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Scenarios for Benefits Case Management

This topic describes how benefits case management might be used. You might use benefits case management differently, depending on your business model. This topic includes the following scenarios:

• Managing Intake
• Updating Data
• Assigning Cases
• Assigning Assessment Activities
• Determining Benefits Eligibility
• Appealing Cases
• Reviewing Cases for Quality Assurance

Managing Intake

An intake agent at a social service agency meets with a citizen who needs agency benefits. He works with the citizen to complete an electronic application for benefits on a self-service Web site. On the self-service Web site, the intake agent submits the completed application to the agency. Additionally, citizens can access the same self-service Web site to complete applications for benefits themselves.

An intake agent might also receive a referral for benefits from a social worker. The agent might receive referral documents by mail from the citizen's doctor and other social service specialists. The referral information includes the citizen's personal information such as an address, the reason for the recommended services, and a brief description of the problem.

Updating Data

The agent assigned to the submitted application reviews the application and looks for matching contact records for that application. If she does not find a matching contact record for a contact in the application, then she creates a contact record for the citizen. She associates the submitted application with each contact record in the application. She then uploads the information in the application into Siebel Public Sector to distribute data in the application to appropriate data fields for the case and contacts.

If necessary, the agent interviews the citizen to obtain additional information. She can add additional details to the case record and associate scanned document files with the case record. She can also update the contact records to enter additional details about the citizen's family.

After the application is complete, the agent checks the information in the application to make sure that none of this information is falsified, inaccurate, or invalid.

Assigning Cases

The agent assigns the case to a manager who assumes primary responsibility for coordinating assessment activities. Agents can manually assign cases by adding another user to the Team field of the case and selecting that user as primary. You can also assign cases by setting up an assignment rule. This assignment rule is based on various criteria in the case record.

Assigning Assessment Activities

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

Determining Benefits Eligibility

In the intake process, an agent at a social service agency captures details about the situation for a citizen. The agent then screens the citizen's case to determine the benefits for which the citizen is eligible. She reviews these benefits with the citizen before actually assigning benefits to the citizen's case. After creating benefit plans with associated benefits and benefit payments, the agent creates referral orders for those benefits that service providers supply. When benefit payments are due, the agent processes these payments.

Later, the agent changes data relating to the citizen's case because the household income for the case changes. To determine whether this data change affects the citizen's benefits, the agent automatically scans the citizen's case to see whether she must reassign new benefits to the case. Consequently, she reassigns benefits to the case. Information about the existing benefits is archived, and the payments for the citizen are automatically recalculated.

Appealing Cases

A citizen is not satisfied with the benefits that she receives, so she notifies an agent that she wants to appeal her case. Although the original case is still in effect, the agent creates an appeal case for the citizen's original case. This appeal case contains an attachment with information about the original case. To support the appeal, the citizen provides documentation that the agent includes in the appeal case.

A board reviews the evidence in the appeal case to make a decision about the appeal. After this review, the board rejects the appeal. The agent then closes the appeal case.

Reviewing Cases for Quality Assurance

At any time during case processing or after case completion, an agent reviews the details about the case to determine whether the case is processed according to agency procedures and governmental regulations.