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Scenario for Handling Insurance Agent and Member Inquiries

This scenario features sample tasks performed by a call center representative. Your company may follow a different workflow according to its business requirements.

In this scenario, a call center representative for a health plan or an insurance company is handling multiple calls each day from insurance agents and members.

Typically, members call to ask questions regarding their insurance coverage. The call center representative accesses this information in the Members screen, Summary view. To enroll members in a health program, she uses the Health Programs view. To handle a request for a change of primary care provider (PCP) or a primary network or independent practice association (IPA), she goes to the Benefits view.

NOTE:  Do not add member records in the Members screen. Use the Group Policies screen or the Individual Health Policies screen to add member records. For more information, see Individual Health Policies or Group Policies.

Members often call to request information about providers. After the representative adds provider records in the Providers screen, she can view them in both the Providers and Contacts screens. She can view the member's current provider in the Members Benefits view. She can also use this view to process requests to change a member's primary care provider

NOTE:  Use the Providers screen to add provider records. For more information, see Providers.

In this scenario, end users are the call center representatives. They enter information to:

• Enroll a member in a health program
• Charge a PCP, primary network, or IPA for members
• Add additional benefits coverage