the referral record, and routes it to a department manager. The department manager reviews the referral and assigns it to a field agent for an assessment. The field agent performs the initial assessment of the referral by talking to the social service worker, and the client.

Referral Intake

An intake agent at a Human Services Department meets with an applicant seeking disability relief. The agent works with the applicant to complete an electronic application for disability benefits.

NOTE:  An application for benefits or an eligibility inquiry also can be submitted electronically using a self-service Web site, by email, or in person.

Referral Validation

The agent interviews the applicant to obtain information such as earned income, other benefits income, assets and expenses, and additional pertinent application information. The agent creates a contact record for the applicant and then creates a Household record to enter details about the applicant's family, income and assets.

The agent collects other important documents such as proof of residence, and employment verification that the applicant has provided. Based on the investigation, the agent validates the referral, and moves it to the next step in the process.

Case Management

After the assessment is completed, the field agent updates the referral record, and, depending on the findings, the referral is converted to a case.

The case is approved, and is assigned to the case worker who manages the benefits package, case plan, and case outcome.

Case Record Creation

The agent then creates a case record, and provides the case number to the constituent for reference. In the case record the agent adds other details and associates scanned document files with the case record. The referral that led to this case is stored as a part of the case record.

Assignment of Cases to the Next-Level Agent

The agent assigns the case to a manager who assumes primary responsibility for coordinating assessment activities. Cases can either be assigned manually by adding another user to the Case Team field and selecting that user as primary, or by setting up an assignment rule, based on various criteria of the case record.

Assignment of Case Assessment Activities

A department manager at the Human Services Department provides a predefined assessment template that establishes evaluation criteria for the benefits application. The manager organizes a case team in the department to investigate various aspects of the application, assigns activities to each member of the team, and sets a due date for each assessment activity. The manager can automatically perform these tasks using assignment and workflow rules that are based on worker skills, availability, and on agency work processes.

Case Assessment

A field agent asks an applicant relevant assessment questions, and captures the information. Based on the responses to the questions, the field agent can rule out ineligible applicants, and can flag potential eligible applicants for further review. The field agent completes the assigned assessment task, and creates a report. The field agent attaches the document to the assessment activity, updates the status of the activity, and then enters notes and observations that can be shared with the team. The manager reviews the assessment information, and changes the status of the case to eligible or not eligible. If the case is eligible, it is routed to a social worker.

Benefits Eligibility Determination

The benefits eligibility determination is based on individual details captured during the application intake process, and field agent assessment reports. The social worker uses the Siebel eligibility determination business process to calculate the applicant's cash benefits along with non-cash benefits for a complete care package. The eligibility determination process typically involves integration with either the Oracle Siebel Business Rules Processor or integration with third-party eligibility engine, financial or back-office system.

The social worker meets with the applicant, and reviews the proposed benefits and services package. The applicant signs the agreement, and the agent later scans the agreement to create a file that can be attached to the case record. The social worker updates the case, and the case is routed to the next-level manager for approval and payment authorization.